The following lecture has been approved for University Undergraduate Students

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. BioPsychoSocial Model The CFS Example Prof Craig Jackson Division of Psychology BCU

3. Traditional model of Disease Development Pathogen Disease(pathology) Modifiers Class Health Lifestyle Genes Individual susceptibility

4. Biopsychosocial model of Illness Hazard Illness (well-being) Psychosocial Factors Attitudes Behaviour Quality of Life

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

6. Mystery Health Problems ?

7. Mystery Health Problems ?

8. Mystery Health Problems ?

9. Patient Pathways Time between start #1 and end #1 ? Time between end #1 and start #2 ? Symptoms ? start Ill-Health Present to A&E Present to GP Treatment end Advise end Investigation end Treatment end Management

10. Detection of Chronic Patients Vital due to increased risk of iatrogenic harm Potential chronic patients could be identified by: 1. Size of paper records 2. Attendance records Frequency Regularity Concordance 3. Hospital referral rates 4. Observation by staff Medical Nursing Clerical staff – pattern spotting software

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

12. Assessment of Chronic Patients Once suspected of CMFSS….. Identify 1 practitioner as the patient’s principle carer Systematic assessment: case notes reviewed patient seen for 1 or more extended consultations Case notes: often extensive useful information within compile a summary of case notes evaluate accuracy of previously listed complaints evaluate accuracy of previous diagnoses include key investigations,personal & family circumstances Appointment: current problems & history explored encouraged to talkabout symptoms, associations, concerns and state patient & practitioner to finally agree a problem list

13. Non-Specific Symptoms Often missed in assessment

14. 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 Modern day complaints Multiple Chemical Sensitivity Chronic Fatigue Syndrome Sick Building Syndrome Gulf War Syndrome Low-level Chemical Exposure Electrical Sensitivity Stress-related ill-health Historical complaints Railway Spine Neurasthenia Combat Syndrome

15. 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

16. Case Summary of a Chronic Patient #2 Date Symptoms Referral 1985 (16) Anorexia Secure unit teenagers 1986 (17) Suicide attempt Secure unit teenagers 1986 (17) Self-harm Secure unit CAMHS (A levels) Psychiatry 1987-9 Self-harm. Anorexia UMC (18-20) (university) 1990 Working as au pair GP monitoring & anti-depressants (21) (left university) 1993 Self-harm Secure unit admission (24) (joined commune) ECT Female. Abused by father from 6 to 15. Moved to boarding school, then to grandparents Insomnia - Feeling worthless – Guilt - Recurrent morbid thought - Bleak views - Self harm – Suicide Ideation Scholastically bright. University. Dropped out. Tried own business. Business failed. Admin working.

17. Case Summary of a Chronic Patient #3 Date Symptoms Referral 1985 (17) Pervasive low mood GP monitors 1986 (18) Suicide attempt Child Psychiatry 1986 (18) Self-harm Psychiatry 1987 (19) Anorexia. Self-harm Psychiatry – CPN 1988 (20) Suicide attempt Psychiatry – CPN (failed romance) 1989 (21) Suicide attempt Psychiatry – CPN (failed romance) 1990 (22) Fertility worries Psychiatry – CPN – fertility counselling 1990 (22) Working in office GP monitoring & anti-depressants 1992 (24) Self-harm MH unit (open door policy) CPN 1996 (26) Chronic Fatigue MH unit (open door policy) CPN 1998 (28) Fibromyalgia MH unit (open door policy) CPN

18. 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

19. Professional Meddling

20. On Psychiatry . . . Winston Churchill “I am sure it would be sensible to restrict as much as possible the work of these gentlemen, who are capable of doing an immense amount of harm with what may very easily degenerate into charlatanry. The tightest hand should be kept over them, and they should not be allowed to quarter themselves in large numbers among Fighting Services at the public expense.“ On psychiatrists, in a letter to John Anderson, Lord President of the Council (December 1942)

21. 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

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

23. 21st Century Satanic Mills

24. 21st Century Satanic Mills

25. Somatization and Fashionable Diagnoses Somatoform Disorders (DSM III 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

26. Linking Emotions with Physical Symptoms • Patients with physical symptoms arising from psychological distress • Some may not have made the link themselves • “Anxiety causes muscle tension. Muscle tension causes headaches” • Don’t rush patient to understand • Start from their perspective • What do they think is causing physical problems (clues) • Broaden agenda to where problems can be physical and psychological

27. Linking Emotions with Physical Symptoms Which causes which?

28. Modern-Day Patients Patients more involved in their own care than even before The term “consultation” is disappearing Mistrust of Medicine e.g. Shipman, Allit, Meadows cases Less Mysterious and Powerful Change in what is expected from practitioners… …Has changed how practitioners view patients Emphasis on (1) risk reduction (2) public health “Do you know about statistics?” (3) preventative behaviour Some (older patients) still prefer to be told what the treatment will be Skill is in achieving the correct balance for each patient

29. Terminology of Chronic Patients • Invokes many emotions in practitioners: despair • frustration • anger • “Heartsinkers” • “Difficult” • “Fat folders” Inadvisable terms • “Chronic complainers” • “G.O.M.E.R” • Lose faith • Offensive • Complaints • “CMFSS”

30. 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 Can poor QoL Become a predictor of who will suffer in advance?

31. 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

32. The benefits of support groups?

33. The benefits of support groups?

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. Psychological Consequences of Chronic Illness • Back Pain • Distress Money worries - Disablement • Reduced Quality of Life • Delay in seeking help Fear Denial • Depressed / Anxious • Increased somatic complaints Pain Fatigue Breathlessness • Begins bad habit of seeking help too readily • Adjustment Disorder – commonest psychiatric diagnosis • Increased risk of suicide in early stages (of some conditions)

44. Behavioural Yellow Flags of Chronic Ill-Health • Indicative of long term chronicity and disability • Back Pain • Negative attitude – back pain is harmful and disabling • Fear avoidance – stops trying things – disability mindset • Reduced activity • Expects passive treatment to be better than active treatment • Tendency to low morale, depression and social withdrawal • Social / Financial problems

45. Somatization & Sick Role The process by which psychological needs are expressed in physical symptoms: e.g., the expression or conversion into physical symptoms of anxiety, or a wish for material gain associated with a legal action. 1. Auxiliary social support 2. Rationalisation for failure 3. Gratification of nurturance 4. Manipulate interpersonal relations 5. Articulate distress: cry for help 6. Misinterpretation of anxiety / depression symptoms 7. Over-vigilance for significant symptoms 8. Avoids stigma with a physical cause 9. Over-attention reflects learned behaviour 10. Amplification and Negative Affectivity 11. Primary, Secondary and Tertiary gains 12. Unexplained physical symptoms in trauma victims (e.g. abuse)

46. 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.

47. Route of problems? Psych Social or Phys? Chemicals Gasses Dusts Particles Light Heat Noise Vibration Stress Radiation Slips, trips, falls Working hours Ergonomics