Overview and Description
The term “illness behavior”, originally coined by sociologist David Mechanic in 1962, describes the manner in which individuals perceive, evaluate, and act on physical or observable changes in their health. The concept explains how psychosocial influences affect the way people define and interpret their symptoms, identify with their disabilities, and seek help from professionals. Illness behaviors can vary over time and across health conditions and reflect the person’s psychological state and the broader socioeconomic and cultural context in which they exist.1 Illness behaviors encompass coping mechanisms, which can be either adaptive or maladaptive. Adaptive coping strategies are beneficial and promote long-term well-being, while maladaptive coping strategies are detrimental and can lead to negative outcomes.2 In the clinical setting, distinguishing adaptive from maladaptive coping mechanisms and accurately identifying which coping mechanisms a patient is using is imperative for developing an effective treatment plan. Various adaptive and maladaptive coping behaviors are listed in table 1.3
Table 1: Adaptive and Maladaptive Coping Behaviors3
Adaptive Coping Behaviors | Maladaptive Coping Behaviors |
Active Coping | Passivity |
Social Support | Avoidance or Denial of Illness |
Patient Optimism | Hyperrationality |
Humor | Rumination |
Positive Cognitive Appraisal and Acceptance | Catastrophizing |
Planning | Substance Use |
Relevance to Clinical Practice
Research shows that psychological well-being is associated with reduced likelihood of symptom onset and a slower rate of disease progression.4 This is thought to be mediated at least in part by the promotion of healthy behaviors and positive psychosocial and coping responses. Cohort data on a large sample of the U.S. population found that each standard deviation increase in reported psychological well-being resulted in 11% reduction in risk of stroke and 26% reduction in risk of heart failure.4 Health similarly modulates psychological well-being.5 Patients with chronic diseases are at higher rates for depression as well as more severe forms of depression and anxiety.5 While the prevalence of major depressive disorder in the general population is 3.7-6.7%, the prevalence of depression accompanying chronic illness is substantially higher: estimated 5-10% in hospitalized patients and 9-16% in the community.6 In order to care for patients as a whole, physical and psychological aspects of health must be addressed concurrently.
The term “psychologically informed healthcare” is an interdisciplinary model that centers the patient and their experiences. Psychology can be integrated into healthcare directly via traditional psychological care or indirectly, in which a psychologist supports other healthcare providers in delivering care in a psychologically informed way.7 Indirect psychologically informed healthcare has been growing steadily in recent years. This approach has a wider reach and cultivates the adoption of psychological principles into healthcare. An example of psychologically informed healthcare is the training of physiotherapists to assess psychological risk factors in patients with acute or chronic pain.7 Multidisciplinary management should be considered based on each individual patient’s needs. Additional resources that may be considered include medication management, psychiatry, social work, or comprehensive pain management programs.7
What is “abnormal” illness behavior?
“Abnormal” illness behavior describes an inappropriate or maladaptive mode of experiencing, perceiving, evaluating or responding to one’s own state of health. This term was initially usedto characterize syndromes of excessive or inadequate response to symptoms, including hypochondriasis, somatization, and denial of illness.8 Abnormal illness behavior can be likened to overreacting or misinterpreting symptoms, even when there is no significant medical reason to do so, potentially impacting quality of life and daily functioning. While the term can be useful for characterizing a type of maladaptive behavioral response, it is important to acknowledge the shortcomings of this terminology. The term suggests a dichotomy between normal and abnormal when in reality a range of behaviors exist that is highly individualistic and variable.2 It is important that providers understand the illness’s pathology and its implications for the patient, while acknowledging that patients may display a diverse set of emotional and physical reactions as a result of or in reaction to their condition.
Steps to address illness behavior
Assess the patient’s perception of their disease
It is important to assess the patient’s perception of their condition, which is an integral first step in building rapport and beginning care. This can be done by asking a patient to explain their illness in their own words. Asking patients how they view their illness allows practitioners to identify areas of potential misunderstanding.9 Multiple reviews have shown that illness perception greatly affects health outcomes in patients with chronic conditions.10 Recovery from acute illness or adjustment to chronic illness in part depends on effective self-management behaviors. A common maladaptive behavior seen in patients with chronic illness is catastrophizing, or a perception of a diagnosis being worse than it actually is, which can enhance impairments related to the diagnosis.11
Understand patient coping responses
Coping is an emotional experience dependent on conditioning, disposition (e.g., personality, long-standing behaviors), comorbid mental health (e.g., depression, post-traumatic stress), and situation.12 It is important to recognize that illness behavior is directed at coping with the predicament, not just the disease.12
Identifying coping strategies as passive or active is helpful for predicting outcomes. Passive coping strategies are defined as those that allow the person to disengage with the stressor by avoiding or denying, and active coping strategies are defined as ways to engage with the external world by relying on internal resources. Passive coping methods include distraction or mental disengagement, such as occurs by watching television, or passively waiting for the symptoms to subside without tangible action. Active coping methods include exercise, creative expression, and engaging in relaxation, mediation, or mindfulness.13 Active coping strategies are consistently associated with lower pain ratings, contrasted with passive coping strategies which are associated with poorer emotional well-being.13 Assessment of the patient’s use of relevant coping responses can inform healthcare and guide treatment plans. This is typically approached by history, interdisciplinary examinations, or structured instruments. Common assessment tools are listed in table 2.
Table 2: Tools for Assessing Patient Coping Responses
Assessment Tool | Description |
Pilowsky’s Illness Behavior Questionnaire | Consists of 62 yes/no items such as, “If the doctor told you that he could find nothing wrong with you, would you believe him?” |
Coping Responses Inventory | Assesses eight classes of health reactions to symptoms and diagnosis |
Anxiety, Depression, Coping (ADAF)Screening Tool | Screens for anxiety, depression, and coping mechanisms |
The Ways of Coping Questionnaire | A 66-item questionnaire that elucidates how people deal with internal or external demands of specific stressful encounters |
The Coping Orientation to Problems Experienced (COPE)Inventory | A questionnaire that assesses a broad range of coping responses. |
Address major situational factors
Situational factors are external influences that can affect a person’s behavior, actions, and decision-making in a given context. Examples of this include needing assistance with activities of daily living, lack of transportation, job insecurity, as well as problems with fertility and sexual intimacy, etc.
Socioeconomic status and physical and psychological health are closely linked.14 Research suggests that people with job insecurity are more likely to experience mental illness, chronic pain, poor health, and high-risk behaviors.14 Furthermore, jobs that involve manual labor may be associated with higher levels of psychophysiological stress. Medical mistrust prevalent in low-income communities is another social determinant of health that impacts timely utilization of healthcare services when illness presents.15
Treating the patient as a whole person who lives a full and complex life allows for conversations about these situational factors. It is imperative that physicians keep open lines of communication with patients, connect patients to resources and specialists when indicated, and provide support as needed.
Provide coping tools
Clinicians should consider a patient’s various medical impairments and encourage healthy coping behaviors relevant to the specific clinical context.
Understanding how individual patients cope with various stressors is an essential step in working together to generate effective health-related coping responses. Developing a shared understanding and defining achievable goals recognized by the entire multidisciplinary healthcare team can support the patient in their coping response. Identifying maladaptive coping behaviors such as avoidance, substance abuse, or emotional numbness is equally important. Shifting the focus toward problem solving and creating an action plan can minimize misinterpretations and over testing and facilitate recovery.16
Health self-management and resilience
The ability of the patient to manage illness through an effective therapeutic plan is influenced by social and behavioral factors. When the clinician is able to align care goals with the patient’s personal goals, there is greater likelihood for patient buy-in and treatment compliance. Pre-existing beliefs may influence an individual’s receptiveness to new medical information. It is important that patients are able to understand how medical facts and information provided are pertinent to their own health conditions. How a patient reacts to health information can inform recommended coping strategies and self-management behavior. The option to utilize multiple coping mechanisms can support a patient in gaining a feeling of control and autonomy over their health.17 A major objective of cognitive-behavioral approaches is health self-management. The Common-Sense Model of Self-Regulation outlines the processes by which patients become aware of a health threat, navigate affective responses to the threat, formulate perceptions of the threat and potential treatment actions, create action plans for addressing the threat, and integrate continuous feedback on action plan efficacy and threat-progression.18
Adaptive coping fosters resilience. Resilience is defined as the person’s ability to cope with and effectively adapt to changed circumstances and continue to engage in meaningful activities and maintain quality of life. The Relational, Intrapersonal, Social and Environmental (RISE) Model of Resilience, is a framework that describes how intrapersonal factors (e.g., coping, personality), interpersonal characteristics (e.g., relationship quality and social support), and socio-ecological influences (e.g., accessibility, cultural attitudes) impact coping, which can be applied to both research and clinical practice. There are three primary classes of resilient outcomes: recovery (a “return to normal” following stressful experiences), sustainability (the extent to which sources of personal and social meaning in a person’s life are preserved), and growth (new learning that arises as a consequence of the stressful experience).19 Resilience helps people manage stress and uncertainty of current and potentially future health conditions while protecting against depression, anxiety, and other adverse mental health effects associated with illness.
Cutting Edge/Unique Concepts/Emerging Issues
The challenges of abnormal illness behavior
Maladaptive illness behaviors can impact the focus and length of a medical visit. Time consuming interactions may appear tangential to the medical purpose at hand, and the clinician may incorrectly perceive that the real source of patient distress is outside their scope. Limited time and support may be insufficient to positively impact a patient’s recovery or foster adaptive behaviors. A potential consequence is an inappropriate or premature conclusion that further use of medical resources is unnecessary because the problem is not medical, and further physician effort could be ineffective.
As an example, pain is a sensation that triggers fear and anxiety, driving behaviors like escape, avoidance, and adaptation that are crucial for survival. However, when pain becomes chronic, focus and motivation disproportionally shift toward pain-related stimuli. This shift can impair functionality, resulting in maladaptive patterns of fear, anxiety, and avoidance .16 Education on the physiologic and psychological processes that contribute to pain can improve physical performance as well as reduce pain and perceived disability.11
Another challenge is the impact of secondary gain on the development of maladaptive illness behaviors. Secondary gain is defined as advantages that occur secondary to the inciting illness or diagnoses. Types of secondary gain include but are not limited to: using illness for personal advantage, exaggerating symptoms, consciously using symptoms for gain, and unconsciously presenting symptoms with no physiological basis.20 Secondary gain is characteristically attributed to scenarios in which there are perceived financial rewards associated with disability.20 Psychosocial support and a holistic approach to patient care can help the physician understand whether the primary motivators are conscious or unconscious and how best to navigate a path forward that is ultimately therapeutic for the patient.
Comprehensive pain management programs: a model for comprehensive and interdisciplinary care
Comprehensive pain management programs have emerged address biological, psychological, and social factors involved in maintaining and exacerbating chronic pain. Typical programs use a biopsychosocial approach and interdisciplinary treatment programs to address all aspects of the pain experience. The treatment team often consists of physicians, psychologists or counselors, physical therapists, occupational therapists, case managers, and other health professionals. Nonpharmacologic treatments include pain education, cognitive behavioral therapy, physical therapy, and instruction in self-regulatory techniques. One unique feature is the intensive nature of the programs, with one program citing a schedule of 6 hours per day, 5 days per week, for four weeks. Outcomes are promising showing improvement in pain severity and interference of pain on function at 6-months and 1-year.21
Gaps in Knowledge/Evidence Base
Addressing illness behavior in disability
Arriving at a shared mental model of illness can be particularly challenging when there are concurrent cognitive, communication, and/or psychological impairments present. For example, chronic pain is frequently under-recognized and under-treated in individuals with limited communication, which can exacerbate physical and psychological distress.22 Identifying and promoting coping behaviors is similarly challenging. An interdisciplinary approach to diagnosis, counseling, and treatment is especially important in these circumstances. Further research is needed on illness behavior and outcomes in the setting of disability.
References
- Mechanic D. The concept of illness behaviour: culture, situation and personal predisposition. Psychol Med. 1986;16(1):1-7. doi:10.1017/s0033291700002476
- Institute of Medicine (US) Committee on Pain, Disability, and Chronic Illness Behavior; Osterweis M, Kleinman A, Mechanic D, editors. Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Washington (DC): National Academies Press (US); 1987. 8, Illness Behavior and the Experience of Pain. Available from: https://www.ncbi.nlm.nih.gov/books/NBK219238/
- Tan, Gabriel PhD, ABPP*; Teo, Irene MS†; Anderson, Karen O. PhD‡; Jensen, Mark P. PhD§. Adaptive Versus Maladaptive Coping and Beliefs and Their Relation to Chronic Pain Adjustment. The Clinical Journal of Pain 27(9):p 769-774, November/December 2011. | DOI: 10.1097/AJP.0b013e31821d8f5a
- Hernandez R, Bassett SM, Boughton SW, Schuette SA, Shiu EW, Moskowitz JT. Psychological Well-being and Physical Health: Associations, Mechanisms, and Future Directions. Emot Rev. 2018;10(1):18-29. doi:10.1177/1754073917697824
- Cho, Jinmyoung, Martin, Peter, Margrett, Jennifer, MacDonald, Maurice, Poon, Leonard W., The Relationship between Physical Health and Psychological Well-Being among Oldest-Old Adults, Journal of Aging Research, 2011, 605041, 8 pages, 2011. https://doi.org/10.4061/2011/605041
- Kim H, Kim SH, Cho YJ. Combined Effects of Depression and Chronic Disease on the Risk of Mortality: The Korean Longitudinal Study of Aging (2006-2016). J Korean Med Sci. 2021;36(16):e99. Published 2021 Apr 26. doi:10.3346/jkms.2021.36.e99
- Dekker J, Sears SF, Åsenlöf P, Berry K. Psychologically informed health care. Transl Behav Med. 2023 May 13;13(5):289-296. doi: 10.1093/tbm/ibac105. PMID: 36694354; PMCID: PMC10182422.
- Kirmayer, L. J., & Looper, K. J. (2006). Abnormal illness behaviour: physiological, psychological and social dimensions of coping with distress. Current opinion in psychiatry, 19(1), 54–60. https://doi.org/10.1097/01.yco.0000194810.76096.f2
- “Mind over Matter: Patients’ Perceptions of Illness Make a Difference.” Association for Psychological Science – APS, 24 Jan. 2012, www.psychologicalscience.org/news/releases/mind-over-matter-patients-perceptions-of-illness-make-a-difference.html.
- Lisbeth Frostholm, Eva Oernboel, Kaj S. Christensen, Tomas Toft, Frede Olesen, John Weinman, Per Fink,Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study, Journal of Psychosomatic Research,Volume 62, Issue 2,2007,Pages 129-138,ISSN 0022-3999, https://doi.org/10.1016/j.jpsychores.2006.09.003.(https://www.sciencedirect.com/science/article/pii/S0022399906004259)
- Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Arch Phys Med Rehabil. 2011;92(1):146-160. doi:10.1016/j.apmr.2010.09.021
- DeGood DE, Tait RC. Psychosocial Assessment: Comprehensive Measures and Measures Specific to Pain Beliefs and Coping. In: In D. C. Turk & R. Melzack (Eds.), Handbook of Pain Assessment. ; 2001:320–345.
- Little, B. (2018). Passive Coping Strategies. In: Zeigler-Hill, V., Shackelford, T. (eds) Encyclopedia of Personality and Individual Differences. Springer, Cham. https://doi.org/10.1007/978-3-319-28099-8_1867-1
- Wang J, Geng L. Effects of Socioeconomic Status on Physical and Psychological Health: Lifestyle as a Mediator. Int J Environ Res Public Health. 2019 Jan 20;16(2):281. doi: 10.3390/ijerph16020281. PMID: 30669511; PMCID: PMC6352250.
- Becker G, Newsom E. Socioeconomic status and dissatisfaction with health care among chronically ill African Americans. Am J Public Health. 2003 May;93(5):742-8. doi: 10.2105/ajph.93.5.742. PMID: 12721135; PMCID: PMC1447830.
- Bruce M, Lopatina E, Hodge J, Moffat K, Khan S, Pyle P, Kashuba S, Wasylak T, Santana MJ. Understanding the chronic pain journey and coping strategies that patients use to manage their chronic pain: a qualitative, patient-led, Canadian study. BMJ Open. 2023 Jul 25;13(7):e072048. doi: 10.1136/bmjopen-2023-072048. PMID: 37491089; PMCID: PMC10373679.
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- David A. Fishbain, Secondary gain concept: Definition problems and its abuse in medical practice, APS Journal, Volume 3, Issue 4,1994,Pages 264-273,ISSN 1058-9139,https://doi.org/10.1016/S1058-9139(05)80274-8. (https://www.sciencedirect.com/science/article/pii/S1058913905802748)
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Original Version of the Topic
Dinesh A. Kumbhare, MD, William Parkinson, PhD. Influence of psychosocial factors on illness behaviors. 10/22/2013.
Previous Revision(s) of the Topic
Sherry Igbinigie, MD, Stephanie Sneed, MD, and Matthew Igbinigie, BS. Influence of psychosocial factors on illness behaviors. 4/28/2017.
Stephanie Sneed, MD, Irvin Quezon, MD. Influence of Psychosocial Factors on Illness Behaviors. 10/21/2021
Author Disclosure
Aditi Mahajan, MEd
Nothing to Disclose
Laura Malmut, MD, MEd
Nothing to Disclose