Prototypes Creating Representations of Illness and Targets for Management

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Representations are dynamic; a "sore/blemish" on the skin may transform from an infection to a skin cancer, and the type of cancer (basal cell versus melanoma) may change the meaning of the prognosis from life threatening to curable. Feedback from self-examination, social comparisons, and care-seeking can reshape illness and treatment representations. Representations are unstable and the instability of a dynamic process poses challenges for descriptive studies and interventions.

The schemata and/or prototypes in declarative and procedural memory that underlie representations and shape behavioral strategies and the prototype checks (PCs) that activate and connect schemata to ongoing experiences are likely more stable and therefore better targets for assessment. Numerous studies have assessed and demonstrated the importance of the check mechanisms in predicting care-seeking. However, the empirical literature for assessing prototypes is less robust and not well integrated with findings regarding representations and the check process.

1.2.1 The Formation of Prototypes and the Activation of Representations

Representations of illness, treatments, and outcomes are dynamic, and both their experiential base and abstract features can be implicit (active and below awareness) (Henderson et al, 2007; Williams et al, 2003) or in conscious awareness. In this regard, they are similar to other everyday experiences. For example, when we enter the waiting room of a medical office, we scan the behavioral environment, occupied and unoccupied seats, and walk to sit in one of the unoccupied chairs. The rug and floor are likely implicit (unnoticed unless one slips), while selected features of the chairs and seated patients are represented in consciousness at different levels of salience. The representations guiding movement (the affordances perceived in the environment) are activated by perceptual features that activate underlying schemata of rooms, floors, chairs, and people.

The CSM provides a detailed description of the processes involved in the activation of prototypes, the process that elaborates the meaning of implicit and explicit observations of somatic and functional cues. The core of the process is an ongoing scanning, checking, and comparing of somatic sensations, as well as physical and mental function, to the underlying prototype and schemata of the physical and functional self. A representation of illness is activated when the scanning or check process detects a deviation in somatic sensations and/or physical and mental function that exceeds normally expected variability in the self and matches an underlying illness prototype. The representation formed at that moment is an operating hypothesis about the nature and meaning of the experienced deviations. For example, the deviations may reflect one of several acute conditions such as a migraine headache, common cold, heartburn, and/or stomach ache from bad food, or a potentially chronic condition such as an ulcer, hypertension, diabetes, a cancer, or something more benign such as psychological stress or normal aging. The checks connecting experience to prototypes address these questions by evaluating the sensory properties (e.g., sharp, dull, or throbbing), location (e.g., head, belly, legs, or heart), duration (e.g., felt and clock time), rates of change (e.g., sudden onset, gradual increase, steady), consequences (e.g., disrupted breathing or impaired walking), causes (e.g., bad tasting food or little sleep), and the effects of behavior or, control of, the experience (e.g., used alcohol or salve, rested and it cleared). The "primary prototype checks" built into the nervous system match the specific attributes of experience to "slots" in the underlying prototype (Gobet, 1998). The representation that emerges and changes from this ongoing process of matching experience to prototypes generates motivation for action, and the feedback from these actions confirms or disconfirms the meaning of the somatic experience.

1.2.2 Prototype Checking Is a Social Process

Prototype checks are not only at the core of the intra-personal processes that give meaning to experience but also central for interpersonal communication. Once the opening niceties are completed ("How are you?"), a medical practitioner will address the presenting complaint with the same checks the patient uses: "What is bothering you?" "Where is it?" "How does it feel?" "How long has it been going on?" "Has it been getting worse?" "What were you doing when it started?" "Have you done anything to self-treat it?" "What happened?" This exchange reinforces the check process and may or may not provide an alternative explanation for the presenting symptoms and physical and cognitive dysfunctions. An additional set of PCs emerge from social comparison processes. We assign meaning to symptoms and functional changes by checking for common exposure (e.g., exposure to someone with SARS), familial linkage (e.g., family member had breast cancer), similarities in physiognomy, temperament, and response to aging (e.g., parental dementia a sign of risk to self). These processes are less well explored in the CSM (Leventhal et al, 2007).

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