Psychological influences on the course of physical disease

The question of whether psychological factors are directly linked to the development or prognosis of physical disease is controversial, and difficult to study. Classing certain illnesses as 'psychosomatic' is no longer accepted, but psychological factors can certainly make an indirect contribution by their effects on lifestyle. Links include the following:

• Behavioural factors: patients with psychiatric illness or abnormal personalities are especially prone to:

- voluntary behaviour that endangers health, such as heavy smoking and drinking, and reckless driving

- poor compliance with medical management of disease; for example, delay in reporting new symptoms and failure to take tablets or follow lifestyle advice.

- all psychiatric disorders carry a raised mortality, with about 80 per cent of the excess being due to physical illness and about 20 per cent to accidents or suicide.

• Personality and attitudes: some research studies suggest that people who tend to repress their emotions, especially anger, have an increased risk of developing cancer. Other research suggests that patients with established cancer tend to live longer if they adopt a 'fighting spirit' stance against their illness than if their response is a 'helpless-hopeless' one. The validity of these associations remains disputed; there are difficulties in establishing the direction of cause and effect in studies of this kind, and behavioural factors such as degree of treatment compliance might account for any links which are found.

• Life events and social stress: mortality and morbidity increase after major adverse life events such as bereavement. This may reflect changes in behaviour, such as self-neglect or deliberate self-harm, or it might have a direct physiological basis, such as hormonal or immunological change.

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