30th October 2023

Sick Role and Illness Behaviour

‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ – The World Health Organisation (WHO)

Definitions

There are no universally accepted definitions for these terms. These are terms which are frequently used as synonyms in society, but the general consensus in the medical community is as follows:

• Disease – Harmful deviation from an organism’s normal structure / functional state, often associated with signs ± symptoms; not as a result of physical injury. A pathological process.
• Illness – It is how the person experiences ill health and their reaction to disease. A feeling experienced by the person/patient.
• Sickness – Generally refers to how the disease is externally interpreted, the change in social expectations in society, and how society reacts to someone who is unwell, e.g. taking time off work or cancelling social plans. A social role.

Illness behaviour

The term ‘illness behaviour’ refers to how patients cope and behave with their illness. It includes taking days off sick and avoiding regular activities (e.g. social commitments). ‘Abnormal illness behaviour’ encompasses patients who react and behave with their illness in a way that is less acceptable to society and the healthcare system, for example, taking unnecessary medications or showing high levels of anxiety related to their illness and requesting unnecessary investigations.

The sick role

The sick role was first described by Talcott Parsons. Parsons was an American sociologist who proposed a theoretical system for analysing society – this came to be known as ‘structural functionalism’. This essentially means that all of the constituent parts of a society (including institutions, individuals, relationships, roles, etc.) serve a purpose, and therefore, the roles that individuals fit into are shaped by how these roles support the society they are in. Parsons described the ‘sick role’ – he argued that someone who is in the ‘sick role’ enters a role of ‘sanctioned deviance’ and is not a productive member of the society they are in.

Parsons identified four key characteristics of the ‘sick role’:

1. The sick person is exempted (temporarily) from performing normal social roles. The greater the severity of the illness, the more exempt from these roles they are.
2. The sick person is not responsible or blamed for their illness. Their illness is beyond the control of the sick person, and they have a right to be taken care of by others until they can resume their normal role.
3. Being sick is undesirable, and the sick person should try to get well as quickly as possible.
4. After a period of time, the sick person should seek competent help (i.e. doctor/healthcare professional) and cooperate with their advice.

Criticisms of Parsons’ sick role

Parsons’ concept of the ‘sick role’ has a strong emphasis on the power of the doctor-patient relationship, which is not always the case. It assumes that patients will accept and value the physician’s professional advice. However, the reality is that many people do not go to the doctor and instead seek informal advice.

Some research has shown that sick role behaviour is more applicable to patients within higher income groups rather than lower income groups. This applies to aspects of the sick role, such as taking medication and attending appointments.

Another of the assumptions made by Parsons was that employers would accept when their employees take time off as ‘sick’ and exempt them from their usual duties. However, some evidence suggests that employers do not always believe that their employees are sick. An example of this was written by Lesley Cooper in 1997, who found that many people diagnosed with myalgic encephalomyelitis or chronic fatigue syndrome had significant difficulties achieving the ‘sick role’ status due to employers’ disbelief.

ICD-11 conditions

Hypochondriasis (6B23) – Characterised by persistent preoccupation/fear about having one or more serious, progressive or life-threatening illnesses. This is accompanied by either repetitive/excessive health-related behaviours or maladaptive avoidance behaviour related to health. The symptoms result in significant distress or significant impairment in functioning (work, social, family, etc.) Hypochondriasis is graded with different levels of insight: fair to good insight or poor to absent insight.

Factitious disorder is characterised by intentionally falsifying, inducing, or aggravating medical/psychological/behavioural signs and symptoms in oneself or another person. People with factitious disorder seek treatment/care for themselves / the other person based on feigned signs/symptoms/injuries. In contrast to malingering, the deceptive behaviour is not solely motivated by obvious external rewards or incentives.

• 6D50 Factitious Disorder Imposed on Self (has been known as Munchausen syndrome).
• 6D51 Factitious Disorder Imposed on Another (has been known as Munchausen syndrome by proxy).

Malingering (QC30) – Feigning, intentional production or significant exaggeration of physical or psychological symptoms, specifically motivated by external incentives or rewards (e.g. time off work, medications, disability benefits).

Bodily distress disorder (6C20) – Characterised by the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms. It can present as recurrent and excessive contact with healthcare professionals. Excessive attention to their symptoms is not reduced by appropriate reassurance and investigation. Bodily symptoms are persistent and present on most days for at least several months.

The biomedical model of health

There are three underlying assumptions with a biomedical model of health and illness:

1. All illnesses have a single underlying cause
2. Pathology is always the single cause
3. Removal of the pathology/disease will result in a return to health

There is sufficient evidence which proves that these three assumptions cannot be applied to every illness and condition. In psychiatry, the biomedical model suggests that mental illness is a direct consequence of brain diseases and that pharmacological treatments can target these assumed diseases. Over time, we have moved away from this model of health as there are many conditions which cannot be explained by this model, including chronic pain, functional neurological disorders and myalgic encephalomyelitis. Instead, we have moved towards the biopsychosocial model, which accepts that health is related to the interface between biological, psychological and social factors.

Resource allocation and distributive justice in healthcare

There are significant differences between different countries in the way that resources are allocated for healthcare. Within a country, there can be inequalities in health due to lots of different factors, particularly demographics and socioeconomic status. As a result, most countries rely on a structured and ethical approach to making decisions, particularly with regard to resource allocation. There are different ethical approaches that can be taken.

Deontological – Harmful actions are unacceptable, even if overall the end result is a ‘net benefit’. This approach is very much centred on rules and duty.

Egalitarian – Built on the concept of social equality – all people are equal and deserve equal opportunities and rights. It is not the individual’s perceived or experienced healthcare need that is key, but instead, the objectively determined healthcare need that is central.

Libertarian – Here, the central focus is on the individual’s experienced healthcare needs – subjective. The view is that resources are available on a free-market basis – i.e. if someone is willing to pay for something, they should be able to access it.

Restorative – Providing greater opportunity to those with the least – e.g. people with lower incomes can access NHS dental care. In contrast, higher-income people are not prioritised as they can access private dental care.

Utilitarian – This approach focuses on outcomes. It holds that the correct choice is the one which will produce the greatest good for the greatest number. All patients are assumed to be equal and are considered equal, as are different conditions and treatments. The rights and best interests of the community/society are considered rather than primarily focusing on the best interests of that individual patient. The aim is to increase the health of the whole population.

The health beliefs model

The health beliefs model is a model of social cognition. It was originally developed in the 1950s by Hochbaum and Rosenstock to explain the failure of people participating in screening for disease. The model was further influenced by Janz and Becker, who published a paper in 1984 which suggested that cues to action’ should be included as an important factor.

The key components of the Health Beliefs Model are:

• • Perceived susceptibility – What someone believes about the risks of getting a disease or condition.
  • Perceived severity – How severe a person believes a condition might be.
  • Perceived benefits – How beneficial someone believes the medical advice is to reduce risk/impact.
  • Perceived barriers – Perceived barriers between intervention and person, e.g. time, financial cost, psychological stress.
  • Self-efficacy – How confident someone feels in taking the advised action.
  • Expectations – Sum of perceived benefits, barriers and self-efficacy.
  • Cues to action – How to prompt someone to take action and engage with the intervention.
  • Demographic and socioeconomic factors.

The transtheoretical model (TTM)

The transtheoretical model (TTM) is a theoretical model of behaviour change involving an individual progressing through six stages. It was developed by Prochaska and DiClemente in the late 1970s. The original research examined smokers and their differing abilities to quit.

Six stages of change

1. Precontemplation – No intention to take action in the foreseeable future (next 6 months). They are unaware that their behaviour produces negative consequences.
2. Contemplation – Might take action in the next 6 months. They recognise their behaviour as having negative consequences but might still be unsure about changing their behaviour.
3. Preparation – Intends to take action soon, in the next 30 days, and has taken some steps in the direction of changing their behaviour.
4. Action – They have changed their behaviour for less than 6 months and intend to keep going.
5. Maintenance – Changed behaviour for over 6 months and intends to continue.
6. Termination – No temptation to relapse.

The 10 processes of change

For someone to progress through all 6 stages of change, they need strategies and to use them to change their behaviour. The 10 processes of change helps us understand how these changes in behaviour occur and how the progression through the six stages is maintained.

1. Consciousness-raising – Finding and learning facts and ideas to help support the new behaviour change.
2. Dramatic relief – Experiencing and accepting the emotions that come with a change in behaviour – fear, anxiety, or hope.
3. Self-reevaluation – Understanding that the behaviour change is part of who that person wants to be/become.
4. Environmental reevaluation – Appreciating how the old/unhealthy behaviour affects others around them.
5. Social liberation – Appreciating that society is changing to be supportive of the new behaviour.
6. Self-liberation – Making the commitment to change.
7. Helping relationships – Having relationships with people who support the change.
8. Counterconditioning – Using substitutes for the old behaviour, which are healthier.
9. Reinforcement management – Increasing the rewards for the new behaviour and reducing rewards for the old behaviour.
10. Stimulus control – Removing reminders or cues that encourage the old behaviour / using reminders or cues for the healthy behaviour.

In addition to the 10 processes of change, the individual who is trying to change their behaviour also needs an awareness of decisional balance and self-efficacy. Decisional balance constitutes weighing up the pros and cons of changing that behaviour. Self-efficacy constitutes the balance between the confidence of that individual to engage in the new behaviour, even in challenging situations, vs the temptation to re-engage in the old behaviour.

References

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