Internal picture of the disease

Nature of laureate's internal picture of disease

The physician's position and the patient's position differ fundamentally. The physician investigates the alloplastic picture — the objective manifestations of a disorder that can be measured with instruments or detected using special methods. Meanwhile, the patient perceives the autoplastic picture (the IPD itself) — the subjective reflection of the illness.

For the patient, any disease acts as a threat to their basic needs, social status, and life. This threat inevitably triggers psychological defense mechanisms that reduce anxiety but often hinder a realistic assessment of the need for therapy. Three groups of factors influence the formation of the IPD:

• Core of the IPD (four levels of perception).
• External factors (alloplastic picture, reactions of others, current life situation).
• Internal factors (patient's personality, body schema, habitual coping strategies, and internal picture of health).

Four levels of attitude toward illness

The core of the internal picture of disease is traditionally divided into four interrelated levels:

1. Sensitive level. Based on physical sensations (pain, weakness, nausea). Due to individual pain thresholds, identical organic changes cause completely different feelings in different people (e.g., during childbirth). The absence of pain (in remission or when taking analgesics) does not mean a person considers themselves healthy, as the evaluation continues at other levels.
2. Emotional level. The overall affective impression of the illness. Symptoms may be perceived as a catastrophe, punishment, challenge, or even a gain. For example, a delayed menstrual period is a long-awaited joy for one woman, but a source of panic for another. In depression, negative emotions can become the sole manifestation of illness without organic causes.
3. Intellectual level. Logical evaluation of the situation based on knowledge and experience. Adults rely on their life experience (the death of a relative from lung cancer will cause a commonplace tracheitis to be perceived as a tragedy), media information, and medication leaflets. Children, however, judge danger primarily by the presence or absence of discomfort.
4. Behavioral level. The patient's actions in response to the disease. This may include active treatment-seeking, indifferent ignoring, or apathy with a passive wait for the end. The patient always compares the physician's prescriptions with their own internal beliefs about proper treatment (which sometimes leads to refusal of interventions, e.g., mastectomy for a small tumor).

Perceptual distortions and non-harmonious reactions

Patients often interpret their symptoms incorrectly, relying on a distorted subjective "body schema" (their own concept of anatomy). Any changes that do not fit into this schema (especially during puberty) cause fear.

Sometimes a fictitious internal picture of disease develops, where a person feels ill in the absence of real internal organ pathology. The causes include:

• Cenesthopathies (false, bizarre bodily sensations characteristic of mental disorders).
• Hypochondriasis (excessive anxiety and constant searching for illnesses).
• Incorrect interpretation of the norm (e.g., panic at a temperature of 37 °C).
• Malingering (conscious fabrication of symptoms for personal gain).

All non-harmonious reactions to illness are divided into two types: exaggeration of severity and its underestimation. Conscious distortions include malingering (fabrication), aggravation (exaggeration of real symptoms), and concealment (dissimulation).

Features of IPD diagnosis

To establish a trusting relationship and prevent iatrogenesis, the physician must ask the right questions that reveal the patient's subjective world.

Key questions to elicit the IPD:

• What do you think is wrong with you? (Uncovers bizarre ideas and misconceptions).
• What specifically prompted you to see a doctor? (Pain, demands from superiors, decreased work capacity).
• Describe your sensations in your own words, without medical terms. (An excellent test for malingering: malingerers often use memorized bookish phrases).
• What do you expect from recovery, and what treatment methods do you consider unacceptable? (Helps assess the realism of expectations and prevent treatment refusal).
• Show me with your hand which part of the body bothers you the most? (For example, in depression, patients often point to the chest).

It is also extremely important to ask the patient to rank complaints from most significant to least significant, in order to prioritize what troubles them the most.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Internal picture of health and its impact on symptom perception
• Formation of the subjective "body schema" and its distortions during puberty
• Cenesthopathies and hypochondriasis as causes of a fictitious IPD
• Differences between aggravation, malingering, and dissimulation
• The role of coping strategies in shaping the behavioral level of the IPD

Other topics in the section "Chapter 30. Inner Picture of Disease. Psychosomatic Disorders"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.