Lecture 5: Symptom perception and illness

There are many factors which influence symptoms and symptom perception. An experiment is done to show this. Factors like temperature, background information and cognition, colours of the objects and environment are examples. The experiment consists of two parts. During the first part of the experiment, the scientist said touching the ice water with chemical substances in the tank would increase pain and during the second part of the experiment, the scientist said the water tank was filled with pain reducing substance. This kind of information and the different appearances of the substances in the tanks can influence one’s perception of their symptoms and stated level of pain.

Complaints

About two third of the general practitioner’s come across patients’ complaints which they have no explanation for. Somatically unexplained physicial symptoms are quite common in general practice. About 20-50% of the complaints are somatic. This means that no objective physical distortions or disrupted bodily processes can explain the complaints. These complaints often disappear spontaneously, usually after reassurance by the general practitioner.

The Symptom Perception Model describes how psychological factors influence symptom perception. One of these factors is negative affectivity. Negative affectivity is the tendency to experience negative mood, feel distressed and feel critical about oneself, and to view the self and the world in generally negative terms. It is related to neuroticism. Symptom perception can lead to long-term activation and reactivation of symptom related cognitive networks, like paying attention to and earlier detection of somatosensory signals, interpretation of ambiguous internal and external information in terms of somatosensory symptoms and attribution of signals as somatosensory symptoms. There is a bidirectional relationship between the attention paid to the symptoms and the perception of those symptoms. An overview of this model is shown on slide 12.

Mood also influences symptoms and symptom perception. Negative mood results in more pain and itch reports in healthy subjects. Anger and sadness enhance pain in response to experimental pain exposure in healthy controls and chronic pain in patients with fibromyalgia.

Pennebaker once did an experiment in which he investigated the role of somatic attribution in symptom perception. According to this research, misattribution of physical arousal may occur due to certain information, e.g. information about catching a common cold or not. Subjects who received information about common cold reported more symptoms of a common cold.

Placebo and nocebo effects also play a role in symptom perception. Placebo and nocebo effects are (un)favourable treatment effects not due to treatment mechanisms itself. The effects are induced by expectations of improvement or worsening symptoms. An example is decreasing pain when only seeing a pain killer. Once an experiment was done in which they concluded that pain killers may not work if the person doesn’t know he or she is receiving the pain killer. Other examples of placebo and nocebo effects are a decrease of willingness to take medication after reading an information leaflet, an increase in their occurrence after being warned about side effects of certain medication and reporting more (cognitive) side effects after information about possible side effects of chemo cures for cancer.

The placebo effect and the role of learning

Learning principles like verbal suggestions and conditioning influence symptom perception and therefore placebo effects. When using verbal suggestions, short term effects are more likely to occur, particularly in nocebo. When using conditioning techniques, more stable long-term effects will occur and those techniques will have effect on the physiological response system, since it influences implicit processes.

Verbal suggestions and conditioning techniques can be manipulated in experiments. For example, when saying “Green light signals a decrease itch intensity”, subjects are likely to report no change in itch intensity when seeing green light.

Placebo and nocebo responses have neurobiological effects, are acquired or learned and both conscious (e.g. (verbal) suggestions) and automatic (e.g. conditioning) learning mechanisms play a role.

There are many ethical questions to be asked when it comes to using placebo effects, like Should all patients be informed about placebo and nocebo effects when a treatment is prescribed?, Should a doctor or therapist emphasise the positive consequences of a treatment, even if he/she is not convinced about these effects? and Should a doctor or therapist be trained in a good doctor-patient relationship to optimise placebo effects and minimize nocebo effects?. Clinical recommendations are to inform patients about placebo and nocebo effects and to train health professionals in communication about placebo and nocebo effects.

Beneficial effects after information about nocebo effects are decreased health complaints in subjects who experience health complaints ascribed to wind turbines after information about nocebo effects and beneficial effects of expectation-based psychotherapy on recovery in patients undergoing coronary artery bypass graft surgery.

What is medical consultation?

Medical consultation is about reviewing a patient’s medical history and making recommendations to as to care and treatment. It is often done by a specialist with expertise in a particular field of medicine, like a cardiologist, physiatrist or a dermatologist.

As a specialist, it is important to build a trust in care and doctor-patient bond/communication. Evidence for beneficial effects when involving the patient in the interaction and decision-making process has been found. Quality of the medical consultation is determined by:

• Being able to communicate knowledge to the patient
• Achieving a good relationship with the patient
• Establishing the nature of the patient’s medical problem
• Gaining an understanding of the patient’s understanding of their problem
• Engaging the patient in the decision-making process
• Managing time so that the consultation does not appear rushed

The last decades it has grown to be more likely to use a patient-centred approach, rather than using a specialist-centred approach. In a patient-centred approach, the patient and specialist make decisions together, the specialist listens to the patient, the patient actively participates in the conversation, the patient and the specialist inform each other as much as they can with relevant information and by the end of the consult they agree about the decisions being made.

The most preferred communication styles are when a physician makes treatment decision following discussion with the patient, shared decision making and when the patient makes the decision following a discussion with the doctor.

Non-adherence occurs in 3 of 4 patients in medical settings. Other terms for adherence are compliance and concordance. It means attachment or commitment to, for example, treatment. Determinants of adherence are social factors, psychological factors, treatment factors, family dynamics and beliefs about the nature of the illness and its treatment regime. Adherence may be enhanced by using patient-centred approaches and sharing decision making, maximizing satisfaction with the process of treatment, maximizing understanding of condition and its treatment and maximizing memory for information given.

Clinical examples

Imagine you are a health psychologist working at the medical psychology department of a large hospital. The following patient is referred to you:

• Yasmin, a 23 year old woman, suffers from Diabetes Mellitus Type 1 (DM)
• Iraqi refugee, residence permit, works as shop assistant
• Depressed mood, ‘bad’ boyfriends, badly regulated DM
• Wants to take better care of herself and regulate her blood glucose

How would you treat this patient? For example, you can have multiple sessions with her to talk about her, and you can refer her to websites about diabetes self-management.