Table Of ContentAn Outline of
Psychology
as applied to Medicine
John Weinman BA PhD
Reader in Psychology,
Unit of Psychology as applied to Medicine
Guy's Hospital Medical School
London
Second Edition
WRIGHT
1987 Bristol
© John Weinman, Unit of Psychology as Applied to Medicine,
Guy's Hospital Medical School, London SE1 9RT. 1987.
All Rights Reserved.
No part of this publication may be reproduced,
stored in a retrieval system, or transmitted
in any form or by any means, electronic,
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otherwise without the prior permission
of the Copyright owner.
Published under the Wright imprint by
IOP Publishing Limited,
Techno House, Redcliffe Way,
Bristol BS1 6NX, England.
First edition, 1981
Reprinted, 1982
Second edition, 1987
British Library Cataloguing in
Publication Data
Weinman, John
An outline of psychology as applied to
medicine.—2nd ed.
1. Psychology 2. Medicine and psychology
I. Title
150'.2461 BF131
ISBN 0 7236 0890 3
Typeset by
Activity Limited, Salisbury, Wiltshire
Printed in Great Britain by
The Bath Press, Lower Bristol Road, Bath BA2 3BL.
To My Family
Preface to the Second Edition
In planning the changes for the second edition,
I have been guided by feedback from students
and colleagues both in deciding on what
changes to make to the original volume and in
selecting new areas for inclusion. I have tried
to improve the format of the book by clarifying
the text where necessary and by a better use of
subheadings and spacing. Many topics have
been brought up to date by including
references to more recent developments both
in the text and in the recommendations for
further reading at the end of each chapter. In
addition, a number of other topics, which
either were missing from the first edition or
have developed mainly since that time, are
now included. Thus there are new sections on
psychological influences on the immune
system and on psychological approaches to
the management of pain, stress-related
disorders and stressful medical procedures.
Two chapters have undergone major
structural changes. The chapter on
Ooctor-patient communication' in the first
edition is now entitled 'Patients and doctors'
and begins with a consideration of health
attitudes and behaviour prior to outlining
more specific communication issues. The
chapter on 'Coping with illness and handicap'
replaces the one on 'Psychological reactions to
physical illness and handicap' and focuses on
the processes involved in coping with physical
illness and with chronic and terminal illness.
Finally, the last chapter now has an enlarged
section on cognitive approaches to treatment
and ends with an outline of counselling and its
applications.
The changes which have been made reflect
the major developments in the field of
psychology as applied to medicine and the
emergence of 'health psychology' as a
separate and substantial specialty. Since
health psychology is concerned with the
psychological aspects of health and illness, it
is hoped that this book will provide both a
starting point and a framework for the reader.
J. W.
Preface to the First Edition
Psychology is the discipline concerned with
the study and understanding of human
behaviour. In recent years it has become an
important part of the curriculum for students
of medicine and allied health disciplines. This
book is intended to provide an outline of the
subject for the benefit of those students. In this
book I have therefore tried to integrate basic
and applied areas by including psychological
topics which can be related to medicine as well
as looking at psychological aspects of clinical
issues. Although the earlier chapters tend to
cover the basic topics and the later ones the
clinical areas, there is deliberately a great deal
of overlap. Wherever appropriate, clinical
applications are used to illustrate so-called
basic topics and areas of basic psychology are
elaborated to clarify and augment the more
clinical sections.
References to research findings are supplied
in the text. The use of these will be found to be
variable between the chapters in that some
sections lend themselves to the presentation
of a fair amount of experimental evidence
whereas in others a general description of the
key issues seems more appropriate.
Recommendations for further reading are also
given at the end of each chapter and these will
allow the interested reader to pursue any of
the topics in greater depth.
Many areas in psychology can appear
complicated, controversial or even poorly
resolved. I have attempted to look at some of
these areas and to examine the evidence
critically so that the reader can be aware of the
current 'state of the art' rather than be
presented with an over-simplified view of the
issues. Thus this book has been written in the
belief that the reader will welcome being given
an insight into current issues as well as
complexities inherent in attempting to
understand human behaviour.
J. W.
Acknowledgements
This book originally emerged from a course in
psychology for medical students which began
at Guy's Hospital Medical School twelve years
ago. I am indebted to many students who have
provided invaluable feedback not only about
the course but also on the first edition of this
book. Many colleagues also offered very
useful advice and information for the first
edition as well as helpful comments for
preparing this edition. In particular David
Armstrong has continued to provide
encouragement and critical discussion.
I would like to thank the following for the use
of diagrams and tables which appear in the
book: Plenum Publishing Co. for Fig. 2; Van
Nostrand Reinhold Co. for Fig. 3; W. H.
Freeman and Co. for Figs. 5 and 12; Churchill
Livingstone for Figs. 6 and 14; Dr C. M. Hawkes
and Medical Education for Fig. 15; British
Journal of Orthodontics for Table 3.
Many thanks are also due to Carol
Butterfield for typing the manuscript so
capably and to Tony Hale for drawing the
cartoons. Finally, Mary Anne, Anna and
Jonathan deserve my warmest thanks for
supporting and putting up with me while I
struggled to turn my thoughts into words.
1
Psychology and medicine
In the first part of this chapter there is an attempt to outline the different
ways in which psychology can relate to medicine. Following this there is an
account of the mechanisms which mediate pain perception. The decision to
include a discussion of pain mechanisms in this opening chapter has been made for
two reasons. First, it is a fundamental topic in medicine and one in which a
psychological perspective forms an integral part. Second, it provides a clear
example of the limitations of adopting a narrow biological approach to health and
disease. Thus the analysis of pain perception will be used to demonstrate the
importance of considering psychological and biological approaches in conjunc-
tion.
• 1.1. Psychology in relation to medicine
Psychology is concerned with understanding human behaviour and as such
is inextricably bound up with the practice of medicine. In many ways psychology
can be seen to have a more diverse relevance to medicine than the traditional
preclinical sciences and because of this it is sometimes difficult to grasp an overall
picture of the contributions which can be made. Five fairly distinct but
nevertheless related areas of relevance can be identified and the reader might find
such an overview useful before proceeding with the other sections. These five
areas are:
a. Changes in behaviour associated with such factors as ageing, psychiatric
illness and neurological impairment.
b. The role of psychological factors in the aetiology of medical problems.
c. Doctor-patient relations.
d. The patient's response to illness and treatment.
e. Psychological approaches to treatment.
Each of these areas is covered in detail in different sections of the book but
in this introductory chapter a brief summary of each is presented.
a. Changes in behaviour
Identifying signs and symptoms is a basic part of diagnosis and for a wide
1
2 An outline of psychology
range of problems this may involve recognizing changes in behaviour. Psychiatric
patients occupy the largest number of all hospital beds and it can also be argued
that, in the majority of general practice patients, there is a significant
psychological component in their illness. Also many of the disorders of
development and ageing, as seen by paediatricians and geriatricians respectively,
are characterized by changes in such aspects of behaviour as impairments of
speech, learning or memory. Perhaps the most striking examples of changes in
behaviour are those seen in neurology and which arise from damage to localized
brain regions. These areas in medicine, in which the observation of behavioural
change is central, should serve to illustrate the importance of understanding
1
aspects of 'normal behaviour and the relation between neurological structure and
function as a basis for investigating and dealing with certain disorders.
It might be thought from the foregoing discussion that this area of
relatedness is directly parallel to the relation between, for example, anatomy and
surgery in that the understanding of 'normal' functions serves as a basis for dealing
with pathologies. Such a conclusion is only partly acceptable since the relation
between normality and abnormality in behaviour is neither agreed nor clear-cut.
For neurological disturbances of behaviour, a knowledge of psychological
processes can be of direct value in understanding the nature of the dysfunction.
For example, the sometimes dramatic losses of memory which can follow on from
damage to certain brain regions can be more clearly understood with reference to
unimpaired memory processes. However, the relation of normal to abnormal
cannot really be extended to psychiatry in such a clear way.
Many people imagine that psychiatric illness is abnormal in the sense that it
falls far outside the realm of normal everyday behaviour and is therefore easily
defined. While this may be true for a small number of bizarre psychological
problems, many of the problems seen by psychiatrists or clinical psychologists
comprise aspects of behaviour which many people show or feel at times. Anxiety
and depression constitute two of the commonest psychiatric problems, yet just
about everyone has experienced both of these to some degree at some time. Also
there is no clear 'normal' state in relation to the clinical entity of depression and
which corresponds to the way in which one might describe normal lung function in
relation to a lung disorder such as bronchial asthma.
It is important to bear these points in mind because problems of behaviour
do not simply separate off in a simple and universally agreed way from so-called
'normal' behaviour. Normal behaviour is largely socially defined and so
definitions of abnormal behaviour vary from generation to generation and from
culture to culture. As we shall see, psychological problems are not purely defined
by changes within the individual but will depend on the context within which they
occur and the ability of the individual to cope. Moreover, with many psychological
problems, subjective rather than objective criteria may be used for defining
problems.
The first nine chapters of this book present aspects of 'normal' behaviour.
Chapters 2-4 are concerned with basic behavioural processes and their
neuroanatomical substrates. Chapter 5 examines the nature of emotion and stress
together with the links between associated physiological and psychological
processes. Individual differences in personality and intelligence are described in
Chapters 6 and 7 while the changes in behaviour which accompany child
development and ageing are outlined in Chapters 8 and 9. In addition to
