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Psychological Aspects of Illness
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Emotions
Behaviors
Cognitive States
Psychiatric Disorders
Relevance for Physicians
• Diagnosis
• Treatment
• Screening for Psychiatric Disorders
Role of Psychological Factors in
Diagnosis and Treatment
• History - Symptom Reporting
• Physical Exam
– Blood Drawing
– Other Diagnostic Procedures
• Treatment
– Compliance vs. Non-Compliance
Emotional Responses to Illness
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Anxiety - Fear - Panic
Sadness - Despair - Hopelessness
Irritability - Anger - Rage
Passivity - Helplessness
Relief - Happiness - Mania
Problematic Behaviors in
Response to Illness
• Withdrawal - Social Isolation - School
Refusal
• Oppositional Behavior - Tantrums Aggression
• Head-banging - Self-Mutilation - Suicide
• Attention-Seeking Behaviors
Potential Cognitive Changes in
Physical Illness
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Impairments in Intellectual Functioning
Attentional and Learning Problems
Slowed or Racing Thoughts
Hallucinations and Delusions
Potential Responses to
Chronic Illness
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Denial
Why Me? or Why My Child?
Guilt
Feeling of Being “Different”
Fears of Disfigurement, Disability, Death
Physical Illness as Risk Factor
for Psychiatric Disorder
• Psychiatric Disorders found in 20% or more
of medically ill children
• High Rates of psychiatric disorders in
children with CNS impairments (ie.,
epilepsy, AIDS, Brain Tumors, Head
Injuries)
Approaches to Understanding
Psychological Responses
• Need for Conceptual Framework
• Awareness of Risk and Protective Factors
• Applications to Patient Care
Conceptual Frameworks
• Biopsychosocial Model
• Developmental Models
• Applications of Developmental Concepts
Biopsychosocial Model:
A Systems Approach to Disease
• Biological Component - anatomical,
biochemical and molecular substrates
• Psychological Component - emotions,
motivations, cognition
• Social Component - Family, School,
Community, including Medical System
Developmental Approach:
Basic Tenets
• Development occurs as a continuous series
of interactions between the child’s
biological endowment and the environment
• The child’s understanding of and
psychological response to medical illness is
contingent on his or her developmental
level and environmental experiences
Potential Effects of Illness
on Development
• Regression from previous levels of mastery
• Delay in Achievement of Developmental
Landmarks - Emotional, Social, Motoric,
Linguistic, Academic
• Acceleration of Cognitive Understanding of
Illness and Death
• Neglect or Excessive Attention to Somatic
Concerns
Cognitive Development: Piaget
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Sensorimotor Stage (Birth to 2 Years)
Pre-operational Stage (2 to 7 years)
Concrete Operations (7 to 11 years)
Formal Operations (11 years through
adolescence)
Applications of Developmental
Concepts
• Regression
• Children’s Understanding of Illness and
Death
• Adolescents’ Sense of Invincibility
Regression
• Return to developmentally earlier mode of
functioning - emotional, behavioral,
cognitive, linguistic or motoric
• Example: a 12 year old boy insists that his
mother feed him and sleep in his room after
he returns home from a hospitalization for a
broken leg sustained in a bicycle accident
Cognitive Understanding
of Illness
• Pre-operational Stage: “Immanent Justice” illness as punishment
• Concrete Operations (Early): “Contagion”
• Concrete Operations (Late) and Formal
Operations: Growing Understanding of
Disease Mechanisms and Etiological
Complexity
Understanding of Illness:
Examples
• A 3 year old boy states that he has asthma
attacks because he is “bad”
– (concept of “immanent justice”)
• A 6 year old girl states that she “caught”
diabetes from her sister (contagion)
• A 12 year old boy with diabetes describes
the role of the pancreas and insulin in
regulating blood levels of glucose
Concepts of Death and Dying
• Below Age 5: Fears of Abandonment, Lack
of Awareness of Irreversibility
• Ages 5 to 10: Confusion, Focus on body
parts
• Ages 10 to 15: Reality, Despair
Concepts of Death and Dying:
Examples
• A 3 year old girl asks who will “take care”
of her if she dies
• A 6 year old boy wonders who he will be
able to “eat ice cream” with in his grave
• A 13 year old boy with osteosarcoma asks
why he has to go to school since he is
“going to die anyway”
Mediating Factors in
Emotional Response to Illness
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Child Characteristics
Illness Characteristics
Family
School
Community
Health Care System
Mediating Factors:
Child Characteristics
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Age
Sex
Developmental Level
Temperament
Previous Experiences
Mediating Factors:
Illness Characteristics
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Acute vs. Chronic
Systemic vs. Local
Disability
Disfigurement
Pain
Restrictions on
Activity
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Etiology
Age at Onset
Diagnosis
Prognosis
Mediating Factors: Family
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Family Structure: Intact vs. Fragmented
Socio-economic Status
Family Members’ Previous Experiences
Supportive
Capacity for Collaboration with Treating
Staff
Mediating Factors:
Other Environmental Variables
• School
• Peers
• Health Care System
Mediating Factors:
Treatment Variables
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Short vs. Long-Term
Invasive vs. Non-invasive
Frequency
Need for Hospitalization - Single vs.
Multiple
• CNS Effects
• Other Side Effects
Insulin-Dependent Diabetes
Mellitus (Juvenile Diabetes)
• Affects about 1 in 600 children below age
12 in North America
• 11,000 - 12,000 new cases per year
• 7 million people with Diabetes Mellitus in
U.S.; 5 - 10% have IDDM
IDDM: Management Issues
• Need for Daily Monitoring and Treatment
• Effects on Broad Range of Activities (Diet,
Exercise, School, Social Situations)
• Risk of Acute Crises (Seizures, DKA)
• Uncertainty about long-term outcome
IDDM: Cognitive Factors
• Risk of Neurocognitive Impairments from
Hypo- and Hyper-Glycemia and Seizures
• Age of Onset and Duration
• Role of Cognitive Understanding by Parents
and Child to Disease Management and
Control
IDDM:
Emotional & Behavioral Problems
• Symptoms of Depression and Anxiety at
time of diagnosis
• Impairment in Self Esteem
• Non-compliance with daily management
regimen
• Involvement in High-Risk Activities in
Adolescence
IDDM: Management Approach
• Parent Education regarding the disorder
• Child Education appropriate to age and
developmental level
• Involvement of School Staff
• Psychotherapy and family counseling when
indicated
• Peer Support Groups - Local and National
– American Diabetic Association
– Juvenile Diabetes Foundation
Emotional Aspects of Physical
Disease: Management Summary
• Assess child, family, environment
• Know Illness Characteristics - onset, course,
treatment side effects, prognosis
• Identify Risk and Protective Factors
• Formulate Developmentally Appropriate
Plan for Child and Family