Symptom Perception Slides PDF

Genes, Behaviour and Environment 4MBBS103 Neuroscience, Behaviour and Social Science Symptom Perception Symptoms: any variation in a physiological or emotional state that is interpreted as unusual or harmful. Symptoms are remarkably common. Yet, relatively few seek medical advice. Instead, man...

Genes, Behaviour and Environment 4MBBS103 Neuroscience, Behaviour and Social Science Symptom Perception Symptoms: any variation in a physiological or emotional state that is interpreted as unusual or harmful. Symptoms are remarkably common. Yet, relatively few seek medical advice. Instead, many ignore the symptoms, treat themselves or rely on a natural recovery. (Petrie, 2014, Elnegaard 2015) Feeling tired/run down Headach es Joint pain McAteer, 2011  Learning objectives 1. Describe the psychosocial factors that can explain variation in symptom reporting and health care utilisation i. Attention ii. Attribution (Top-down processing) iii. Emotions 2. Explain how symptom perception may delay help seeking and its implications for health outcomes 3. Identify psychological factors that increase health care utilisation 4. Recognise how psychological interventions can support people in accurately detecting their symptoms Objective 1 Describe the psychosocial factors that can explain variation in symptom reporting and health care utilisation i. Attention ii. Attribution (Top-down processing) iii. Emotions Sensation and Perception: Recap Sensation (Biological): The functioning of our sensory system. The process of stimulating our sensory receptors. Perception (Cognitive): Interpretation of sensory input, organising the input, and assigning meaning. Symptom Perception Symptom reports do not correlate with objective tests or markers (Pennebaker, 1984). Biomedical model: assumes a one-to-one ratio between physiological change and symptom reports. Psychological factors can account for the nonlinear relationship. Fearful appraisal of pain is associated with less tolerance of pain, increased reporting of pain and less engagement in distraction tasks (Van Damme et al., 2008) Attention The degree of attention we pay to our internal bodily states influences our symptom perception. We have to process multiple external and internal sensory inputs. Our attentional capacity is limited (e.g. sensory store). Competition of cues (Pennebaker, 2000). Recognising changes in our internal states relative to competing cues in our environment. Stimuli Sensory Short- Long- Response store Term term Memory memory Attention Attention - capacity Unstimulating environments= less competition placed on our limited attentional capacity = more likely to detect changes in our internal states. Unemployed report more symptoms than employed (Pennebaker, 2012). People living alone report more symptoms than those cohabitating (Pennebaker, 2012). Music as a distraction in exercise (Silva 2016) Kerri Strug’s Gold Medal Vault 1996 Olympics Attentional bias Higher levels of pain associated with higher levels of attentional bias Experience of pain associated with attention and bodily threat monitoring, as well as cancer recurrence Symptoms | Attribution  Case example b https://www.youtube.com/watch?v=gwd-wLdIHjs Case example a  Case example b https://www.youtube.com/watch?v=gwd-wLdIHjs Attribution Schemas are structures in our long-term memory that allow us to store information into meaningful categories. Schemas are influenced by past learning and new assimilated knowledge. People will have sets of beliefs, or schemas, about: which illnesses they are vulnerable to which symptoms indicate potential illness which illnesses compromise a threat to their overall health Attribution contd. Medical student disease (Broadbent & Petrie, 2007/18). Up to 1/3 medical students worry they have an illness they have just studied. Patients are lay diagnosticians - make common-sense interpretations of their symptoms based on their lay illness schemas. Symptoms can be attributed to somatic causes, psychological causes or environmental causes. Research suggests people have different attribution styles. Flint water crisis Flint water crisis Flint water of 2015 believed to have led to increased special education enrollment in Flint children HOWEVER the incidence of elevated blood lead in Flint children (≥ 5µg/dL) was always at least 47% lower than in the control city of Detroit (p <.0001) There was no association between special education enrolment and lead exposure Media predicted brain damage -> negative psychological effects Nocebo effect could have created self-fulfilling prophecy Attribution | Illness SchemaIllness beliefs are not necessarily accurate or coherent. The development of illness schemas (Leventhal, 1980): Prior illness experience Interactions with peers & media Interactions with medical professionals Attribution | Illness perceptions More on this in the next lecture Illness schemas consist of five domains: Symptoms associated with a specific illness Identity are given a label (e.g. rash = meningitis?) Understanding of aetiology (e.g. contact Cause with virus?) Illness Timeline perceptions Expected duration (e.g. 1-2 weeks?) Consequences Impact of symptoms (e.g. cannot go into work, pain) Steps needed to manage symptoms (e.g. Cure and Control see Doctor)  Impact of illness perceptions Illness perceptions related to self-care (e.g., nonadherence) Illness perceptions related to clinical outcomes (e.g., disease progression to end-stage, serum phosphorus, potassium, hemoglobin, and albumin; cardiovascular complications; mortality;)  Impact of illness perceptions Illness perceptions related to self-care (e.g., nonadherence) Baseline perceptions predicted Illness perceptions related to poorer outcomes controlling clinical outcomes (e.g., disease for baseline severity (disability, pain progression to end-stage, serum phosphorus, severity, impaired functioning, QOL) potassium, hemoglobin, and albumin; cardiovascular complications; mortality;) Attribution Schema symmetry rule ILLNESS LABEL DECTECTION OF SYMPTOMS Emotions Negative emotions include: Depression Anxiety Negative Affect (distress) Studies consistently show a link between negative emotions and symptom reporting Why? Emotions contd. Physiological arousal occurs in response to negative emotions Arousal symptoms attributed to physical illness (label mismatch) When feel threatened/anxious we are alerted to threats to our health (hypervigilant) Negative emotions can cause negative interpretations of our environment Catastrophic beliefs about benign symptoms Emotions – Case study in Asthma Emotions – Asthma treatment Beta2 – agonists reliever symptoms. No anti-inflammatory effects (e.g. do not target cause) Daily use of reliever medication of more than 3-4 times per day = poorly controlled asthma Measured: mood, symptom reports, use of reliever, and peak flow Emotions – Asthma study results Average daily reliever use in the 8 study: Mean = 3.26, SD = 2.13 7 6 5 31% used reliever more than 4 4 times a day. 3 2 1 Use of reliever was not correlated 0 with objective clinical need (e.g. 0 1 2 3 4 5 6 7 >7 peak flow reading). average daily reliever use Emotions – Key asthma symptoms Emotions – Patient reported symptoms Upset Stomach 17 Nausea 17 Sore Throat 31 Body Tension 31 Pounding Heart 33 Shakiness 36 Headache 38 Flushed Face 41 Loss strength 48 Fatigue 62 Tight Chest 81 Breathless 85 Wheezy 91 0 10 20 30 40 50 60 70 80 90 100 Percentage of subjects attributing symptom to asthma Emotions – a worked example Summary of results: Reliever use was unrelated to peak flow (measure of lung function) Symptoms associated with anxiety were attributed to asthma by a third of patients Daily levels of distress were positively related to number of uses of reliever High distress was related to tendency to label a wide range of symptoms as signs of Relationship between key variables: asthma. Objective 2 Explain how symptom perception may delay help seeking and its implications for health outcomes In the last 6 months, have you…? Noticed a symptom, felt unwell, stayed in bed due to illness? Gone to the doctor or other health care professional? Biomedical approach? Quantity and severity of symptoms explain only a small amount of variance of help-seeking (Scott 2008) Delayed help seeking Experiencing symptoms is common. 2-3 per week (Broadbent & Petrie, 2007). Over a two week period the following symptoms are commonly reported across the general population (Petrie and Pennebaker, 2004): Headache (38%) Aches and Pains (29%) Poor sleep (16%) What influences a person’s decision to seek health care? Reasons for delays in help seeking Delays can occur at the following three stages (Safer et al., 1979): 1) Appraisal Delay – Am I ill? Time taken to attribute a symptom to an illness 2) Illness Delay – Do I need medical attention? Time taken to reach a decision about whether treatment is needed. 3) Utilisation Delay – I’m going to get treatment. Time taken between symptom detection and presenting to a health care service Appraisal delay Influenced by: Early symptoms of a heart attack Attention pain, fullness, and/or squeezing sensation of - E.g. do not perceive symptom/ interpret as the chest nonthreatening jaw pain, toothache, headache shortness of breath nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort Misattribution sweating - Symptoms interpreted incorrectly heartburn and/or indigestion arm pain (more commonly the left arm) upper back pain general malaise (vague feeling of illness) Illness and Utilisation delay Evidence shows that women suffering a heart attack can take up to twice as long to get to hospital as men (Walsh et al., 2004) Factors influencing illness delay: Use of heuristics: age/menopause/stress A systematic review of factors “ E.g. I’m just getting old.” associated with delays in medical and psychological help-seeking among men Factors influencing utilisation delay found the most prominent barriers were disinclination to - Dispositional factors express emotions/concerns - Social pressure about health, embarrassment, - No clear action plan/implementation intention anxiety & fear, and poor - Fear-Avoidance communication with health- care professionals (Yousaf et al., 2015). Qualitative synthesis (Smith, Pope, & Botha, 2005) Recognition & interpretation of symptoms Vague / mild symptoms, Belief will go away, No awareness of cancer symptoms / risk Fear of ‘embarrassment’ Considered a time-waster or neurotic, Beliefs about help-seeking, Sensitive / sexual area Fear of ‘cancer’, Serious & painful symptoms, fatal, incurable, Previous negative experience, Unpleasant treatment or side effects The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms Meechan et al., (2003) Studied the relationship between symptoms and psychological factors to delay in seeking medical care for breast symptoms Demographics NOT related to patient delay. No significant association between delay time and fear of cancer treatment. Breast lump ~ SHORTER patient delay. Higher levels of emotional response ~ SHORTER delay.  Delays in help seeking and outcomes Poorer prognosis: Cancer : patients who delay help seeking > 3 months have lower survival (Richards et al., 1999) Heart Attack : Efficacy of thrombolytic drugs on morbidity and mortality = dependent on administration within first few hours of symptom onset (Horne et al. 2000) Stroke : Early admission to hospital on detection of stroke symptoms = decreased morbidity (Carroll et al. 2003) Objective 3 Identify psychological factors that increase health care utilisation Reasons for increased help seeking Frequent attenders commonly present with medically unexplained persistent physical symptoms, that do not have a clear physiological cause (‘medically unexplained symptoms’) (Reid et al, 2001) A number of factors associated with presentation: (Deary et al., 2007) Personality traits – neuroticism/perfectionism Significant life events Combination of infections and other health problems and associated distress Effective treatment for medically unexplained symptoms = CBT (White et al., 2011) More on this next year Objective 4 Recognise how psychological interventions can support people in accurately detecting their symptoms  Public health campaign intervention Campaign targets: Appraisal delay FAS –Symptom appraisal Navigation delay T - Action plan Limitations? Targets only those with a help seeking disposition (Dracup et al., 2006)  Tailored help-seeking interventions How do we target those who need it? Need for more tailoring (De Nooijer et al., 2002), Personalised mail-outs/social media campaigns Address during face – to – face consultations Need to address the following points: Appraisal delay: Improve a patients illness schema for target condition (e.g. symptom to label matching) Illness delay: Address heuristics used (e.g. is patient relying on an “old-age schema” Utilisation delay: Address barriers to attendance: Clear action plan put in place “if-then” rule. Fearful – emphasise the support options/care plans available Involve a family member where necessary Summary Degree to which symptoms are detected is influenced by: Attentional resources given to our internal states Activation of illness schemas in response to either: Detection of symptom Learning about a new illness label Emotional states Delays in help seeking can occur across three stages Appraisal delay Illness delay Utilisation delay Negative emotions can account for increased health care utilisation Psychological interventions to increase help seeking need to address factors that influence: Appraisal delay Illness delay Utilisation delay  A patient requests an urgent GP appointment worried about sharp pains in their lower back. They first noticed this symptom yesterday and when they started monitoring the pain it became more intense. After examination there is no clear pathological origin. What Quick factor is most likely to contribute to the patient’s experience of pain? quiz 1Q A: Hypochondria B: Unstimulating environment C: Psychological distress D: Symptom focusing E: Personality characteristics  A patient requests an urgent GP appointment worried about sharp pains in their lower back. They first noticed this symptom yesterday and when they started monitoring the pain it became more intense. After examination there is no clear pathological origin. What Quick factor is most likely to contribute to the patient’s experience of pain? quiz 1A A: Hypochondria B: Unstimulating environment C: Psychological distress D: Symptom focusing E: Personality characteristics  Why is negative affectivity (mood/state) important to consider with regard to symptom perception? A: Because those with negative Quick affectivity report symptoms more frequently quiz 2Q B: Because those with negative affectivity are more introspective C: Because those with negative affectivity attend negatively to symptoms D: All of the above  Why is negative affectivity (mood/state) important to consider with regard to symptom perception? A: Because those with negative Quick affectivity report symptoms more frequently quiz 2A B: Because those with negative affectivity are more introspective C: Because those with negative affectivity attend negatively to symptoms D: All of the above Reading Ayers, S., & De Visser, R. (2017). Psychology for medicine and healthcare. Sage. Ogden, J. (2012). Health psychology: A textbook: A textbook. McGraw-Hill Education (UK). Useful references Ayers, S., & De Visser, R. (2017). Psychology for medicine and healthcare. Sage. Pennebaker, J. W. (2012). The psychology of physical symptoms. Springer Science & Business Media. Pennebaker, J. W. (2020). Accuracy of symptom perception. In Handbook of Psychology and Health, Volume IV (pp. 189-217). Routledge. McAteer, A. (2011). Symptoms in the Community: Prevalence, management and preferences for care in a UK working-age population (Doctoral dissertation, University of Aberdeen). Chalder, T., Patel, M., James, K., Hotopf, M., Frank, P., Watts, K.,... & Garrood, T. (2019). Persistent physical symptoms reduction intervention: a system change and evaluation in secondary care (PRINCE secondary)–a CBT- based transdiagnostic approach: study protocol for a randomised controlled trial. BMC psychiatry, 19(1), 307. Yon K, Habermann S,Rosenthal J, et al. Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop. BMJ Open 2017;7:e014720. doi:10.1136/ bmjopen-2016-014720 Deary, V., Chalder, T., & Sharpe, M. (2007). The cognitive behavioural model of medically unexplained symptoms: a theoretical and empirical review. Clinical psychology review, 27(7), 781-797.