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Symptom perception
Page 58 Black blue 58 HEALTH PSYCHOLOGY psychological adjustment was related to positive reinterpretation, seeking emotional support, not using substances and not venting emotions. Conclusion The results from this study provide support for the predicted association between cognitive variables (illness representations and coping) and level of functioning (psychological adjustment, well-being and dysfunction) in CFS. In addition, the results provide support for Leventhal’s self-regulatory model as illness representations were related to coping and a measure of outcome (level of functioning). However, because of the cross-sectional nature of the design it is not possible to say whether illness representations cause changes in either coping or outcome and as the authors conclude ‘only a prospective design can clarify some of these issues’. Problems with assessment This dynamic, self-regulatory process suggests a model of cognitions that is complex and intuitively sensible, but poses problems for attempts at assessment and intervention. For example: 1 If the different components of the self-regulatory model interact, should they be measured separately? For example, is the belief that an illness has no serious consequences an illness cognition or a coping strategy? 2 If the different components of the self-regulatory model interact, can individual components be used to predict outcome or should the individual components be seen as co-occurring? For example, is the appraisal that symptoms have been reduced a successful outcome or is it a form of denial (a coping strategy)? The individual processes involved in the self-regulatory model will now be examined in greater detail. STAGE 1: INTERPRETATION Symptom perception Individual differences in symptom perception Symptoms such as a temperature, pain, a runny nose or the detection of a lump may indicate to the individual the possibility of illness. However, symptom perception is not a straightforward process (see Chapter 12 for details of pain perception). For example, what might be a sore throat to one person could be another’s tonsillitis and whereas a retired person might consider a cough a serious problem a working person might be too busy to think about it. Pennebaker (1983) has argued that there are individual differences in the amount of attention people pay to their internal states. Whereas some individuals may sometimes be internally focused and more sensitive to symptoms, others Page 58 Black blue Page 59 Black blue ILLNESS COGNITIONS 59 may be more externally focused and less sensitive to any internal changes. However, this difference is not always consistent with differences in accuracy. Some research suggests internal focus is related to overestimation. For example, Pennebaker (1983) reported that individuals who were more focused on their internal states tended to overestimate changes in their heart rate compared with subjects who were externally focused. In contrast Kohlmann et al. (2001) examined the relationship between cardiac vigilance and heart beat detection in the laboratory and reported a negative correlation; those who stated they were more aware of their heart underestimated their heart rate. Being internally focused has also been shown to relate to a perception of slower recovery from illness (Miller et al. 1987) and to more health protective behaviour (Kohlmann et al. 2001). Being internally focused may result in a different perception of symptom change, not a more accurate one. Mood, cognitions, environment and symptom perception Skelton and Pennebaker (1982) suggested that symptom perception is influenced by factors such as mood, cognitions and the social environment. Mood: The role of mood in symptom perception is particularly apparent in pain perception with anxiety increasing self-reports of the pain experience (see Chapter 12 for a discussion of anxiety and pain). In addition, anxiety has been proposed as an explanation for placebo pain reduction as taking any form of medication (even a sugar pill) may reduce the individual’s anxiety, increase their sense of control and result in pain reduction (see Chapter 13 for a discussion of anxiety and placebos). Stegen et al. (2000) directly explored the impact of negative affectivity on both the experience of symptoms and attributions for these symptoms. In an experimental study, participants were exposed to low intensity somatic sensations induced by breathing air high in carbon dioxide. They were then told that the sensation would be either positive, negative or somewhere between and were asked to rate both the pleasantness and intensity of their symptoms. The results showed that what the participants were told about the sensation influenced their ratings of its pleasantness. The results also showed that although people who rated high on negative affectivity showed similar ratings of pleasantness to those low on negative affectivity they did report more negative meanings and worries about their symptoms. This indicates that expectations about the nature of a symptom can alter the experience of that symptom and that negative mood can influence the attributions made about a symptom. Cognition: An individual’s cognitive state may also influence their symptom perception. This is illustrated by the placebo effect with the individual’s expectations of recovery resulting in reduced symptom perception (see Chapter 13). It is also illustrated by Stegen et al.’s (2000) study of breathing symptoms with expectations changing symptom perception. Ruble (1977) carried out a study in which she manipulated women’s expectations about when they were due to start menstruating. She gave subjects an ‘accurate physiological test’ and told women either that their period was due very shortly or that it was at least a week away. The women were then asked to report any premenstrual symptoms. The results showed that believing that they were about to start menstruating (even though they were not) increased the number of reported Page 59 Black blue