John Weinman Health Psychology Section, Institute of Psychiatry, King’s College London.

1. ILLNESS PERCEPTIONTheory, Assessment and Application Workshop for NZ Psychology SocietyWellington, 20th April 2012 John Weinman Health Psychology Section, Institute of Psychiatry, King’s College London.

2. RESPONSE TO ILLNESS • HUGE VARIATION between patients. • SOME – cope well & illness may have relatively little impact (+ benefit finding) • OTHERS – major problems & cope in ways which may exacerbate illness outcome • WHY? - Not severity or type of illness - ?Due to patient’s perception of illness

3. ‘Illness’ Representation Coping procedure Appraisal Illness or Health Threat Emotional Response Coping procedure Appraisal Leventhal’s self-regulation model

4. ‘Illness’ Representation Coping procedure Appraisal Stimulus Health Threat Emotional Response Coping procedure Appraisal Leventhal’s self-regulation model IF-THEN RULES

5. Beliefs about illness • CORE BELIEFS • IDENTITY What is this? • CAUSE What caused this? • TIMELINE How long will it last? • CONSEQUENCES What will happen as a result of this? • CURE / CONTROL What will make it better? How to assess these beliefs?

6. Assessing Illness Perceptions • Interviews ( e.g Leventhal et al) • Questionnaires - IPQ (Weinman et al 1996) - IPQ-R (Moss Morris, 2002) - BIPQ (Broadbent et al, 2006) • Questionnaire + cognitive interviewing • Drawings

7. IPQ website http://www.uib.no/ipq/

8. Patients drawings

9. ILLNESS PERCEPTIONPSYCHOSOCIAL OUTCOMES • Quality of life and adjustment • Mood • Functioning • Return to work • Adherence to treatment *Psychology & Health, 2003, vol.18, No.2, pp141-184

10. ILLNESS PERCEPTIONPHYSICAL OUTCOMES • Pain & Symptoms MI; Whiplash • Disease development / recurrence MI; IBS • Wound healing post-op; burns; foot/leg ulcers • Mortality ESRD *

11. ILLNESS PERCEPTIONOUTCOME STUDIES • Meta-analysis of 57 data sets (*Hagger & Orbell, 2003) shows consistent links between illness perception, coping and outcome. • Methodological problems re. duration of illness, timing of assessments, study design etc. • Myocardial infarction (MI) as a model *Psychology & Health, 2003, vol.18, No.2, pp141-184

12. RECOVERY FROM MI • Medical Advances – less deaths in acute stage • Less success in the functional recovery of MI survivors , in terms of : • Return to Work • Social & Physical Functioning • Rehabilitation Attendance • Continuing Chest Pain (+ effects on QL)

13. ROLE OF BELIEFS IN MI RECOVERY • Previous work on attributions (eg Affleck et al, 1987), self-efficacy (DeBusk et al, 1994) etc. • Recent Illness Perception based work shows that different BASELINE dimensions predict different recovery outcomes : • Lower cure/control less Rehab attendance. (Petrie et al, 1996; Cooper et al, 1999) • Higher consequences  slower Return to Work + more chronic timeline (Petrie et al, 1996) • Causal beliefs health behaviour change (Weinman et al, 2000)

14. TASK • Read description of post-MI patient • Write brief answers to the questions at the end using your understanding of the CS-SRM • Work in groups to pool the answers and prepare a brief presentation

15. SINCE ILLNESS REPRESENTATIONS (3 days after MI) CLEARLY PREDICT MI OUTCOME :- Can an early intervention which modifies illness representations result improved recovery? Petrie, KJ, Cameron, LD, Ellis, CJ, Buick, D & Weinman, J. (2002) Changing illness perceptions after myocardial infarction : an early intervention randomised controlled trail. Psychosomatic Medicine, 64, 580-586.

16. Design of Heart Attack Recovery Project N=31 Hospital Intervention Home IPQ etc IP Sessions IPQ etc 3 & 6/12 RTW Rehab Function Compliance First time MI patients <70 Standard care Rehab Nurse Control N=34

17. The intervention (3 x 30 mins sessions)NB – sessions broadly equivalent but depend on individual’s baseline IPQ) Session 1 • Brief outline of nature of MI and symptoms • Confirm and explore patients perceptions of MI • Broaden causal model (starting from stress) – to include role of lifestyle in CHD (underlying MI)

18. Session 2 • Start from causal model to focus on developing plan for reducing risk factors and increasing control beliefs • Challenge negative consequences and timeline beliefs. • Agree personalised recovery action plan

19. Session 3 • Review action plan • Discuss recovery symptoms; concerns re. Medication and hazards of using symptoms as guide for medication adherence. • Address concerns re. return home.

21. Rehabilitation attendance, angina pain reports and return to work at 6 weeks

23. Intervention results • Illness perceptions change in response to the intervention in expected ways • Relationship with outcome variables is encouraging BUT • Does it work for all patients -too cognitive? • No sig. effects on medication adherence.

24. EFFECTS OF NA ON MI INTERVENTION • Used data from MI intervention study • NA (PANAS) median split for exp. & control group • HYPOTHESIS :- NA will be associated with poorer response to intervention because the intervention inhibits emotion regulation through its emphasis on problem focused coping. Cameron, Petrie, Ellis & Weinman (2005) Psychol. & Health,

25. 5 4.5 4 3.5 Intervention 3 Standard 2.5 2 1.5 1 0.5 0 High NA Low NA NA and Rehab Attendance

26. NA and SIP Disability score

27. NA and Exercise (times per week)

28. Extending the self-regulation model

29. Treatment Representation ‘Illness’ Representation Coping procedure Appraisal Stimulus Health Threat Emotional Response Coping procedure Appraisal Emotional response to Treatment Self-regulation and treatment decisions: extending Leventhal’s self-regulatory model

30. SPECIFIC BELIEFS Views about prescribed medication Necessity Beliefs about necessity of prescribed medication for maintaining health Concerns Arising from beliefs about potential negative effects

31. CURRENT WORK • More longitudinal studies with clinical outcomes (e.g. Chilcott, 2010) • Intervention studies • Illness perceptions in carers • Illness perceptions in people with mental health problems. • Illness perceptions in response to health threats (eg genetic and other health risks)) • Illness perceptions in health care professionals.

32. CONCLUSIONS • SRM provides a rich and complex framework for investigating responses to illness, treatment and health threats in patients across a wide range of conditions • Now considerable scope for:- - further methodological developments - further research to investigate all the components of the SRM. To improve our understanding of how patients respond to illness and treatment.