1. Health Psychology Section, Institute of Psychiatry,
ILLNESS PERCEPTION Theory, Assessment and Application Workshop for NZ Psychology Society Wellington, 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. Leventhal’s self-regulation model
Illness or
Health
Threat
‘Illness’
Representation
Appraisal
Coping
procedure
Emotional
Response
Coping
procedure
Appraisal

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

5. Beliefs about illness How to assess these beliefs? 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?
Health psychology studies have shown that when faced with a health threat (e.g. experiencing symptoms or receiving a medical diagnosis) people try to ‘make sense of it’ by answers five basic questions:
What is it?, How long will it last?, What caused it? How will it/has it affected me?, Can it be controlled or cured?
People form a mental model or representation of the illness which is made up of their answers to these questions and is strongly influenced by their experience of symptoms. They are more likely to follow health advice (e.g. to take medication) if it makes ‘common sense’ in the light of their own representation of the illness.
Lets look at it from the patients’ perspective. Before getting a diagnosis of hypertension , the average person’s experience of illness is an acute one. You feel unwell, you take action (e.g. take a medicine), the symptoms go away, you feel better, you stop taking the action. (Few people continue to take paracetamol after the headache has gone).
Research with hypertensive patients has shown that many develop a model of their illness, which differs from the medical view. In one study, many patients conceptualised their illness as an acute problem linked to stress (‘high-tension’). This influenced the action they took in dealing with it . They were significantly more likely to drop out of treatment or tended to use their anti-hypertensive medication intermittently, in response to perceived symptoms of stress such as headache or flushing, rather than taking it regularly as prescribed. This action, although mistaken from the medical view, is an understandable, logical response to mistaken beliefs about the nature of hypertension.
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

8. Patients drawings

9. ILLNESS PERCEPTION PSYCHOSOCIAL OUTCOMES
Quality of life and adjustment
Mood
Functioning
Return to work
Adherence to treatment
*Psychology & Health, 2003, vol.18, No.2, pp

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

11. ILLNESS PERCEPTION OUTCOME 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, pp

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,

16. Design of Heart Attack Recovery Project
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 BUT
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. NA and Rehab Attendance
0.5 1
1.5 2
2.5 3
3.5 4
4.5 5
Low NA
High NA
Intervention
Standard

26. NA and SIP Disability score

27. NA and Exercise (times per week)

28. Extending the self-regulation model

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

30. Views about prescribed medication
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.