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 DualismMind / Body Divide Rene Descartes' Biopsychosocial Unification popular in last 10-15 years

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

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

8. Mental States & Physical Well-being “Triggering” Hypothesis Chinese # 4Phillips et al. 2001 World cup 1998Carroll et al. 2002 Stressful Events and Breast CancerChen et al. 1995 Scottish Heart Attack DeathsEvans 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 CortisolGlucocorticoids 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 AnxietyDepressionTensionSleeping problems Apathy ApprehensionAlienationResentment Confidence AggressionWithdrawalRestlessness Indecision Worry Concentration Tired

12. Common Chronic Ill-Health Complaints Low Back Pain Low Back Pain Carpal Tunnel Syndrome Carpal Tunnel Syndrome Cumulative Trauma DisordersFORMS OF Cumulative Trauma DisordersFORMS OF TendonytisCHRONIC PAIN TendonytisCHRONIC PAIN Repetitive Strain Injury& FATIGUE Repetitive Strain Injury& FATIGUE Fibromyalgia Fibromyalgia Irritable Bowel Syndrome Irritable Bowel Syndrome Chronic Fatigue 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 Work Environment EnvironmentChemicalsStressToxinsVirusAllergies Traumatic injury Traumatic injury Anatomy / Ergonomic 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 Somatization1. Rationalisation for psychosocial problems 2. Coping mechanism 3. Becomes a way of life Fibromyalgia Multiple Chemical SensitivityDysautonomia Reactive HypoglycemiaIrritable 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 DateSymptoms ReferralInvestigationOutcome 1980 (18)Abdominal painGP --> surgical OPAppendicectomyNormal 1983 (21)PregnancyGP --> obs and gynae Termination (boyfriend in prison)OP 1985-7Bloating, abdominal GP --> Gastro andAll tests normalIBS diagnosis (23-25)blackouts (divorce)neurology OPunexplained syncope 1989 (27)Pelvic painGP --> obs and gynaeSterilisedPain persists for 2 years (wants sterilisation)OP 1991 (29)FatigueGP --> infectiousNothing abnormalDiagnosis of ME by patient diseases unitand self help group 1993 (31)Aching musclesGP --> rheumatologyMild cervical Pain clinic - Tryptizol clinicspondylosis 1995 (34)Chest pain, breathlessA&E --> chest clinicNothing abnormalRefer to psychiatric services (child truanting)poss hyperventilation

21. Case Summary of a Depressed Patient ? NO! DateSymptoms Referral Feb 2004Back PainGP – referred to physiotherapy Mar 2004Sciatica?Physiotherapy twice a week Apr 2004Symptoms continueSees private Osteopath Apr 2004Symptoms continue Discontinues Physiotherapy Apr 2004Symptoms continueBumps into GP in supermarket – GP refers for MRI May 2004Symptoms continueMRI scan shows left-side, disc 5 slipped Jun 2004Symptoms continueReferred to orthopaedic surgeon. Surgery required Female36 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 SymptomPrevalence % Stuffy nose46.2 Headaches33.0 Tiredness29.8 Cough25.9 Itchy eyes24.7 Sore throat22.4 Skin rash12.0 Wheezing10.1 Respiratory10.0 Nausea9.0 Diarrhoea5.7 Vomiting4.0 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. OVER FOCUS ON SYMPTOMS ComparisonsAttributionsResponsesBlamePessimism Factors Influencing Symptom Development Selective Internal Attention Tedious & un-stimulating environment Tedious & un-stimulating environment Little communication Stressful environment Little communication Stressful environment Learned behaviours “Negative Affectivity” Learned behaviours “Negative Affectivity”

25. Factors Influencing Symptom Development Selective External Attention  Heightened concern about risk involuntary involuntary uncontrolled uncontrolled lack of information lack of information dreaded consequences 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 ComparisonsAttributionsResponsesBlamePessimism

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-workersLoners Psychology important in how symptoms are perceived and reacted to

28. Chronic Fatigue Syndrome Non-specific subjective symptom Non-specific subjective symptom Overlap with psychiatric diagnoses (66%) Overlap with psychiatric diagnoses (66%) Chronic long-term inability and tiredness Chronic long-term inability and tiredness Both Physical and Psychological fatigue Both Physical and Psychological fatigue Most prevalent in white, middle class thirtysomething females Most prevalent in white, middle class thirtysomething females Fatigue dominates activities and life 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 Big pills better than smaller pills Red pills better than blue Red pills better than blue 4 pills better than 2 4 pills better than 2 30% of pop. 30% of pop. Sham surgery vs arthroscopy for osteoarthritis 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 PlanningChanges MALADAPTIVE COPING DrinkEat Substance use

32. Hierarchy of Needs GROWTHNEEDSHOMEOSTATICNEEDS Belonging (group membership, affection, companionship) Self actualisation (personal growth and fulfilment) Esteem (self and others) Bodily needs (food, drink, safety) Security (safety, stability, continuity) 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-healthdepression, 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 Failure to improve with treatment until compensation issue settled Accident must occur in circumstances with potential for compensation payment Accident must occur in circumstances with potential for compensation payment Inverse relationship to severity of injury - Accident neurosis rare in cases of severe injury Inverse relationship to severity of injury - Accident neurosis rare in cases of severe injury Low socio-economic status favors accident neurosis Low socio-economic status favors accident neurosis Complete recovery common following settlement of compensation issue Complete recovery common following settlement of compensation issue ? ? ? ? ? ? Miller, 1961

37. Abnormal Illness Behaviour after Compensable Injury Mendelson, 1984 Accident neurosisAccident victim syndrome Aftermath neurosisAmerican disease Attitudinal pathosisBarristogenic illness Compensatory hysteriaCompensationitis Compensation neurosisFright neurosis Functional overlayGreek disease Greenback neurosisInvalid syndrome Justice neurosisPerceptual augmenter Post accident anxiety syndromePensionitis Postaccident fibromyalgia Post-traumatic syndrome Profit neurosisPsychogenic invalidism Railway spineSecondary gain neurosis Traumatic hysteria Symptom magnification syndrome Traumatic neurastheniaTraumatic neurosis Triggered neurosisUnconscious malingering Vertebral neurosisWharfie’s back Whiplash neurosis

38. Secondary Gain Pre-disposition What is the Motivation? What is the Motivation? Desire for attention Desire for attention Punish spouse / others Punish spouse / others Solve life’s problems Solve life’s problems Cry for help Cry for help Diversion from work Diversion from work Socially approved task avoidance Socially approved task avoidance sex with spouse work military duty

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

40. Secondary Gain Pre-disposition Who are the Potential Claimants? Who are the Potential Claimants? Military patients nearing severance Military patients nearing severance Workers under retirement age Workers under retirement age Low job satisfaction Low job satisfaction Workers soon to be made redundant Workers soon to be made redundant Members of support groups Members of support groups

41. Abnormal Illness Behaviour (Care Eliciting Behaviour) Disability disproportionate to detectable illness Disability disproportionate to detectable illness Constant search for disease validation Constant search for disease validation Relentless pursuit of “enlightened doctors” Relentless pursuit of “enlightened doctors” Appeals to doctor’s responsibility Appeals to doctor’s responsibility Attitude of personal vulnerability and entitlement to care by others Attitude of personal vulnerability and entitlement to care by others Avoidance of health roles due to lack of skills and fear of failure Avoidance of health roles due to lack of skills and fear of failure Adoption of sick role due to rewards from family, friends, physicians Adoption of sick role due to rewards from family, friends, physicians Behaviours which sustain the sick role - complaints, demands, threats Behaviours which sustain the sick role - complaints, demands, threats Blackwell, 1987

42. Return to Work Longer off work = Less likely to return to work Longer off work = Less likely to return to work % returning to work 10 20 30 40 50 60 70 80 90 100 months not working <1 2 4 6 8 10 12 14 16 18 20 22 24 Waddell, 1994

43. Conclusion Somatization influenced by numerous factors Somatization influenced by numerous factors Sick role resolves intrapsychic, interpersonal or social problems Sick role resolves intrapsychic, interpersonal or social problems Fashionable diagnoses have considerable overlap Fashionable diagnoses have considerable overlap Occupational and Environmental syndromes Occupational and Environmental syndromes Non specific and subjective complaints Non specific and subjective complaints Underlying depression, anxiety, and history of unexplained complaints Underlying depression, anxiety, and history of unexplained complaints Mass communication + support groups = fashionable way to solve distress Mass communication + support groups = fashionable way to solve distress Behavioural aspects of chronic patients – blame, refusal, over-reporting etc. Behavioural aspects of chronic patients – blame, refusal, over-reporting etc.