Psychological Factors in Ill-Health

1. The following lecture has been approved for University Undergraduate Students This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging It is not intended for the content or delivery to cause offence Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation

2. Psychological Factors in Ill-Health Dr. Craig Jackson Senior Lecturer in Health Psychology Faculty of Health BCU www.health.bcu.ac.uk/craigjackson Gabriel T Byrne

3. Linking Emotions with Physical Symptoms “The good physician treats the disease, but the great physician treats the person.” William Osler

4. Non-Specific Symptoms Often missed in assessment

5. Dualism “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 moment” Marcus Aurelius 180BC Dualism Mind / Body Divide Rene Descartes' Biopsychosocial Unification popular in last 10-15 years

6. Traditional model of Disease Development Pathogen Disease(pathology) Modifiers Lifestyle Individual susceptibility

7. Dominance of the biopsychosocial model Mainstream in last 15 years Hazard Illness (well-being) Psychosocial Factors Attitudes Behaviour Quality of Life Rise of the worker as a “psychological entity”

8. 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

9. Is disease real or is it in the mind?

10. 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

11. 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

12. 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

13. Chronic Patient’s Attributions of Ill-Health • Work • Environment • Chemicals • Stress • Toxins • Virus • Allergies • Traumatic injury • Anatomy / Ergonomic

14. Common Misconceptions about Health “I like money” “I like money too”

15. “Exploit someone new today”

16. Allergies – the role of psychology

17. Allergies

18. 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 Fibromyalgia 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

19. Linking Emotions with Physical Symptoms Which causes which?

20. 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

21. 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 Female 36 Academic Researcher Unhappy in job Received written warnings about time-keeping and performance

22. Modern day complaints Multiple Chemical Sensitivity Chronic Fatigue Syndrome Sick Building Syndrome Gulf War Syndrome Low-level Chemical Exposure Electrical Sensitivity Historical complaints Railway Spine Neurasthenia Combat Syndrome Symptom Prevalence % Stuffy nose 46.2 Headaches 33.0 Tiredness 29.8 Cough 25.9 Itchy eyes 24.7 Sore throat 22.4 Skin rash 12.0 Wheezing 10.1 Respiratory 10.0 Nausea 9.0 Diarrhoea 5.7 Vomiting 4.0 Heyworth & McCaul, 2001 Prevalence of Non-Specific Symptoms

23. Psychological / Perceptual Process of Illness Internal Processes • “Do I notice internal changes?” • “Should I interpret them negatively?” • “Should I think they are important?” External processes • “Do I notice external sources?” • “What should I believe about it?” • “What should I do about it?” MENTAL SCHEMA Internal representation of the world (knowledge, attitudes, beliefs) What do we believe about health? What do we believe affects health?

24. Factors Influencing Symptom Development Selective Internal Attention Tedious & un-stimulating environment Little communication Stressful environment Learned behaviours “Negative Affectivity” OVER FOCUS ON SYMPTOMS Comparisons Attributions Responses Blame Pessimism

25. Factors Influencing Symptom Development • Selective External Attention • Heightened concern about risk involuntary uncontrolled lack of information dreaded consequences • Mistrust of government / industry • Attitudes about medicine • Political agenda • Legal agenda • Social and political climate • Media and pressure group activity OVER FOCUS ON SYMPTOMS Comparisons Attributions Responses Blame Pessimism

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

27. Irritable Bowel Syndrome Common digestive disorder Functional syndrome Traumatic life events, Personality disorders, Stress, Anxiety, Depression Somatization Not a psychological disorder Night-workers Loners Psychology important in how symptoms are perceived and reacted to

28. 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

29. Bias – The placebo effect really does work! • Most effectivemedication known! • In approx. 30% of pop. • Subjected to more clinical trialsthan any other medicament • Nearly always does better thananticipated • 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 • 4 pills better than 2 • 30% of pop. • Sham surgery vs arthroscopy for osteoarthritis Patient’s “knowledge” of their treatment causes biase.g. Benedetti & the Turin study

30. Treatment Bias of Healthcare A.A. Mason Congenital Ichthyosis Hypnosis Cured severe case of 16yr old male Mistaken C.I. for Acne Vulgaris Could not repeat successful treatment Bennedetti & the Turin Study

31. Behavioural Responses to Diagnoses Hedonism Put life in order Premature grieving Sick Role Illness Behaviour Over-sensitivity to symptoms Premature death ADAPTIVE COPING Talk about it Planning Changes MALADAPTIVE COPING Drink Eat Substance use

32. Hierarchy of Needs GROWTH NEEDS HOMEOSTATIC NEEDS Self actualisation (personal growth and fulfilment) Esteem (self and others) Belonging (group membership, affection, companionship) Security (safety, stability, continuity) Bodily needs (food, drink, safety) Maslow 1954

33. 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

34. 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

35. 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?

36. Accident Neurosis • Failure to improve with treatment until compensation issue settled • Accident must occur in circumstances with potential for compensation payment • 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

37. 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

38. 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 • work • military duty

39. Secondary Gain Pre-disposition • Non-economic motivation? • Loneliness • Difficulty expressing emotional pain • Previous history of attention seeking when ill • Depression • Anxiety

40. 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

41. 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

42. 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 months not working • Return to Work • Longer off work = Less likely to return to work Waddell, 1994

43. Conclusion • 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.