Hälsopsykologi & Beteendemedicin Flashcards
Reductionism
Fokus på detaljerna för att förstå helheten, bryter ned till mindre beståndsdelar
SAM - Sympathetic nervous system, Adrenal, Medulla (binjuremärgen)
Hypothalamus scannar för faror, skickar info till hypofys som skickar ut kortisol, kortisol skickas ut i kroppen och aktiverar binjuren som släpper ut adrenalin.
General adaptation syndrome
ALARM:
Chock - SAM
Counterchock - Kroppen reagerar på stressorn som skapade chocken. Aktiverar fysiologisk respons via sympatiska nervsystemet, fight or flight.
Resistance: Stage where the body attempts to adapt to the stressor. If however the resources are depleted or the stressor persists, one enters exhaustion.
Exhaustion: Prolonged exposure to stressors can deplete the body’s resources, including energy stores, hormones and neurotransmitters. Impairs physiological homestasis and negatively affects ability to cope with additional stressors. Leads to vulnerability to stress. Lead to fatigue, irritability, anxiety, depression, insomnia, muscle tension and gastrointestinal issues.
Allostasis
The body’s response to physiological change due to stress, through which the body tries to maintain homeostasis. Functional adaption to changing needs and demands.
Allostatic load
When the stress response is inadequate or insufficient.
- Too frequent of activation of the stress response.
- Lack of adequate response to reoccuring stressors.
- Lack of recovery after stressor.
- Insufficient activation.
Allostatic load -
Good stress
Manageable stress
Toxic stress
Good:
Challenge - Allostas - Recovery
Manageable: Challenge - Allostasis - Coping - Recovery
Toxic - Challenge - Allostasis - No coping - Overload
Individual responses to stress that aren’t ways of coping
Challenge/Demand
Stress response - Physiological response
Pathogenic processes
Diathesis-stress/Dual-risk model
Interaction between biological predispositions (diatheses) and environmental stressors in the development of mental health disorders. If the individual is vulnerable biologically due to genetics, childhood experiences or other reasons and they are in a negative environment or have a bad experience they will most likely suffer a negative outcome. A person who is resilient will most likely have a positive outcome regardless of environments & experiences.
Stress threshold
The point at which the stress exceeds the person’s capacity to endure it and thus their coping capacities are depleted and they develop anxiety, depression, burnout or exacerbation of existing health issues.
Early life stress exposure and it’s implications for subsequent vulnerability
The function is not linear, it is quadratic, thus the vulnerability is severely increased even with small increments of stress in childhood.
Kritik mot biologiska perspektiv
Experimentell påfrestning leder till en momentär fysiologisk respons, men detta säger föga mycket om den kroniska stressen som leder till faktiska patologiska processer utanför labbet. Ekologisk validitet är låg. Studier av reaktionerna erbjuder inga kliniska implikationer för hur man ska behandla utsatta och öka hälsan i samhället.
Ambient stressors
Lågintensiva men kroniska stressorer i mijlön.
Mätbara fysiska fenomen:
Oljud/Brus
Dålig luft/temperatur
Trängsel
Medvetenheten om stressor minskar pga habituering men lågintensiv stress kvarstår ändå. Omedveten ansträngningen för att copea förbrukar resurser.
Role stress
Leva upp till svårförenliga normer, ansvar och behov.
Minority stress
Värderingskonflikter mellan grupper med olika socioekonomisk hållning med olika status/dominans.
Utgår från sociala processer, strukturer och institutioner.
Drabbar specifika grupper, ej slumpmässigt.
Inbäddade i varaktiga sociokulturella konstruktioner.
Självselekteringseffekter
De effekter på resultatet av studier som påverkas av deltagarnas vilja att tillhöra vissa grupper och vilka studier de vill vara med i. De som är mer hälsomedvetna och potentiellt mer hälsosamma kan välja att delta i studier jämfört med mindre medvetna, och därför sker en snedvridning av resultat.
Neurologiska faktorer som del av psykoneurokronologi
Nervsystemets funktioner kan påverka endokrina processer som utsöndrar hormoner som fungerar som signalsubstanser och reglerar olika kroppsprocesser samt vice versa. Alltså hur endokrina processer påverkar signalering i hjärnan.
Endokronologiska faktorer i psykoneuroendokronologi.
Här studeras hormonernas såsom oxytocin, adrenalin och kortisol påverkar beteenden, känslor, tankar och kognitioner.
Pskyologiska faktorer som del av psykoneuroendokronologi
Hur psykologiska processer påverkar och påverkas av tankar, stress, känslor, kognitiva processer och beteenden - samt hur de påverkar endokrin aktivitet och nervsystemets funktion. Kronisk stress frisläpper överflödiga mänger kortisol och adrenalin som kan negativt påverka kroppsfunktioner och hälsa.
Psykoneuroendokronologis syn på stress
Ej en stereotyp reaktion på stress utan snarare individens självreglering av otrygghet.
NUTS:
Novelty
Unpredictability
Threat to the ego - Social evaluative threat
Sense of uncontrollability
Kognitiva transaktionella modellen
Reaktion på stress
En unik individ möter en specifik situation.
Primär tolkning: Vad innebär detta för mig.
Obetydligt/Harmlöst - Ingen åtgärd
Hot/Utmaning/Skada/Förlust - leder till sekundär tolkning
Sekundär tolkning: Vad kan jag göra åt det?
Vad krävs av mig?
Vilka resurser finns.
Om resurser finns - COPING
Om de inte finns - negativ stressrespons
Kritik mot kognitiva transaktionella modellen
Stoppar stress i svarta lådan.
Fokus på upplevelse snarare än på orsakande processer.
Relativiserar och subjektiviserar stress. Det beror på hur individen upplever och uppfattar potentiellt stressande situationer.
Åtgärdsfokus läggs på individ snarare än att adressera stressorn.
Falsk dikotomi mellan stress och coping.
Conservation of resources model
Normativ transaktionell modell
Adapativa resurser kan identifieras empiriskt - vad människor generellt sett värderar och eftersträvar.
Stress kan sedan defineras normativt som:
- Förlust av resurser
- Hot mot resurser
- Misslyckade resursinvesteringar.
Kritik mot conservation of resources model
Residualbehaviorism - Reducerar människan till mekanik där personliga upplevelsen ignoreras.
Onödigt med normativa konceptualiseringar av stress: vill vi veta om någon är stressad kan vi fråga dem.
Irrelevant: Starkaste proximala prediktorn för stressrespons och sjukdomsrisk är individens egna upplevelse.
Tend & befriend
Stress är mycket mer än påslag och fight-or-flight.
Oxytocin som stresshormon.
Tend- Ta hand om och skydda det viktigaste.
Befriend - Sök stöd hos andra genom närhet och samarbete för att skydda från stress.
Stress
Konceptuell karta - Teoretisk, Praktisk Premiss och Slutsats.
Teoretisk: Patogenes - Hur sjukdomar utvecklas
Praktisk: Krav utmanar förmågan till anpassning
Slutsats: Minska krav.
Coping
Konceptuell karta - Teoretisk, Praktisk Premiss och Slutsats.
Teoretisk: Salutogenes - Hur hälsa och välbefinnande uppstår
Praktisk: Anpassning kräver resurser
Slutsats: Öka kvalité av och tillgång till resurser.
Återhämtning
Konceptuell karta - Teoretisk, Praktisk Premiss och Slutsats.
Teoretisk: Hälsoekologi - hur individs hälsa påverkas av interaktion mellan individ och omgivande miljö.
Praktisk: Hållbar anpassning är beroende av återhämtning
Slutsats: Öka möjligheter och förutsättningar för återhämtning.
Rehab
Konceptuell karta - Teoretisk, Praktisk Premiss och Slutsats.
Teoretisk: Klinisk/Terapeutisk
Praktisk: Anpassningssystemen är för svaga/skadade
Slutsats: Förbättra anpassningssystem genom att (åter)skapa copingmekanismer och resurser.
Epidemologiska perspektiv på coping
Individer har mer eller mindre tillgångar till resurser för att deala med påfrestningar.
- En resursvariabel som modererar sambandet mellan stressor-exponering och risk för ohälsa.
- Det som gör att samma påfrestning påverkar typer/grupper av individer olika mycket.
Normativa copingresurser- Personliga
Personliga:
- Kroppsförmågor
- Psykologiska förutsättningar
- Kunskaper & färdigheter
Normativa copingresurser - Sociala
- Tjänster
- Information
- Känslomässigt
Normativa copingresurser - Materiella
- Pengar
- Verktyg
- Hjälpmedel
Normativa copingresurser - Miljömässiga
- Framkomlighet & tillgänglighet
- Platser för samvaro, rekreation osv
- Arkitektur & design
Effort - Reward imbalance model
Effort
Reward
Imbalance
Psychological and physiological responses
Moderating factors
Effort refers to demands on an individual. Work load, emotional stress, time pressure and responsibility. High levels of effort are correlated with heightened stress and strain.
Reward: Positive outcome or resources that individuals expect to receive in return for effort. Extrinsic - Salary, promotions, job security. Intrinsic - Work satisfaction, self-actualization, recognition, opportunity for self-development.
Imbalance: Stress occurs when there an imbalance between effort and reward. Lack of control may be experienced as well. Subjective perception that varies from person to person.
Psychological and physiological responses: Prolonged exposure to stress may over time lead to chronic stress and consequently depression, anxiety and burnout.
Moderating factors: Personality traits, social support, coping strategies, as well as organizational context such as culture, job insecurity and socio-economic status.
Effort-Reward imbalance model - Maintaining factors and overcommitment
No alternatives
Style of coping
Personal factors - overcommitment
Accepting inbalance temporarily for future pay off
Maintaining factors:
No alternative
Style of coping mechanism (overcommitment)
Accepted for strategic reasons
Overcommitment:
Personality trait that maintains imbalance. One may be overly invested in their work and seek recognition for their work. Lack of recognition may lead to high levels of stress.
Job burnout
Engagement:
Job resources
Personal resources
Burnout:
Job demands
Interpersonal demands
Emotional exhaustion
Depersonalization
Poor work performance
COPING - Definition
Constantly changing cognitive and behavioral efforts to manage specific external & internal demands that are appraised as taxing or exceeding the capacity of the person.
Yerkes Dodson Curve
Optimal performance is when stress levels are optimal, nor too high nor too low.
Costs of coping
Subsidiary task failure
Strategic adjustment
Compensatory costs - strain
Fatigue after-effects
Subsidiary task failure
Strategic adjustment - Shifting to simpler strategies, less use of working memory
Compensatory costs - Strain because of active control during performance maintenance
Fatigue after-effects: Post-task preference for low-effort strategies, risky decision-making
Cost of coping
Fysiskt
Kognitivt
Emotionellt
Socialt
Materiellt och temporalt
Fysiskt - Allostasis
Kognitivt - Attention fatigue
Emotionellt - Burnout / Empatitrötthet
Socialt - Tärda relationer/nätverk
Materiellt - olika opportunity costs
Health psychology
How biological, psychological, evnironmental and cultural factors affect physical health and illness.
Health psychologists work in clinical settings, on behavior change in public health promotion, at unviersities and conduct research.
Cartesian dualism
Two systems - mind and body, persists in psychological theory.
Behavior is often a reflection of something else. What does this mean?
A machine-like “chain metaphor”, emphasizing contiguity (bordering with something, or being in contact with something). The internal mediating constructs such as expectations, intentions, beliefs, desires, attitudes, motivation act as links in the chain. All of these things therefore affect behaivor.
Are they however onthologically valid? How do we know how they operate, do they immediately indicate how to make change happen, how can we affect them to mediate change?
Three fundamental difficulties in developing good psychological theories
- A lack of (sufficient) robust phenomena
- A lack of validity and epistemic iteriation for psychological constructs.
- The problem of establishing psychological causes. We don’t quite understand what leads to change.
Återhämtning
Definiton, Förutsättning Process
Definition: Returning to normal state after adaptive response.
Förutsättning: Removal of stressor
Process: Autonoma nervsystemets reglering (Parasympatisk aktivering för att nå homeostas, motverkar sympatisk)
Restoration
Definition
Förutsättningar
Process
Definition: Reinstatement of adaptive resources and associated functions.
Förutsättning: Positiva återhämtningsfaktorer
Process: Transaktionell
Rehabilitation
Definition
Förutsättningar
Process
Definition: Rebuilding normal functions through therapy or training
Förutsättningar: Expert-intervention
Process: Resursinvestering
How the recovery process looks
Resting state
Stressor
Coping
Recovery
Initially one is in resting period. Then a stressor emerges which leads to an increase in stress, of course, until which the stressor has been dealt with or other coping mechanisms have been deployed, when this happens the stressor is removed and the stress levels decrease.
SAM vs HPA
Sympatiska, Adrenala, Medulla tar några sekunder för att kicka in och minuter för att avta.
HPA-axeln är långsammare och tar 10-40 minuter att kicka in och sen tar det timmar för den att avaktiveras.
Perseverative cognition hypothesis
The repetetive and persistent nature of negative thoughts can take form in worry, rumination and intrusive thoughts. Worry concerns future threats or negative outcomes. Rumination is when one dwells on past experiences, mistakes or failures. Intrusive thoughts are automatic negative thoughts that enter consciousness without voluntary controll.
This repetetive pattern of negative thinking often leads to suffering without resolution. This leads to negative moods and impaired daily functioning as it is very distracting and both time and energy-consuming. This leads to dysregulation in prefrontal cortex and amygdala.
Default mode network
Misconceived to be a state of rest. In reality it is an active state of complex cognition marked by internal dialouge, mental imagery, emotions, retrieval of episodic memories, problem solving and planning.
Generalized Unsafety Theory
When we are not certain that we are safe we are in a default state of stress, which is inhibited when we feel safe.
Restorative environments
En miljö som bara möjliggör utan underlättar återhämtning av förbrukade adaptiva resurser.
Evolutionära anledningar
Sociokulturella anledningar
Personliga anledningar
Stress recovery theory
Stimuli som signalerar trygghet och möjlighet att återhämta resurser.
Perceptual fluency account
Easy or fluency with which information is presented affects how we interpret it. If it is perceived as fluent and smooth then it is perceived as positive and vice versa.
Attention restoration theory
- Two types of attention
- Attention fatigue
- Restorative environments
- Soft fascination
- Stress reduction
Suggests that exposure to natural environments can help restore cognitive resources and improve attentional functioning. The theory contrasts natural settings with urban environments. One is able to recover and restore attention easier in nation because one is easily fascinated and one is able to be effortlessly attentive.
- There is directed attention and involuntary attention. Directed for studying etc. Involuntary is for naturally appealing stimuli such as nature.
- Attention fatigue: Directed attention can get fatigued when it is active for too long, has to filter through too much distracting stimuli etc, common for urban environments.
- Restorative environments: Natural environments can replenish directed attention. Rich in fascination, perceived as coherent or rich in order, serene landscapes, tranquil water bodies and lush greenery effortlessly draw our attention.
- Soft fascination: We can engage our attention with nature without cognitive effort. Leads to relaxation and mental restoration.
- Stress reduction: Exposure to natural environments has been associated with reduced stress, improved mood, enhanced well-being. Due to restorative effects of natural environments on cognition and attention.
Restoration skills training
Stress reduction techniques
Cognitive restructuring
Behavioral activation
Mindfulness practices
Problem-solving skills
Relapse prevention
Stress reduction techniques: Different techniques to decrease stress - mindfulness, deep breathing, progressive muscle relaxation or guided imagery, helps with relaxing and reducing physiological activation.
Cognitive restructuring: Mentally reappraising different situations, reframing them whilst challenging negative thoughts or assumptions about the world. If we reframe negative thinking and adopt more adaptive perspectives we can reduce emotional reactivity and improve coping ability.
Behavioral activation: Strategies aimed at helping individuals increase engagement in meaningful activites and enjoyable activities, even when one is not motivated to do so. If we schedule and participate in rewarding activities we can enhance our mood and sense of accomplishment. Gives our life meaning.
Mindfulness practice: Mindfulness exercises such as meditation, mindful breathing or body scans are frequently incorporated into restoration skills training to help individuals better cope with their experiences by building present-moment awareness and cultivating non-judgemental acceptance of their experiences. This helps regulate emotions and may reduce rumination and worry.
- Problem-solving skills: RST helps individuals equip themselves with practical tools and techniques to deal with concrete daily problems - by breaking them down into smaller steps to easier tackle the issue.
- Relapse prevention - Helps anticipate and manage setbacks or potential triggers that may hamper progress. If we develop a
Kritik mot beteendemedicinska insatser mot utmattningssyndrom
Interventioner med många komponenter omöjjliggör slutsatser om vad det är som egentligen ger eventuella effekter.
Dåligt specifierade komponenter förhindrar replikering.
Syfte att påverka hälsa och arbetsåtergång, men effekterna är bara process- och upplevelsemått.
Man lägger mycket ansvar på individen att hantera sin situation men det kan väl inte antas att folk helt plötsligt blivit sämre på att deala med stress, snarare så att samhället har fler stressande faktorer jämfört med förr i tiden.
Behavioral medicine - definition
Interdisciplinary field that applies biomedicine and behavoral science that pertain to health and illness and to apply these to prevent, diagnose, treat and rehabilitate.
Relation between behavior, biology, environment and health.
Behavior and environment can influence biological processes in the body. Although we don’t quite understand how. It is therefore more relevant to focus on behavioral outcomes like how long one lives, their quality of life and symptoms they experience. Instead of focusing on biology for which we have methods lacking in validity and reliability, we should instead focus on the processes we think are determined by biological ones, such as daily functioning or symptomatology.
So if we agree that behavior influences health, we should strive to find the behavioral interventions that maximize benefit with minimal investment.
Health psychology
Health psychology might also be related to behavioral medicine but is more interested in investigating what psychological factors are involved in health and how we can affect these. It may be behavioral activation but also more broad such as CBT as well as mindfulness-based practices to increase mental and physical well-being.
Health belief model
Perceived severity
Perceived suscepitibility
Perceived benefits of action
Perceived barriers associated with action
Cues to action
Self-efficacy
Perceived severity: How severe is the dangerous situation?
Perceived suscepitibility: How likely is it that I might be subjected to the danger?
Perceived benefits of action: How much can I gain from acting?
Perceived barriers associated with action: What we perceive as holding us back from acting.
Cues to action: External or internal triggers that may nudge someone to act.
Self-efficacy: Do we feel we are capable of acting?
Transtheoretical model/Stages of change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Precontemplation is when individuals are not yet considering change. May be due to lack of awareness of issue or denial of the consequences of their behavior.
Contemplation: Aware of need to change and are considering action. Weighing pros and cons, but haven’t commited to change yet. May be prolonged state due to ambivalence or uncertainty about whether they should proceed.
Preparation: Preparing to change in the near future. Take initial steps, gather info, set goals, seeking support from others. Committed to change but may face obstacles or setbacks.
Action: Acting on preparation. Requires ongoing effort and overcoming obstacles and managing replases.
Maintenance: Successfully changed behaivor is maintaned through preventing relapse. Requires ongoing effort, self-monitoring and development of coping strategies to deal with potential challenges.
Termination: Sometimes included in the model, behavioral change is ingrained, leading to lack of risk of relapse and thus they do not need to actively work to maintain the change.
Reciprocal determinism
A person is both a responder and an agent for change. Changes in the environment lead to change in the individual but conversely, a change in the individual leads to a change in the environment.
Personal factors determine how one might respond to environmental factors. And environmental factors are influenced by personal factors.
Personal factors can be self-efficacy, self-confidence etc.
Environmental factors can be culture, norms, social support network, access to resources etc.
Social Cognitive Theory
Behavior, personal factors, environment.
Behavior, personal factors and environmental influences all affect each other.
Social Ecological Model - Behavior in relation to environment
Multiple levels of influence (individual, interpersonal, organizational, community and public policy). Notion that behaviors both shape and are shaped by social environment. Consistent with social cognitive theory that says that creating an environment conducive to change is important.
Theory of planned behavior
Attitude towards behavior
Subjective norm
Perceived behavioral control
Attitude: The way we feel about a behavior
Subjective norm: How we perceive the norm to regarding the behavior
Perceived behavioral control: If we think we are able to control our behavior.
All three interact to form an intention which leads to a behavior.
This theory is not correct, does not allign with experiment results.
Critcism of Theory of Planned Behavior TPB
Too simple, too focused on rational reasoning, not enough of unconscious influences. Limited predictive validity.
COM-B system
Capability and opportunity lead to motivation to behave in a way, which reinforces all three of the aforementioned.
The Behavior Change Wheel
Capability
Opportunity
Motivation
At the core of the wheel there are 3 components.
Capability - Refers to psychological and physical capacity to perform behavior.
Opportunity - Environmental factors that allow for the behavior to arise, physical, social and economic factors
Motivation - Encompasses psychological processes that energize and direct behavior, including both conscious and unconscious processes.
The behavior change wheel
Intervention functions
Policy categories
Behavioral change techniques - BCTs
Intervention functions - Broad mechanisims through which change can be achieved. Education, persuasion, incentivization, coercion and training.
Policy categories - These are the types of interventions that can be applied at a population level to influence behavior, such as legislation, fiscal measures, guidelines and regulation.
Behavioral change techniques - BCTs - Specific strategies or methods used within interventions to bring about behavior change. Examples of techniques are goal-setting, self-monitoring, feedback, social support and reinforcement.
Theory effectiveness hypothesis
Theoretical basis/Framework
Understanding behavior
Predictive power
Effectiveness of an intervention is directly related to the extent to which it is based on relevant and applicable psychological theories of behavior change.
- Theoretical basis: Interventions that are well-established in theories of behavior change are more likely to be effective. These theories serve as a framework to understand the underlying mechanisms of behavior change and allow us to use targeted and evidence-based strategies to induce behavior change.
- Understanding behavior: Theories offer insights into how and why people act and which factors influence the behavior. Interventions targeted at specific barriers and facilitative processes can lead to change.
- Theories allow for predictions of how people will react to different interventions. ‘
Allows for precise tailoring of interventions. based on individuals needs and characteristics. - Evaluation and refinement - Interventions based on theory can be evaluated and refined. We can compare them to the appropriate outcome measures and see if we succeeded. If not, we can get an idea of how to improve.
- Generalizability - Interventions grounded in theory are more likely to be generalizable across different populations and contexts. If the mechanisms underlying behavior is identified by a theory, they can often transcend cultural and demographic borders. This allows us to adapted and apply interventions to diverse populations with greater confidence.
Psykologiska faktorer vid smärta
Stämningsläge
Katastrofiering
Stress
Hantering
Biologiska faktorer vid smärta
Sjukdomsgrad
Smärtreceptor
Inflammation
Hjärnfunktion
Sociala faktorer som påverkar smärta
Kulturella faktorer
Social omgivning
Ekonomiska faktorer
Socialt stöd
Smärta - modern definition
Obehaglig sensorisk och/eller emotionell upplevelse, ofta förenad med vävnadsskada eller hotande vävnadsskada, dock är smärta subjektivt och kan uppstå trots frånvaro av vävnadsskada.
Smärt-terminologi - Nociceptiv
Viceral
Vävnadsskada
Viceral - smärta från interna organ (referred pain)
Smärt-terminologi
Neuropatisk
Nervskada - perifera vs centrala nervsystemet
Smärt-terminologi
Nociplastisk
Förändrat smärtsystem
Smärt-terminologi
Idiopatisk
Oklar orsak, specifik för pat.
Smärt-terminologi Psykogen/somatoform
Rent psykologisk orsak
Föråldrar kategori, främst historisk intressant.
Fantomsmärta
Smärta från amputerad kroppsdel. Hälften av amputerade upplever någon form av fantomsmärta.
Primär vs sekundär smärta
Primär smärta härstammar direkt från en händelse eller skada
Sekundär smärta uppstår som biprodukt av ett annat problem.
T.ex:
Cancer-relaterad smärta
Post-kirurgisk eller post-traumatisk smärta
Neuropatisk
Huvudvärk eller orofaciell smärta
Viceral
Muskoskeletal smärta
Akut smärta
Tidsram
Typ av skada
Återhämtning
Återkommande
Begränsade konsekvenser
0-3, max 6 månaders smärta
Vävnadsskada - objektiva fynd
Försvinner när skadan läkt
Återkommer endast i vissa fall:
- Migrän
- Spänningshuvudvärk
- Tandvärk
Begränsade psykosociala konsekvenser
Kronisk smärta
Tidsram
Objektivt/Subjektivt
Förknippad med andra kroniska sjukdomar:
- Reumatism
- Diskbråck osv
Går ofta i skov - påverkas av omgivande faktorer t.ex mående och kontext
Omfattande psykosocialt begränsande konsekvenser - disability
Smärta - somatisk samsjuklighet
Somatiska sjukdomar kan orsaka samt förvärra smärta
Diabetes
Hjärt-kärlsjukdomar
Fetma
Respiratoriska sjukdomar
Ehlers-Danlos syndrom
Reumatisk sjukdom
Yrsel
Cancer
Psykiatrisk samsjuklighet - kronisk smärta
Kan förvärra och vidmakthålla smärta. Försämrar funktion ytterligare, komplicerar behandling för att det försämrar effekterna av rehab.
- Egentlig depression
- Ångestdiagnos
- Insomni
- PTSD
- Substansbruksbruksyndrom
Mäta smärta
Subjektiva självrapporter med t.ex VAS - Visuell analogskala
0-10, ingen smärta - värsta tänkbara smärta
Multidimensional pain inventory
Objektiva mätningar av “smärta”
Observation - Fysiologi och funktion
Intensitet
Lokalisation
Hur smärtan “upplevls” - Smärtans egenskaper, adjektivlista
Konsekvenser, livskvalitet “disability”, hur mycket begränsas man?
Smärtans hälsopsykologi
Smärta varnar om hot och skada samt signalerar om att man är skadad.
Utlöser försvaret i from av fysiologisk aktivitet och beteende för att skydda och begränsa hot/skada - en evolutionsbiologisk bas.
Snabb, skarp signal - akut = fly
Långvarig, molande signal = vila
Nyckelfaktorer för smärtupplevelsen
Humör
Uppmärksamhet
Kognition
Social kontext
Humör - förvärrar och förvärras av smärta (cykliskt)
Uppmärksamhet - Ökad uppmärksamhet ökar smärtupplevelsen, distraktion minskar den (motiverar undvikande)
Kognition - Attributioner, self-efficacy, förväntningar, katastrofiering
Social kontext - Stöd, socialt sammanhang och miljö generellt kan modulera smärtupplevelse
Smärtkänslighet
Tolerans vs smärttröskel
Psykisk ohälsa
Primär hyperalgesi - nociception ökad lokalt vid skada
Sekundär hyperalgesi - Smärta upplevs i andra distana kroppsdelar.
Smärtkänslighet/tolerans vs smärttröskel:
- Tröskeln likartad hos alla, tolerans varierar mycket
- Depression och ångest kan sänka båda.
Hyperalgesi = gör mer ont än vad det “borde”
- Primär: Ökad känslighet till smärta vid vävnadsskadan. Nociceptorerna blir sensitiviserade i påverkade området.
- Sekundär: Ökad smärtkänslighet till närliggande eller distanta kroppsdelar. Kemiska mediatorer/transmittorer kan aktivera bihängande nociceptorer som sprider signalen vidare till andra kroppsdelar som får sensitiviserad nocioception. Kroniska smärta, neuropatisk smärta och centrala sensitivisering associeras ofta med hyperalgesi.
Allodyni - smärta
Smärta av normalt sett icke-smärtsam stimulans
Taktil, värme, rörelse, ljus.
Gate control theory
Nociceptive signals
The “Gate”
Opening and closing the gate
Central processing
Modulation of pain perception
Pain signlas are transmitted and modulated within the nervous system. The signals can bli amplified or inhibited, depending on the neural mechanisms in the spinal cord that modulate the signals.
- Nociceptive signals: A signal is transmitted to the spinal cord.
- Hypothetical ‘“gate” mechanism, controlled by both large-diameter nerve fibers (A-beta fibers) - non-painful sensory info (fast signaling) . Small-diameter nerve fibers (A-delta and C fibers) - pain signaling that is slower.
- Opening and closing the gate - Small-diameter fibers try to send afferent nocioceptive signals to spinal cord, but this signal can be blocked by a Large-Diameter fibre that is already active thus the gate is closed, and the pain signal is inhibited. Rubbing a bumped knee can provide relief from pain.
- Central processing - Once signals pass through the gate, they are further processed and interpreted, leading to the conscious experience of pain.
- Modulation of pain perception: Suggets that factors such as emotions, attention and cognitive processes can also influence the gating mechanism, thereby modulating perception of pain. For example, distractions or positive emotions may help to close the gate and reduce nocioception.
Fördelar med gate control teorin
Smärta ses som perception som går att modulera via aktivt engagemang, ej passiv mottagare av stimuli. Individuell variation med olika stor öppning i grinden, hur mycket large-diameter krävs för att blockera en smärtsignal?
Multipla orsaker till smärta
Olika kombinationer av fysiologiska och psykologiska faktorer som ursprung till smärta.
Samspel body-mind?
Gate control theory - nackdelar
Mekanismerna förefaller vara väldokumenterade men var finns grinden?
Förutsätter frf organisk/fysiologisk orsak till smärtan (stimulus-respons modell i grunden)
Dikotomi - mind/body, ej integrerad och unifierad
Neuromatrix
Pain is not simply a result of tissue pain and sensoric awareness of this. It is a complex experience generated by various factors, including sensory, emotional, cognitive and psychosocial/environmental factors.
Neuromatrix refers to a network of connected neurons that are distributed all around the brain that are processesing and interpreting pain signals. These signals are moderated by other processes such as emotional, cognitive and factors such as sensory ones, attention and enviornmental factors. Memory and attention are important for our pain experience.
Perception of pain is influenced by individual differences in genetics, past experiences, psychological factors and social context. Two people with the same injury may experience pain in wildy different ways.
Doesn’t say that there is an superimposed physiological cause for pain, rather it is a combination of different factors.
The advantages of gate-control theory are preserved but match better with the biopsychosocial model.
Criticism of neuromatrix
Weak design, no evidence of causality - bad intern validity.
Anecdotal, unsystematic measures and therefore dubious data.
Lack of generalization, bad extern validity.
Speculate and vague theory - is it adding anything new?
Utveckling av kronisk smärta - Fear-avoidance modellen
Smärta kan få två huvudutfall.
Kronisk smärta:
Smärtupplevelse som leder till smärtkastrofiering som ger upphov till negativ affekt - hotande info om hälsobesvär att man har ont, kommer det vara så för alltid? Patientens förväntningar på smärtfrihet kan leda till mer lidande, man accepterar ej situationen.
Detta leder till smärtrelaterad rädsla som ger upphov till undvikande via distraktioner som negativt förstärker smärtupplevelsen eller så är man istället hypervigilant och fixerar sig vid smärtan som leder till sensitivisering av smärtupplevelsen. Detta ger upphov till inaktivitet, uppgivenhet, depression och blir ett handikapp som gör att man har mer ont osv.
Gott utfall: Smärtupplevelse som möts utan rädsla, man konfronterar situationen och återhämtar sig.
Etiologi bakom kronisk smärta -
1. Process
Early trauma
Fear, catastrophic thoughts
Not just duration
- Cyclical variation
- More occassions for negative learning
Early trauma - predisposing one to get worse
Cyclical: sometimes better sometimes worse
More possibility to learn maladaptive behavior
- Gets worse over time
Utveckling av kronisk smärta -
2. Kontext
Environment is dynamic, external and internal cues
Insensitivity to these cues can lead to rigid coping mechanisms
- Exaggerated resting, or being too careful and avoidant
One’s response to pain is important for the devlopment of pain.
development of chronic pain
3. Gains of illness
Primary - intrapersonell
Secondary - interpersonal
Tertiary for someone else
Primary - Expressing that one is in pain can lead to not having to do something you don’t want to or that is discomforting.
Secondary - Interpersonal: Pain behavior leads to positive experience, like someone showing empathy, comfort and understanding.
Tertiary: Pain behavior that leads to positive feeling and satisfaction for someone else, feeling like one is helping another person who’s in a tough sitaution as well.
Ethiology of chronic pain
3. Transdiagnostical processes
Predisposing processes
Triggering processes
Protective processes
Driving processes
Catalytic processes
Comorbidity is a big part of it.
- Depression, anxiety, insomnia, PTSD and stress/exhaustion
- Can sustain pain and make it hard to rehabilitate.
Same underlying mechanisms:
Worry, avoidance, catastrophizing, inflexibility
Predisposing processes
Triggering processes
Protective processes
Driving processes
Catalytic processes
Ethiology of chronic pain -
Risk factors for chronic pain
Psychosocial factors:
Psychiatric problems
Social work situation
System- and social factors
Psychological and social variables have more meaning than the biomedical för development for long-term disability and pain.
Psychosocial variables:
- Psychiatric issues
- Social work situation, support from bosses and coworkers
- System- and societal factors: Laws, insurance, work characteristics
Ethiology of chronic pain
5. Learning
Respondent
Operant
Learning makes environment predictable, that’s why we learn things. Natural reactions become maladaptive.
Respondent/Classical conditioning - Pain is salient stimulus, associated with neutral ones. Pain triggers natural stress. Stress is associated with former neutral stimuli.
Fear, catastrophizing and traumatic memories.
Operant conditioning:
- Pain, normally a primary negative punishment but if we have constant negativ punishers then we get a lot of negatively reinforced avoidances.
- Discriminative learning: One stimulus leads to one response.
Kinesiophobia
Severely excessive irrational and debilitating fair of physical activity and movement, often a factor driving chronic pain. Often a result of pain catastrophizing, body will break or pain will become worse. Natural consequence of traumatic events.
TSK - Tampa Scale of kinesiophobia to measure it.
Treatment: Exposure to movement and confronting catastrophic thoughts.
Treatment and prevention of chronic pain
Prevention:
Physiotherapy
Naprapathy
Chiropratic treatment
Acupuncture
Treatment: Multimodal, combination of biopsychosocial interventions and physical ones.
Psychological components of treatment of chronic pain
Self-regulation
Behavioral therapy
CBT
ACT
Self-regulation: Biofeedback, relaxing, hypnosis, mindfulness
Behavioral therapy: Working with pain behavior, balancing activities, behavioral activation, exposure and physical activity - this is implementing and activating positive behavior.
Cognitive behavior therapy: Knowledge, coping and application in daily life - Cognitive methods
Third wave CBT and ACT: Acceptance, Values and mindfulness (psychological flexibility)
Multimodal rehab
Focus on what psychologist does
Transdisciplinal rehab with doctors, physiotherapists, work therapists, curators and psychologists.
Psychologist’s work: Activity balancing
Behavior activation and stress management
Worry and rumination
Feelings and anxiety
Communication skills and setting boundraries
Sleep and insomnia
Treat each comorbid psychiatric condition individually
Bristande fokus på sexuell hälsa
Utbildning och kunskap
Rädsla för att prata om det
Attityder
Genans
Kultur
Brist på utbildning och praktisk träning
Rädsla
Bristande förmåga att tala om sex
Attityder
Rädsla att genera patient/klient
Genans för sig själv
Förutsättningar för att prata om sex som professionell
Kunskap om begrepp och ord och praktiker
Hitta inkluderande ord
Förhålla oss till olika synsätt, tolerans
Träna på att säga vissa ord högt
Kunskap om begrepp och ord och praktiker
Hitta inkluderande ord - underlätta kommunikation
Förhålla oss till olika synsätt, tolerans för andras livsstil
Träna på att säga vissa ord högt - hjälper ord att tappa laddning
Bra att tänka på inför samtal om sex
Självreflektion och medvetenhet
Medvetendegöra sina egna åsikter
Upprepa uttryck på okonstlat sätt
Vilka ord känns obekväma/bekväma att använda? Vad känns bra? Hur påverkas patient?
Målmedveten träning
Våga vara kvar
Öva utanför - för in
Självreflektion och medvetenhet, bra för att kunna prata om sex och sexualitet, kanske extra viktigt
Medvetendegöra sina egna åsikter - så dessa inte påverkar arbetet för mycket - motöverföring.
Upprepa uttryck på okonstlat sätt - för att itne väcka negativa reaktioner hos behandlaren och känna osäkerhet kring ämne och uttryckssätt.
Vilka ord känns obekväma/bekväma att använda? Vad känns bra? Hur påverkas patient? Hur kan man bli bättre på att uttrycka sig och att positivt påverka sin patient?
Målmedveten träning - träna på att ställa frågor om och igen
Våga vara kvar
Öva utanför - för in i samtalet
Hindrande faktorer i sexuellt terapiarbete
3 punkter
motstånd
prydhet
egenterapi
Omedvetet motstånd att ta i det
Medveten prydhet, jobbigt att snacka - genant
Brist på egenterapi - självreflektion och upplösande av motstånd
