PSYCHOSOMATIC MEDICINE AND THE

PSYCHOLOGY OF THE SOMATICLY ILL -

practical

Magdalena Lazarewicz

Dept. of Medical Psychology,
Warsaw Medical University

[e-mail]

Psychological
consequences of
somatic disease

Past…



Main Schools of Psychology



Psychology + Medicine Disciplines



Stress



Situational risk factors in somatic disease



Personality risk factors in somatic disease



Type A behaviour as a risk factor in
somatic disease

Literature concerning topics discussed

so far

Wrzesniewski, K., Skuza, B. (2004).

Psychosomatic Medicine and The
Psychology of the somatically ill. Selected
issues. A Textbook for Medical Students.
Introduction & PART I, pp. 1-38.

Ogden, J. (2001). Chapter 10. Stress. In:

Health Psychology: A textbook. pp. 231-254.

Future…



Psychological consequences of somatic
disease



Psychological Aspects of Treatment of the
Somatic Patient



Selected Aspects of Psychosomatic Diagnosis

• Role-playing +

Essay

• Test

Today…



Psychological consequences of somatic
disease

–

Effects of disease on human functioning

–

Illness Cognitions (IC)

–

Attitudes Towards Illness (ATI)

Indirect effects of disease on

human functioning 1



How does being ill influence your behaviour?



How does it influence your everyday life?



What is the worst thing about being ill? What do you

concentrate on

(e.g. symptoms, diagnosis, not being able to

achieve your goals, relaxing and watching TV)?



How do you usually feel when you’re ill?



Have you ever been to the hospital as a patient? How

did you feel?

Indirect effects of disease on human functioning

2

–

somatic disease as a stressful situation

Discomforts of
illness

•Pain

•Breathlessness

•Itchiness

•Chronic dizziness

•Vomiting

•

Modified hierarchy of

incoming information

•

Impairment of cognitive

processes

•

Impairment of affective

processes

•

Decrease in general

mental efficiency (memory
functions, attention and
learning ability)

•

Emotional disturbances

(depression, irritability,
impulsiveness, anxiety)

•

Activity impairment

(conscious and organized
goal-directed behaviour)

often

conceptualis

ed as a

disease

itself

Limitations

(mainly in

chronic diesese)

•

Difficulties with walking and eating

•

Diet

•

Difficulties with personal hygiene

and dressing

•

Giving up old habits: smoking,

coffee, strong tea, alcohol

Hospitalizati
on

Disruption of famiy
and profesional
roles

Indirect effects of disease on

human functioning 3 -

HOSPITALIZATION

„I’M GOING TO THE HOSPITAL!!!”

„I’M VERY VERY SICK!”

Indirect effects of disease on

human functioning 4 –

HOSPITALIZATION



Interruption of ongoing social relationships



New environment – new people:

–

Hospital staff (discipline, obey orders)

–

Other patients (different habits, interests, customs as

well as their suffering and severity of illness)



Specific diagnostic and therapeutic procedures

–

Undressing in public for physical examination

–

Routine collections of blood samples

–

Invasive diagnostic procedures

Indirect effects of disease on

human functioning 5 –

HOSPITALIZATION



Hospital schedule / rules / regulations

(e.g.

early mornings)



Depersonalization

(PERSON as a „CASE from room 12”,

„kidney stone case”, „interesting case”)



Being treated like a child



Sensory deprivation

Indirect effects of disease on

human functioning 6



Disruption of family

–

Disruption of the previous rhythm of family life

–

New roles

–

Dependence



Disruption of professional roles

–

Economic deterioration

–

Lowering social status

–

Giving up goals and ambitions

Possible responses to the

situation of being ill

How the patient responds to the situation of

being ill will depend not only on objective

physical and psychosocial threat but also on the

subjective appraisal of the situation and

personal concepts of health and illness.



Illness may be viewed (appraised) as:

–

Obstacle

–

Loss

(e.g. invalidism)

–

Relief

(e.g. illnes as an excuse)

–

Benefit

(material

<e.g. pensions, reparations>

or psychological

<extra care and support>

advantages)

–

Value

(e.g. deeply religious people – metaphysical value

ascribed to suffering)

Personal concepts of health and

illness

What
does it
mean to
be
healthy?

What
does it
mean to
be ill?

What does it mean to be

healthy?

Health

as „a state of complete physical, mental

and social well being”

WHO (1947)

Illness Cognitions 1 - qualitative

studies

Positive definitions

(energetic,

plenty of exercise, feeling fit, eating

the right things, being the correct

weight, having a good life / marriage)

Negative definitions

(don’t get

coughs and colds, only in bed once,

rarely go to the doctor and have

check-ups – nothing wrong)

Calnan (1987)

Physiological/physical

(e.g. good

condition, have energy)

Psychological

(e.g. happy, energetic)

Behavioural

(e.g. eat, sleep properly)

Future consequences

(e.g. live

longer)

The absence of…

(e.g. not sick, no

disease, no symptoms)

Lau (1995)

Lay people answered the question „what does it mean to be
healthy?”

What does it mean to be

sick?



Not feeling normal

(e.g. „I don’t feel right”)



Specific symptoms

(e.g. „physiological / psychological)



Specific illness

(e.g. cancer, cold, depression)



Consequences of illness

(e.g. how long the symptoms

last)



The absence of health

(e.g. not being healthy)

Lau (1995)

Illness Cognitions 3



„a patient’s own implicit common sense

beliefs about their illness”

(Leventhal et al.. 1980,

1997)



IC provide patients with a framework or a

scheme for:

–

coping with their illness

–

understanding their illness

–

telling them what to look out for if they are

becoming ill

Illness Cognitions 4

Five cognitive dimensions of these beliefs:



Identity

(label given to the illness and the symptoms experienced,

e.g. I have a cold <the diagnosis> with a runny nose <the symptoms>)



The perceived cause of the illness

(biological e.g. virus, or

psychosocial e.g. stress, smoking)



Time line

(how long the illness will last, whether it is short-term or

chronic)



Consequences

(physical e.g. pain, lack of mobility, emotional e.g.

loneliness, loss of social contact, a combination of factors, e.g. „My cold

will prevent me from playing football, which will prevent me from

seeing my friends”)



Curability and controllability

(e.g. „If I rest, my pain will go

away”, „If I get medicine from my doctor my cold will go away”)

(Leventhal et al.. 1980,
1997)

Illness Cognitions 5

Summing up:

Individuals may show consistant beliefs

about illness that can be used to make

sense of their illness and help their

understanding of any developing symptoms

(Ogden, 2000)

IC have been incorporated into a model of illness

behaviour to examine the relationship between an

individual’s cognitive representation of their illness

and their subsequent coping behaviour.

Why are IC’s important?

Stage 1:
Interpretation

• symptom perception
• social messages

- > Deviation from
norm

Representation
of health threat

•Identity
•Cause
•Consequences
•Time line
•Cure / control

Stage 2: COPING

• Approach coping
•Avoidance coping

Stage 3: Appraisal

• Was my coping
strategy effective?

Emotional
response to
health threat

•Fear
•Anxiety
•Depression

Leventhal’s self-regulatory model of illness

behaviour (Ogden J. (2000) Health
Psychology. A textbook. Buckingham: Open
University Press, s. 48)

Imagine you discover you have a strange

rush and increased temperature…



What do you think?



How do you feel?



What do you do?

Attitudes Towards Illness

(ATI) 1

Attitudes Towards Illness

(ATI) 2



The patients approach to the fact that
he/she has fallen ill and to the situation
of treatment and rehabilitation



Three components of ATI:

–

Cognitive

–

Affective

–

Motivational

ATI 3 – Cognitive Component



Information about causes and nature of the

illness, the principles of treatment and prevention



Ways of selecting, organizing and classifying

incoming information



Conceptualization of the self and future (family

life, career)



Expectations (towards medical staff, family

members etc)

ATI 4 – Affective Component



Emotions experienced with respect to the
illness, treatment and hospitalization

–

Anxiety

–

Fear

–

Hope

–

Anger

–

Harm/Loss etc

–

Denial

ATI 5 – Motivational

Component



Striving / determination



Intentions



Dispositions towards specific behaviour
related to illness and health

ATI 6 - modification

Cognitive

Component

„What is it?”

„What’s wrong with
me?”

„I feel just like my
Aunt Petunia – It
must be kidney
stone!”

Affective

Component

e.g. anxiety

Motivational
Component

„What can I do?”

„Shell I do
anything?”

ATI 7. Components – the

empirical indices



Cognitive component:

–

Range and adequacy of the patient’s
information concerning his/her illness, its
causes and treatment

–

Adequacy of the patient’s conceptualization
of his/her future professional capacities and
performance of family roles

–

Type of patient’s expectations concerning
the medical staff and family

ATI 8. Components – the

empirical indices



Affective component

–

Observation of the patients behaviour and

vegetative-somatic symptoms

–

voice, face expressions, topic he/she doesn’t want to

talk about

–

eyes!



Motivational component

–

How he/she behaves at the onset of symptoms and

during treatment and rehabilitation?

–

Plans for future?

Attitudes Towards Illness 9

Disease

ATI (cognition+ emotions +
motivation)

Ambivalen

t attitude

(mixed)

Attitude

favourable for

the treatment

and

rehabilitation

process

Attitude unfavourable for

the course of treatment

and rehabilitation process

dominant

ANXIETY

compone

nt

dominant LACK

OF ACCEPTANCE

of the diagnosis

and medical

recommendations

OK, but what do I do to get to

know my patients true ATI or IC?

Questionnaire



Illness Perception Questionnaire (Weinman et al.. 1996)



ATI Questionnaire (Wrzesniewski) – polish version

Interview



Climate of security and understanding



Interview the patient in a skilled way

(and that’s what we’ll

practice soon)



LISTEN to the patient!



Remamber the 3 components of ATI and their empirical

indicies.

Case study



Determinants of the myocardial infarction (bio-

psycho-social risk factors).



The patient’s responses to illness and treatment



ATI components.



Implications for the doctor in charge of the case

and for the patients family.

Literature



This week reading:

–

Basic textbook, pages 39-52

–

Illness Perception Questionnaire at:

http://www.uib.no/ipq/



Reading for the next week:

–

Gorney, M., Bristow, J. (2003). Effective

physician communication skills. From:

http://www.thedoctors.com/risk/general/communication/J42

38.asp