Psychological aspects of medical practice

Question 1

What is the difference between illness and disease?

Answer 1

1. Illness is SUBJECTIVE perception of change in structure or function of the body that gives rise to concern
2. Disease is OBJECTIVELY observable abnormality in bodily structure or function

It is often assumed these are the same thing
It is often assumed that disease causes illness

Question 2

What is the first example of how illness and disease are different things?

Answer 2

Illness without disease - MUS

- experiences severe chest pain but extensive investigation finds no disease - what is wrong?

Question 3

In secondary care, how often is illness unexplained by disease?

Answer 3

In 1/3 of cases

Question 4

What is the overall prevalence of MUS in the clinic?

Answer 4

10% symptoms without any disease

30% symptoms inadequately explained by disease

Question 5

MUS-related diagnoses

Answer 5

PSYCHIATRY: ICD-10 somatoform disorders, DSM-V somatic symptom disorders
MEDICINE: functional syndromes such as IBS, chronic fatigue syndrome, pain syndromes
NOT A DIAGNOSIS: malinering (pretending to be ill)

Question 6

Give a second example of how disease is not the same as illness

Answer 6

‘Disproportionate’ illness in people with disease - ‘comorbidity’
- had cancer now successfully treated, still feels extremely weak and tired - what is wrong?

Question 7

What may these corbidities be associated with?

Answer 7

Depression

This psychological disorder occurs commonly in cancer patients -in about 10%, and can lead to persistence of symptoms of unwellness well into remission.

Importantly, it has been shown that depression significantly reduces the already lower mean health score of people with chronic conditions, and depression comorbid with a physical condition is worse on that scale than two chronic physical conditions (Moussavi et al, 2007).

Question 8

Therefore, how should illness be explained?

Answer 8

From a biosocial rather than simply biological point of view with:

• psychological factors
• biological factors (including disease)
• social factors

Question 9

Describe biological factors

Answer 9

• Disease is important – but not the only cause of illness
• Effect of behavioural change – e.g. bed rest
• Physiological changes associated with pain and depression

Question 10

Describe psychological factors

Answer 10

• Fears – e.g. ‘my dad died when he got chest pain’
• Low or anxious mood – e.g. exaggerated concern about having a brain tumour
• Focusing of attention on symptoms – e.g. I always ‘listen to my body’

Question 11

Describe social factors

Answer 11

• Common beliefs in society – e.g. ‘all chest pain is dangerous’
• What other people say – ‘my son had that; he died’
• What doctors say – ‘it is probably nothing…but it might just be a fatal disease’

Question 12

Describe how iatrogenesis can also be a social factor

Answer 12

This is important to understand when trying to avoid iatrogenesis, which can be not only biological (e.g. side effects of treatments), but also psychological (e.g. doctor’s advice causing anxiety about symptoms) and social (e.g. the medicalisation of harmless aches and pains)

Iatrogenesis (doctor caused harm)
• Physical e.g. effects of unnecessary medical treatment
• Psychological e.g. doctors advice causing anxiety about symptoms
• Social e.g. the medicalization of aches and pains

Question 13

How can be summarise the multiple factors that cause illness?

Answer 13

Biopsychosocial formulation of illness
vs predisposing - precipitating and perpetuating

Treatments target the perpetuating factors