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    3 The common-sense model of a self-regulation of health and illness 4 Howard Leventhal, lan Brissette, and # Elaine A. Leventhal’ TThe past decade has been witness to an unprecedented growth in research on. selfsegulation, For example, of the 2,700-plus chapters, dissertations, and journal articles containing the keyword ‘self-regulation’ archived in PsychINFO, a well-used social science citation index, over 1,800 have been published since 1990 alone. It is not entirely clear whether this trend is due toa shift in the Zeitgeist or a change in semantics. Though we suspect that both are involved, the Zeitgeist in Western, industrialized nations is the likely driving force, The focus on the consumer, individual choice, and populist movements that emphasize individual and community empower- ‘ment ereate @ context congenial to self-egulation models, These models represent efforts at maintaining a sense of individual autonomy in the face ‘of technological changes and monopolistic, corporate conglomerates that are actually shrinking the individual's options. Whereas the exact reason for the proliferation of self-regulation models is not clear, what is clear is that an increasing number of researchers and practitioners in the fields of health ‘and social science are adopting concepts and principles from self-regulation theory (o explain human behavior and promote behavior change indifferent ‘contexts (See Boekaeris et a. (2000) for a discussion of applications in areas other than health). ‘The overall goal of this chapter is to present our perspective on the nature of self-regulation as it applies to the enactment of health and illness behaviors. We begin by defining self-regulation, Then we provide a brief historical overview of the factors Jeading to the development of the 'SM) of self-regulation, We describe the assump: tions and features of the CSM and review the empirical and theoretical work that contributed to its development, In the process, we discuss how the CSM differs from existing frameworks of self-regulation (eg., see Scheier and Carver, this volume, Chapter 2) and ftom theories of the factors ‘governing the enactment of health behaviors (Ajzen and Fishbein, 1980; Becker, 1974; Rogers, 1983; Rosenstock, 1974). ‘common-sense mode! ( Leven Bris, L Levent EA Gi} The commun muenaddcfsclepiaen of ean ise LD Cron Leet) The atmos fin lth PEP. Condom Rouledge Taylor & Francis Goap The commonsense nnadel 8 History and the regulation rent status of the common-sense of self- Comcepeuatizing self-regulation as regulation of the selfsystem Much of human cognition and be! havior iy characterized as inherently purposefal, dieeted to achieve Is andl fo reduce and remove abstucles to those pouls (Anderson, 1983: Newell. 1980), The term “problem solving” iy often used to refer to the processes involved in purposeful setion: identifying ols representing ones eursent state relative To these geal, selecting ad {enacting strategies to achieve the goals and to remove sy obstacle, and determining the utility of implemented strategies. Many of our daily acti fics ean be characterized as forms oF problem solving. assuming, that We wnply the phrase 10 & broad range of highly complex. consciously generated executive Hunetions. Activities stich ts tin and making colle and navig through craic jams, through t manag tions rallier dhan 3 narrow set of luily work tasks and working social plans into busy routine, involve goal setiing mained future states to comparing present and oals, and selecting andl generating phins for gos attainment, The essential elements of problem solving insolt re heen represented (Carver and Scheer, 981: Powers, 197%), Some have anued tht any system capable of individual problem seein san be considered to be capable of self-regulation (Powers, 1993). This Pproach (0 sell-nepulation is based on the principles of eybernetie control theory and posits simple feedback loop ar TOTE (est, oper unit gowns the setions of selF-rey Me systems (Mile 196 The aes the put ao else to the tere wale, and evs inp agains the reftuncvale pa Tepes ne prow unl a sacl depres of vanconanue bec the apa aa The TOTE mechanism provides : self-regulating systems fess its cut ites t© produce output that $n output (et entciie model (or concepiaalizng teed: back systems, it can be applied to pihysicit as well as biological systems I does not, however. tell us what is being regulated and how rept achieved These “details behavior of biological syste to profeet and miaiotain health andl 10 aid and vontrolillaess, Aw We sicw i the CSM provides a tumework and specific suriables that be some of these details, Prablent solyi fe critically important for understanding. the neluding the efforts of human bein 0 to specify is the management of the phy ‘cal 44 Hossand Leventhal eat self and the subjective feelings of the self (Brownlee et a, 2000), The teem self-regulating refers not only to the fact that ichieve identified goals, but to fem can operate 10 it that what is being regulated is the physical machinery and functional resources The goals for sef= Fegulation ate the concrete, perceptual experiences, the physical sensations for symptoms, moods and emotions, and feelings of vigor and competence igenerated by the biological and psychological self. The specific procedur land strategies chosen for regulation are defined by the properties of the threat to health, and the resources available to the individual and the soci ‘context and culture, Within the context of (he CSM, sell-regulation is both description of the property of the system and a label connoting what is being regulated, This emphasis on content is one of the features that dist guishes the CSM from alternative frameworks, and in our view leads it to be more suitable for studying self-regulation as it pertains to health. The addi- tion of content has two effects: first, it allows for more specific hypotheses: second, it introduces new structural and functional mechanisms into the self-regulation system, Fundamental features of the common-sense model of self-regulation: Iistorical development A very brief review of the origins of the CSM will help to contrast it with ‘other models of health behavior; for example, the health belief model and ‘models of coping. Our veview differs fiuus prive ones as its emphasis is on the origins of the substantive features of the common-sense self-regulation system ‘The CSM is an extension of the parallel processing’ Middel, a mode designed to account for the findings 3 studies of fear-arousing communica ‘ons focused on health behaviors (Leventhal, 1970). The fist studies were based upon the Feat-Drive model which assumed that fear was a motiva ional state and that actions or procedures that reduced or eliminated fear were reinforced or learned (Dollard and Miller, 1950). The studies presented low and high fear messages about specitic health threats (ee, tetanus, lung cancer) by varying the language (technical and impersonal versus graphic and personal) and photographs (black and white and benign versus color images of tracheotomy wounds) describing the health threat. though presenting otherwise identical information (see Leventhal, 2000. for Teview). In three studies two on the threat of tetanus (Leventhal ¢ a, 166, Leventhal eal 1965) and one on cigarette smoking (Leventhal et al. 1967) some ofthe participants were randomly assigned (0 conditions where they were encouraged to develop specific action plans for coping with the threat Tor example, the tetanus studies participants were asked to review ther daily Schedules and find the time when ther class changes would bing them near the medial center where tetanus shots were available. The Feat-Drive model predicted that when the strategies were paired with @ high as opposed to & The commn-sense snntel AS » participants would develop more favorable attitudes about the strategies for avoiding the threat presented ind be more likely to enact them (Leventhal and Singer, 1966). The data trom these studies were consistent with high fear messages be mrore effective tha low fear mess sin changing attitudes inthe directo advocated in the communication, The elfects of fear on attitudes, howe, Proved short-lived (lasting from 24 10 48 hours: Leventhal and Nis. 1965). Moreover, and more detrimental tthe Fear-Drive model, high tor messutes were no more effective than low fear messsges in kone: ing adhe cenve (9 Fecommended health promoting aetions. Linus, whether the mesaBes high oF low in feae content, they sweceeded in generating ation if They f° combined pation plan. The combination of low oF bigh threat message and ay action plan produced substantial tnerements in anus vaccination (Leventhal er af 1966: Leventhal et al. 1963). and smoking (Leventhal er a. 1967). These itfeast in size and curable, emerging dass sand weeks after exposure to the threat message. el fear states hal eecayed (Leventhal and Niles, 1965), Taken together, the absence of the interaction of fear fevel and setion plans and the results of studies varying fuetors hypothesized to fuclitste tear reduction and learning (Dubbs and Leventhal, 966, Leventhal and Si 1966; Leventhal and Watts, 1966) proved (9 be fatal (9 the Fear-Deive model. The absence of an interaction of fear and stction plans should not, hawerer, be interpreted to sean Ul hese (He hey ftckors Heaney independent effects on behavior. By consulling the “olY des (oven subjects were presented only sith ation phan messages). it was clear that there was Fundamental dependeney between the two types af informa tion, Namely, no subject exposed to an ation plan asked for a tenes ingculation in the absence of exposure to s thecal message, Thus, alton ction plans were “independent” of the level oF Feat, they affected behavior only in the presence of a fear message Revent studies confirm that plans to implement goal-directed wetion have large eflects on the performance of health behaviors as diverse as breast self esamination. cervieil cane the efleats of Screening, and vitamin supplement use (Gollwitzer and Oettingen, 1998, Orbel und Sheeran, 21K2), These dat Ted (0 the development of the parallel process mode (Leventhal 1974). This model posited that health threats generate bork csoniiann siatesof fear um itreerenc a eoreperwng we for procedanss sage these emotions (Fear control as well as a cognitive representation I the threat and a correspond for procedures for ing hse threats (danger control). B rl cr como releroxd to the Parallel actions that were ner and apprsed for the iicy in Padang the negative cots evoke eth teats ear con ad ted the themselves anger conteak: we nlso Lazarus and Launiet 1978) A diagram of the parallel process nel is depicted in Figure 31. The 46 Howard Leventhal et at epresertation of Coping >| Procedures, | Zz ‘Danger (Getion pans) feos ‘Stuationat ‘Sie j}_——________________ Representation coping ol Fer +] Procedures >) “Presa! ‘gure 3.1 The parallel process model model proposed that somiati stimuli and information about health threats are processed as perceived representations of danger and as emotional experien ‘Action plans ate the activities that are undertaken to reduce fear and danger. Individuals are depicted us actively appraising the elficacy of these action plans and incorporating this information into their representations. “The parallel process model proposed that a cognitive representation of the health threat was a necessary condition for danger control, This representa tion established the goals for danger control, the specific procedures and strategies for control, the criteria for appraising success, and the ongoing perceptions of response efficacy. Though the combination of a threat message ‘and an action plan succeeded in generating the motivation which led to the performance of specific procedures for controlling danger (ex, take a tetanus shot; quit smoking), it was not clear which features of the message were essen tial for generating this motivation. Selfregulation in navigating noxious medical treatments, If fear per se is not the source of motivation for health-promoting action, what aspeet or specific content of the message is responsible for activating plans of action? Neither our early studies (Leventhal, 1970) nor more recent ‘ones have answered this critical question (Witte and Allen, 2000)? In Fact we did not know whether the motivational effect was due to specific content for to how the content was structured. Four types of data strongly suggested, however, that the critical source for the motivational effects of illness repre- sentations, and indeed of fear itself, was the individual's conerete, perceptual ‘experience and how that experience was interpreted! The first source of concretizing future actions, imagining the time and piace to initiate specifi fcts, The sevond source was from the findings of the first health belief model studies: they showed that perceived risk was best assessed by accessing visual ‘tes ofthe sells either healthy or sick. al the obs tion of ethers infected with fu (Rosenstock er wf, 1960): responses to Likert fr probability s los dit not predict behavior The thitd Source was the observations of patients during medical provedures indicating that con pavatie stimu wwe fear states that interfered with patisats’ eflectiv participation in the procedure: Kindly, anthropological dats indivated th Welop representations of health threats when elt 10 theie own und Child, devices {Whiting 1. The lay health-threat theories that the dovlops hhc practices to reduce the perceived dangers. Bway also elear that these iy representations of health dangess often bad lithe eotresponutence (0 Western medictl models The tscus on perception led us to unglertake a series of studies to evaluate hie hypttess that perceptual experienee of somatic sensations could ithe simul rent (an lependding upon how the sensations were anterpreted. The studies wer fear or Kea 10 effective selfom Conducted with patients about to undergo s nexsions medical procedure such fis an endoscopy (Johuson ane Leveathatl, 1974) oF 3 p oy Gohnson. 1975). The sewsations experienced during these procedures could elicit fear and powerful awoidance reactions if the find experienced as signs of impending danger. In contrast, these identical behaviors iP they were perecived a is for well-defined, participatory fesponses. The prototypical study varied fro factors: seasory information andl specie coping insteuetions, The sansory infamation used te prepace patients for an endoscopy Fst eseribed und you sil feel as if you had Farge meal). Examples of specifi ‘coping instructions meluded su jstions us to how to breath when the throat is being swabbed wth anesthetic and how to make swallowing motions when Ine endoscopy tube is intcoduced into the gullet The renults showsed that sensory information and coping plans bad ind: snd enhanced Siromental behaviors for Magn the movedkate situation (ea. ee 1 wets else tat information tha prepared an individual to expect spevifie sensory ewes and provided benign nendent effects in redhicing emowonal reactions (ea. gakeine Views of these cues could shift the response from fearful avoidance to sel Tepuitedl pooblem solving. The results reinforced the motion hat health threats were represented on at Teast wo levels; semantically abstract Knowledge. !and perceptually aS conerete experience, Moreover. they 48 Howard Leventhal et al Epstein, 1994). Somatic sensations could elicit fear by means of bottom-up influence and activate beliefs that one was in danger. Abstract information about the meaning of these physical sensations could short-circuit the perception of danger and the experience of fear by exerting a top-down influence (defining the symptoms as benign and manageable). Action plans reduced distress by linking sensory information to specific responses that allowed the patient to participate in and exert control over the noxious teximination, Action plans and sensory information allowed patients to experience the somatic sensations during examination as predictable, Controllable and benign by-products of a novel and noxious medical exami nation ‘That fear is a product of the interaction of abstract and concrete levels of processing was clear from a study of cancer-worry conducted by Easterling and Leventhal (1989). Questionnaires featuring items on worrying about cancer, daily mood (anxious or depressed), symptom reports (non-cancer symptoms such as fatigue, headaches), and question asking, ‘What do you think the chances are that you will get cancer?” were completed by 54 women who had been successfully treated for cancer and by 81 women who had no history of cancer. The 81 women in the control group were either friends of the ex-patients or women seho did not know the ex-patients, In both groups, ‘cancer-worry was greater for women who felt the chances were great that they would get cancer, but only if they experienced (non-cancer) symptoms ‘Women who felt that their chances of recurrence were great were not worried if they did not have symptoms. Similarly, women who had symptoms did not worry if they did not feel they would get cancer. Worry requited both factors, symptoms and a belief that one could get cancer. The pattern was identical within the two groups, but the women who had been treated for breast cancer reported higher levels of cancer-worry than the women lacking a history of breast cancer. The two groups did not differ in daily anxious mood, suggesting that the worry was specific to the threat of cancer. The finding that the experience of somatic symptoms would activate a cognitive label, nd that providing cognitive label could influence the interpretation of Somatic sensations was consistent with Schachter and Singers (1962) proposal that emotions are a product of physiological arousal and cogsitive interpretation. The similarity of findings does not require, however, that one accept the Schacter-Singer model as a complete and adequate account of ‘emotional processes (Leventhal, 1984). Representations: content and rulest heuristics for construction Content: identity as g core domain We suspected and soon found that the joining of abstract cognition (feelings of vulnerability) to concrete experience (general symptoms) was impostant not only for the experience of emotion, but for the identity of illness threats. serviews with patients suffering from by ated that 45 out of 30 patie P siakiness) indicated when their blood pressure was elevated, Mor fal, 1985) nsion believed that their symptoms {e.. Mushed face, headache cension (Meyer « Used their medication as prescribed if they perce fod that it conteolled thed roby if the medication was perceived not 10 conteol their s¥empton Notably; 40 out oF these sume 5M patients agreed that “People eannot (e ssl thie Bh sure is np” Tha while they aysoal that others were Jnoran of their blood pressure, the core, oF identity. of thei person epresentation of hypertension, was & combiaation of symptoms an aby nd everyelay illnesses (Lass and Hartinan, 1983) to lifethreatening conlitio 'Nerend eta. 1982) final that this eorbination of synyptenns ra label Tes at the he oF illness representations, Common aise suggested and subscquent investigations valida symptoms represented only one type of perceptual information asociate with the seperience of a health condition, and that the label represented fonly 2 small portion of ats semantic information, The other domains ot a niifed by methods ranging from open-end Views that elicited qualitative dats on pattieipants’ understanding ie presentations were ide ment a conditions such as the commion cold (La, Bernat Tartana, 1989, Law and Hatetmann, 1983), hypertension (Bauman at Lownthal, 1985: Meyer et af, 1985), snl pulmonatry disease [Larois ef TOIT. to quantitative appraaclies such as multidimensional sealing und factor analysis that assessed the structure underlying representations of hheatth conchtions (Bishop. 1991; Bishop and Comverse, 1986), For example ‘Peiod's (1980) application oF multidin nto aisease labels and ional -dounains: consequences (severity Timelines (daiation). and eause. A combination of methods were used by Bishiop (19%) open-ended to obtain tnd quantitative to classily these descriptions, When participants were ask to indicate what else woul! be experienced by individuals desertbing specifi snigs:adentity, case, Gee, consequences. nd The empinial sha was eongruc with the tw, basie propositions thet underlie the self-regulation mod first that people act as common-sense Scitists when constructing representations oF ifness treats: and See st these representations generate goals for self-management nd sugges procedures for goal aitainnent and criteria for evaluating response elficaey. The mformation or knoxsledge about disease threats within each oF the five 50. Howard! Leventhal et al domains consisted of factors such as symptoms and names’ (identity) ethected duration or expected age of onset (Gmeling), severity of pain and Fapact on life functions (Consequences), infection or genes (internal and fxternal causes), and whether the disease was perceived as preventable, Eurable, oF controllable (conteellability). Each of these domains contains Specific types of semantic and perceptual information about an illness threat dnd each Variable in a domain is both abstract and concrete, For example, ‘our causal concept of contagion includes the concept of germs and the perception of contact with an infected person (Nemeroff and Rozin, 1994), Timelines, meanwhile, are represented abstractly (This viral Nu will last for ‘wo to three weeks') and experientially (It seems as if this cold has lasted as, long as this house’), Time is often coneretized by spatial representations (Boroditsky and Ramscar, 2002) Heuristics! Rules for evaluating less indicators Figure 3.2 depicts the five content domains of illness representations: iden- tity, timeline, cause, consequences, and control. The information represented within each of these domains is represented in both abstract (semantic) and ‘concrete (perceptual or experiential) form. A number of rules or heuristics have been identified as being involved in converting stimuli into represent tions. These heuristics are used in the ongoing interpretation of the stimuli generated by an illness and efforts to control it, The result is an increasingly elaborate representation of the iliness threat. The symmetry rule reers to the pressure to connect abstract experience with labels. Our hypertension patients and cancer patients linked labels to symptoms (Easterling and ed ee ee ‘oom | TwELNe | cowseouences] cause | conTRo toe (erator [eapct ctcees ‘yeuro Smotare | Puceveatine | Prseataaaoiny | Lucctsiee | Tratrets igure 3.2 The five domains of illness representations Leventhal, 1989; Meyer of al. 1985), Morcover, subjects in laboratory Srudics reported symptoms when told that their blood pressure was hich (Bauman ef al, 1989), The connection is bidirectional and symmet Tical. as labels seek symptoms and symptoms se abstractions to pe labels, Symmetty. by xis to the repre. Mas new information 8 integrated with existing se are new symnptonts suxl behavioral dysfunctions, by the fnhvcrvation of these changes in athers, aad by input from various mica Representations are shaped and reshaped by the sucess or failure of speci ppawodures for preventing, moderating, and curing disease processes, Ho fict information is processed. and its meaning and the conclusions dasa Fron it, will eflet he questions or euristies the dividual uses for eval sing its implications. Dal are wsaitable on four such rules, in addition to thst of SSM y: the streseillness rule, the ggesiigess rule, the evilice rate (Ceoyhe snl Jemmott, 1991} and che dlran rule (Mora et a, 2002). The first two rales question whether symptoms or Functional ehnges relic iintepersanally induced emotional sess). The prevalenee andl duration rules iidress the potential severity or Seri The question implicit in 13 of a syimptom or risk indicator istics leads to specilie procedures Steseillness appraisals appear to involve an evaluation of one's ongoing cal events This evalation of one sess Tevel ean be tcpliit (eg. sicted by instructions to review the events of the day on which 1 set of symptoms fitst appear) or implicit (ex. if the dy on shel they ‘ppea happens €0 be a high- versis & lowesteess day). Whether explicit or ris if the events oF the day are steessful, symptoms aire more likely to ‘expected ats sighs of sires rather than as indicators of illness (Baumann tl 1989}, AL least to conditions limit the application of the stresillness heuriste: the nature of the symptoms and the duration of the stressor. Stress “nerpretations are mest ikely when symptoms are psychophysiologieal tex fatigue, aching, heinkuche) snk! have low specificity as mdicators of discos In aaidition, when stressors are roatively chronic, they ean fre seen as cases DoF less gn met eae WH Be SOUL EveH lo specfiity (Cameron ef af. 1995). The stessillness heuristic 1s not inpied mindlessly: it has limiting eondibons (see Cameron. this volun Ciiapter 8) Common sense also suggests tht the duration and failure of « about a beni, stress snterpretation and activate soeial communication and care seeking. Indeed duration is ome oF the most powerful predictors of eure seeking (Mora es al, 2002), and ea 52 Howard Leventhal et ab be considered a heuristic or rule for judging symptom seriousness. And \whereas symptom duration implies seriousness, perceptions that a symptom Co condition is prevalent among others can reduce inferences of its severity (Croyle and Jemmot, 1991). Tt is conceivable that heucistics may differ with regard to the point at Which they are most likely to be applied. For example, symmetry, stress illness and ageillness rules seem especially valuable for deciding that one is for is not ill, whereas the prevalence rule seems to serve as an indic: disease severity and to affect the decision to call for care. The duration rule, ‘on the other hand, might be equally likely to function for both decisions - that is, that one is ill and in need of medical care. Studies examining the duration of appraisal delay (the time from noticing symptoms to the deci- sion that one is ill) and illness delays (the time from deciding one is ill to calling for eare), have not examined this issue (E. Leventhal er al, 1993; E. Leventhal et al, 1995). Hopefully, these questions will be addressed in future studies Coping procedures and action plans Illness representations set the stage for coping; they guide the selection of procedures to eliminate and conteol potential or ongoing iliness threats. The procedures for managing illness threats are legion, ranging from the use of dietary supplements and other ‘natural’ products, through over-the-counter medications, {0 treatments prescribed by physicians, non-traditional practi: tioners, family members, friends, and acquaintances, Nowadays, personal recommendations can be made both face-o-face and over the Intemet (Berland et al, 2001; Rice and Katz, 2001). ‘Anthropological studies provide dramatic examples of the way in which representations shape self-regulation coping procedures (Chrisman, 197: Heurtin-Roberts and Reisin, 1992; Kleinman, 1980; Pachter, 1993; Simons, 1993), For example, parents of babies suffering from ‘molera caida, the folk name for the fallen fontanelle that is a symptom of dehydration, will apply pressure to the roof of the mouth or suck and draw up the Fontanelle in efforts to cure the disease and prevent infant death. Similar mechanical! ‘geographical principles are common in everyday life in Western cultures; the choice of procedure often reflects concrete-perceptual relationships between symptoms and procedures. We apply cold compresses to the head to exse Ireadaches and salves to skin irritations, we imbibe home remedies for stomach upset, and billions of dollars are spent (Consumer Reports, 2000) fon vast quantities of vitamins, herbal ‘medications’ and other alternative products (Cassileth, 1998; Eisenberg er al, 1998). Cold compresses and salves seem irrelevant as cures for stomach upsets, and although we take pills to cure headaches, intuition suggests they are less relevant for curing skin rashes, Each procedure seems of special value for dealing, with specific isorders and their symptoms; the linkages are not random, The conmnasense met 8. Given the expected match between representations and procedures. it Follows that the Feilues oF procedures cam also be lasified in the five mains. Procedures have identities with ibels and symptomatic sie elfects | routes of action, consequences (expected outcomes including both somatic and non-somatic side effets). und eonirol expecta tions eegusding particular symptoms diseases. For example, food od as useful ways oF preventing and controlling eancer (the consequence) by strengthening ianmune Fanetion supplements and diet selection «sn be pore fae eausal router In addition, may iraditional, wellevsludated mediations suclhas analgesics sand amti-epressants are pereenved {0 lave consequences Or ‘side elfcets? including harm 10 the body, weakeniog of the immune system, anid risk of addiction (Horne, 1997; see also this volume, Chapter 7) {As with ness representations. individuals” represent tai components In terms of w medication’ Timeline. for example, medication ean have an expected timeline Cl should Feel better in a week) at actus timeline (The patient should begin to Feel better in about tour weeks, ancl an experiential timeline CH els tke it is scant of the bi-level nature of these representations can be useful in understanding individuals” ‘adherence to their pharmacological and behavioral Procedures specify both a class of etions (eg.. use an analgesic) and a taking Forever for this medication to work’). Takin specie chowe (e 2. ibuprofen): wetion plans specify the ume and place for the initial and subsoquent steps requited for set completion. Once the repre sentation and procedures are Finke! 1@ an action plan, the self-regulation System is complete and coherent (Horowitz er af, in review), From the perspective of the ivi, coherence ean be expressed as an ifn” ques tion «Brownlee cr 2000, That iF Fam suffering from a stress headache identity) due to 9 bad day at work (cause; timtine), then taking {wo asparins (procedure) should elimmate the patin (consequences: control) in 20 to W ‘imutes (time frame for eonsequences) Moderators and mediators of self-regulation Coherent sel-repuliton systems (systems in which representations have set goals and defined procedures for yout attain 1d which lead to specific action plans} ar in contexts of the self’ and the social system. The iHthen questions that generate a sell ulation system reler to sel fonowledae and social factors when drawing cortclusions abut a pathogen For example, deciding i 4 symptom reflects illness or ae requires reference to the self and what it means to be oll (what symptoms or signs ate indica tots of agingy. The grin question that is raised and) answeced reflects the properties of the sell) Hooker and: Kaus (1994) have examined future hnvaltherelevant identities, but selatively hale work hus been done examinyn the interaction of the sellsystem ancl illness representations, Heidrich ef aS {1994p analysis of the factors affecting emotional distros in breast cancer 54 Howard Leventhal et al tients suggests that the selésystem (discrepancies Between current and Fopedsfor self) mediates the elles of factors such as chronic timelines on tlevations of emotional distress. It is unclear, however, whether or not the Statistical notion of mediation provides the appropriate interpretation as to hhow sefdscrepancis relate to the variables of chronic timelines and phy ical dysfunction that are central to these women's representations of be Saifcapalalin ratigied Elderly patients regularly express their strategies for self-regutation in elin- ‘cal encounters with their geriatric physician (Leventhal and Crouch, 1997). These strategies appear to be linked (o selidentities. For example, many elderly patients express concerns about taking medication as they perceive their bodies as unusually sensitive. Beliefs that one possesses a “sensitive soma’ have been related to concerns about medication (Horne, 1997), and this selF-construal encourages a strategy of minimizing contact with medication servation, a self-management strategy designed to protect the age related decline in somatic resources and to avoid isk from pathogenic processes, appears to be at the core of the rapid seeking of medical advice and hhealth care by elderly patients (Leventhal and Crouch, 1997). In comparison {0 individuals aged 45-55 (the middle-aged) those over 65 yeurs of age are swifter (o appraise symptoms as signs of illness, and use medical care when symptoms are perceived as potentially serious (Leventhal er al, 1998: Leventhal e¢ wl, 1993). The elderly and middle-aged are equally swilt to use care when symptoms are clearly serious. Minimizing delay avoids prolonged ‘worry and the depletion of energy, and it reduces the risk of developing an advanced and incurable disease. Conservation is not always. beneficial, however. When serious health problems disrupt ongoing activities, then ‘conservation (unlike optimism, social support, and social demands) will

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