A chronic illness is defined as an illness that is enduring. The course of the disease may be progressive or characterized by symptom flare-ups and remissions. The unique feature of a chronic illness is that it is not reversible. It is long lasting, which distinguishes it from an acute illness, such as a cold or a flu or even appendicitis.
Two of the most common chronic illnesses in our culture, heart disease and cancer, are also the first and second leading causes of death. Heart disease is not considered curable or reversible, but is treatable. People who have coronary artery disease (blockages in the arteries that provide blood to the heart) are often treated with medication, coronary angioplasty, or bypass surgery. It is difficult to discuss cancer as a broad category of chronic illness because there are over 150 kinds of cancer. The most prevalent kind of cancer in men is prostate cancer and the most prevalent kind of cancer in women is breast cancer. Both are highly treatable because the majority are diagnosed at an early stage. The leading cause of cancer death in both men and women is lung cancer because it is typically diagnosed at a more advanced stage of disease and is less treatable. Common cancer treatments include surgery, chemotherapy, and hormonal therapy.
A large class of chronic illnesses are those in which the immune system attacks and destroys healthy tissue. In other words, the immune system cannot discriminate between tissue that belongs to the self and tissue that is foreign. These are known as autoimmune disorders. One autoimmune disease that has increased dramatically in our country since the 1980s is acquired immunodeficiency syndrome (AIDS), which caused by the human immunodeficiency virus (HIV), which destroys the white blood cells of the immune system. Early symptoms of HIV infection include a low-grade fever, fatigue, diarrhea, and rashes. When the virus has spread to the point of severe damage to multiple parts of the body, the person is said to have AIDS. AIDS is the end stage of HIV infection. HIV is thought to be terminal, meaning that there is no cure. However, treatments for HIV can prolong life, sometimes by more than 10 years.
Other common autoimmune disorders include lupus, arthritis, and multiple sclerosis. Systemic lupus erythematosus, or lupus, is a chronic inflammatory disease of the connective tissue (muscles, tendons) and is incurable. It affects multiple systems of the body and is accompanied by symptom flare-ups (e.g., achiness, fatigue, fever) but is generally not fatal. Arthritis affects one in seven Americans and there are more than 100 kinds of arthritis. Osteoarthritis is the most common form and involves the breakdown of cartilage and bones. It is a disease that increases in prevalence with age. Rheumatoid arthritis is the most severe form of arthritis and is manifested by an inflammation of peripheral joints (e.g., knees), pain, swelling, and stiffness. As it progresses, it may affect the heart and lungs. Multiple sclerosis (MS) is a progressive disorder of the central nervous system and results from the loss of the myelin sheath that surrounds neurons and facilitates neural transmission. People with MS vary in the severity of impairment from mild disabilities to a disabling form of the disease that requires use of a wheelchair. The cause of these autoimmune disorders is largely unknown.
Diabetes is an autoimmune disease that occurs when the immune system attacks the beta cells in the islets of Langerhans on the pancreas. Beta cells produce insulin, a hormone necessary for glucose metabolism. Someone with Type 1 diabetes must administer insulin on a daily basis because the body no longer produces any insulin. Someone with Type 2 diabetes may be able to control blood sugar levels through diet or medication because insulin production is impaired but not absent. There are long-term consequences of diabetes, including blindness, kidney disease, nerve disease (which may result in amputations), heart disease, and stroke. The management of diabetes by diet, testing, exercise, and medication influences whether these complications occur.
Chronic illnesses differ in controllability, predictability, severity, and progression. For example, the long-term complications from diabetes are amenable to personal control. The behaviors required to exert this control, however, are extensive (i.e., medication, exercise, diet). The disease course of breast cancer, by contrast, is much less amenable to personal control. Treatments may prolong life but there are not a set of behaviors that one can advise a patient to perform to keep the breast cancer from progressing. Chronic illnesses also vary in predictability. Many people with heart disease have symptoms of the disease, such as chest pain and shortness of breath, that would lead them to seek medical attention or signify disease progression. People diagnosed with breast or prostate cancer, by contrast, often feel healthy just prior to diagnosis and have few if any warning signs of the disease. Many illnesses naturally progress in severity over time, such as heart disease with age, but other illnesses, such as asthma, may remain stable over a long time.
These dimensions of chronic illness may influence how one adjusts to the disease psychologically as well as physically. A less controllable, less predictable, and more severe disease will be associated with greater emotional distress and more disruption to daily life. There are also characteristics of the person and the environment that influence psychological and physical adjustment to disease.
Personality and Chronic Illness
Personality characteristics can be grouped into vulnerability factors and resistance factors. One of the first vulnerability factors identified in the history of behavioral medicine was the Type A behavior pattern. People characterized as Type A are hard driving, impatient, and hostile. In large epidemiologic studies of healthy people, this behavior pattern prospectively predicted the onset of heart disease. In more recent years, researchers have learned that the toxic component of Type A is hostility (Williams, 1989). Depression is another vulnerability factor to disease. Depression has been most strongly linked to heart disease. A vulnerability factor, which has been associated with depression and also mortality, is the pessimistic attributional style. People who tend to attribute negative outcomes to internal, stable, and global causes while attributing positive outcomes to external, unstable, and specific causes are characterized by a pessimistic attributional style. This style has been examined from records of Harvard student interviews and newspaper quotes from baseball Hall of Famers and shown to predict poor health (Seligman, 1990).
One of the first resistance factors to disease identified was hardiness. Hardy people were characterized by the three c’s: a sense of commitment, control, and challenge (i.e., they view obstacles as challenges). Early research showed that hardy people were less vulnerable to illness during times of stress. More recent research has examined the separate components of hardiness. The construct of control has received a large amount of attention. People with a sense of personal control typically adjust better to chronic illness.
One theory about how people would adjust better to traumatic events, including chronic illness, is cognitive adaptation theory. According to cognitive adaptation theory (Taylor, 1989), people who have a high regard for themselves (positive self-esteem), an optimistic view of the future, a sense of personal control, and the ability to derive meaning from a negative experience adjust better to disease. This theory has been supported among women with breast cancer, people with heart disease, and men with HIV. Optimism is one component of the theory that has generated a research area of its own. Optimism has predicted quicker recovery from bypass surgery, fewer heart attacks during bypass surgery, and reduced mortality among people with cancer (Carver & Scheier, 1998).
Social Environment and Chronic Illness
The impact of the social environment on the onset of disease and adjustment to disease has been examined from three perspectives. First, measures of social networks have been calculated. This is a quantitative indicator of the number of social contacts and/or the amount of social contact one has. In epidemiologic studies, social network variables have predicted mortality (House, Landis, & Umberson, 1988). Second, the quality of people’s relationships has been studied and measures of their supportiveness examined. Typologies of social support include three core components: emotional, informational, and instrumental. Among these, emotional support has the strongest links to psychological and physical adjustment to disease. More recently, researchers have realized that not all relationships are supportive, and unsupportive interactions have been identified. When both positive and negative features of relationships are measured, the negative aspects are often stronger predictors of disease adjustment.
A third way that the impact of the social environment has been studied is from studies of support interventions. Peer support groups exist in communities for a wide array of chronic illnesses (e.g., cancer) or chronic strains (e.g., caregivers of Alzheimer patients). A review of group support interventions for people with cancer concluded that peer support groups with an education focus (i.e., informational support) were more effective than peer support groups with a focus on emotional support (Helgeson & Gottlieb, 2000).
The impact of personality factors and the social environment on disease depends on a host of factors, such as age, severity, and controllability of the situation. For example, some studies have found that personality variables are more strongly related to health among younger people (Scheier & Bridges, 1995). The stress-buffering hypothesis says that social support is only related to good health among people who are under high levels of stress (Cohen & Wills, 1985). There is some evidence that perceptions of personal control are more strongly related to positive health outcomes when situations are amenable to control. Thus, the etiology of chronic illness as well as the disease course and adjustment process are determined by multiple factors that cut across the mind, the body, and the environment.
- Carver, C. S., & Scheier, M. F. (1998). On the self-regulation of behavior. New York: Cambridge University Press.
- Cohen, S., & Wills, T. A. (1985). Stress, social support and buffering. Psychological Bulletin, 98, 310-357.
- Helgeson, V. S., & Gottlieb, B. H. (2000). Support groups. In S. Cohen, L. G. Underwood, & B. H. Gottlieb (Eds.), Social support measurement and intervention: A guide for health and social scientists, (pp. 00-00). New York: Oxford University Press.
- House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science, 241, 540-545.
- Scheier, M. E, & Bridges, M. W. (1995). Person variables and health: Personality predispositions and acute psychological states as shared determinants for disease. Psychosomatic Medicine, 57, 255-268.
- Seligman, M. E. P. (1990). Learned optimism. New York: Springer-Verlag. Taylor, S. E. (1989). Positive illusions: Creative self-deception and the healthy mind. New York: Basic Books. Williams, R. (1989). The trusting heart. New York: Times.
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