ILLNESS PERCEPTION Theory, Assessment and Application Workshop for

ILLNESS PERCEPTION Theory, Assessment and Application Workshop for NZ Psychology Society Wellington, 20th April 2012 John Weinman Health Psychology Section, Institute of Psychiatry, King’s College London.

RESPONSE TO ILLNESS HUGE VARIATION between patients. SOME – cope well & illness may have relatively little impact ( benefit finding) OTHERS – major problems & cope in ways which may exacerbate illness outcome WHY? - Not severity or type of illness - ?Due to patient’s perception of illness

Leventhal’s self-regulation model ‘Illness’ Representation Illness or Health Threat Emotional Response Coping procedure Coping procedure Appraisal Appraisal

Leventhal’s self-regulation model IF-THEN RULES ‘Illness’ Representation Coping procedure Appraisal Stimulus Health Threat Emotional Response Coping procedure Appraisal

Beliefs about illness CORE BELIEFS CORE BELIEFS IDENTITY What is this? IDENTITY What is this? CAUSE What caused this? CAUSE What caused this? TIMELINE How long will it last? TIMELINE How long will it last? CONSEQUENCES What will happen as a CONSEQUENCES result ofWhat this?will happen as a result of this? CURE / CONTROL What will make it better? CURE / CONTROL What will make it better? How to assess these beliefs?

Assessing Illness Perceptions Interviews ( e.g Leventhal et al) Questionnaires - IPQ (Weinman et al 1996) - IPQ-R (Moss Morris, 2002) - BIPQ (Broadbent et al, 2006) Questionnaire cognitive interviewing Drawings

IPQ website http://www.uib.no/ipq/

Patients drawings

ILLNESS PERCEPTION PSYCHOSOCIAL OUTCOMES Quality of life and adjustment Mood Functioning Return to work Adherence to treatment *Psychology & Health, 2003, vol.18, No.2, pp141-184

ILLNESS PERCEPTION PHYSICAL OUTCOMES Pain & Symptoms MI; Whiplash Disease development / recurrence MI; IBS Wound healing post-op; burns; foot/leg ulcers Mortality ESRD *

ILLNESS PERCEPTION OUTCOME STUDIES Meta-analysis of 57 data sets (*Hagger & Orbell, 2003) shows consistent links between illness perception, coping and outcome. Methodological problems re. duration of illness, timing of assessments, study design etc. Myocardial infarction (MI) as a model *Psychology & Health, 2003, vol.18, No.2, pp141-184

RECOVERY FROM MI Medical Advances – less deaths in acute stage Less success in the functional recovery of MI survivors , in terms of : Return to Work Social & Physical Functioning Rehabilitation Attendance Continuing Chest Pain ( effects on QL)

ROLE OF BELIEFS IN MI RECOVERY Previous work on attributions (eg Affleck et al, 1987), self-efficacy (DeBusk et al, 1994) etc. Recent Illness Perception based work shows that different BASELINE dimensions predict different recovery outcomes : – Lower cure/control less Rehab attendance. (Petrie et al, 1996; Cooper et al, 1999) – Higher consequences slower Return to Work more chronic timeline (Petrie et al, 1996) – Causal beliefs health behaviour change (Weinman et al, 2000)

TASK Read description of post-MI patient Write brief answers to the questions at the end using your understanding of the CSSRM Work in groups to pool the answers and prepare a brief presentation

SINCE ILLNESS REPRESENTATIONS (3 days after MI) CLEARLY PREDICT MI OUTCOME :Can an early intervention which modifies illness representations result improved recovery? Petrie, KJ, Cameron, LD, Ellis, CJ, Buick, D & Weinman, J. (2002) Changing illness perceptions after myocardial infarction : an early intervention randomised controlled trail. Psychosomatic Medicine, 64, 580-586.

Design of Heart Attack Recovery Project Interventio n N 31 Hospital Home IP Sessions 3 & 6/12 First time MI patients 70 IPQ etc IPQ etc Standard care Control N 34 Rehab Nurse RTW Rehab Function Complian ce

The intervention (3 x 30 mins sessions) NB – sessions broadly equivalent but depend on individual’s baseline IPQ) Session 1 Brief outline of nature of MI and symptoms Confirm and explore patients perceptions of MI Broaden causal model (starting from stress) – to include role of lifestyle in CHD (underlying MI)

Session 2 Start from causal model to focus on developing plan for reducing risk factors and increasing control beliefs Challenge negative consequences and timeline beliefs. Agree personalised recovery action plan

Session 3 Review action plan Discuss recovery symptoms; concerns re. Medication and hazards of using symptoms as guide for medication adherence. Address concerns re. return home.

Rehabilitation attendance, angina pain reports and return to work at 6 weeks 80 70 60 50 40 control intervention 30 20 10 0 rehab angina rtw-6 weeks

Intervention results Illness perceptions change in response to the intervention in expected ways Relationship with outcome variables is encouraging BUT Does it work for all patients -too cognitive? No sig. effects on medication adherence.

EFFECTS OF NA ON MI INTERVENTION Used data from MI intervention study NA (PANAS) median split for exp. & control group HYPOTHESIS :NA will be associated with poorer response to intervention because the intervention inhibits emotion regulation through its emphasis on problem focused coping. Cameron, Petrie, Ellis & Weinman (2005) Psychol. & Health,

NA and Rehab Attendance 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Intervention Standard Low NA High NA

NA and SIP Disability score 120 100 80 Intervention Standard 60 40 20 0 Low NA High NA

NA and Exercise (times per week) 6 5 4 Intervention Standard 3 2 1 0 Low NA High NA

Extending the self-regulation model

Self-regulation and treatment decisions: extending Leventhal’s self-regulatory model Treatment Representation ‘Illness’ Representation Coping procedure Appraisal Stimulus Health Threat Emotional Response Emotional response to Treatment Coping procedure Appraisal

SPECIFIC BELIEFS Views about prescribed medication Necessity Concerns Beliefs about necessity of prescribed medication for maintaining health Arising from beliefs about potential negative effects

CURRENT WORK More longitudinal studies with clinical outcomes (e.g. Chilcott, 2010) Intervention studies Illness perceptions in carers Illness perceptions in people with mental health problems. Illness perceptions in response to health threats (eg genetic and other health risks)) Illness perceptions in health care professionals.

CONCLUSIONS SRM provides a rich and complex framework for investigating responses to illness, treatment and health threats in patients across a wide range of conditions Now considerable scope for:- further methodological developments - further research to investigate all the of the SRM. components To improve our understanding of how patients respond to illness and treatment.