There are a number of characteristics of an experience that increase the chances of it being appraised as threatening. These include immediacy, ambiguity, uncontrollability, or undesirability. The probability that many people will share an interpretation of a particular episode explains the similarity of people’s responses to certain illnesses. The possibility of individual, even idiosyncratic, interpretations can explain sharp differences between people with apparently the same disorder.

A useful way to construe individual appraisals of illness is outlined by Leventhal et al.⁽⁵⁾ in their theory of internal illness representations. The common elements of the illness representation can be identified from a simple self-report questionnaire⁽⁶⁾.

Illness beliefs cannot be assumed solely on the basis of the illness from which a person is suffering, or from his or her social context.⁽⁷⁾ Individuals may hold unpredictable beliefs—that an illness is inherited from a family member, or that it is a punishment for a misdemeanour, or that it may be curable by adopting an unusual diet. For some, the representation of illness overlaps with the representation of self, so that sufferers see themselves as living their illness rather than suffering from it.⁽⁸⁾ (see Box 5.3.1.1)

The characteristics of a particular disease are not the only component of the illness that can make it threatening. Illness occurs in a social and interpersonal context, and while the responses of other people may be helpful, they may in some cases contribute to the demands of the situation. For example, a partner may withdraw or become depressed, or family members may become intrusive or overcontrolling. Being ill confers a special status, the so-called sick role, but it is a status acquired at a cost in the loss of independence and certain rights. While disability may arise largely from the impairments caused by a disease, much handicap is socially determined.

The focus of secondary appraisal is twofold: the person’s personal resources, and the resources external to them, mainly in the immediate social network.

Personal resources may be defined in a number of ways, for example cognitive attributes, personal characteristics, or personality traits.

The other resource for the individual is social support. There are many approaches to understanding support, but a useful one⁽⁹⁾ is to regard it as having four components:

The family’s reaction to illness has an important impact on the type of support available. If they are rejecting, intolerant of dependence, or unsympathetic to the needs of the patient—for example, to change their diet, or stop smoking, or take more (or less) exercise— then they may offer too little support. On the other hand, they may be overprotective, refusing to allow the patient a reasonable degree of autonomy and discouraging active coping. Sometimes, members of a family will hold different views about the nature of an illness, leading to conflict, which is not always revealed to doctors. More often, they share views. If such views are inaccurate (so-called family myths) and yet strongly held, then they can be a powerful barrier to the patient accepting medical advice. It is a common observation that patients with chronic illness who are depressed often have a carer who is depressed, and this tendency to share (often dysfunctional) beliefs and coping styles is one reason for that.

Coping refers to efforts to reduce the gap between demands and resources. Coping is described according to its aims, the techniques used to achieve those aims, and according to the overall coping style adopted.

The aims of coping are either problem focused, designed to modify the demands of the situation, or emotion focused, designed to modify how one feels about a situation.⁽⁴⁾ Emotion focused coping generally works well but only transiently. It is best reserved for brief stresses, such as unpleasant medical procedures, or for situations in which nothing can realistically be done to modify the stress.

The techniques for coping serve to mobilize available resources. Vocabularies differ for describing them. Cognitive coping techniques include information seeking, downplaying, or adopting a defiant or overoptimistic attitude. In psychodynamic terms, the two most commonly used techniques are probably denial and regression. In common usage, the techniques referred to by these vocabularies overlap. Behavioural coping may involve changing ones lifestyle, such as exercising more or excessive drinking of alcohol. Social coping is a particular form of behavioural coping, and may involve increasing contacts or accepting help from professional agencies. In chronic illness, successful coping may be accompanied by a slower process of reappraisal—in which the patient comes to a different understanding of the illness, from that apparent at initial diagnosis—through for example benefit-finding and downward comparison (with others who have worse disability, pain, or whatever).

Coping styles are more general approaches to coping. Two contrasted styles are active/engaged (sometimes called ‘approach’) coping and passive/disengaged (sometimes called ‘avoid’) coping.⁽¹⁰⁾ While it is appealing to characterize people as having a particular coping style, and while it is possible to think of typical examples from personal experience, in fact most people do not have a sufficiently unchangeable repertoire of coping techniques to merit the label of a style.

The emphasis in ICD-10⁽¹¹⁾ is on emotional disturbance as the characteristic feature of adjustment disorders—some disturbance of behaviour is acknowledged, particularly in adolescence.
However, it is common to encounter cognitive or behavioural changes that interfere with social functioning and quality of life, and yet which are not attributable to the consequences of mood disorder. DSM-IV⁽¹²⁾ acknowledges this possibility more directly, including a category of ‘Adjustment disorder, unspecified’, which covers ‘maladaptive reactions (e.g. physical complaints, social withdrawal, or work or academic inhibition)’.

Examples of cognitive problems are extreme helplessness, denial of the existence of illness, or of the handicap associated with it. Behavioural problems may include marked social withdrawal or lack of self-care, or irrational non-adherence to treatment. Emotional problems are typically thought of as anxiety or depression, but irritability is also common.

The diagnostic features of adjustment disorders are relatively nonspecific, comprising mood symptoms and behaviour disturbances, which do not meet the criteria for a diagnosis of another disorder, and yet which are sufficient to amount to a mental disorder. The two main diagnostic questions are as follows.

What distinguishes normal adjustment from a disorder? The first criterion is whether the symptoms are persisting beyond the time when they might be attributable to the stressor. This judgement is relatively straightforward when the stressor is a single event. However, if illness is more persistent or intermittent—such as cancer followed by intensive treatment, or multiple sclerosis—then it is less easy to judge.

The second criterion is whether the response is causing avoidable social dysfunction. For example, in many cultures illness is followed by a period of convalescence, during which activity is reduced and a return to full social responsibilities is deferred. This may be a healthy avoidance of activity, if it allows full recovery from illness, but prolonged avoidance of activity may lead to secondary physical problems as well as social isolation and loss of role.

When adjustment disorders are associated with chronic illness and handicap, the duration criterion cannot apply. An individual may present symptoms because his or her response is outside the culturally acceptable range; for example, he or she may be too demanding or uncooperative, or too passive and dependent. It is unwise to regard a presentation as disordered simply on these grounds. The best indicator is whether the individual is achieving the highest level of function and the lowest level of distress of which they are capable under the circumstances. This means that each person must be diagnosed according to his or her own context, and that a standardized set of criteria cannot be applied.