Clinical Implications of Illness Denial

Abstract

Illness DenialPatient delay, usually defined as waiting more than 3 months to seek medical care, may be seen as an attempt to resolve or postpone the crisis brought on by suspicion of severe illness with all its negative implications. Denial is frequently thought to be the primary defense responsible for patient delay [1]. Illness denial is usually diagnosed through a thorough history and clinical examination, sometimes supported by semi-structured interviews or survey instruments.Patierno and colleagues [2] have made an important contribution to the literature on illness denial with their scholarly systematic review of the clinical importance of this health behavior in the setting of multiple diseases. Key among their findings are the following conclusions. Illness denial is a relatively common condition impacting a host of health attitudes and behaviors and resulting in a continuum of health consequences. This continuum involves on one end a health benefit that accrues from the enhanced coping that such an adaptive denial of distressing uncertainty provides. Adaptive denial early after symptom onset can be an appropriate psychological adaptation that titrates a person's stress level and aids in decision-making, resulting in presentation to the physician and adherence to recommendations. Adaptive denial can also be a health asset later in the course of a serious illness by dampening excessive health anxiety and thus mitigating the kind of toxic hyper-awareness that can promote symptomatology and iatrogenic complications. On the other end, excessive and prolonged illness denial can become maladaptive, delaying early diagnosis and treatment, impairing adherence, and disturbing selfmonitoring and self-care later in the course, with clear adverse health outcomes.The authors also discuss the need to operationalize the definition, diagnosis, and severity of illness denial and suggest for this purpose the use of The Diagnostic Criteria for Psychosomatic Research (DCPR) revised version [3]. In the revised DCPR, illness denial is one of 14 psychosomatic syndromes, along with allostatic load, type A behavior, alexithymia, hypochondriasis, disease phobia, thanatophobia, health anxiety, persistent somatization, conversion symptoms, anniversary reaction, demoralization, irritable mood, and secondary somatic symptoms.Many factors may play a role in the spectrum of attitudes that relate to illness perception and treatmentseeking behavior [4]. The severity continuum of adaptive to maladaptive denial mentioned above exists within another continuum, that of illness awareness, which moves from hypochondriasis and disease phobia on the engagement/approach end through health anxiety, delay in seeking treatment, lack of adherence to medical advice, and finally illness denial on the disengagement/avoidance end of the spectrum. It has been speculated that early in acute symptom perception, being on the health anxiety side of the spectrum and not on the patient delay side aids in detection and may lead to health benefits related to earl...