Psychosocial health

Models of health and illness

• The biomedical model explains illness by disease of body parts alone. The biopsychosocial model adds psychological (beliefs, anxiety, coping) and social (family, work, income, culture) factors. A doctor treating chest pain who also weighs the patient's fear of losing his job and his family support is using the biopsychosocial model.
• The health belief model predicts health decisions (perceived susceptibility, severity, benefits, barriers, cues to action, self-efficacy); it does not explain the causes of illness.
• Locus of control: people with an internal locus believe their actions matter and adhere better. Repeated failure despite effort can produce learned helplessness (giving up because nothing seems to work); an internal locus of control protects against it.

Illness behaviour and the sick role

• Illness behaviour is how people perceive, evaluate and act on symptoms. It depends on how visible, severe and disabling symptoms are, beliefs, culture, cost and access, and others' reactions. Most symptoms never reach a doctor (the clinical iceberg); many people first consult family and friends (lay referral).
• Sick role: rights are exemption from normal duties and not being blamed for the illness; obligations are to want to recover and to seek and cooperate with competent help. It fits acute illness better than chronic or stigmatised illness.

• Illness anxiety disorder: preoccupation with having a serious disease despite reassurance. Factitious disorder imposed on another (Munchausen by proxy): a carer induces illness in a child; a safeguarding emergency.
• Stigma ("spoiled identity") attaches to epilepsy, HIV, TB, leprosy and mental illness; felt stigma (shame, fear) is often more disabling than enacted stigma (actual discrimination).

Prevention, education and promotion

• Cardiac rehabilitation after MI (exercise, education, risk-factor and psychological support) reduces cardiovascular deaths and readmissions and improves quality of life; it adds to drug treatment and never replaces it.
• Health education informs individuals to change behaviour. Health promotion is broader: it also changes policy and environments (taxes on tobacco, smoke-free laws, safe roads), as set out in the Ottawa Charter (1986).
• The Alma-Ata Declaration (1978) made primary health care the key to "Health for All".

Social determinants and culture

• Social determinants of health are the conditions in which people are born, live, work and age: income, education, employment, housing, sanitation, gender and social support. Maternal education strongly predicts child survival.
• Inverse care law: good care tends to be least available to those who need it most.
• Culture shapes beliefs about cause (spiritual, humoral, biomedical), symptom expression (somatisation), help-seeking (hakeems, faith healers, shrines) and decision-making (often family-centred in Pakistan). Culture-bound syndromes include Dhat syndrome (South Asian anxiety about semen loss) and koro.
• Cultural competence: respect beliefs, use professional interpreters, avoid stereotypes and ethnocentrism, negotiate care.

Reactions to illness and loss

• Hospital brings anxiety, loss of control and privacy, regression and dependency. Separated young children show protest, despair and detachment, so parents should stay.
• Stages of reaction to dying or loss: denial, anger, bargaining, depression and acceptance, not necessarily in order.
• Normal grief: shock and numbness, yearning and searching, despair, then reorganisation. Crying, guilt, poor sleep and briefly hearing or sensing the dead person are normal. It eases over months (about 6–12, varying with culture).
• Abnormal (prolonged) grief: delayed, absent or prolonged beyond about 12 months with marked impairment, or with severe depression, suicidal thinking or psychosis. Risk is higher after sudden or traumatic death, the death of a child, an ambivalent or dependent relationship and poor support.

Family

• Nuclear, joint or extended (common in Pakistan: support but sometimes conflict) and single-parent families.
• High expressed emotion (criticism, hostility, emotional over-involvement) predicts relapse in schizophrenia and responds to family intervention.
• Birth spacing of at least 2–3 years (an interval of 24 months or more after a live birth before the next conception) lowers maternal and infant risk.
• Collusion: when relatives ask that a capable patient not be told a diagnosis, explore their fears and ask the patient what he wants to know.
• Domestic violence and child abuse: ask sensitively, ensure safety, document, refer; safeguarding overrides confidentiality.

Burnout in doctors

• Early warning signs are emotional exhaustion and cynicism (depersonalisation): detachment from patients and work, irritability, then reduced sense of achievement, errors, absenteeism and substance misuse.
• Prevention: manageable workload, rest, peer support, supervision and early help.

Stages of change

Addiction

• Dependence: craving, loss of control, tolerance, withdrawal, neglect of other interests and persistence despite harm. Denial is the commonest defence in early substance misuse.
• Reward pathway: mesolimbic dopamine from the ventral tegmental area to the nucleus accumbens, reinforced by cues.
• Screening: CAGE (two or more positive answers suggest problem drinking) and AUDIT.
• Alcohol withdrawal: tremor and sweating from 6–24 hours, seizures 12–48 hours, delirium tremens at 48–72 hours (confusion, visual hallucinations, autonomic instability). Treat with a reducing benzodiazepine (chlordiazepoxide) and thiamine. Relapse prevention: acamprosate (craving), naltrexone, disulfiram (aversive).
• Opioids: substitution with methadone or buprenorphine; naloxone and needle exchange for harm reduction. Injecting drug use drives HIV spread in Pakistan.
• Nicotine: replacement therapy, varenicline, bupropion with behavioural support. Cannabis raises psychosis risk in adolescents. Gambling is a behavioural addiction.

Remember Factitious disorder fakes to be a patient; malingering fakes for a reward; conversion does neither on purpose.

Exam trap Pap smear screening is secondary prevention; cardiac rehabilitation is tertiary.

Exam trap Hearing the voice of the deceased briefly can be part of normal grief.

How FCPS asks about this

• Doctor considers job worry and family support in chest pain: biopsychosocial model.
• Gives up after repeated failure; protective trait: learned helplessness; internal locus of control.
• "I'm thinking about stopping, but not yet": contemplation; stopped 8 months and avoiding triggers: maintenance.
• Pap smear screening: secondary prevention.
• Health promotion versus education: promotion also changes policy and environment.
• Declaration making primary health care the key to Health for All: Alma-Ata, 1978.
• Early warning sign of burnout: exhaustion and cynicism.