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 cog-

nitive, emotional and behavioural responses induced in every sick

person by all the illness-related information they receive.

3 Main sources of information

1. somatic perceptions

2. the patient's own knowledge of and beliefs about

disease

3. messages from the social environment especially the

doctor's statements

3 Key components of psychosocial reaction

1. meaning of illness

2. emotional responses to illness

3. coping with illness

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, gratifi-

cation 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 hard-

ship. Illness may also help attenuate an inner conflict. Noncom-

pliance 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 indi-

vidual'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 pat-

ient, 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.

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.

COPING WITH ILLNESS

How a patient copes with the illness reflects his or her

habitual tendencies to deal with stressful life events in indivi-

dually 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.

PATIENT'EMOTION

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.

Some patients may be anxiety, anger, hostile, regression or

depression.

Stages of dying

Elizabeth Klubler-Ross (1969) presented five stages of dying.

1. Denial "No, not me"

2. Anger "Why me?" "I'm still alive"

3. Bargaining "Yes, me, but."

4. Depression "Yes, me." "It's very sad."

5. Acceptance "Yes, me."

Now we recognize that these five stages do not occur with predictable regularity.

References

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.

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Voralaksana Theeramoke, M.D.

Department of Psychiatry,

Faculty of Medicine, Ramathibodi Hospital.