Gabriel T ByrneGabriel T Byrne

The Biopsychosocial The Biopsychosocial ApproachApproach

Dr. Craig A. JacksonDr. Craig A. JacksonOccupational PsychologistOccupational Psychologist

Research DirectorHealth Research Consultants

ResearchConsultants.co.uk

Linking Emotions with Physical SymptomsLinking Emotions with Physical Symptoms

““The good physician treats the disease, but The good physician treats the disease, but the great physician treats the person.” the great physician treats the person.”

William Osler William Osler

DualismDualism

“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 180BCMarcus Aurelius 180BC

DualismDualism Mind / Body DivideMind / Body DivideRene Descartes'Rene Descartes'

Biopsychosocial Unification popular in last 10-15 yearsBiopsychosocial Unification popular in last 10-15 years

PathogenPathogen DiseaseDisease (pathology)(pathology)

ModifiersModifiersLifestyleLifestyleIndividual susceptibilityIndividual susceptibility

Traditional model of Disease DevelopmentTraditional model of Disease Development

Dominance of the biopsychosocial modelDominance of the biopsychosocial model

Mainstream in last 15 yearsMainstream in last 15 years

Hazard Hazard

Psychosocial FactorsPsychosocial FactorsAttitudesAttitudesBehaviourBehaviourQuality of LifeQuality of Life

Illness Illness (well-being)(well-being)

Rise of the worker as Rise of the worker as a “psychological a “psychological entity”entity”

Mental States & Physical Well-beingMental States & Physical Well-being

““Triggering” HypothesisTriggering” Hypothesis

Chinese # 4Chinese # 4 Phillips Phillips et al.et al. 2001 2001

World cup 1998World cup 1998 Carroll Carroll et al.et al. 2002 2002

Stressful Events and Breast CancerStressful Events and Breast Cancer Chen Chen et al.et al. 1995 1995

Scottish Heart Attack DeathsScottish Heart Attack Deaths Evans Evans et al.et al. 2002 2002

The Baskerville EffectThe Baskerville Effect

Physiological Response to StressPhysiological Response to Stress

Chronic stress & Acute stressChronic stress & Acute stress

Pituitary Gland, Hypothalamus and AmygdalaPituitary Gland, Hypothalamus and Amygdala

Adrenal glandsAdrenal glands == Secrete hormonesSecrete hormonesEpinephrineEpinephrine Cortisol Cortisol GlucocorticoidsGlucocorticoids

HeartHeart == beats fasterbeats fasterArteriesArteries == widenwidenStomach Stomach == digestion stopsdigestion stopsLungsLungs == faster / shallowfaster / shallowMusclesMuscles == tensetense

Damage from StressDamage from Stress

Arterial damageArterial damage

Increased glucocorticosteroids Increased glucocorticosteroids weaken immune systemweaken immune systemreduce bone massreduce bone massreproductive suppressionreproductive suppressionmemory problemsmemory problems

AnxietyAnxiety DepressionDepression TensionTension Sleeping problems Sleeping problems

Apathy Apathy ApprehensionApprehension AlienationAlienation ResentmentResentment

Confidence Confidence AggressionAggression WithdrawalWithdrawal RestlessnessRestlessness

IndecisionIndecision Worry Worry Concentration Concentration Tired Tired

Common Chronic Ill-Health ComplaintsCommon Chronic Ill-Health Complaints

• Low Back PainLow Back Pain• Carpal Tunnel SyndromeCarpal Tunnel Syndrome• Cumulative Trauma DisordersCumulative Trauma Disorders FORMS OF FORMS OF • TendonytisTendonytis CHRONIC PAINCHRONIC PAIN• Repetitive Strain InjuryRepetitive Strain Injury & FATIGUE& FATIGUE• FibromyalgiaFibromyalgia• Irritable Bowel SyndromeIrritable Bowel Syndrome• Chronic FatigueChronic Fatigue

Those with heightened symptoms choose attributions to match concepts of Those with heightened symptoms choose attributions to match concepts of

what is currently acceptable in medicinewhat is currently acceptable in medicine

External cause for illness preferred - patient becomes a helpless victimExternal cause for illness preferred - patient becomes a helpless victim

Case Summary of a Depressed Patient ? NO!Case Summary of a Depressed Patient ? NO!

Date Symptoms Referral

Feb 2004Feb 2004 Back PainBack Pain GP – referred to physiotherapyGP – referred to physiotherapy

Mar 2004Mar 2004 Sciatica?Sciatica? Physiotherapy twice a weekPhysiotherapy twice a week

Apr 2004Apr 2004 Symptoms continueSymptoms continue Sees private OsteopathSees private Osteopath

Apr 2004Apr 2004 Symptoms continue Symptoms continue Discontinues PhysiotherapyDiscontinues Physiotherapy

Apr 2004Apr 2004 Symptoms continueSymptoms continue Bumps into GP in supermarket – GP refers for MRIBumps into GP in supermarket – GP refers for MRI

May 2004May 2004 Symptoms continueSymptoms continue MRI scan shows left-side, disc 5 slippedMRI scan shows left-side, disc 5 slipped

Jun 2004Jun 2004 Symptoms continueSymptoms continue Referred to orthopaedic surgeon.Referred to orthopaedic surgeon.Surgery requiredSurgery required

FemaleFemale

3636

Academic ResearcherAcademic Researcher

Unhappy in jobUnhappy in job

Received written warnings about time-keeping and performanceReceived written warnings about time-keeping and performance

Prevalence of Non-Specific SymptomsPrevalence of Non-Specific Symptoms

Modern day complaintsModern day complaints

Multiple Chemical SensitivityMultiple Chemical SensitivityChronic Fatigue SyndromeChronic Fatigue SyndromeSick Building SyndromeSick Building SyndromeGulf War SyndromeGulf War SyndromeLow-level Chemical ExposureLow-level Chemical ExposureElectrical SensitivityElectrical Sensitivity

Historical complaintsHistorical complaints

Railway SpineRailway SpineNeurastheniaNeurastheniaCombat SyndromeCombat Syndrome

SymptomSymptom Prevalence % Prevalence %

Stuffy noseStuffy nose 46.246.2HeadachesHeadaches 33.033.0TirednessTiredness 29.829.8CoughCough 25.925.9Itchy eyesItchy eyes 24.724.7Sore throatSore throat 22.422.4Skin rashSkin rash 12.012.0WheezingWheezing 10.110.1RespiratoryRespiratory 10.010.0NauseaNausea 9.09.0DiarrhoeaDiarrhoea 5.75.7VomitingVomiting 4.04.0

Heyworth & McCaul, 2001Heyworth & McCaul, 2001

Psychological / Perceptual Process of IllnessPsychological / Perceptual Process of Illness

Internal ProcessesInternal Processes

““Do I notice internal changes?”Do I notice internal changes?”

““Should I interpret them negatively?”Should I interpret them negatively?”

“ “Should I think they are important?”Should I think they are important?”

External processesExternal processes

“ “Do I notice external sources?”Do I notice external sources?”

“ “What should I believe about it?”What should I believe about it?”

“ “What should I do about it?”What should I do about it?”

MENTAL SCHEMAMENTAL SCHEMA

Internal representation of the world Internal representation of the world

(knowledge, attitudes, beliefs)(knowledge, attitudes, beliefs)

What do we believe about health?What do we believe about health?

What do we believe affects health?What do we believe affects health?

OVER FOCUS ON SYMPTOMSOVER FOCUS ON SYMPTOMS

ComparisonsComparisons

AttributionsAttributions

ResponsesResponses

BlameBlame

PessimismPessimism

Factors Influencing Symptom DevelopmentFactors Influencing Symptom Development

Selective Internal AttentionSelective Internal Attention

Tedious & un-stimulating environmentTedious & un-stimulating environment

Little communication Little communication Stressful environment Stressful environment

Learned behavioursLearned behaviours “Negative Affectivity” “Negative Affectivity”

Factors Influencing Symptom DevelopmentFactors Influencing Symptom Development

Selective External AttentionSelective External Attention

Heightened concern about risk Heightened concern about risk involuntaryinvoluntary uncontrolleduncontrolled lack of informationlack of information dreaded consequencesdreaded consequences

Mistrust of government / industryMistrust of government / industry Attitudes about medicineAttitudes about medicine Political agendaPolitical agenda Legal agendaLegal agenda Social and political climateSocial and political climate

Media and pressure group activityMedia and pressure group activity

OVER FOCUS ON SYMPTOMSOVER FOCUS ON SYMPTOMS

ComparisonsComparisons

AttributionsAttributions

ResponsesResponses

BlameBlame

PessimismPessimism

Irritable Bowel SyndromeIrritable Bowel Syndrome

Common digestive disorderCommon digestive disorder

Functional syndromeFunctional syndrome

Traumatic life events, Personality Traumatic life events, Personality disorders, Stress, Anxiety, Depression disorders, Stress, Anxiety, Depression SomatizationSomatization

Not a psychological disorderNot a psychological disorder

• Night-workersNight-workers

• LonersLoners

• Psychology important in how symptoms are perceived and reacted toPsychology important in how symptoms are perceived and reacted to

Chronic Fatigue SyndromeChronic 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 tirednessChronic long-term inability and tiredness

• Both Physical and Psychological fatigueBoth Physical and Psychological fatigue

• Most prevalent in white, middle class thirtysomething femalesMost prevalent in white, middle class thirtysomething females

• Fatigue dominates activities and lifeFatigue dominates activities and life

Placebo & NoceboPlacebo & Nocebo

In approx. 30% of pop.In approx. 30% of pop.Subjected to more clinical trialsSubjected to more clinical trials than any other medicamentthan any other medicamentNearly always does better thanNearly always does better than anticipatedanticipatedThe range of susceptible conditions seems limitlessThe range of susceptible conditions seems limitlessDoes not always occurDoes not always occurPresent in subjective and objective outcomesPresent in subjective and objective outcomesNegative outcomes can occur (Nocebo effect)Negative outcomes can occur (Nocebo effect)

PlaceboPlaceboBig pills better than smaller pillsBig pills better than smaller pillsRed pills better than blueRed pills better than blue4 pills better than 24 pills better than 2 30% of pop.30% of pop.

Treatment Bias of HealthcareTreatment Bias of Healthcare

A.A. MasonA.A. Mason

Congenital IchthyosisCongenital Ichthyosis

HypnosisHypnosis

Cured severe case of 16yr old maleCured severe case of 16yr old male

Mistaken C.I. for Acne VulgarisMistaken C.I. for Acne Vulgaris

Could not repeat successful treatmentCould not repeat successful treatment

Bennedetti & the Turin StudyBennedetti & the Turin Study

Behavioural Responses to DiagnosesBehavioural Responses to Diagnoses

HedonismHedonism

Put life in orderPut life in order

Premature grieving Premature grieving

Sick RoleSick Role

Illness BehaviourIllness Behaviour

Over-sensitivity to symptomsOver-sensitivity to symptoms

Premature deathPremature death

ADAPTIVE COPINGADAPTIVE COPINGTalk about itTalk about itPlanningPlanningChangesChanges

MALADAPTIVE COPINGMALADAPTIVE COPINGDrinkDrinkEatEatSubstance useSubstance use

Is disease real or is it in the mind?Is disease real or is it in the mind?