The Illness is Me? Inclusion of Illness in the self and health-promoting behaviors among cardiac patients

The psychological toll of illness is doubled when the patient’s body is diseased. In addition to the pain and weakness of the handicapped body, the patient’s sense of self is shaken (Segal, 2018). The largest change seen in patients with a life‐threatening disease or chronic illness is the alteration of the individual's concept of self and a fundamental shift in the meaning, direction or purpose of one's life is necessary (Rasmussen et al., 2007). Research has shown that serious illness disturbs our perception of a planned, controllable world which was once taken for granted, leading to the breakdown of the normal experience of the self and the self in interaction with others (Bury, 1982; Frank, 1991; Kleinman, 1988; Good, 1994).

Until now, medical psychology has focused on how disease affects specific aspects of loss of self including self goals and the social self. Additionally, most research has been conducted on head trauma patients. An extensive search of the literature (including qualitative methods) failed to find additional research addressing the extensive disturbance to a person’s sense of self when diagnosed with a life threatening illness, nor with the ramifications of this disturbance. Therefore, the purpose of this current research is to pioneer an theoretical concept which encapsulates the human experience of disturbance of the sense of self during illness. Thus, this study will focus on an innovative theoretical concept “the inclusion of the illness in the self” which expresses the extent to which the disease takes over the identity of the patient. Because this concept has not been studied before, this research is based on research of the similar concepts of identity and perception of illness. In addition to the theoretical innovation of this study, the study also establishes an empirical tool for measuring the concept. This measure consists seven pairs of circles, where one circle represents the self and the second represents the disease. The patient is asked to choose between different amount of overlapping.

This research will focus on heart disease patients as a case study. Heart disease is a chronic, life threatening illness in which patients are at increased risk for relapse and premature death. Unlike other diseases which are treated with various medications and procedures, heart disease requires behavioral, lifestyle change. This required lifestyle change helps us to effectively identify how inclusion of illness in the self contributes to better or worse coping with the disease.

This innovate new theoretical variable was first analyzed for interactions between IIS and the following variables: sociodemographic and medical background, anxiety and depression. IIS’s contribution to health promoting behaviors in HD patients was then examined.

The relationships between IIS and sociodemographic and medical background were checked using exploratory data analysis. We expected to find a positive correlation between the two mental health variables (anxiety and depression) and IIS with elevated levels of anxiety and depression associated with raised levels of IIS. We anticipated that there would be a curvilinear relationship between health promoting behaviors and IIS such that patients with either low and high scores (compared to average ratings) in IIS would report less smoking cessation, less medication adherence, and would less frequently join rehabilitation programs.

This quantitative, correlational research was partially based of a database of a longitudal prospective study of male heart disease patients and their wives. 143 men between the ages of 33-85 cohabiting with their romantic partner, with a diagnosis of Ischemic heart disease (ACS, MI, UA) or cardiac arrest (CA) who are treated in the cardiac intensive care unit at Sheba hospital in Tel Hashomer, signed informed consent forms and participated in this study. Patients were questioned in two stages: during hospitalization and four months later in the patient’s house. 3 types of health promoting behaviors were measured: smoking cessation, medication adherence, and joining a rehabilitation program. Medical and demographic background were extracted from the patient’s medical file. IIS and mental health variables (anxiety and depression) were measured in both stages. Data analysis was completed using correlation analysis, chi-squared tests, and logistic regressions.

The following results were found: patients who reported high levels of IIS in time 1 were, on average, younger, belonged to a lower socio-demographic level, and had a family history of heart disease. As per this research’s hypothesis, a positive correlation was found between high IIS in both measurements and mental health variables. Patients who reported high inclusion of illness in the self also reported elevated depression and anxiety levels. No significant relationships were found between health promoting behavior and IIS.

This research contributes to our understanding of identity when facing disease. Our results point to a connection between IIS and both anxiety and depression. When the disease engulfs larger parts of the patient’s self-identity, mental health declines. Conversely, when patients suffer from elevated depression and anxiety levels, the probability of greater inclusion of the illness in the self increases.

From a clinical perspective, we recommend that teams of psychologists and social workers identify patients for whom the illness has taken over a large part of their identity and intervene by helping them find relief from the depression and anxiety in the hopes of restoring a healthier, more normative balance between the disease and the self.