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[CATANAOAN, CHAN, CHENG] 1 of 3

Trans Number: #13 Concept of Illness and Disease HS 202: Biopsychosocial Dimensions of Illness EXAM # 1

August 24, 2015

Name of Lecturer Dr. Karin Estepa-Garcia

!!

I.#DISEASE#VS#ILLNESS#!

! Disease! ! Illness! !

!

What!happens!to!the!body.!

What!he!has!on!the!way!home!

from!the!doctor’s!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! •!Disease!•!Most!representative!M!average! •!Unusually!low/high!–!extreme!

•!Most!suited.for.survival! left/right!of!a!bell!curve!

•!Product!of!consensus!by! !

experts! !

•!Most!perfect! !

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•! 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#!

!

•! 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#!

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!

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!doesn’t!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#!

!

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!!

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[POPO, KOR, J] 2 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#Maria’s#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,# tai’chi,!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! one’s! 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!!

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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!patient’s!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! patient’s# understanding# of# his/her!

illness.#!o! Ethmomedical!beliefs,!assumptions,!and!expectations!!

•! To! treat!chronic! illness,! it! isn’t!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] 3 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! individual’s!

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! It’s! 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! TREATMENT!BIOMEDICAL! TB!bacilli! Triple!/quadruple!

! anti!Kochs!

HOLISTIC!**Transers’,note:!shouldn’t,this,be!BEHAVIORAL?!

Inadequate!diet! Better!nutrition,!

Overwork! Sufficient!rest!

! Drug!treatment!

! !

ETHNODMEDICAL! Ranges!from! Healing!of!stigma!

Heredity!to! through!health!

environmental! education!

factors,! Drug!treatment!

“natuyuan!ng! !

pawis”,! !

“nahipan!ng! !

masamang! !

hangin”! !

BIOPSYCHOSOCIAL!#ETHNODTRANSACTIONAL!

Life!context! DOTS!(5!

Poverty!and! components)!

congestion! Poverty!alleviation!

Health!delivery! Structural!changes!

systems! !

!

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.couldn’t.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##

!

!

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

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Summary:!