Abstract
The measures of disease status alone are insufficient to describe the burden of illness or one’s attitudes toward illness and life. The subjective health status including psychological resources and well-being is as valid as that of the clinician when it comes to evaluating outcomes. The aim of this chapter is to provide a theoretical framework for the assessment of psychological well-being and positive functioning and to review the literature supporting the influence of these positive dimensions on illness development and health protection. We selected the assessment tools such as Kellner’s Symptom Questionnaire, Antonovsky’s Sense of Coherence, Ryff’s Psychological Well-Being Scales and Psychosocial Index that we found most helpful in clinical and psychosomatic practice and that displayed clinimetric properties of sensitivity in research.
A considerable body of evidence has accumulated in psychosomatic medicine related to both psychosocial correlates of medical disease, such as quality of life (QoL), and psychosocial factors affecting individual vulnerability, such as psychological well-being [1]. The measures of disease status alone are in fact insufficient to describe the burden of illness or one's attitudes and psychological resources toward illness and life. The subjective health status including well-being, demoralization, difficulties fulfilling personal and family responsibilities, is as valid as that of the clinician when it comes to evaluating outcomes [2‒5]. These are not new concepts. In 1948, the World Health Organization defined health as a ‘state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ [6]. On the other hand, early experts in psychosomatic realm, such as Kissen [7], Engel [8], and Lipowski [9] suggested the importance of evaluating the complexity of clinical phenomena [10]. Kissen [7] clarified that the relative weight of psychosocial factors may vary considerably from one individual to another within the same illness, and underscored the basic conceptual flaw of considering diseases as homogeneous entities. Engel developed a biopsychosocial model of illness [11] resulting from interacting systems at the cellular, tissue, organismic, interpersonal and environmental levels. In Engel's view, the study of the diseases must then include the individual, his/her body and his/her surrounding environment as essential components of the total system [11]. In the same vein, Lipowski [9] underlined the importance of studying the relationships of biological, psychological and social determinants of health and disease. Thus, researchers recognized the need for multiple indicators in assessing health and treatment outcomes [12‒15]. The area of research that has resulted from this recognition is termed ‘health related quality of life’ [16]. Research in this field seeks essentially two kinds of information: the functional status of the individual and the patient's appraisal of health [2]. The model proposed by Wilson and Cleary [17] is an example of a classification scheme for different measures of health outcome. The authors divided these outcomes into five levels: biological and physiological factors, symptoms, functioning, general health perceptions, and overall QoL. The concept of QoL is substantially based on the classic psychosomatic concept of disease: ‘How a person experiences the pathological process, what it means to him, and how this meaning influences his behavior and his interaction with others are all integral components of disease viewed as a total human response’ [18]. Even though the concept of QoL has rapidly become an integral variable of outcome in clinical research, it is often difficult to know what is being measured since there are no agreed criteria for what constitutes QoL, and such instruments lack validity [14]. As a result, skepticism remains about its usefulness in medical research [19].
The central document of health promotion, the Ottawa Charter [20], introduced the concept of ‘good quality of life’, paving the way to research and clinical developments in psychosomatic medicine. The document declared that health promotion is the process of enabling the individuals to increase control over and to improve their health in order to reach a state of complete physical, mental and social well-being and to lead an active and productive life, that is, a good QoL [20]. This means that individuals must be able to identify and realize aspirations, as well as to satisfy needs and cope with their environment [21]. The direction is clear, that is, to focus on health rather than disease [22, 23]. The essence of the Ottawa Charter harmonizes well with the philosophy behind the salutogenic theory introduced by Antonovsky in 1987, focusing on resources for health and health-promoting processes [24]. He describes a state of health and well-being, characterized by the presence of competence, internal and external resources and active use of coping strategies. Antonovsky introduced the salutogenic concept of ‘Sense of Coherence’ (SOC) [24, 25]. He was intrigued by the question why some people, regardless of major stressful situations and severe hardships, stay healthy while others do not. According to Antonovsky, these people have a certain life orientation, precisely called sense of coherence, which helps them dealing and coping with external stressors. SOC refers to an enduring personal attitude and measures how people view life and, in stressful situations, identify and use their resources to maintain and develop their health. It consists of at least three dimensions: comprehensibility, manageability and meaningfulness. A large body of research has documented how SOC is strongly related to perceived health, especially mental health, and is an important contributor for health maintenance [26]. Along the same line, Ryff and Singer [27] proposed the concept of ‘positive human health’, which refers to a comprehensive - holistic consideration of health, where stressors but also positive resources are taken into account. Accordingly, health is maintained by good health habits (i.e. good nutrition, regular physical activity, no smoking, or use of drugs and other risky habits) and by the presence of emotional and psychological well-being. Ryff and Singer [28] have suggested that, by an etiological point of view, the presence of stress and negativity as well as the absence of well-being work together to influence human health. The absence of positivity represents a vulnerability factor, whereas the presence of well-being and flourishing can be considered a protective factor in case of adversities. There is substantial evidence [28‒30] that psychological well-being is an important contributor to general QoL and it plays a buffering role in coping with stress. Psychological well-being has a favorable impact on disease course, and important immunological and endocrine connotations. For instance, maintenance of psychological well-being following the onset of breast cancer implies longer survival time [31], whereas impaired well-being tends to shorten it [32]. Other examples may be concerned with the role of optimism and coping style in transplantation outcome [33], anxiety and hope in the course of medical disorders [34], and the relationship between life satisfaction and cardiac variables [35, 36].
The aim of this chapter is to provide a theoretical framework for the assessment of psychological well-being and positive functioning and to review the literature supporting the influence of these positive dimensions on illness development and health protection. We selected the assessment tools that we found most helpful in clinical and psychosomatic practice and that displayed clinimetric properties of sensitivity in research [37, 38].
Relationship between Well-Being and Symptomatology: Kellner's Symptom Questionnaire
In a naive conceptualization, yet the one implicitly endorsed by DSM-IV, well-being and distress may be seen as mutually exclusive (i.e. well-being is lack of distress). According to this model, well-being should result from removal of distress. Yet, there is evidence, both in psychiatric [30, 39, 40] and psychosomatic research [29, 41], to call such views in question. Early in the 1980s Robert Kellner developed a simple, self-rated questionnaire to be used in psychiatric and psychosomatic settings, for assessing both symptomatology and emotional well-being and their relationship. Kellner's Symptom Questionnaire (SQ) [42] (see online suppl. appendix) is a self-report questionnaire which originates from Symptom Rating Test [43], but is simpler and briefer than the previous version (i.e. it contains single word items instead of questions). The total number of items (92 items) has been increased in order to improve scale's sensitivity [44]. Responders should answer yes/no or true/false to the item, instead of measuring frequency and severity of symptoms. The main novelty introduced by Kellner is the presence of items assessing emotional well-being. They were introduced to obtain a more complete evaluation of patients’ clinical status and improving scales’ internal consistency. The final SQ version yields 4 principal scales: Anxiety, Depression, Somatization and Hostility-Irritability, which can be divided into 8 subscales: 4 symptom subscales (Anxiety, Depression, Somatization, Hostility) and 4 corresponding well-being subscales (Relaxation, Contentment, Physical well-being and Friendliness; see table 1)OSM
