Models of adjustment to chronic illness: Using the example of rheumatoid arthritis

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Abstract

There are a number of theoretical frameworks that attempt to explain how individuals may adjust to threats to health and serious physical illness. The three major paradigms that attempt to organize key components of health and adaptation to illness include the following: the biomedical model which emphasizes disease; psychological models of adaptation to illness; and biopsychosocial models with the latter two emphasizing health, functioning, and well-being. Each of these three major paradigms, including biomedical, psychosocial, and biopsychosocial frameworks, is discussed and critiqued in turn, and contributions and theoretical issues in terms of adjustment to chronic illness, particularly rheumatoid arthritis (RA), are highlighted. Furthermore, a biopsychosocial framework for conceptualizing adjustment to physical illness is proposed that incorporates elements from key existing biomedical and psychosocial models of adaptation to chronic physical health issues.

Introduction

Dubos (1961) identified the complex nature of health and adaptation to illness when he likened our perception of health to a receding mirage. He went on to explain that from a distance, health and adaptation to illness appear to be a clear concept, but as researchers and clinicians approach and attempt to define it, the substance disappears. In fact, there are three major paradigms that attempt to organize key components of health and adaptation to illness which include the following: the biomedical model which emphasizes disease; psychological models of adaptation to illness; and biopsychosocial models with the latter two emphasizing health, functioning, and well-being Greenfield & Nelson, 1992, Larson, 1999. These three paradigms were selected for review as they are currently the predominant models of explanation of how individuals adjust to chronic physical illness in both research and clinical practice. Each of these three major paradigms, including biomedical, psychosocial, and biopsychosocial frameworks, is discussed in turn, and the contributions and theoretical issues in terms of adjustment to chronic illness. Rheumatoid arthritis (RA) was selected as a focus of the paper because it is a serious chronic medical condition, and is among the most common causes of musculoskeletal pain, estimated in community studies to affect 0.5–1% of the population Arnett et al., 1988, Lawrence et al., 1998, Wolfe et al., 1990. As well, RA is a good exemplar of physical illness as it involves obvious pathophysiological factors and psychosocial issues, which enables a close inspection of the strengths and limitations of each model of adjustment to chronic physical conditions.

Section snippets

Biomedical models of adjustment to illness including RA

The first scientific paradigm for health originated with development of the machine model of the human body. Descartes (1596–1650) saw the body as a homologue of the machine. Descartes considered illness to be both natural and occurring on an individual basis, and further recommended that investigation of disease be divided into understandable components rather than a holistic approach Kelman, 1975, Larson, 1999. The methodologies that developed from this view continue to dominate the practice

Psychological models of adaptation to illness

The acceptance that psychological factors may play a role in the etiology and course of serious illnesses, including rheumatic conditions, has been acknowledged only for half a century with the skepticism of the medical profession expressed by the prominent physician Arnott (1954 as cited in Larson, 1999) who said: “So far as I can see, this hypothesis [i.e., the role of psychological factors, especially stress, in disease progression] has no scientific credible basis whatsoever—in fact most of

The biopsychosocial framework of adaptation to illness

As previously detailed, there is a growing body of literature that suggests that psychological variables may indeed influence disease activity, and related physical adjustment variables, such as pain and disability, via neuroendocrine and immune pathways in healthy individuals and those with RA Affleck et al., 1987, Affleck et al., 1992, Burckhardt et al., 1997, Cutolo et al., 1999, Harrington et al., 1993, Jacobs et al., 2001, Kiecolt-Glaser, 1999, Martin et al., 1996, Nicassio et al., 1999,

A proposed biopsychosocial model of adjustment to RA as an exemplar of chronic physical illness

Based on research conducted to date, albeit disparate research, an integrated biopsychosocial model is proposed of how stressors may impact on disease activity and related physical functioning outcomes in rheumatic conditions (Fig. 3). For the purposes of this research, Lazarus and Folkmann's (1984) stress and coping paradigm is the theoretical framework of the proposed model of psychosocial and physical adjustment to RA as an exemplifier of chronic physical illness. The stress and coping

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