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Dimensions of illness behaviour in survivors of myocardial infarction
Journal of Psychosomatic Research, Vol. 22, pp. 485-491. Q Pergamon Press Ltd. 1978. Printed in Great Britain.
DIMENSIONS OF ILLNESS BEHAVIOUR JN SURVIVORS OF MYOCARDIAL INFARCTION* D. G. BYRNE? and H. M. WHYTE (Received 10 April 1978) Abstract-Psychological responses to illness of 120 survivors of myocardial infarction were examined using the Illness Behaviour Questionnaire (IBQ). All patients were seen in general hospital medical wards, IO-14 days after admission to hospital. Principal components analysis of the data with varimax rotation yielded 8 clinically meaningful factors accounting for 61.5 % of the variance. These were interpreted as somatic concern, psychosocial precipitants, affective disruption, affective inhibition, illness recognition, subjective tension, sick role acceptance and trust in the doctor. These factors are consistent with common preconceptions of the experience of myocardial infarction and are similar, in part, to responses after myocardial infarction reported in a small number of previous studies. They are, however, only marginally similar to patterns of illness behaviour reported for other illnesses, which suggests that the nature of myocardial infarction imparts a unique quality to illness behaviour developed after it. The significance of these factors was discussed in terms of the contributions they might make to the more effective structuring of psychotherapeutic components of rehabilitation and secondary prevention following myocardial infarction.
THE PSYCHOLOGICALantecedents of coronary heart disease (CHD) have received considerable attention [l-3]. However, with the exception of some aspects of postCHD anxiety [4, 51 and rehabilitation [6, 71, studies of the psychological consequences of CHD have been rare. This is regrettable in view of the assertions [8, 91 that psychological responses to clinical episodes of CHD are important determinants of the process and progress of rehabilitation, and in view of the early but encouraging evidence on the role of psychotherapy in the secondary prevention of CHD [lo, 1 I]. The notions of illness behaviour [12] and abnormal illness behaviour [13] would seem to provide the theoretical framework within which such studies might be conducted. These hold that persons adopt characteristic modes of perceiving, evaluating and reacting in relation to their illnesses [12] and where these are inappropriate to the nature of the illness [13], it may be exacerbated or its course prolonged [14]. Two recent studies of illness behaviour, one with patients reporting intractable pain [15] and one with long-term haemodialysis patients [16], have shown sufficiently disparate results to suggest that patterns of illness behaviour are somewhat dependent on the nature of the illness. Psychotherapeutic intervention plays an effective role both in the secondary prevention of CHD [lo, 1 l] and in the amelioration of other organically manifest disease 117, 181. The active focus of such therapy depends largely on the particular pattern of psychological responses to iilness which is evident [19, 201; therapy must be tailored to modify those psychological consequences of illness which are potentially noxious. As these appear to be largely unique to specific illnesses, the absence of systematic descriptions of illness behaviour in patients with CHD may be seen as a significant gap in our knowledge. *From the NH and MRC Social Psychiatry Research Unit, Australian National University, Canberra, A.C.T. 2601, Australia. tReprint requests to be sent to Dr. D. G. Byrne, Social Psychiatry Research Unit, A.N.U., P.O. Box 4, Canberra. A.C.T. 2601, Australia. 485
486
D. G. BYRNEand II. M.
WHYTE
The present study aims to describe systematically patterns of illness behaviour in survivors of myocardial infarction (MI), relate these to the clinical attributes of MI and foreshadow the use of this information in devising programmes aimed at rehabilitation and the prevention of future illness. METHOD Subjects These were 120 survivors of MI (93 men and 27 women, of x age = 52.36, S.D. = 7.92) admitted to all coronary care units in an Australian city (population 200,000) in a 1Zmonth sampling period. The population pool consisted of consecutive admissions, 65 years or less, fluent in English, who had survived MI long enough to be discharged from coronary care and for whom both patients’ and physicians’ free consent had been given for participation. Additionally, to attract an unequivocal diagnosis of MI, 2 or more of the following criteria of (a) unequivocal serial ECG changes, (b) elevated serum enzymes, and (c) typical clinical history of MI, were required to be met. Double-blind cross checks of these features for all patients ensured homogeneity of diagnosis. Thirteen persons, or 10 % of the eligible population, were missed, due either to refusal to co-operate or failure by referring cardiologists to notify the study team. Scrutiny of these patients’ case records revealed no discrepancies in x age (52.57), sex distribution, socio-occupational status, marital status and certainty of diagnosis between them and the sample examined. The study sample may thus be considered a large and representative sample of the one year incidence of survived MI (within the age and language restrictions) in this city. Material Data were collected using the Illness Behaviour Questionnaire (IBQ) developed and reported by Pilowsky and colleagues [15, 211. This is a 62-item instrument constructed to assess *‘. . . the patient’s attitudes and feelings about his illness, his perceptions of the reactions of significant others in the environment (including his doctor’s) to himself and his illness, and the patient’s own view of his current psychosocial condition.” It has been usefully employed to gather data in a wide variety of clinical settings, both with inpatients and outpatients [15, 221, and Pilowsky and Spence [I51 suggested it to be broadly relevant to the assessment of many clinical groups. The IBQ was introduced to each patient as a means of “. . . asking you about your own reactions to being ill, and to being in hospital”. It was administered in a general medical ward following discharge from coronary care, between 10 and 14 days after admission to hospital. All patients were aware they had sustained a MI, and had consented to participate in a multi-faceted, follow-up study on CHD. RESULTS Raw data (62 IBQ items and age) were subjected to a principal components analysis and rotated to simple structure (varimax) after Kaiser normalization [23]. This yielded 15 factors with eigenvalues > 1, accounting for 84.7 “/, of the variance. Adhering to the criterion adopted by Pilowsky and Spence [l5] in examining similar-data, only factors with 2 or more significant loadings were clinically intermeted. Eight factors, accounting for 61.5 X of the variance, fulfilled this criterion. Critical values of factor loadings were calculated using the Burt-Banks formula [24]. Table I presents IBQ items signiticantly loading on these 8 factors, together with appropriate factor loading levels. Factor descriptions (4 Factor I (19.9% variance) was characterized by 5 items reflecting general somatic concern, and a single item suggesting concern with psychological function. Principal factor loadings were on items relating to one’s own and other people’s states of health, and one’s own appearance. Pilowsky and Spence [15] obtained a genera1 factor defined by a similar conglomerate of items, and labelled it “hypochondriasis”. However, as the main concern of this factor is both health and appearance, it seems more appropriate to label it “somatic concern”. (b) Factor II (8.7% variance) was characterized by 6 items relating to the recognition that personal, social and financial worries prior to illness may have contributed to the present episode. It can be labelled “psychosocial precipitants”.
481
Illness behaviour in myocardial infarction survivors TABLET.--RANKED-ORDEREDITEMSFROM
IBQ
IBQ
LOADINGSIGNIFICANTLYONFACTORS@
I $0.76
29. Jealous of other people’s good health 38. Diseaseattention through radio, T.V. etc. +0.72 +0.55 44. Thinks something matter with mind +0.49 40. Upset by appearance of face or body 6. Thinks more liable to illness than others +0.46 $0.45 20. More sensitive to pain than others 27. Other problems in life 60. Personal worries not caused by illness 43. Family problems 31. Financial problems 52. Work problems 57. Thinks symptoms caused by worry 18. Gets anxious easily 47. Gets sad easily 17. Illness influences relationships with others 62. Hard to show personal feelings 22. Can express personal feelings to others 3. Illness interferes with life 2. Thinks something seriously wrong with body 34. Worries about possibility of serious illness 12. Trouble with nerves 59. Hard to relax 54. Often gets depressed 30. Obsessional thoughts about health 9. Annoyed at reassurance by others 42. Frequently try to explain to others how feeling 13. Easily cheered up by doctor 7. Belief in doctor’s judgement ‘A Variance 19.9 19.9 Cumulative % variance
II
III
Factors IV v
VI
<
0.01)
VII
VIII
1-0.75 +0.74 +0.56 +0.50 +0.46 +0.42 +0.69 -:-0.60 i 0.41 +0.77 -0.71 +0.68 +0.62 to.59 +0.68 +0.59 $0.45 +0.69 +0.54 +0.43
8.7 28.6
7.1 35.7
6.0 41.7
5.8 47.5
5.4 52.9
+0.59 +0.41 4.2 4.4 57.3 61.5
(cl Factor III (7.1% variance) was characterized
by 3 items suggesting an affective response to illness, to the point where interpersonal relationships are interfered with. It might be labelled “afTective disruption”. (4 Factor IV (6.0% variance) was characterized by 2 items indicating difficulty in expressing personal feelings, and can be labelled “affective inhibition”. (4 Factor V (5.8 % variance) was characterized by 3 items indicating a recognition by the patient of the presence of serious illness, and can be labelled “illness recognition”. (0 Factor VI (5.4 % variance) was characterized by 3 items suggesting the experience of subjective tension, and can be labelled “subjective tension”. Cd Factor VII (4.4 % variance) was characterized by 3 items indicating a recognition and acceptance of the sick role, and can be labelled “sick role acceptance”. (h) Factor VIII (4.2% variance) was characterized by 2 items suggesting acceptance of medical reassurance, and can be labelled “trust in the doctor”. DISCUSSION
While reporting on a factor-analytic study is essentially an exercise in clinical interpretation [25], emergent patterns of intercorrelated attributes are very often both theoretically sensible and of clinical utility [26]. Theoretically sensible dimensions of illness behaviour should relate to the affective, behavioural and cognitive meanings which a particular illness has to those afflicted with it [16, 271. Factors emerging from
488
D. G. BYRNE and H. M. WHYTE
this study are indeed both appropriate and relevant to common experience of MI. Their clinical utility is open to discussion.
preconceptions
of the
Before commenting on these however, two broadly relevant considerations deserve mention. Firstly, although the IBQ was designed to assess immediate responses to present illness, it is possible that patients were also, to a degree, commenting on themselves as they were prior to illness. Secondly, as methods of data collection and analysis were identical to those used by Pilowsky and Spence [15], differences in emergent factors between that study and the present one can be construed as arising from true differences in patterns of illness behaviour between the two samples. Concern for one’s state of health, sometimes of hypochondriacal proportions, has emerged prominently from some studies of illness behaviour [15, 28, 291 and has been evident in others [16, 301. The first and largest factor emerging from the present study was defined by items distinctly indicative of somatic concern. Collectively they depicted an attitude of concern with bodily function and dysfunction, extending also to concern with appearance and psychological function. Certainly, patients affirming these items may have done so prior to illness. However, such attributes have been found not to characterize potential sufferers of MI [31], but to become evident only after the experience of the clinical event [32]. An enhanced sensitivity to one’s somatic state and a concern for its correct functioning, would therefore appear to be mobilized by the experience of MI. precipitants”, is a corroboration, from the The second factor, “psychosocial patient’s viewpoint, of the well-documented contention that clinical episodes of MI are commonly preceded by an accumulation of worrying or distressing life circumstances [33]. The items suggest firstly the recognition that worrying circumstances existed prior to illness, and secondly the realization that these may have contributed to the present illness. The desire to search for illness precipitants has not previously been described within the context of illness behaviour, but has been mentioned as a possible contaminant in studies of stressful life events [34]. Emotional or affective responses to illness are commonly observed forms of illness behaviour [15-171. Two qualitatively unique factors emerged from the present study to represent this form of illness behaviour. The first (factor III), suggested an affective response to illness, to the point where interpersonal relationships are disrupted. Both anxiety and depression have been reported as common responses to MI 14, 5, 351. The disruptive effect of these, however, has not previously been described in relation to patients with MI. It may to a degree resemble the irritability previously reported [15] in relation to patients with intractable pain. Factor VI, also characterized by items of an affective nature, carries a quality of subjective tension. This may have been mobilized by illness, resulting in a person who, having sustained a MI, has trouble with “nerves”. and finds it difficult to relax as a result. However, as anxiety and tension commonly precede MI [I]. it is quite likely that this factor reflects a premorbid attribute. Factor IV, defined by items suggesting the inability to express affect, is identical to a factor described by Pilowsky and Spence [15]. In so far as this relates to behaviour mobilized by MI, it may compare with an attribute of obsessional control reported by Segers and Mertens [36] in relation to CHD sufferers. Pilowsky and Spence [ 151 interpreted their factor in accord with the notion that psychosomatic illness arises in
Illness behaviour in myocardial infarction survivors
489
persons unable to express anger and resolve conflict. It has certainly been suggested that persons prone to MI typically exercise strict control over aggression [37]. Factor V seems to indicate patients’ explicit recognition that they were suffering from a serious illness, not surprising as all were aware they had sustained a MI. The emergence of this factor appears to contradict previous observations of denial of serious illness among survivors of MI [38, 391, and denial, if it exists, might only become evident in a failure to affirm items defining this factor. The items defining factor VII appear also in a larger factor labelled hypochondriasis by Pilowsky and Spence [ 151. As, however, all patients in the present study were aware they had a serious illness (MI), these items might more appropriately represent an affirmation of the sick role [40], and a wish that this be accepted by significant others. Factor VIII clearly relates to behaviour mobilized by the present illness, and reflects a confidence in the medical attention being received. This is a positive attribute previously observed among survivors of MI [14, 411. The results of this study suggest that patterns of illness behaviour following MI are substantially different from those following other illnesses. Close methodological similarities between this study and that of Pilowsky and Spence [15] produced sufficiently disparate results to reinforce this claim. Illness behaviour is an expression of the affective, behavioural and cognitive meanings which a particular illness has for those afflicted with it [14], and can be seen as arising from the interplay between the nature of the illness and the psychological characteristics of the afflicted person. It is unlikely that the meanings which MI holds for the patient are exactly the same as those imparted by other illnesses, as illnesses will vary in terms of severity, chronicity, amount of information available to the patient, expected prognosis, subjective perception of the physiological state and perhaps other things as well. Thus, Pilowsky and Spence’s [15] findings of hypochondriacal preoccupation, conviction of underlying pathology and confusion as to whether this is psychological or somatic in origin, are consistent with a condition, intractable pain, which is chronic and for which pathology is often indeterminate. Similarly, the factors emerging from the present study, particularly heightened somatic concern, anxiety and depression, recognition of the presence of serious illness, acceptance of the sick role and explicit trust in the doctor, are all consistent with a condition, MI, which is an acute clinical episode, sometimes dramatic in onset, potentially life endangering and portentous of residual disability. The factors are also consistent, to a degree, with affective, behavioural and cognitive responses to MI previously reported [4, 5, 14, 32, 351. The clinical utility of these results lies in their ability to predict future problems, both rehabilitative and cardiologic, which the patient might experience. This would require the construction of illness behaviour profiles for individual patients, representing the degree to which the items defining each of the 8 factors were affirmed, and the prospective test of the relationships which these profiles bore to rehabilitation history and medical prognosis. Not all aspects of illness behaviour in response to MI will necessarily be noxious; some may indeed by adaptive. Furthermore, as this study examined illness behaviour only in the acute phase of illness, the possibility exists that some aspects of illness behaviour may change with time. Finally, the potentially noxious effects of some aspects of illness behaviour may change with time. The
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D. G. BYRNEand H. M.
WHYTE
physiologically arousing effects of anxiety [42] for example, may prove threatening to a vulnerable myocardium in the early stages of illness, but provide a useful motivating influence on compliance with therapeutic directions later in the course of recovery and rehabilitation. However, notwithstanding these provisos, the value of psychological intervention on prognosis following MI, has been foreshadowed [IO, 111, and it is likely that the mechanism lies largely in the modification of potentially damaging psychological responses to MI. The results of the present study provide, so far as we can tell, the first comprehensive description of psychological responses to MI, and the establishment of the relationships which these bear to prognosis may then be used as a guide to the design and implementation of more precisely focussed and structured programmes of psychotherapeutic intervention following MI. We are currently in the process of examining these relationships in a prospective extension of the present study. Acknowledgemenrs-The authors are pleased to express their gratitude to all physicians and coronary care unit staff who co-operated in this study, and in particular to MS Shelley McInnis, Dr. D. Coles and Dr. P. F. Sinnett. The study was supported in part by grant No. G1193 from the National Heart Foundation of Australia. REFERENCES 1. JENKINSC. D. Psychologic and social precursors of coronary disease. New Engl. J. Med. 284, 244, 307 (1971). 2. JENKINS C. D. Recent evidence supporting psychologic and social risk factors for coronary disease. New Engl. J. Med. 294, 987, 1033 (1976). 3. BYRNED. G. and HENDEMONA. S. Behavioural epidemiology and coronary heart disease: some sources of error and an alternativeconceptual model. Aust. N.Z. J. Med.6,425 (1976). 4. DELLIPIANIA. W.. CAY E. L.. PHILIP A. E.. VE~ER N. J.. COLLINGW. A., DONALDSONR. J. and MCCORMACKP. Anxiety afte; a heart attack Br. Heart J.38,752 (1976). 5. VETTERN. J., CAY E. L., PHILIPA. E. and STRANGER.C. Anxietyon admission to a coronary care unit. J. Psychosom. Res. 21, 73 (1977). 6. STOCKSMEIER U. (Ed.) Psychological Approach to the Rehabilitation of Coronary Patients. Springer, Berlin (1976). 7. DOEHRMANS. R. Psychosocial aspects of recovery from coronary heart disease: a review. Sot. Sci. Med. 11, 199 (1977). _ 8. DEGREE-C•USTRYC. Psychological problems in rehabilitation programmes. In Psychological Amroach to the Rehabilitation of Coronary Patients (Edited by STOCKSMEIER U.). Springer, Bkilin (1976). 9. FRIEDMANE. H. Psychosocial factors in coronary risk and rehabilitation In Psychological Approach to the Rehabilitation of Coronary Patients (Edited by STOCKSMEIER U.). Springer, Berlin (1976). 10. IBRAHIMM. A., FELDMANJ. G., SULTZ H. A., STAIMANM. G., YOUNG L. Z. and DEAN D. The management of myocardial infarction: a controlled trial of the effect of group psychotherapy. Znt. J. Psychiat. Med. 5, 253 (1974). 11. RAHE R. H., O’NEIL T., HAGAN A. and ARTHURR. J. Brief group therapy following myocardial infarction: eighteen month follow-up ofa controlled trial. Znt. J. Psychiat. Med. 6,349 (1975). 12. MECHANICD. Response factors in illness : the study of illness behaviour. Sot. Psychiat. 1, (1966). 13. PILOWSKY1. Abnormal illness behaviour. Br. J. Med. Psychol. 42,347 (1969). 14. WRZESNIEWSKI K. The attitudes towards illness of patients after myocardial infarction undergoing rehabilitation. Sot. Sci. Med. 9, 237 (1975). 15. PILOWSKYI. and SPENCEN. D. Patterns of illness behaviour in patients with intractable pain. J. Psychoson?. Res. 19, 279 (1975). 16. PRITCHARDM. Further studies of illness behaviour in long term haemodialysis. J. Psychosom. Res. 21, 41 (1977). 17. LIPOWSKIZ. J. Physical illness, the individual and the coping process. Znt. J. Psychiat. Med. I,91 (1970). 18. FRANK J. D. Psychotherapy of bodily disease. Psychother. Psychosorn. 26, 192 (1975).
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19. STERNBACH R. A. Pain Patients: Traits and Treatment. Academic Press, New York (1974). 20. KELLNERR. Psychotherapy in psychosomatic disorders: a survey of controlled studies. Archs Gen. Psychiat. 32, 1021 (1975). 21. PILOWSKYI., CHAPMAN C. R. and BONICAJ. J. Pain, depression and illness behaviour in a pain clinic population. Pain 4, 183 (1977). 22. PILOWSKYI. and SPENCE-N. D. Pain and illness behaviour: a comparative study. J. Psychosom. Res. 20, 131 (1976). 23. NIE N. H., HULL C. H., JENKINSJ. G., STEINBENNERK. and BENT D. H. Statistical Packagefor the Social Sciences. McGraw-Hill, New York (1975). 24. BURT C. and BANKSC. A factor analysis of bodily measurements for British adult males. Ann. Engen. 13, 238 (1947). 25. BYRNED. G. and MURRELLT. G. C. Self-descriptions of mothers of asthmatic children. Amt. N.Z. J. Psychiat. 11, 179 (1977). 26. BYRNED. G. Cluster analysis applied to self-rated depressive symptomatology. Acta Psychiat. Stand. 57, 1 (1978). 27. LIPOWSKIZ. J. Physical illness, the patient and his environment. ln American Handbook of Psychiatry (Edited by ARIETIS.). Basic Books, New York (1975). 28. COMREY A. L. A factor analysis of items on the MMPI hypochondriasis scale. Edu. Psycho!. Measurement 17,568 (1957). 29. PILOWSKYI. Dimensions of hypochondriasis. Bv. J. Psychiat. 113,89 (1967). 30. TIMMER~IANS G. and STERNBACH R. A. Factors of human chronic pain: an analysis of personality and pain reaction variables. Science 184, 806 (1974). 31. OSTFELDA. M., LEBOVITSB. Z. and SHEKELLER. B. A prospective study of the relationship between personality and coronary heart disease. J. Chron. Dis. 17, 265 (1964). 32. LEBOVITSB. Z., SHEKELLER. B. and OSTFELDA. M. Prospective and retrospective psychological studies of coronary heart disease. Psychosom. Med. 29, 265 (1967). 33. THEORELLT. and RAHE R. H. Psychosocial characteristics of subjects with myocardial infarction in Stockholm. In Life Stress and Illness (Edited by GUNDER~ONE. K. E. and RAHE R. H.). Charles C. Thomas, Springfield, Ill. (1974). 34. BROWN G. W., SKLAIR F., HARRIS T. 0. and BURLEYJ. L. T. Life events and psychiatric diyorders: some methodological issues. Psycho/. Med. 3, 74 (1973). 35. CAY E. L., VE~ER N., PHILIP A. E. and DUGARDP. Psychological status during recovery from an acute heart attack. J. Psychosam. Res. 16,425 (1972). 36. SEGERSM. J. and MERTENSC. Preventive behaviour and awareness of myocardial infarction: a factorial definition of anxiety. J. Psychosom. Res. 21, 213 (1977). 37. FRIEDMANE. H. and HELLEIL~TEIN H. K. Coronary risk factors, the socio-economic hierarchy and the control of aggression in a group of middle aged businessmen. Circulation 36, 113 (1967). 38. OLIN H. S. and HACKER T. P. The denial of chest pain in 32 patients with acute myocardial infarction. J. Am. Med. Ass. 190, 103 (1964). 39. GROOG S. H., SHAPIROD. S. and LEVINES. Denial among heart patients. Psychosom. Med. 33, 38.5 (1971). 40. PARSONST. The Social System. Free Press, Glencoe (1951). 41. CAY E. L., VETTERN., PHILIP A. E. and DUGARDP. Psychological reactions to a coronary care unit. J. Psychosom. Res. 16, 437 (1972). 42. FRANKENIIAEUSER M. Experimental approaches to the study of catecholamines and emotion. In Emotions: Their Parameters and Measurement (Edited by LEVI L.). Raven Press, New York (1975).
DIMENSIONS OF ILLNESS BEHAVIOUR JN SURVIVORS OF MYOCARDIAL INFARCTION* D. G. BYRNE? and H. M. WHYTE (Received 10 April 1978) Abstract-Psychological responses to illness of 120 survivors of myocardial infarction were examined using the Illness Behaviour Questionnaire (IBQ). All patients were seen in general hospital medical wards, IO-14 days after admission to hospital. Principal components analysis of the data with varimax rotation yielded 8 clinically meaningful factors accounting for 61.5 % of the variance. These were interpreted as somatic concern, psychosocial precipitants, affective disruption, affective inhibition, illness recognition, subjective tension, sick role acceptance and trust in the doctor. These factors are consistent with common preconceptions of the experience of myocardial infarction and are similar, in part, to responses after myocardial infarction reported in a small number of previous studies. They are, however, only marginally similar to patterns of illness behaviour reported for other illnesses, which suggests that the nature of myocardial infarction imparts a unique quality to illness behaviour developed after it. The significance of these factors was discussed in terms of the contributions they might make to the more effective structuring of psychotherapeutic components of rehabilitation and secondary prevention following myocardial infarction.
THE PSYCHOLOGICALantecedents of coronary heart disease (CHD) have received considerable attention [l-3]. However, with the exception of some aspects of postCHD anxiety [4, 51 and rehabilitation [6, 71, studies of the psychological consequences of CHD have been rare. This is regrettable in view of the assertions [8, 91 that psychological responses to clinical episodes of CHD are important determinants of the process and progress of rehabilitation, and in view of the early but encouraging evidence on the role of psychotherapy in the secondary prevention of CHD [lo, 1 I]. The notions of illness behaviour [12] and abnormal illness behaviour [13] would seem to provide the theoretical framework within which such studies might be conducted. These hold that persons adopt characteristic modes of perceiving, evaluating and reacting in relation to their illnesses [12] and where these are inappropriate to the nature of the illness [13], it may be exacerbated or its course prolonged [14]. Two recent studies of illness behaviour, one with patients reporting intractable pain [15] and one with long-term haemodialysis patients [16], have shown sufficiently disparate results to suggest that patterns of illness behaviour are somewhat dependent on the nature of the illness. Psychotherapeutic intervention plays an effective role both in the secondary prevention of CHD [lo, 1 l] and in the amelioration of other organically manifest disease 117, 181. The active focus of such therapy depends largely on the particular pattern of psychological responses to iilness which is evident [19, 201; therapy must be tailored to modify those psychological consequences of illness which are potentially noxious. As these appear to be largely unique to specific illnesses, the absence of systematic descriptions of illness behaviour in patients with CHD may be seen as a significant gap in our knowledge. *From the NH and MRC Social Psychiatry Research Unit, Australian National University, Canberra, A.C.T. 2601, Australia. tReprint requests to be sent to Dr. D. G. Byrne, Social Psychiatry Research Unit, A.N.U., P.O. Box 4, Canberra. A.C.T. 2601, Australia. 485
486
D. G. BYRNEand II. M.
WHYTE
The present study aims to describe systematically patterns of illness behaviour in survivors of myocardial infarction (MI), relate these to the clinical attributes of MI and foreshadow the use of this information in devising programmes aimed at rehabilitation and the prevention of future illness. METHOD Subjects These were 120 survivors of MI (93 men and 27 women, of x age = 52.36, S.D. = 7.92) admitted to all coronary care units in an Australian city (population 200,000) in a 1Zmonth sampling period. The population pool consisted of consecutive admissions, 65 years or less, fluent in English, who had survived MI long enough to be discharged from coronary care and for whom both patients’ and physicians’ free consent had been given for participation. Additionally, to attract an unequivocal diagnosis of MI, 2 or more of the following criteria of (a) unequivocal serial ECG changes, (b) elevated serum enzymes, and (c) typical clinical history of MI, were required to be met. Double-blind cross checks of these features for all patients ensured homogeneity of diagnosis. Thirteen persons, or 10 % of the eligible population, were missed, due either to refusal to co-operate or failure by referring cardiologists to notify the study team. Scrutiny of these patients’ case records revealed no discrepancies in x age (52.57), sex distribution, socio-occupational status, marital status and certainty of diagnosis between them and the sample examined. The study sample may thus be considered a large and representative sample of the one year incidence of survived MI (within the age and language restrictions) in this city. Material Data were collected using the Illness Behaviour Questionnaire (IBQ) developed and reported by Pilowsky and colleagues [15, 211. This is a 62-item instrument constructed to assess *‘. . . the patient’s attitudes and feelings about his illness, his perceptions of the reactions of significant others in the environment (including his doctor’s) to himself and his illness, and the patient’s own view of his current psychosocial condition.” It has been usefully employed to gather data in a wide variety of clinical settings, both with inpatients and outpatients [15, 221, and Pilowsky and Spence [I51 suggested it to be broadly relevant to the assessment of many clinical groups. The IBQ was introduced to each patient as a means of “. . . asking you about your own reactions to being ill, and to being in hospital”. It was administered in a general medical ward following discharge from coronary care, between 10 and 14 days after admission to hospital. All patients were aware they had sustained a MI, and had consented to participate in a multi-faceted, follow-up study on CHD. RESULTS Raw data (62 IBQ items and age) were subjected to a principal components analysis and rotated to simple structure (varimax) after Kaiser normalization [23]. This yielded 15 factors with eigenvalues > 1, accounting for 84.7 “/, of the variance. Adhering to the criterion adopted by Pilowsky and Spence [l5] in examining similar-data, only factors with 2 or more significant loadings were clinically intermeted. Eight factors, accounting for 61.5 X of the variance, fulfilled this criterion. Critical values of factor loadings were calculated using the Burt-Banks formula [24]. Table I presents IBQ items signiticantly loading on these 8 factors, together with appropriate factor loading levels. Factor descriptions (4 Factor I (19.9% variance) was characterized by 5 items reflecting general somatic concern, and a single item suggesting concern with psychological function. Principal factor loadings were on items relating to one’s own and other people’s states of health, and one’s own appearance. Pilowsky and Spence [15] obtained a genera1 factor defined by a similar conglomerate of items, and labelled it “hypochondriasis”. However, as the main concern of this factor is both health and appearance, it seems more appropriate to label it “somatic concern”. (b) Factor II (8.7% variance) was characterized by 6 items relating to the recognition that personal, social and financial worries prior to illness may have contributed to the present episode. It can be labelled “psychosocial precipitants”.
481
Illness behaviour in myocardial infarction survivors TABLET.--RANKED-ORDEREDITEMSFROM
IBQ
IBQ
LOADINGSIGNIFICANTLYONFACTORS@
I $0.76
29. Jealous of other people’s good health 38. Diseaseattention through radio, T.V. etc. +0.72 +0.55 44. Thinks something matter with mind +0.49 40. Upset by appearance of face or body 6. Thinks more liable to illness than others +0.46 $0.45 20. More sensitive to pain than others 27. Other problems in life 60. Personal worries not caused by illness 43. Family problems 31. Financial problems 52. Work problems 57. Thinks symptoms caused by worry 18. Gets anxious easily 47. Gets sad easily 17. Illness influences relationships with others 62. Hard to show personal feelings 22. Can express personal feelings to others 3. Illness interferes with life 2. Thinks something seriously wrong with body 34. Worries about possibility of serious illness 12. Trouble with nerves 59. Hard to relax 54. Often gets depressed 30. Obsessional thoughts about health 9. Annoyed at reassurance by others 42. Frequently try to explain to others how feeling 13. Easily cheered up by doctor 7. Belief in doctor’s judgement ‘A Variance 19.9 19.9 Cumulative % variance
II
III
Factors IV v
VI
<
0.01)
VII
VIII
1-0.75 +0.74 +0.56 +0.50 +0.46 +0.42 +0.69 -:-0.60 i 0.41 +0.77 -0.71 +0.68 +0.62 to.59 +0.68 +0.59 $0.45 +0.69 +0.54 +0.43
8.7 28.6
7.1 35.7
6.0 41.7
5.8 47.5
5.4 52.9
+0.59 +0.41 4.2 4.4 57.3 61.5
(cl Factor III (7.1% variance) was characterized
by 3 items suggesting an affective response to illness, to the point where interpersonal relationships are interfered with. It might be labelled “afTective disruption”. (4 Factor IV (6.0% variance) was characterized by 2 items indicating difficulty in expressing personal feelings, and can be labelled “affective inhibition”. (4 Factor V (5.8 % variance) was characterized by 3 items indicating a recognition by the patient of the presence of serious illness, and can be labelled “illness recognition”. (0 Factor VI (5.4 % variance) was characterized by 3 items suggesting the experience of subjective tension, and can be labelled “subjective tension”. Cd Factor VII (4.4 % variance) was characterized by 3 items indicating a recognition and acceptance of the sick role, and can be labelled “sick role acceptance”. (h) Factor VIII (4.2% variance) was characterized by 2 items suggesting acceptance of medical reassurance, and can be labelled “trust in the doctor”. DISCUSSION
While reporting on a factor-analytic study is essentially an exercise in clinical interpretation [25], emergent patterns of intercorrelated attributes are very often both theoretically sensible and of clinical utility [26]. Theoretically sensible dimensions of illness behaviour should relate to the affective, behavioural and cognitive meanings which a particular illness has to those afflicted with it [16, 271. Factors emerging from
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this study are indeed both appropriate and relevant to common experience of MI. Their clinical utility is open to discussion.
preconceptions
of the
Before commenting on these however, two broadly relevant considerations deserve mention. Firstly, although the IBQ was designed to assess immediate responses to present illness, it is possible that patients were also, to a degree, commenting on themselves as they were prior to illness. Secondly, as methods of data collection and analysis were identical to those used by Pilowsky and Spence [15], differences in emergent factors between that study and the present one can be construed as arising from true differences in patterns of illness behaviour between the two samples. Concern for one’s state of health, sometimes of hypochondriacal proportions, has emerged prominently from some studies of illness behaviour [15, 28, 291 and has been evident in others [16, 301. The first and largest factor emerging from the present study was defined by items distinctly indicative of somatic concern. Collectively they depicted an attitude of concern with bodily function and dysfunction, extending also to concern with appearance and psychological function. Certainly, patients affirming these items may have done so prior to illness. However, such attributes have been found not to characterize potential sufferers of MI [31], but to become evident only after the experience of the clinical event [32]. An enhanced sensitivity to one’s somatic state and a concern for its correct functioning, would therefore appear to be mobilized by the experience of MI. precipitants”, is a corroboration, from the The second factor, “psychosocial patient’s viewpoint, of the well-documented contention that clinical episodes of MI are commonly preceded by an accumulation of worrying or distressing life circumstances [33]. The items suggest firstly the recognition that worrying circumstances existed prior to illness, and secondly the realization that these may have contributed to the present illness. The desire to search for illness precipitants has not previously been described within the context of illness behaviour, but has been mentioned as a possible contaminant in studies of stressful life events [34]. Emotional or affective responses to illness are commonly observed forms of illness behaviour [15-171. Two qualitatively unique factors emerged from the present study to represent this form of illness behaviour. The first (factor III), suggested an affective response to illness, to the point where interpersonal relationships are disrupted. Both anxiety and depression have been reported as common responses to MI 14, 5, 351. The disruptive effect of these, however, has not previously been described in relation to patients with MI. It may to a degree resemble the irritability previously reported [15] in relation to patients with intractable pain. Factor VI, also characterized by items of an affective nature, carries a quality of subjective tension. This may have been mobilized by illness, resulting in a person who, having sustained a MI, has trouble with “nerves”. and finds it difficult to relax as a result. However, as anxiety and tension commonly precede MI [I]. it is quite likely that this factor reflects a premorbid attribute. Factor IV, defined by items suggesting the inability to express affect, is identical to a factor described by Pilowsky and Spence [15]. In so far as this relates to behaviour mobilized by MI, it may compare with an attribute of obsessional control reported by Segers and Mertens [36] in relation to CHD sufferers. Pilowsky and Spence [ 151 interpreted their factor in accord with the notion that psychosomatic illness arises in
Illness behaviour in myocardial infarction survivors
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persons unable to express anger and resolve conflict. It has certainly been suggested that persons prone to MI typically exercise strict control over aggression [37]. Factor V seems to indicate patients’ explicit recognition that they were suffering from a serious illness, not surprising as all were aware they had sustained a MI. The emergence of this factor appears to contradict previous observations of denial of serious illness among survivors of MI [38, 391, and denial, if it exists, might only become evident in a failure to affirm items defining this factor. The items defining factor VII appear also in a larger factor labelled hypochondriasis by Pilowsky and Spence [ 151. As, however, all patients in the present study were aware they had a serious illness (MI), these items might more appropriately represent an affirmation of the sick role [40], and a wish that this be accepted by significant others. Factor VIII clearly relates to behaviour mobilized by the present illness, and reflects a confidence in the medical attention being received. This is a positive attribute previously observed among survivors of MI [14, 411. The results of this study suggest that patterns of illness behaviour following MI are substantially different from those following other illnesses. Close methodological similarities between this study and that of Pilowsky and Spence [15] produced sufficiently disparate results to reinforce this claim. Illness behaviour is an expression of the affective, behavioural and cognitive meanings which a particular illness has for those afflicted with it [14], and can be seen as arising from the interplay between the nature of the illness and the psychological characteristics of the afflicted person. It is unlikely that the meanings which MI holds for the patient are exactly the same as those imparted by other illnesses, as illnesses will vary in terms of severity, chronicity, amount of information available to the patient, expected prognosis, subjective perception of the physiological state and perhaps other things as well. Thus, Pilowsky and Spence’s [15] findings of hypochondriacal preoccupation, conviction of underlying pathology and confusion as to whether this is psychological or somatic in origin, are consistent with a condition, intractable pain, which is chronic and for which pathology is often indeterminate. Similarly, the factors emerging from the present study, particularly heightened somatic concern, anxiety and depression, recognition of the presence of serious illness, acceptance of the sick role and explicit trust in the doctor, are all consistent with a condition, MI, which is an acute clinical episode, sometimes dramatic in onset, potentially life endangering and portentous of residual disability. The factors are also consistent, to a degree, with affective, behavioural and cognitive responses to MI previously reported [4, 5, 14, 32, 351. The clinical utility of these results lies in their ability to predict future problems, both rehabilitative and cardiologic, which the patient might experience. This would require the construction of illness behaviour profiles for individual patients, representing the degree to which the items defining each of the 8 factors were affirmed, and the prospective test of the relationships which these profiles bore to rehabilitation history and medical prognosis. Not all aspects of illness behaviour in response to MI will necessarily be noxious; some may indeed by adaptive. Furthermore, as this study examined illness behaviour only in the acute phase of illness, the possibility exists that some aspects of illness behaviour may change with time. Finally, the potentially noxious effects of some aspects of illness behaviour may change with time. The
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WHYTE
physiologically arousing effects of anxiety [42] for example, may prove threatening to a vulnerable myocardium in the early stages of illness, but provide a useful motivating influence on compliance with therapeutic directions later in the course of recovery and rehabilitation. However, notwithstanding these provisos, the value of psychological intervention on prognosis following MI, has been foreshadowed [IO, 111, and it is likely that the mechanism lies largely in the modification of potentially damaging psychological responses to MI. The results of the present study provide, so far as we can tell, the first comprehensive description of psychological responses to MI, and the establishment of the relationships which these bear to prognosis may then be used as a guide to the design and implementation of more precisely focussed and structured programmes of psychotherapeutic intervention following MI. We are currently in the process of examining these relationships in a prospective extension of the present study. Acknowledgemenrs-The authors are pleased to express their gratitude to all physicians and coronary care unit staff who co-operated in this study, and in particular to MS Shelley McInnis, Dr. D. Coles and Dr. P. F. Sinnett. The study was supported in part by grant No. G1193 from the National Heart Foundation of Australia. REFERENCES 1. JENKINSC. D. Psychologic and social precursors of coronary disease. New Engl. J. Med. 284, 244, 307 (1971). 2. JENKINS C. D. Recent evidence supporting psychologic and social risk factors for coronary disease. New Engl. J. Med. 294, 987, 1033 (1976). 3. BYRNED. G. and HENDEMONA. S. Behavioural epidemiology and coronary heart disease: some sources of error and an alternativeconceptual model. Aust. N.Z. J. Med.6,425 (1976). 4. DELLIPIANIA. W.. CAY E. L.. PHILIP A. E.. VE~ER N. J.. COLLINGW. A., DONALDSONR. J. and MCCORMACKP. Anxiety afte; a heart attack Br. Heart J.38,752 (1976). 5. VETTERN. J., CAY E. L., PHILIPA. E. and STRANGER.C. Anxietyon admission to a coronary care unit. J. Psychosom. Res. 21, 73 (1977). 6. STOCKSMEIER U. (Ed.) Psychological Approach to the Rehabilitation of Coronary Patients. Springer, Berlin (1976). 7. DOEHRMANS. R. Psychosocial aspects of recovery from coronary heart disease: a review. Sot. Sci. Med. 11, 199 (1977). _ 8. DEGREE-C•USTRYC. Psychological problems in rehabilitation programmes. In Psychological Amroach to the Rehabilitation of Coronary Patients (Edited by STOCKSMEIER U.). Springer, Bkilin (1976). 9. FRIEDMANE. H. Psychosocial factors in coronary risk and rehabilitation In Psychological Approach to the Rehabilitation of Coronary Patients (Edited by STOCKSMEIER U.). Springer, Berlin (1976). 10. IBRAHIMM. A., FELDMANJ. G., SULTZ H. A., STAIMANM. G., YOUNG L. Z. and DEAN D. The management of myocardial infarction: a controlled trial of the effect of group psychotherapy. Znt. J. Psychiat. Med. 5, 253 (1974). 11. RAHE R. H., O’NEIL T., HAGAN A. and ARTHURR. J. Brief group therapy following myocardial infarction: eighteen month follow-up ofa controlled trial. Znt. J. Psychiat. Med. 6,349 (1975). 12. MECHANICD. Response factors in illness : the study of illness behaviour. Sot. Psychiat. 1, (1966). 13. PILOWSKY1. Abnormal illness behaviour. Br. J. Med. Psychol. 42,347 (1969). 14. WRZESNIEWSKI K. The attitudes towards illness of patients after myocardial infarction undergoing rehabilitation. Sot. Sci. Med. 9, 237 (1975). 15. PILOWSKYI. and SPENCEN. D. Patterns of illness behaviour in patients with intractable pain. J. Psychoson?. Res. 19, 279 (1975). 16. PRITCHARDM. Further studies of illness behaviour in long term haemodialysis. J. Psychosom. Res. 21, 41 (1977). 17. LIPOWSKIZ. J. Physical illness, the individual and the coping process. Znt. J. Psychiat. Med. I,91 (1970). 18. FRANK J. D. Psychotherapy of bodily disease. Psychother. Psychosorn. 26, 192 (1975).
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