Howard Leventhal

Illness cognition: Using common sense to understand treatment adherence and affect cognition interactions

We summarize basic empirical themes from studies of adherence to medical regimens and propose a self-regulatory model for conceptualizing the adherence process. The model posits that self-regulation is a function of the representation of health threats and the targets for ongoing coping (symptom reduction, temporal expectancies for change) set by the representation, the procedures to regulate these targets, and the appraisal of coping outcomes. The underlying cognitive mechanism is assumed to function at both a concrete (symptom-based schemata) and abstract level (disease labels), and individuals often engage in biased testing while attempting to establish a coherent representation of a health threat. It also is postulated that cognitive and emotional processes form partially independent processing systems. The coherence of the system, or the common-sense integration of its parts, is seen as crucial for the maintenance of behavioral change. The coherence concept is emphasized in examples applying the model to panic and hypochondriacal disorders.

Findings and Theory in the Study of Fear Communications1

Publisher Summary This chapter reviews the empirical results and theoretical underpinnings of studies of fear arousing communications. It focuses on the interrelationship of emotional and instrumental behavior. The chapter presents an overview of the key components of fear communication experiments and introduces the two major theoretical paradigms that can be used to interpret the findings. The first and historically most important of the paradigms is the fear drive model, a variant of the classic drive reduction model used in many animal learning studies. It assumes that the emotional response of fear functions as a drive that mediates belief change and behavior change. The second paradigm was suggested by the experimental data. This model assumes that the communication produces both persuasion and fear; fear does not cause persuasion. The chapter reviews the evidence regarding interactions between the level of fear elicited by the communication and other factors such as personality variables and recommendation effectiveness. It reveals that the outcomes are often influenced by complex contingencies. But despite the complexity, serious effort has been made to identify empirical regularities and presents a theoretical model to provide conceptual integration.

The Relationship of Emotion to Cognition: A Functional Approach to a Semantic Controversy

Abstract We first review the main points in the dispute about whether emotion is primary and independent of cognition (Zajonc), or secondary and always dependent upon cognition (Lazarus), and suggest that the dispute is largely one of definition. Because definitional disputes seldom clarify substantive, theoretical points, we suggest a variety of questions regarding cognition-emotion interaction. To stimulate discussion of these issues, we propose a componential model in which emotions are seen to develop from simpler, reflex-like forms (“wired-in” sensory-motor processes) to complex cognitive-emotional patterns that result from the participation of at least two distinct levels of memory and information processing, a schematic and a conceptual level. These systems are typically activated by a continuous stimulus check process which evaluates five environment-organism attributes: novelty; pleasantness; goal conductiveness; coping potential; and consistency with social norms and self-relevant values. Questi...

Common-Sense Models of Illness: The Example of Hypertension

Our premise was that actions taken to reduce health risks are guided by the actors subjective or common-sense constructions of the health threat. We hypothesized that illness threats are represented by their labels and symptoms (their identity), their causes, consequences, and duration. These attributes are represented at two levels: as concrete, immediately perceptible events and as abstract ideas. Both levels guide coping behavior. We interviewed 230 patients about hypertension, presumably an asymptomatic condition. When asked if they could monitor blood pressure changes, 46% of 50 nonhypertensive, clinic control cases said yes, as did 71% of 65 patients new to treatment, 92% of 50 patients in continuing treatment, and 94% of 65 re-entry patients, who had previously quit and returned to treatment. Patients in the continuing treatment group, who believed the treatment had beneficial effects upon their symptoms, reported complying with medication and were more likely to have their blood pressure controlled. Patients new to treatment were likely to drop out of treatment if: they had reported symptoms to the practitioner at the first treatment session, or they construed the disease and treatment to be acute. The data suggest that patients develop implicit models or beliefs about disease threats, which guide their treatment behavior, and that the initially most common model of high blood pressure is based on prior acute, symptomatic conditions.

Behavioral theories and the problem of compliance

Abstract Capsule presentations are given of the 5 major theoretical approaches to compliance research (Biomedical; Behavioral — Operant and Social Learning; Communication; Rational Decision — Health Belief and Reasoned Action; Self-Regulative Systems) and brief summaries made of their respective contributions and deficits. Suggestions are made for integrating the Biomedical, Behavioral and Rational Decision models into the Self-Regulative Systems Model. The advantages for doing so include completeness of understanding and improved interventions; better integration of the natural history of illness with the individuals perception, understanding, and strategies for coping with illness; recognition of the separate contributions of automatic (habitual) and deliberative (reasoned) determinants of compliance; and the possibility of taking into account the uniqueness of individual understanding of illness and individual patterns of coping with illness. It is also suggested that the self-regulative approach helps to organize insights into the differences between compliance to behavioral measures for prevention and compliance to behavioral measures for cure.

Self-regulation, health, and behavior: A perceptual-cognitive approach

Abstract Self-regulation systems are designed to adapt to threats via coping procedures that make efficient use of resources based upon valid representations of the environment. We discuss two components of the common-sense model of health threats: illness representations (e.g., content and organization) and coping procedures (e.g., classes of procedure and their attributes - outcome expectancies, time-lines, dose-efficacy beliefs, etc.). Characteristics of each of these domains, and the connection between the two, are critical to understanding human adaptation to problems of physical health. Rather than posing a barrier to factors outside the person that control behavior, an emphasis on subjective construal involves a view of the person as an active problem-solver embedded in a bidirectional system of sensitivity and responsiveness vis a vis the social, physical, and institutional environments in which health threats occur and through which intervention efforts may be directed.

The common-sense model of illness representation: Theoretical and practical considerations

This article focuses on several areas. After reviewing the most commonly used approaches in the study of health behaviors, (e.g., the medical model, the health belief model, and the theory of reasoned action) the common-sense model is presented as an alternative. By presenting evidence across a wide range of illness domains, we demonstrate the usefulness of the common-sense, self-regulatory approach. We then discuss the importance of the common-sense model for health research among minorities. We conclude the article with examples of the operationalization of illness representations in past research and directions for future research.

Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population.

The cognitive and emotional determinants of health-care utilization were assessed for middle-aged and older adults matched on age, gender, and health status. Both members of a pair were interviewed when either initiated a medical visit. Interviews were based on a self-regulatory model that assumed that Ss would use symptoms to create and update representations and coping procedures. Care seekers reported more symptoms than did matched controls but did not report more symptoms than did matched controls with new symptoms. The mere presence of atypical symptoms was insufficient to trigger care seeking. Care seeking is driven by well-developed representations of a serious health threat, perceptions of inability to cope with the threat, advice to seek care, and life stress.

The Meanings of Self-Ratings of Health A Qualitative and Quantitative Approach

Self-ratings of health are central measures of health status that predict outcomes such as mortality and declines in functional ability. Qualitative and quantitative data are used to test the hypothesis that definitions of health that are narrowly biomedical are associated with underestimates of self-ratings relative to respondents’medical histories, while definitions that are broad and inclusive are related to relatively better self-ratings. A sample of 159 elderly African Americans rates their health and reports “what went through your mind.” Analysis of variance shows that respondents who overestimate their health are more likely to report ratings based on social activities and relationships, or psychological, emotional, or spiritual characteristics, rather than biomedical criteria. The authors conclude that inclusive definitions of health facilitate more positive self-ratings of health, given a fixed health status; methodologically, they conclude that this is a promising method for exploring self-ratings of health.

Gender differences in processing information for making self-assessments of health.

Objective This study proposes that women’s greater inclusiveness of various sources of information when making self-assessed health (SAH) judgments accounts for the finding that SAH is a weaker predictor of mortality in women than in men. Methods Data from a sample of 830 elderly residents of a retirement community and a 5-year mortality follow-up study were used to examine the bases for women’s and men’s reports of negative affect (NA) and judgments of SAH. The degree to which each health-related measure accounts for the SAH-mortality association in each gender group was examined. Results The findings support two possible explanations for the lower accuracy of SAH as a predictor of mortality among women: 1) In both men and women, NA is associated with poorer SAH, but in men, NA is more closely linked to serious disease in conjunction with other negative life events, whereas in women, NA reflects a wider range of factors not specific to serious disease. 2) Men’s SAH judgments reflect mainly serious, life-threatening disease (eg, heart disease), whereas women’s SAH judgments reflect both life-threatening and non–life-threatening disease (eg, joint diseases). Conclusions Women’s SAH judgments and NAs are based on a wider range of health-related and non–health-related factors than are men’s. This difference can explain gender differences in the accuracy of SAH judgments and may be related to other documented differences in women’s physical and mental health and illness behavior. The findings emphasize the need to study the bases of NA and other self-evaluations separately for women and men.