Cognitive models of illness

Research has highlighted that patients are active in trying to understand their symptoms and illness. Evidence shows that patients create illness representations which provide the basis for coping responses or procedures for dealing with threats to health. (5) Consequently, when an individual experiences an unusual symptom or the provision of a diagnosis from a doctor, the individual will construct his or her own representation which, in turn, will determine the individual's behaviour and other responses such as help-seeking and adherence to treatment. Patients' beliefs about medication, particularly perceptions about necessity and concerns or worries about specific tablets, have a close relationship with treatment adherence. (54)

Research suggests patients cluster their ideas about an illness around five coherent themes or components, which health psychologists have called illness perceptions/55 These provide a framework for patients to make sense of their symptoms, assess health risk, and direct action in the recovery phase. The major cognitive components are as follows.

• Identity: the label of the illness and the symptoms the patient views as being part of the disease.

• Cause: personal ideas about aetiology which may include simple single causes or more complex multiple causal models.

• Time-line: the patient's belief about the likely time course of the illness (e.g. acute, chronic, or episodic).

• Consequences: expected effects and outcome of the illness.

• Cure/control: the patient's beliefs about the extent to which the illness is amenable to cure or control.

These components show logical interrelationships. For example, a strong belief that the illness can be cured or controlled is typically associated with short perceived illness duration and relatively minor consequences.

The theoretical framework for this research is derived from the self-regulatory model developed by Leventhal et al.(55) This model views illness perceptions as critical in guiding the patient's coping efforts to deal with symptoms, illness, and threats to health. It consists of four components: the cognitive representation of the illness, the emotional response to the illness and treatment, the coping directed by the illness representation, and the individual's appraisal of the coping outcome.

In a study of chemotherapy patients/56 researchers noted that patients responded to their illness in terms of implicit theories about the disease and its treatment. Patients with malignant lymphoma appeared to determine the effectiveness of chemotherapy by monitoring the size of their palpable diseased lymph nodes. Patients who experienced a sudden disappearance of the nodes were more distressed than those with a gradual remission. The higher levels of distress in patients with the most rapid remission suggests that patients no longer had a useful method of assessing the effectiveness of treatment, and did not understand having to continue with a toxic treatment when they were 'cured' or had no tangible evidence of disease. The results of this study suggest an implicit model of illness in which symptoms define the presence or absence of disease, and facilitate patients psychological response.

Patient cognitive models of their illness are, by their nature, private. Patients are often reluctant to discuss their beliefs about their illness in medical consultations because they fear being seen as stupid or misinformed. Until recently, assessment of illness perceptions has been by open-ended interviews designed to encourage patients to elaborate their own ideas of the their illness. However, recently a questionnaire has been developed to measure illness perceptions in a variety of illnesses^ and scales have also been developed for specific illnesses such as diabetes and specific beliefs about medication. (58)

The illness perception approach has recently been applied to a number of health conditions. One study has shown patients who have suffered a recent myocardial infarction have clear beliefs about the cause, time-line, consequences, and controllability of their heart condition during the acute phase of their hospital stay. Moreover, these beliefs were associated with attendance at cardiac rehabilitation and later return to work. (59) The self-regulatory model has also now been employed to explain responses to cancer screening,(60) how patients cope with cancer treatment/6!) chronic fatigue syndrome/62) and diabetes.(63) Current research in this area is building on these findings to develop cognitive-behavioural interventions designed to modify dysfunctional illness perceptions and provide better recovery.

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