1. Quick question: What do illness representations consist of?

2. Medical Psychology Lecture 17.02.2011. The Psychological Process of Becoming Ill

3. Symptom perception ► Illness is recognized because of the presence of symptoms, either physical or mental ► People respond to symptoms in a variety of ways including - dismissing, - ignoring, denying, - and/or maximizing their symptoms

4. Common symptoms in primary care (Mayou and Farmer, 2002)

5. Prevalence of non-specific symptoms (Heyworth & McCaul, 2001) 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

6. The challenge of communication

7. Factors influencing symptom perception Selective internal attention ► Selective internal attention Tedious & un-stimulating environment ► Tedious & un-stimulating environment Stressful environment ► Stressful environment Learned behaviours ► Learned behaviours Comparisons ► Comparisons Attributions ► Attributions Responses from ► Responses from the environment Negative affectivity ► Negative affectivity Self-blame ► Self-blame Pessimism ► Pessimism

8. Role of expectations An experiment ► Participants’ fingers on vibrating sandpaper –Group 1: expect pain –Group 2: expect pleasant sensation ► Dependent variable –Participants rated the pleasantness or painfulness of the sandpaper experience (Anderson and Pennebaker, 1980)

9. Symptoms and diagnosis ► The asymmetrical relationship between symptoms and the diagnostic label: –People with symptoms seek a diagnostic label –People given a diagnosis seek symptoms

10. Symptom recognition ► Patient recognition of a symptom depends on the cognitive representations that the patient has of the symptom ► Health professionals themselves may be very aware of physical symptoms and this may contribute to professional stress

11. Symptom reporting ► Factors that influence symptom reporting: –Number and persistence of symptoms –Extent of social and physical disability –Identification of the symptom –Perceived severity of the symptoms –Symptom change

12. Perceptual process of illness Internal Process ► Internal Process “Do I notice internal changes?” “Should I interpret them negatively?” “Should I think they are important?” External processes ► External processes “Do I notice external sources?” “What should I believe about it?” “What should I do about it?”

13. Attribution dimensions ► Internal vs. external (e.g., “my getting sick was due to me not looking after myself” versus “my getting sick was due to a virus”) ► Stable vs. unstable (e.g., “I am always prone to getting sick” versus “I am sick because of this incident”) ► Global vs. specific (e.g., “my getting sick influences other areas of my life” versus “my getting sick only influences this specific aspect of my life”) ► Controllable vs. uncontrollable (e.g., “my getting sick was controllable by me” versus “my getting sick was uncontrollable by me”)

14. Accuracy of symptom perception ► Individual differences: –There are differences in what people can tolerate –Differ in how much attention is paid to internal states –Internally focused people overestimate bodily changes and experience slower recovery

15. The „cough” study Portions of movie pre-rated for interestingness. Number of coughs at each 30 sec. portion. The role of attention Fewer coughs at more interesting moments. Correlation of coughs to interestingness = -.57. Can external cues distract people from internal reflex? J. Pennebaker

16. Medical students’ disease ► Studying symptoms leads to greater focus on one’s own symptoms (e.g., of fatigue) that then get interpreted as indicative if disease. More than 2/3 of them come to believe, incorrectly, that they have contracted one of these diseases at one time or another.

17. Stress and mood factors ► Background stress is associated with greater reports of symptoms (people under stress have more nonspecific symptoms which they misinterpret) ► Mood - positive mood associated with fewer symptom reports than negative mood. (negative mood can recall illness-related memories)

18. Expectations ► Prior experience, beliefs, and knowledge influence expectations about symptoms. –Ignore unexpected symptoms and amplify expected symptoms (or vice versa!) –Beliefs about the disease label, causes, time course, and consequences influence symptom awareness and experience.

19. Symptom perception & interpretation (example of dyspnea)

20. Who uses health services? ► Age: young children and elderly use more ► Gender: women use more ► Sociocultural: use increases with income

21. Why people don’t use health services? (1) ► Emotional factors: –fear of serious disease –embarrassment ► Social factors –not wanting to appear weak –lay referral system does not encourage it

22. Why people don’t use health services? (2) ► Fear of iatrogenic conditions resulting from a practitioner’s error or as a normal side effect of treatment. ► Not trusting practitioners –Worry about confidentiality –Worry about discriminatory practices

23. Delay in seeking help Heart attack survivors in Glasgow: ► Only 25% had called for help when the symptoms started, and 60 per cent waited four hours before calling. ► 12% of the patients waited a full day before seeking help. (MacReady, 2000)

24. Gain of illness Disability may hold advantages! ► Financial / Environmental Benefits, equipment, accommodation ► Support, care and attention From family, friends / carers ► Excuse for avoidance E.g of unwanted sexual attentions ► Social mystique or importance Having a ‘rare condition’

25. Healthcare websites for „worried well” ► People use search engines to find medical info –75% don’t verify quality (validity, date, etc.) ► Problem: Search engines for diagnostic reasoning –Link to pages with alarming content –More written about serious than benign explanations

26. „Cyberchondria” Unfounded escalation of concerns about common symptomology based on review of search results and literature online  Query search engine for [headache]  Review results  Browse Web pages  Query for [brain tumor] – Medical anxiety  Query for [caffeine withdrawal] (White and Horvitz, 2008) headache brain tumor caffeine withdrawal

27. Delay as a 3 stages process ► 1. appraisal delay - the time it takes for a person to interpret their symptoms as a sign of illness ► 2. illness delay - the time it takes between realising that you are ill and deciding to seek medical advice ► 3. utilisation delay - the time it takes between deciding to go, and turning up at the surgery.

28. Motivation Phase Volition Phase Behavior Intentions Self-Efficacy Outcomeexpectancies RiskAwareness Self-Efficacy ActionPlanning Health Action Process Approach: A 2-Layer Model (Schwarzer, 1992) pre-intentional intentionalactional