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Recent years have seen a rise in both chronic medical conditions as well as lifestyle disorders. Problems such as cancer, diabetes, sleep disorders, cardiovascular diseases, renal problems, as well as severe skin conditions are becoming increasingly prevalent. Though medicine has advanced by leaps and bounds in the management of these disorders, much work is left to be desired in the area of the psychological sequelae of these conditions. Importance of psychological factors involved in medical conditions, particularly chronic or terminal illnesses, has come to light in recent years, with much work focusing on the psychosocial aspects involved in initiation or exacerbation of symptoms. The role of psychosocial factors in management and therapy is now widely accepted and psychotherapy is increasingly beginning to serve as an adjunct to traditional forms of therapy where chronic, debilitating conditions are concerned. Medicine has, therefore, moved from a purely biological perspective of causation and management to a more biopsychosocial model of disease and treatment.

Biopsychosocial Model of Health and Illness

The biopsychosocial approach, proposed by Engel (1977), reduces emphasis on biological aspects while considering biological, psychological and social factors and their interactions in understanding health, illness and management.

The biological component of the biopsychosocial model focuses on physical functioning and genetic aspects as involved in causation. The psychological component looks for aspects of personality, cognitive functioning, emotional regulation, etc., while the social aspect investigates how different social factors such as socioeconomic status, culture, poverty, technology and religion influence health. In recent years, focus has moved beyond causation into looking at how the biopsychosocial model can be incorporated into healthcare—how it affects patients’ understanding and acceptance of healthcare that is provided, as also the clinical course and outcome of the condition (Fig. 2.1).

Fig. 2.1
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Source http://chiro.org/wordpress/2017/06/the-biopsychosocial-model-and-chiropractic/

Biopsychosocial model of health.

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Awareness and effective application of the model is, therefore, expected to result in improved healthcare practices. It is essential that the clinician follow certain basic principles for effective application of the model to clinical practice. Recognizing that relationships are central to providing healthcare and eliciting the patient’s history in the context of life circumstances is crucial to be able to develop a comprehensive model of the patients’ illness. Further, it is important to decide which aspects of biological, psychological and social domains are most important to understand and promote a patient’s health.

Following from this, DSM IV contains a category on psychological factors affecting mental health, which involves the ‘occurrence of one or more emotional or behavioural factors that aggravate or adversely affect the physical health problem or condition’ (American Psychiatric Association 2000). Subsumed under it are the following conditions:

  • Mental disorders affecting a medical condition

  • Psychological symptoms affecting a medical condition

  • Personality traits or coping style affecting a medical condition

  • Maladaptive health behaviours affecting medical condition

  • Stress-related physiological response affecting medical condition

  • Other or unspecified psychological factors affecting medical condition

As is evident from the categories, a number of conditions can be said to contribute to initiate or exacerbate of medical conditions or to interfere with treatment and outcome. For example, prolonged stress due to interpersonal difficulties or poor coping styles may result in physical problems, such as heart disease. Chronic anxiety or depression resulting from these interpersonal difficulties may then interfere with treatment or prolong recovery period even after the completion of treatment.

Psychosocial Factors as Risk and Protective Factors

Psychosocial factors that are often implicated in medical conditions are prolong or severe stress, anxiety, depression, ineffective coping, personality problems, interpersonal difficulties, maladaptive behaviours such as smoking, etc., among many others.

Enlisted in Table 2.1 are some of the prominent risk and protective factors implicated in poor psychological health complicating medical conditions.

Table 2.1 Psychosocial risk and protective factors
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Role of individual factors has been studied in populations widely varied in demographics. Among adolescents, it was found that searching for a coherent meaning in life served as a protective factor against poor psychological health (Brassai et al. 2011). Studies suggest that adolescents who are depressed and those who attempt suicide share many psychosocial risk factors. A few strong predictors of suicide attempt have been listed as—having a history of past attempt, current suicidal ideation and depression, recent attempt by a friend, low self-esteem and being born to a teenage mother (Lewinsohn et al. 1994).

Role of psychosocial variables in predicting mortality amongst old-age patients has also been extensively studied. Zuckerman et al. (1984) found three psychosocial variables as significant predictors: religiousness, happiness (as rated by the interviewers) and presence of a living offspring. The first two reduced the risk of mortality primarily among the elderly who were in poor health, while the third one did not interact with health status. Another study stressed on the importance of depressive symptoms as one determinant of recovery from hip fracture and indicates the need to attend to the affective status of hip fracture patients following surgery (Mossey et al. 1989).

In a study on clinical course of depression, it was found that better clinical course of depression was associated with patients who had high levels of social support, were more active and had less avoidant coping styles, who were physically active, and who had fewer co-morbid chronic conditions. Improvements in measures of functioning and well-being associated with patients who were employed, drank less alcohol, and had active coping styles (Sherbourne et al. 1995).

Understanding Health Related Behaviour

The Health Belief Model (Rosenstock 1974) attempts to explain and predict health behaviour by focusing on beliefs and attitudes of the individual. From a cost-benefit analysis, the model elaborates on perceived threats and benefits in terms of four constructs:

  • Perceived susceptibility of being afflicted by a condition

  • Perceived severity or seriousness of the condition and its consequences

  • Perceived benefits of the advised action to reduce risk or severity

  • Perceived barriers or costs to the advised action

The model proposed that an evaluation of these four constructs determines to what extent an individual will initiate and comply with a suggested treatment programme. Combined with these, two constructs were later included into the model to better explain health-related action undertaken by individuals—‘cues to action’ which include strategies designed to activate readiness in the patient, and ‘perceived self-efficacy’ or the individuals’ belief in their ability to carry out the required health action (Fig. 2.2).

Fig. 2.2
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Source Author’s representation

Conceptual model: health belief model.

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The health belief model has been applied to a range of health behaviours. Conner and Norman (1996) identified three broad areas where the model has found great applicability: (a) preventive health behaviour, including health-promoting and health-risk behaviours; (b) compliance with recommended medical action; (c) regular follow-up.

Much research has found evidence for the four constructs in predicting health behaviours. In the area of smoking cessation, it has been found that providing information about the effects of smoking and the extent of consequences is effective in initiating cessation (e.g., Sutton 1982). Studies in the area of breast self-examination have found that perceived barriers and perceived susceptibility (Wyper 1990) were the best predictors of healthy behaviours. Rimer et al. (1991) found that knowledge about breast cancer was related to having regular mammograms.

Protection Motivation Theory (Rogers 1983) examines two appraisal processes as being involved in adaptive or maladaptive coping with a health threat. The model posits that health-related behaviours are a product of five components:

  • Coping Appraisal

    • Self-efficacy (e.g. ‘I am confident that I can quit smoking’);

    • Response effectiveness (e.g. ‘Quitting smoking would improve my health’);

  • Threat Appraisal

    • Severity (e.g. ‘Lung cancer is a serious illness’);

    • Vulnerability (e.g. ‘My chances of getting lung cancer are high’);

    • Fear.

According to the Protection Motivation Theory, there are two sources of information—Environmental (e.g., verbal persuasion, observational learning) and Intrapersonal (e.g., prior direct or indirect experience). This information elicits either an ‘adaptive’ coping response (i.e., the intention to improve one’s health) or a ‘maladaptive’ coping response (e.g., avoidance, denial). Protection motivation is a mediating variable whose function is to arouse, sustain and direct protective health behaviour (Boer and Seydel 1996) (Fig. 2.3).

Fig. 2.3
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Source https://www.researchgate.net/figure/6341971_fig1_Flow-chart-of-Protection-Motivation-Theory

Conceptual model: protection motivation theory.

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The above example of smoking cessation illustrates the principles of the model.

Health Locus of Control (LOC), given by Wallston and Wallston, evaluates the degree to which individuals believe that their health is controlled by internal or external factors. Those with an external health LOC are likely to believe that their health is controlled by powerful others, such as medical professionals, or by chance or luck; while those with an internal health LOC are likely to view health as controllable and a consequence of their own actions.

Internal LOC has been linked to positive health beliefs and behaviours. Individuals with internal LOC have ability to stop smoking (Coan 1973), adherence to a medical regimen (Lewis et al. 1978), getting preventive inoculations (Dabbs and Kirscht 1971) etc. Developing an understanding of the origin and nature of LOC is essential to understand individual health-related behaviour and devising individualized treatment programmes and interventions to modify maladaptive LOC. It is believed that development of LOC is affected by parenting style (where a nurturant, consistent style of parenting is correlated with an internal LOC), consistent reinforcement, socioeconomic status and prior experience with sickness and health. Those belonging to a lower socioeconomic status are more likely to have an external LOC due to fewer reinforcements; their general circumstances make them more reliant on external sources of reinforcement. Prior experiences with disease are also important determinants of LOC, wherein an individual who may have continued to suffer through an illness despite all health-related behaviours may start to develop an external LOC. Such knowledge about development of health LOC is important at the individual and social level in developing healthcare practices; and is also related to how individuals change their behaviour and to the kind of communications style they require from health professionals.

Social cognition models such as Theory of Planned Behaviour (TPB) and Theory of Reasoned Action (TRA), proposed by Ajzen and Fishbein (1980), seek to explain health-related behaviour intentions and actions as a combination of beliefs. Theory of Reasoned Action suggests that a person’s attitude towards a particular action along with his/her subjective norm regarding that action determine an individual’s intention to perform that action or behaviour. Behaviour is most likely to be predicted by intention, which is the cognitive representation of a person’s readiness to perform a given behaviour. TRA was related to voluntary behaviour. Theory of planned behaviour is an extension of the TRA, and includes a component of ‘Perceived behavioural control’. Perceived behavioural control refers to people’s perceptions of their ability to perform a given behaviour. These predictors lead to intention, in addition to the previously mentioned attitudes and subjective norms. As a general rule, the more favourable the attitude and the subjective norm, the greater is the perceived control and stronger the person’s intention to perform the behaviour in question (Figs. 2.4 and 2.5).

Fig. 2.4
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Source Adapted from: https://www.med.uottawa.ca/sim/data/BehaviorChange_e.htm

Conceptual model: theory of reasoned action.

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Fig. 2.5
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Source Adapted from: https://www.med.uottawa.ca/sim/data/BehaviorChange_e.htm

Conceptual model: theory of planned behaviour.

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The Health Action Process Approach, developed by Schwarzer in 1992, posits two stages of change—motivation stage and action maintenance stage.

According to this approach, the motivation stage involves a combination of self-efficacy (e.g., ‘I believe I can cut down on unhealthy foods’); outcome expectancies (e.g., ‘Cutting down on unhealthy food will improve my health’), social outcome expectancies (e.g., ‘Other people want me to cut down on bad eating and doing so will be favourable to them’) as well as threat appraisal, which involves beliefs about perceived susceptibility and severity. The action stage comprises action plans (e.g., ‘When tempted with unhealthy food I can think of healthier options’) and action control (e.g., ‘I can resist temptation by thinking of my resolve to be healthier’). Presence of social support and absence of social barriers are mediating factors in the process (Fig. 2.6).

Fig. 2.6
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Source Adapted from Schwarzer (2008)

Conceptual model: health action process approach.

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The Transtheoretical Model of Change emphasizes on the dynamic nature of beliefs, time, and costs and benefits, and proposes the following stages of change:

  • Precontemplation: not intending to make any changes

  • Contemplation: considering a change

  • Preparation: making small changes

  • Action: actively engaging in a new behaviour

  • Maintenance: sustaining change over time

People in the later stages, e.g., maintenance, would tend to focus on the benefits (I feel healthier after giving up smoking), whereas people in the earlier stages tend to focus on the costs (I will be at a social disadvantage if I give up smoking). Strategies such as motivation enhancement, and supportive therapy are primarily used in the precontemplation stage while more structured cognitive behavioural methods are applied in the later stages, such as problem-focused CBT for the contemplation stage and self-management CBT and coping effectiveness are used in the action stage (Fig. 2.7).

Fig. 2.7
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Source Authors’ representation

Conceptual model: transtheoretical model of change.

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Psychosocial Intervention for Health Problems

Chronic illness is a pervasive, often distressing condition that may cause significant psychological changes and impact one’s psychological adjustment. According to a report by the Institute of Medicine (2008), people with a chronic illness need help to learn how to:

  • Cope with the intense, sometimes debilitating, emotions related to their illness.

  • Change behaviours in order to minimize the impact of their disease and maximize treatment protocol.

  • Manage the disruptions their illness may cause to their work, school and family life.

A large number of psychological interventions for general health conditions have been developed and researched over the years. A brief overview of the main approaches is provided in this section.

  • Psychoeducation

The models of health behaviour suggest that an essential predictor of health-related action is the set of beliefs and attitudes that an individual holds about the illness, particularly pertaining to the likelihood of their getting the illness and the severity of its consequences. Research has found that information in the form of fear-arousing warnings may change attitudes and health behaviour in such areas as dental health, safe driving and smoking (Sutton 1982). Several studies have also indicated a positive correlation between knowledge about Breast Self-examination (BSE) and breast cancer and performing BSE (Alagna et al. 1987; Champion 1984).

  • Stress management training

    • Relaxation

    • Guided Imagery

    • Stress Inoculation Training

    • Coping Effectiveness Training: Helping to evaluate and develop a regimen between problem and coping style

  • Cognitive Behaviour Therapy

    A large body of work has focused on using Cognitive Behaviour Therapy (CBT) for a range of conditions such as skin conditions, insomnia, pain management (particularly in cases where pain is chronic, such as cancer, fibromyalgia), cardiovascular diseases, etc. Management techniques have been developed using a combination of the following techniques:

    • Problem-focused counselling

    • Cognitive restructuring

    • Enhancing self-efficacy

    • Behavioural activation

    • Activity scheduling

    • Operant conditioning techniques

  • Emotional disclosure and supportive counselling

  • Family intervention

    • Consistent and nurturant parenting styles

    • Decreasing discord

    • Facilitating open and warm communication

    • Managing Expressed Emotion

  • Self-management approach

    This approach involves transferring the responsibility of treatment to patient by teaching the relevant skills and expecting application of the same in own settings. It has found great applicability in lifestyle disorders such as diabetes, where insulin treatments, compliance and dietary and lifestyle modifications are established as targets. It has also found useful in the treatment of alcohol and drug abuse.

Fekete et al. (2007) reviewed recent studies that have used behavioural or psychosocial interventions aimed at preventing type 2 diabetes mellitus, cardiovascular disease and HIV/AIDS as well as the psychosocial management of cardiovascular disease, HIV and cancer. Behavioural (lifestyle) interventions can decrease risk of type 2 diabetes mellitus and cardiovascular disease. Psychosocial interventions have proven efficacy for alleviating distress in patients medically treated for cancer, cardiovascular disease and HIV/AIDS. Behavioural and psychosocial interventions are useful in preventing some chronic diseases and for alleviating distress in patients who have been medically treated for diseases such as cancer, cardiovascular disease and HIV/AIDS. Barton et al. (2003) carried out interventions to improve coping strategies in patients with asthma and found them effective in reducing symptoms and psychological distress.

Use of psychosocial management as an adjunct to pharmacological treatment in cancer has been extensively studied. Certain modalities of treatment have been shown to be more efficacious at different stages of cancer treatment. Though psychoeducation may be the primary mode of patient interaction in the earlier stage and during diagnosis, group therapy may be more advantageous post diagnosis and to facilitate coping and adjustment (Blake-Mortimer et al. 1999). During extended treatments and chemotherapy, cognitive-behaviour techniques such as relaxation, stress management and cognitive coping may be the modality of choice (e.g., Fawzy et al. 1995; Bottomley 1996). Cunningham has identified a hierarchy of different types of therapy beginning with providing information, emotional support, behavioural training in coping skills, psychotherapy, leading up to spiritual/existential therapy (Cunningham 1995).

Edelman et al. (1999) conducted 12 sessions of CBT for cancer patients, comprising cognitive behaviour therapy, behavioural strategies focusing on communication and coping, and self-expression. At the end of the therapy, depression and low mood states were reported lesser while a significant increase was seen in self-esteem scores. Menzies et al. (2004) used guided imagery of self-efficacy in patients with fibromyalgia and found reportedly decreased stress, fatigue, pain and depression.

It has also been found that behavioural intervention in patients with diabetes helped in increasing treatment compliance, decreasing anxiety and depression and shown positive changes in health LOC. In a conceptual review, Peyrot and Rubin (2007) proposed five Cs to effective psychosocial management in diabetes:

  • Constructing problem definition

  • Collaborative goal setting

  • Collaborative problem solving

  • Contracting for change

  • Continuing support

The working alliance (patient–physician relationship) is important in medical treatment, as it is associated with patient adherence and satisfaction. Patients’ self-efficacy ought to be assessed and promoted as it is also associated with treatment adherence (Fuertes et al. 2007).

Conclusion

The role of psychosocial factors is being increasingly recognized as a critical factor in maintenance as well as management of medical conditions. Understanding of health models, and effective application of psychotherapeutic techniques by experts can go a long way in speedy and effective management of such conditions and their psychological sequelae. Although a majority of the physicians seem to recognize the importance of addressing psychosocial issues, approximately one-third believe that addressing such factors would lead to minimal or no improvements in outcomes. A minority reports that their training regarding the role of psychosocial factors was effective, while relatively a few indicate interest in receiving further training in these areas (Astin et al. 2006). Adequate training of health professionals and appropriate referral systems are required to bridge the gap between medical and psychosocial work in current medical practice.