The following lecture has been approved for

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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
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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
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Linking Emotions with Physical Symptoms The
good physician treats the disease, but the great
physician treats the person. William
Osler
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Non-Specific Symptoms Often missed in assessment
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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
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Traditional model of Disease Development
Pathogen
Disease (pathology)
Modifiers Lifestyle Individual susceptibility
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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
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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
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Is disease real or is it in the mind?
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Physiological Response to Stress Chronic stress
Acute stress Pituitary Gland, Hypothalamus and
Amygdala Adrenal glands Secrete
hormones Epinephrine Cortisol Glucocorticoi
ds Heart beats faster Arteries widen
Stomach digestion stops Lungs faster
/ shallow Muscles tense
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Damage from Stress Arterial damage Increased
glucocorticosteroids weaken immune
system reduce bone mass reproductive
suppression memory problems Anxiety Depress
ion Tension Sleeping problems Apathy
Apprehension Alienation Resentment Confidence
Aggression Withdrawal Restlessness Indecision
Worry Concentration Tired
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• 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

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• Chronic Patients Attributions of Ill-Health
• Work
• Environment
• Chemicals
• Stress
• Toxins
• Virus
• Allergies
• Traumatic injury
• Anatomy / Ergonomic

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Common Misconceptions about Health
I like money
I like money too
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Exploit someone new today
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Allergies the role of psychology
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Allergies
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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
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Linking Emotions with Physical Symptoms
Which causes which?
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Case Summary of a Chronic Patient
1 Date Symptoms Referral Investigation Outcome
1980 (18) Abdominal pain GP --gt surgical
OP Appendicectomy Normal 1983
(21) Pregnancy GP --gt obs and gynae
Termination (boyfriend in prison) OP 1985-7
Bloating, abdominal GP --gt Gastro and All tests
normal IBS diagnosis (23-25) blackouts
(divorce) neurology OP unexplained
syncope 1989 (27) Pelvic pain GP --gt obs and
gynae Sterilised Pain persists for 2
years (wants sterilisation) OP 1991
(29) Fatigue GP --gt infectious Nothing
abnormal Diagnosis of ME by patient diseases
unit and self help group 1993 (31) Aching
muscles GP --gt rheumatology Mild cervical Pain
clinic - Tryptizol clinic spondylosis 1995
(34) Chest pain, breathless AE --gt chest
clinic Nothing abnormal Refer to psychiatric
services (child truanting) poss
hyperventilation
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• 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
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Prevalence of Non-Specific Symptoms
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• 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?
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OVER FOCUS ON SYMPTOMS Comparisons Attributions Re
sponses Blame Pessimism
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• 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 Re
sponses Blame Pessimism
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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?
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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
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• 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

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• 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

Patients knowledge of their treatment causes
biase.g. Benedetti the Turin study
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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
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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 M
ALADAPTIVE COPING Drink Eat Substance use
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Hierarchy of Needs GROWTH NEEDS HOMEOSTATI
C 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
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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
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Compensation Neurosis Pending litigation Treatme
nt 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 patients convictions With time,
care-eliciting behaviour may remain permanent
Bellamy, 1997
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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?
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• 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
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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 Functiona
l 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 Wharfies
back Whiplash neurosis
Mendelson, 1984
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• Secondary Gain Pre-disposition
• What is the Motivation?
• Desire for attention
• Punish spouse / others
• Solve lifes problems
• Cry for help
• Diversion from work
• Socially approved task avoidance
• sex with spouse
• work
• military duty

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

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• 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

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• Abnormal Illness Behaviour (Care Eliciting
  Behaviour)
• Disability disproportionate to detectable
  illness
• Constant search for disease validation
• Relentless pursuit of enlightened doctors
• Appeals to doctors 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
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• Return to Work
• Longer off work Less likely to return to work

Waddell, 1994
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• 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.