HS 202: Biopsychosocial Dimensions of Illness

Concept of Illness and Disease

Dr. Karin Estepa-Garcia

Name of Lecturer
OUTLINE!

I. Disease!vs.!Illness!!
!II. Normal!vs.!Abnormal!!
III.!!History!of!Causes!of!Disease!
!
IV.!!Disease!Causation:!Concepts!
V. Models!of!Disease!Causation!!
A. Biomedical!model!!
B. Biobehavioral!model!!
C. Holistic!model!!
D. Biopsychosocial!model!!
E. EthnomedicalMcultural!model!!
F. Ecological!Transaction!Model!!
VI.!Answering!Ang!Kwento!ni!Maria!!
VII.!The!Medical!Interview!!

EXAM # 1
August 24, 2015
Trans Number: #13

In! contract! to! the! bell! curve! model,! the! IllnessMWellness!

continuum! aims! to! bring! the! patient! not! only! back! to! a!
relative!neutral!point!but!to!a!higher!level!of!wellness.!!

!
III.# HISTORY#OF#CAUSES#OF#DISEASE#
!

!
I.# DISEASE#VS#ILLNESS#
!
!

!
!

!
!
!

Disease!

Illness!

!
What!happens!to!the!body.!
What!he!has!on!the!way!home!
from!the!doctors!office.!
Pathological!changes!diagnosed!
by!signs!and!symptoms:!
Objective,!and!defined!by!
doctors.!

What!happens!to!the!
person.!
What!the!patient!feels!
when!he!goes!to!the!
doctor.!

!
!
In!terms!of!diseases,!doctors!make!the!diagnosis.!However,!
physicians!should!make!sure!to!exercise!care,!because!a!
diagnosis!corresponds!to!a!label.!!
Labels,! on! the! other! hand,! correspond! to! stigmas,!
especially!for!those!with!STI,!HIV/AIDS,!leprosy,!etc.!!
Doctors! have! the! power! and! responsibility! in! stigmatizing!
their!patients.!!
Standard!!for!!diagnosing!!diseases:!!International!!
Classification#of#Diseases:#ICD10#!

!
II.# NORMAL#VS#ABNORMAL#
A.#NORMALCY#IN#BELL#CURVE#
!
Normal!
Abnormal!
!Statistical:!Mean#+/D#2SD!
!Most!representative!M!average!
!Most!suited.for.survival!
!Product!of!consensus!by!
experts!
!Most!perfect!

!Disease!
!Unusually!low/high!!extreme!
left/right!of!a!bell!curve!
!
!
!

!
!
!
!
!
!
!
!
!
!
!
!

In! this! model! of! normalcy,! treatment! aims! to! keep! the!
patient!in!the!normal!range!(middle!part!of!the!bell!curve!as!
the!relative!neutral)!and!not!in!the!extreme!left/right.!!

!
B.#ILLNESSDWELLNESS#CONTINUUM#
!

!
!
Figure#3.#Causes!of!disease!through!the!years!
!!
!4000,years,of,Medicine:!
2000.BC:.Here,.eat.this.root!
1000.AD:.That.root.is.heathen!.Here,.say.this.prayer...
1865.AD:.That.prayer.is.superstition!.Here,.drink.this.
potion.!
1940.AD:.That.potion.is.snake.oil!.Here,.swallow.this.pill...
1985. AD:. That. pill. is. ineffective!. Here,. take. this.
antibiotic...
2000.AD:.That.antibiotic.is.poison!.Here,.eat.this.root.!
!
!
IV.# CONCEPTS#OF#DISEASE#CAUSATION#
!
! How! physicians! approach! patients! and! problems! they!
present! are! much! influenced! by! conceptual# models!
around! which! their! knowledge! is! organized! (George! L.!
Engel).!So!choose!which!model!you!want!to!use.!!
!
! Why,talk,about,models,of,disease,causation?,!
o! influences!management!
o! determines!resource!allocation!
o! determines!policies!and!programs!!
!
!
Epidemiology:!Causation!vs.!Association!!
!
o! Two!things!can!be!associated,!but!it!doesnt!mean!they!
have!a!causeMandMeffect!relationship.!
o! Example!of!Causation:!Smoking!causes!lung!cancer.!!
o! Example! of! Association:! Correlation! between! dietary!
fat!intake!and!breast!cancer!by!country!!
!! Fat!intake!and!Breast!CA!are!both!highest!in!US,!
Germany,!UK,!lowest!in!Japan,!Hong!Kong!!
!! There!is!an!association!between!the!!
!! two,! but! it! cannot! be! concluded! that! dietary! fat!
intake!is!the!sole!cause!
!
o! Nine! guidelines! for! judging! whether! an! association! is!
causal:!!
1.! Temporal#Relationships#!
!2.! Strength#of!association#!
3.! DoseDresponse#relationship#!
4.! Replication#of!findings#!
5.! Biologic#plausibility#!
6.! Consideration!of!alternate#explanations!!
7.! Cessation#of#exposure#!
8.! Specificity#of!the!association#!
9.! Consistency#with!other!knowledge#!
!

[CATANAOAN, CHAN, CHENG]

of 3

HS 202: Concept of Illness and Disease

!
Epidemiology:!Direct!vs.!Indirect!!
o! Direct:.Factor.".Disease!(e.g.,!smoking.".Lung!CA)!!
o! Indirect:.Factor!1.".Factor!2.".Factor!3.".Factor!4!"!
Disease!(e.g.,!radiation,!genes!"""cancers)!
!
V.# MODELS#OF#DISEASE#CAUSATION#
#
Per# model# of# disease# causation,# answer,# what# is# the#
cause#of#Marias#illness?!
!
Kwento#ni#Maria!
!
Maria,! a! 35MyearMold! vendor! in! Divisoria! market,! is! married! to!
Juan,!a!factory!worker.!They!live!with!their!3!young!children!in!a!
small! shanty! in! the! squatter! area! of! Tondo.! She! works! from!
sunrise!to!late!at!night!but!despite!this,!their!combined!income!
could!not!provide!sufficient!food!for!the!whole!family.!Maria!has!
been!coughing!for!more!than!a!month!now.!She!has!been!taking!
herbal!preparations!given!by!their!BHW!with!minimal!relief.!She!
was!thus!advised!to!go!to!their!LHC.!Diagnostic!exams!revealed!
she!has!tuberculosis.!
!
A.#BIOMEDICAL#MODEL##
#
! MindDbody#Dualism:!mind!and!body!are!separate!!
! Linear! causality,! with! a! biophysiologic! cause! for! each!
disease!!
! PhysicianMcentered,! specialistMdominated,! technologyM
dependent!!
! Reductionist!16th!century!paradigm:!Health!=!absence!of!
disease!!
! A! pill! for! every! ill! M! try! to! cure! everything! at! once! "!
encourage!dependency!rather!than!fostering!autonomy.!!
! Medicalization! of! problems! previously! thought! to! be!
problems!of!daily!living!led!to!unrealistic!expectations#of#
cure.#!
!
Problems!identified:!
!
!
! In!general,!the!biomedical!model!FAILS!to:!!
o! Account!for!psychosocial!etiology!of!some!illnesses!
o! Explain!recent!biobehavioral!research!findings!
o! Explain!iatrogenic!disease!(illness.caused!by.medical.
examination. or. treatment),! as. evidenced! by! surprise!
side!effects!from!drugs!
o! Account!for!symbolic!dimension!of!illness!!
o! Explain!variations!in!illness!behavior/pattern!!
!
! Other!problems!with!this!model!include:!!
o! Inadequate! treatment! strategies! for! lifestyle! issues!
related!to!disease!etiology!
o! Frequently!produces!patient!dissatisfaction!!
!
B.#BIOBEHAVIORAL#MODEL##
!
!
!

Psychological#processes#and#emotional#states#influence!
the! etiology! and! progression! of! disease! and! contribute! to!
overall!host!resistance!or!vulnerability!to!illness.!!

!
Behavioral!contribution!to!management!of!illness:!
!
! Stress!and!coping!behavior!!
o! Psychobiology!
o! Psychoneuroimmunology!!
!
! HealthMenhancing!vs.!HighMrisk!behaviors!!
o! Lifestyle!behaviors!(e.g.,!overwork)!!
!
! HealthMseeking!behaviors!and!Adherence!to!treatment!!
o! Screening!and!early!detection!!
!
.
Live. sensibly.... among. a. thousand. people,. only. one. dies. a.
natural. death.. The. rest. succumb. to. the. irrational. modes. of.
living...!(Maimonides.1135P1203.AD)!
!
C.#HOLISTIC#MODEL##
#
!
!
!

Emphasis!on!individual!responsibility!and!personal!control!!
Anticipated!goal!is!highMlevel!wellness!!
Therapy! consists! of! an! eclectic! collection! of! alternative#
therapies# (e.g.! quackery,! herbalism,# taichi,! acupuncture,!

!
!

yoga,!etc.),!excluding!the!conventional!Western!medicines!
and!treatments.!!
4!Assumptions:!!
1.! Psychosomatic#nature!of!illness#!
2.! Person!has!body,#mind,#and#spirit!integrated!!
3.! Illness! stems! from! adaptational# failure,! producing! a!
disturbance! in! the! selfMregulation! of! ones! social,!
behavioral,!psychological,!and!physical!dimensions!!
4.! Illness! is! a! creative# opportunity! (i.e.! the! illness!
chooses!a!person!who!has!done!something!bad)!!

!
D.#BIOPSYCHOSOCIAL#MODEL##
#
! Systems!perspective!(Engel)!!
! Disease!belongs!to!a!person!who!is!part!of!a!system!!
! Context! in! which! symptoms! occur! is! as! important! as! the!
symptom!Itself.!!
! Accepts! interaction! of! many! variablesh! appreciates!
differences,!subjectivity,!and!uncertainty!!
!
!
!
!
!
!
!
!
!
!
!
Figure#4.#Systems#theory!
! PatientMcentered!care:!!
o! Explore!healthMrelated!values!
o! Obtain! psychosocial! and! contextual! info! M! e.g.,!
perceptions!!
o! Formulate!goals!to!optimize!health!
o! Select!options!responding!to!patients!values!M!do!not!
dictate.!!
!
! RelationshipMcentered!care:!!
1.! Relationship!with!your!patient!!
2.! Relationship!with!your!colleagues!!
3.! Relationship!with!the!community!!
4.! Relationship!with!the!world!!
.
The.most.potent.and.frequently.used.intervention.available.to.
the.physician.is.the.physician.themselvesS.yet.how.poorly.the.
physician.understands.the.proper.dosage,.therapeutic.limits,.
and.side.effects.of.such.an.intervention..(Balint,.The.Doctor,.
His.Patient,.and.the.Illness,.1972)!
!
E.#ETHNOMEDICALDCULTURAL#MODEL##
#
!
!

!
!

This!model,!by!Kleinman!et!al.,!differentiates!disease!from!
illness,!healing!from!curing.!!
Emphasizes! the! patients# understanding# of# his/her!
illness.#!
o! Ethmomedical!beliefs,!assumptions,!and!expectations!!
To! treat! chronic! illness,! it! isnt! enough! to! master! relevant!
biology.! Chronic! illness! cannot! be! cured.! A! doctor! must!
appreciate!the!psychological#and#social!components#of!
the!ailment.#!
LEARN#Methodology:#!
1.! Listen###with!!!empathy!!!and!!!understanding!!!for#!
Explanatory.Models.and.Illness.Prototypes.!
a.! Explanatory#models:#culturally!prescribed!sets#of!
generalizations! about! etiology,! prognosis,! and!
therapy!of!a!particular!illness.!!
b.! Illness# Prototypes:# experience! of! an! illness,#
whether! personal,! by! significant! other,! through!
media! (e.g.,! May. kakilalang. nagkaganito.. May!
kapitbahay. na. nagkaPkumplikasyon. sa. gamot. na.
binigay,.therefore.ayaw.magpagamot).!
2.! Explain#perceptions!using!lay!terms#!
3.! Acknowledge# difference! and! similarities! between#
patient!and!doctor!EMs.!
4.! Recommend#and#!
5.! Negotiate#treatment#!

[POPO, KOR, J]

of 3

HS 202: Concept of Illness and Disease

!
F.#ECOLOGICALDTRANSACTIONAL#MODEL##
!

Considers! the! effects! of! poverty! and! inequities! (e.g.!

malnourishment!vs.!Hypertension!&!CVD),!and!the!vital!role!
of!healthcare#delivery#systems.!!

!
!
!

The!patient!is!viewed!holistically!as!union!of!biological!and!
psychocultural! factors! that! determine! an! individuals!
adaptive. capacity! or! the! ability! to! adjust! to! environmental!
influences!and!changes!!

!
!

!!
!

Example:#Tuberculosis#Mortality#in#the#UK#(1828D1963):##
o! There!was!a!decline!in!mortality!before!treatment!was!
discovered!!
o! This! was! due! partially! to! the! Industrial! Revolution,!
which!led!to!more!livelihoods!and!thus!better!quality!of!
life!for!the!general!population.!
o! Its! not! the! bacilli! itself! that! is! problematic,! it! is! the!
system!
o! Socioeconomic#status#and#health#are#inseparable#!
VI.# ANSWERING#ANG#KWENTO#NI#MARIA#

CAUSE!
TB!bacilli!

BIOMEDICAL!

TREATMENT!
Triple!/quadruple!
anti!Kochs!
Better!nutrition,!
Sufficient!rest!
Drug!treatment!

!
HOLISTIC!
**Transers,note:!
shouldnt,this,be!
BEHAVIORAL?!

Inadequate!diet!
Overwork!
!
!

Ranges!from!
Heredity!to!
environmental!
factors,!
natuyuan!ng!
pawis,!
nahipan!ng!
masamang!
hangin!
BIOPSYCHOSOCIAL! Life!context!
#
Poverty!and!
ETHNOD
congestion!
TRANSACTIONAL!
Health!delivery!
systems!

!
From.2017:
Sample#questions:
What!model!of!disease!causation!is!described!in!the!ff.?!(the!choices!are!
the!AMF!as!written!above!in!the!trans)
1.! Patient!complained!of!painful!urination.!Only!urinalysis!was!done.!!
2.! Patient! refuses! to! use! insulin! because! she! knows! of! significant!
others!who!used!insulin!but!died!anyway.!!
3.! She! insisted! not! to! use! insulin! and! instead! ate! ampalaya! salad!
everyday.!!
4.! She! blames! her! boyfriend! for! her! broken! heart! and! eats! a! lot! to!
compensate.!!
5.! Ang!mga!lalaking!maraming!kapareha!ay!sadyang!naghahanap!ng!
mga!sakit!tulad!ng!syphilis.!!
6.! Nagkakasakit! ang! bata! kapag! nagkukulang! ng! gamot! sa! health!
center.!!
!
Do!the!following!statements!pertain!to!disease!or!illness?!!
7.! What!is!the!reason!for!the!consult?!!
8.! Where!does!it!hurt?!!
9.! When!did!you!first!notice!the!symptoms?!!
10.! How!does!your!family!feel!about!it?!!
11.! What!are!your!ideas!on!why!this!happened!to!you?!!
Answer#key:#A,!E,!C,!B,!B,!F!||!Illness,!Disease,!Disease,!Illness,#
Illness

!
!
!
!
Summary:!

ETHNODMEDICAL!

Healing!of!stigma!
through!health!
education!
Drug!treatment!
!
!
!
!
!
DOTS!(5!
components)!
Poverty!alleviation!
Structural!changes!
!

!
Kwento,ni,Maria,,continued:!
!
The. doctor. at. the. LHC. included. her. in. the. Tutok. Gamutan.
program.and.advised.her.to.rest.and.eat.nutritious.food..She.
couldnt.tell.him.this.was.not.possible.because.she.needed.the.
income.from.her.work.and.had.three.little.children.to.care.for..
The.doctor.inquired.about.her.living.conditions.and.arranged.
for. some. help. from. their. active. BHWs.. Other. members. who.
were.screened.and.received.the.same.treatment.included.her.
husband.and.the.youngest.child.!
!
With.the.support.of.the.BHWs,.some.financial.assistance.
from.social.welfare,.and.the.free.medication.for.6.months,.
they.recovered.from.TB..
!
VII.# THE#MEDICAL#INTERVIEW#
!
!
!
!
!
!
!
!

The!medical!interview!is!the!basis#of#medical!practice.#!
60M80%!of!medical!diagnoses!are!made!on!the!basis!of!the!
info!from!the!medical!interview!alone.!!
The! answers! you! get! from! the! patient! depend! on! the!
questions#you!pose!and!how!you!do!so#!
o! What! we! observe! is! not! nature! itself,! but! nature!
exposed!to!our!method!of!questioning!!
PersonalMsocial! History:! aside! from! lifestyle! questions,!
include:!!
o! Emotions!attendant!to!the!problem!!
o! Explanatory#models!(beliefs)!and!Illness!Prototypes#
(previous!experience),!etc.#!

!
END#OF#TRANSCRIPTION#
#
!

[POPO, KOR, J]

of 3