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2. Psychological Factors in Ill-Health
Dr. Craig Jackson
Senior Lecturer in Health Psychology
Faculty of Health
BCU
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 years

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

7. Rise of the worker as a “psychological entity”
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 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
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. 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
Historical complaints
Railway Spine
Neurasthenia
Combat Syndrome
Symptom Prevalence %
Stuffy nose 46.2
Headaches 33.0
Tiredness 29.8
Cough
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

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. Psychology important in how symptoms are perceived and reacted to
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 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
4 pills better than 2
30% of pop.
Sham surgery vs arthroscopy for osteoarthritis
Patient’s “knowledge” of their treatment causes bias e.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
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. Return to Work Longer off work = Less likely to return to work
% returning to work
months not working
<
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.