Psychological Factors in ill-Health - Faculty of Health

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                     Psychological Factors
                               in Ill-Health

                          Dr. Craig Jackson
      Senior Lecturer in Health Psychology

                               Faculty of Health


Gabriel T Byrne
Linking Emotions with Physical Symptoms

“The good physician treats the disease, but
the great physician treats the person.”

                                          William Osler
Non-Specific Symptoms
Often missed in assessment

“If you are distressed by anything external, the pain is not due to the thing
itself, but to your estimate of it; this you have the power to revoke at any
                                                    Marcus Aurelius 180BC

Dualism         Mind / Body Divide
                                                          Rene Descartes'

Biopsychosocial Unification popular in last 10-15 years
Traditional model of Disease Development

  Pathogen                            Disease (pathology)

       Individual susceptibility
Dominance of the biopsychosocial model

Mainstream in last 15 years

                                           Illness (well-being)

               Psychosocial Factors
               Behaviour              Rise of the worker as
               Quality of Life
                                      a “psychological
Mental States & Physical Well-being

“Triggering” Hypothesis

Chinese # 4                          Phillips et al. 2001

World cup 1998                       Carroll et al. 2002

Stressful Events and Breast Cancer   Chen et al. 1995

Scottish Heart Attack Deaths         Evans et al. 2002

The “Baskerville” Effect
Is disease real or is it in the mind?
Physiological Response to Stress

Chronic stress & Acute stress

Pituitary Gland, Hypothalamus and Amygdala

Adrenal glands =        Secrete hormones
                        Epinephrine      Cortisol      Glucocorticoids

                        Heart          =       beats faster
                        Arteries       =       widen
                        Stomach        =       digestion stops
                        Lungs          =       faster / shallow
                        Muscles        =       tense
Damage from Stress

Arterial damage

Increased glucocorticosteroids weaken immune system
                               reduce bone mass
                               reproductive suppression
                               memory problems

Anxiety           Depression    Tension         Sleeping problems
Apathy            Apprehension Alienation       Resentment

Confidence        Aggression    Withdrawal      Restlessness

Indecision        Worry         Concentration   Tired
Common Chronic Ill-Health Complaints

• Low Back Pain
• Carpal Tunnel Syndrome
• Cumulative Trauma Disorders             FORMS OF
• Tendonytis                              CHRONIC PAIN
• Repetitive Strain Injury                & FATIGUE
• Fibromyalgia
• Irritable Bowel Syndrome
• Chronic Fatigue

Those with heightened symptoms choose attributions to match concepts of
what is currently acceptable in medicine

External cause for illness preferred - patient becomes a helpless victim
Chronic Patient’s Attributions of Ill-Health

• Work

• Environment

• Traumatic injury

• Anatomy / Ergonomic
Common Misconceptions about Health

               “I like

                                 “I like
                               money too”
“Exploit someone new today”
Allergies – the role of psychology
Somatization and Fashionable Diagnoses

Somatoform Disorders (DSM IV category) “Somatization disorder”

Psychiatric diagnosis
Somatization             1. Rationalisation for psychosocial problems
                         2. Coping mechanism
                         3. Becomes a way of life

            Multiple Chemical Sensitivity             Dysautonomia
           Reactive Hypoglycemia           Irritable Bowel Syndrome
                          Chronic Fatigue Syndrome

1.   Vague subjective multisystem complaints
2.   Lack of objective lab findings e.g no organic cause
3.   Semi-scientific explanations e.g “post-viral syndrome”
4.   Symptoms consistent with Depression, Anxiety or general unhappiness
Linking Emotions with Physical Symptoms

Which causes which?
Case Summary of a Chronic Patient #1
Date        Symptoms                Referral               Investigation         Outcome
1980 (18)   Abdominal pain          GP --> surgical OP     Appendicectomy        Normal

1983 (21)   Pregnancy               GP --> obs and gynae                          Termination
            (boyfriend in prison)   OP

1985-7      Bloating, abdominal     GP --> Gastro and      All tests normal      IBS diagnosis
(23-25)     blackouts (divorce)     neurology OP                                 unexplained syncope

1989 (27)   Pelvic pain             GP --> obs and gynae Sterilised              Pain persists for 2 years
            (wants sterilisation)   OP

1991 (29)   Fatigue                 GP --> infectious      Nothing abnormal      Diagnosis of ME by patient
                                    diseases unit                                and self help group

1993 (31)   Aching muscles          GP --> rheumatology Mild cervical            Pain clinic - Tryptizol
                                    clinic              spondylosis

1995 (34)   Chest pain, breathless A&E --> chest clinic    Nothing abnormal      Refer to psychiatric services
            (child truanting)                              poss hyperventilation
Case Summary of a Depressed Patient ? NO!
Date       Symptoms              Referral
Feb 2004   Back Pain             GP – referred to physiotherapy

Mar 2004   Sciatica?             Physiotherapy twice a week

Apr 2004   Symptoms continue     Sees private Osteopath

Apr 2004   Symptoms continue     Discontinues Physiotherapy

Apr 2004   Symptoms continue     Bumps into GP in supermarket – GP refers for MRI

May 2004 Symptoms continue       MRI scan shows left-side, disc 5 slipped

Jun 2004   Symptoms continue     Referred to orthopaedic surgeon.
                                 Surgery required

Academic Researcher
Unhappy in job
Received written warnings about time-keeping and performance
Prevalence of Non-Specific Symptoms

Symptom              Prevalence %   Modern day complaints

Stuffy nose                 46.2    Multiple Chemical Sensitivity
Headaches                   33.0    Chronic Fatigue Syndrome
Tiredness                   29.8
                                    Sick Building Syndrome
Cough                       25.9
Itchy eyes                  24.7    Gulf War Syndrome
Sore throat                 22.4    Low-level Chemical Exposure
Skin rash                   12.0    Electrical Sensitivity
Wheezing                    10.1
Respiratory                 10.0    Historical complaints
Nausea                      9.0
Diarrhoea                   5.7
Vomiting                    4.0     Railway Spine
                                    Combat Syndrome
Heyworth & McCaul, 2001
Psychological / Perceptual Process of Illness

Internal Processes
“Do I   notice internal changes?”
                                                   MENTAL SCHEMA
“Should   I interpret them negatively?”
                                           Internal representation of the world
   “Should I think they are important?”     (knowledge, attitudes, beliefs)

                                           What do we believe about health?
External processes
   “Do I notice external sources?”
                                           What do we believe affects health?
   “What should I believe about it?”
   “What should I do about it?”
Factors Influencing Symptom Development

Selective Internal Attention

                   Tedious & un-stimulating environment
          Little communication             Stressful environment
       Learned behaviours                      “Negative Affectivity”

                        OVER FOCUS ON SYMPTOMS
Factors Influencing Symptom Development

Selective External Attention

 Heightened concern     about risk
                                         OVER FOCUS ON SYMPTOMS
        lack of information
        dreaded consequences                   Comparisons
 Mistrust   of government / industry          Attributions
 Attitudes about medicine                     Responses
 Political agenda                               Blame
 Legal agenda                                  Pessimism
 Social and   political climate
 Media and    pressure group activity

                  A good sign or a bad sign?
Hey. On Are
Hi Claire.way
home. Left
you around and
lecture early
do you fancy a
cos feel like               Personality type
brew?Next time!
                    Optimism vs Pessimism

                         Negative Affectivity

Irritable Bowel Syndrome

Common digestive disorder

Functional syndrome

Traumatic life events, Personality
disorders, Stress, Anxiety, Depression

Not a psychological disorder

Psychology important in how symptoms are perceived and reacted to
Chronic Fatigue Syndrome

• Non-specific subjective symptom

• Overlap with psychiatric diagnoses (66%)

• Chronic long-term inability and tiredness

• Both Physical and Psychological fatigue

• Most prevalent in white, middle class thirtysomething females

• Fatigue dominates activities and life
Bias – The placebo effect really does work!
Most effective medication known!
In approx. 30% of pop.
Subjected to more clinical trials than any other medicament
Nearly always does better than anticipated
The range of susceptible conditions seems limitless
Does not always occur
Present in subjective and objective outcomes
Negative outcomes can occur (Nocebo effect)

•Big pills better than smaller pills
•Red pills better than blue
                                     Patient’s “knowledge” of their treatment causes bias
•4 pills better than 2
                                     e.g. Benedetti & the Turin study
•30% of pop.
•Sham surgery vs arthroscopy for osteoarthritis
Treatment Bias of Healthcare

A.A. Mason

Congenital Ichthyosis


Cured severe case of 16yr old male

Mistaken C.I. for Acne Vulgaris

Could not repeat successful treatment

                                        Bennedetti & the Turin Study
Behavioural Responses to Diagnoses


Put life in order               ADAPTIVE COPING
                                Talk about it
Premature grieving              Planning
Sick Role
                                MALADAPTIVE COPING
Illness Behaviour
Over-sensitivity to symptoms    Substance use

Premature death
  Hierarchy of Needs

                   Self actualisation (personal growth and fulfilment)
  NEEDS                         Esteem (self and others)

                Belonging (group membership, affection, companionship)

  HOMEOSTATIC            Security (safety, stability, continuity)
                            Bodily needs (food, drink, safety)

Maslow 1954
Four Pathways of Psychological Factors in Ill-Health

1)    Part of Cause of Health Condition
      e.g.    Influencing factors (personality)
              Risky behaviours

2)    Part of Health Condition
      e.g.    Stroke, Metastases

3)    Effects of Health Condition
      e.g.    Chronic ill-health        depression, anxiety, withdrawal

4)    Psychological Interventions
      e.g.  Therapeutic benefits
            Increased compliance
  Compensation Neurosis

  Pending litigation

  Treatment results often poor

  Some overt malingering

  Exaggerated illness due to:
  suggestion      +        somatization
  rationalization +        distorted sense of justice
  victim status   +        entitlement

  Adverse legal / admin. systems

  Harden patient’s convictions

  With time, care-eliciting behaviour may remain permanent
Bellamy, 1997
Compensation Neurosis

                         Improvement in health.....

                         ...may result in loss of status

Patient compelled to guard against getting better

Financial reward for illness is a powerful nocebo

Exacerbates illness

 In a litigious society, will compensation neurosis become more widespread?
Accident Neurosis

• Failure to improve with treatment until compensation issue settled

• Accident must occur in circumstances with potential for compensation

• Inverse relationship to severity of injury - Accident neurosis rare in cases of
severe injury

• Low socio-economic status favors accident neurosis

• Complete recovery common following settlement of compensation issue

Miller, 1961
Abnormal Illness Behaviour after Compensable Injury
Accident neurosis                Accident victim syndrome
Aftermath neurosis               American disease
Attitudinal pathosis             Barristogenic illness
Compensatory hysteria            Compensationitis
Compensation neurosis            Fright neurosis
Functional overlay               Greek disease
Greenback neurosis               Invalid syndrome
Justice neurosis                 Perceptual augmenter
Post accident anxiety syndrome   Pensionitis
Postaccident fibromyalgia        Post-traumatic syndrome
Profit neurosis                  Psychogenic invalidism
Railway spine                    Secondary gain neurosis
Traumatic hysteria               Symptom magnification syndrome
Traumatic neurasthenia           Traumatic neurosis
Triggered neurosis               Unconscious malingering
Vertebral neurosis               Wharfie’s back
Whiplash neurosis
                                                 Mendelson, 1984
Secondary Gain Pre-disposition

 What is the Motivation?

• Desire for attention

• Punish spouse / others

• Solve life’s problems

• Cry for help

• Diversion from work

• Socially approved task avoidance
         sex with spouse
         military duty
Secondary Gain Pre-disposition

 Non-economic motivation?

• Loneliness

• Difficulty expressing emotional pain

• Previous history of attention seeking when ill

• Depression

• Anxiety
Secondary Gain Pre-disposition

 Who are the Potential Claimants?

• Military patients nearing severance

• Workers under retirement age

• Low job satisfaction

• Workers soon to be made redundant

• Members of support groups
 Abnormal Illness Behaviour (Care Eliciting Behaviour)

 • Disability disproportionate to detectable illness
 • Constant search for disease validation
 • Relentless pursuit of “enlightened doctors”
 • Appeals to doctor’s responsibility
 • Attitude of personal vulnerability and entitlement to care by others
 • Avoidance of health roles due to lack of skills and fear of failure
 • Adoption of sick role due to rewards from family, friends, physicians
 • Behaviours which sustain the sick role - complaints, demands, threats

Blackwell, 1987
 Return to Work

  Longer off work = Less likely to return to work
                           10 20 30 40 50 60 70 80 90 100
     % returning to work

                                                            <1 2 4 6 8 10 12 14 16 18 20 22 24
Waddell, 1994                                                         months not working

• Somatization influenced by numerous factors

• Sick role resolves intrapsychic, interpersonal or social problems

• Fashionable diagnoses have considerable overlap

• Occupational and Environmental syndromes

• Non specific and subjective complaints

• Underlying depression, anxiety, and history of unexplained complaints

• Mass communication + support groups = fashionable way to solve distress
• Behavioural aspects of chronic patients – blame, refusal, over-reporting etc.

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