MIND AND BODY GO TOGETHER, MOVE TOGETHER, GET WELL TOGETHER AND GET SICK TOGETHER
The Healer within : The new medicine of mind and body American Board of Internal Medicine requires internists to be able to “recognize and be attentive the patient’s emotional needs and recognize their potential influence on the symptoms and course of the illness.”
Psychosocial reaction to illness refers to a set of cognitive, emotional and behavioural responses induced in every sick person by all the illness-related information they receive. 3 Main sources of information
the patient’s own knowledge of and beliefs about disease
messages from the social environment especially the doctor’s statements
3 Key components of psychosocial reaction
1. MEANING OF ILLNESS
“Meaning” connotes the subjective significance for the patient of all the illness-related information that impinges on him or her.
4 Major categories of meaning
1. Challenge or threat: The usual behviour responses are flight, fight and withdrawal.
2. Loss: “Loss” mean both concrete and symbolic. Concrete losses involve body parts and functions. Symbolic ones concern personally significant values and needs, such as security, pleasure, gratification and self-esteem. Abnormal emotional response to loss is grief. The coping behaviours associated with grief may include withdrawal, helpless attention-seeking, hostile confrontations, noncompliance, substance abuse and suicide.
3. Gain or relief: For some patients being ill signifies, consciously or not, a welcome respite from the demands and responsibilities of social roles or from a difficult interpersonal situation or economic hardship. Illness may also help attenuate an inner conflict. Noncompliance with treatment is common in such patients, some may manifest conversion symptoms and generally cling to the sick role. Doctors tend to resent such patients : they make them feel ineffectual and helpless.
4. Punishment: The patient may regard the illness as either a just or an unjust punishment. The emotion may range from depression and shame to anger or elation. If the patient views the illness as a just punishment, then he or she may surrender to it passively or even eagerly. He or she often make no attempt to get well or may even die despite effective treatment. By contrast, if he or she views as unjust punishment, it likely to be anger and bitterness. Hostile, litigious or even paranoid behaviour may result. Hope, optimism and occasionally even elation may result when he or she views it as just punishment.
4 Determinants of meaning
1. Intrapersonal factors include personality, past experience and emotional state at the onset of illness. The individual’s emotional state at the time of illness onset is likely to influence the evolved meaning of illness. Augmenters are also more likely to view illness as a threat or loss than are the reducers, whose easier to disregard or even deny.
2. Interpersonal factors include (1) support from family members and (2) a good doctor-patient relationship. These factors protect one against adverse effects of stressful life events.
3. Illness-related factors Generally the greater personal value of the lost or disorders body part or function is for the patient, the more likely it is that the illness is seen as a grave threat or loss.
4. Sociocultural and economic factors include beliefs about, attitudes toward illness and social stigmata. If the economic consequences of illness lead to a lowering of the patient’s standard of living or to abandonment of life goals, then the illness is a strongly negative appraisal.
2. EMOTIONAL RESPONSES TO ILLNESS
The commonest emotions are anxiety, grief, depression, shame, guilt and anger. They vary in quality, intensity, duration, physiologic concomitants and appropriateness to the objective aspects of the illness and situation. These emotional responses may elicit maladaptive defense mechanisms, such as denial or regression, which may make the patient noncompliant, excessively dependent or drug/alcohol abuse. What matters in practice is the impact of the evoked emotions on the patient’s illness and distress as well as on his or her behaviour.
Thus, emotional responses have an important effect on the patient’s manner of coping mechanism and ultimately on its course and outcome.
3. COPING WITH ILLNESS
How a patient copes with the illness reflects his or her habitual tendencies to deal with stressful life events in individually characteristic ways.
2 Coping styles (in cognitive sphere)
1. Minimization implies a tendency to habitually play down the personal significance and emotional impact of a stressful event.
2. Vigilant focusing is a tendency to respond with a heigh level of attention and concern that may range from purposeful and rational to exaggerated and obsessive.
3 Coping styles (in behavioural sphere)
1. Tackling means actively dealing with stressful events and illness.
2. Capitulating is to submit to such events and being passive or overly dependent.
3. Avoiding means attempting to get away from event by withdrawing or fleeing.
The dominant coping styles are reflected in his or her communication and action. The timing of seeking medical advice and the manner and language with which the patient deals with the sick role are all overt manifestations of coping styles and related strategies.
The patient-doctor relationship is one that usually color the relationship. Most patient are able to accept dependency on their doctor. In general, patients with unresolved dependency conflicts may be divided into two groups : overt dependency and independent focade which was the reaction formation from fear of it.
Overt dependency Independent facade
excessive dependency on parents – often only child – childhood illness – overconcern by insecure # frustrated dependency needs – large family – lack of love – rejecting parents # fearful of helplessness – rejection as child # ashamed of helplessness – pushed to independent by parents
Some patients may be anxiety, anger, hostile, regression or depression.
Stages of dying
Elizabeth Klubler-Ross (1969) presented five stages of dying.
Denial “No, not me”
Anger “Why me?” “I’m still alive”
Bargaining “Yes, me, but.”
Depression “Yes, me.” “It’s very sad.”
Acceptance “Yes, me.”
Now we recognize that these five stages do not occur with predictable regularity.
Author: Voralaksana Theeramoke, M.D., Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital.
1. Martin MJ. Psychiatry and medicine. In: Kaplan HI, Sadock BJ, Freedman AM, eds. Comprehensive textbook of psychiatry. Baltimore : Williams & Wilkins, 1975:2030-41.
2. Milano MR, Kornfeld DS. Thanatology. In: Kaplan HI, Sadock BJ, Freedman AM, eds. Comprehensive textbook of psychiatry. Baltimore : Williams & Wilkins, 1975:2042-55.
3. Lipowski ZJ. Psychosocial reaction to physical illness. Can Med Assoc J 1983; 128:1069-72.
4. Lipowski AJ. Psychosocial aspects of disease. Ann Intern Med 1969; 71(6) : 1197-206.