Health Pschology and Human Diversity Flashcards
(167 cards)
0
Q
What are examples of bad news?
A
- terminal illness
- disabling condition
- traumatic/sudden death
- infertility
- ante-natal testing
- intra-uterine death
1
Q
What is bad news?
A
- any information that drastically alters a patients view of their future or both
- situations where there is either a feeling of no hope, a threat to a persons mental or physical well being, a risk of upsetting an established lifestyle or where a message is given which conveys to an individual fewer choices in his or her life
2
Q
Why not bad news be always bad news?
A
- patient may feel relief at diagnosis
- cancer may feel that there burden has been lifted
- determination that the minds is bad is with the mind if the perceiver and may vary according to personal circumstance such as age, family obligations and single mum?
3
Q
Why is it important that doctors tell their patients when it is bad news?
A
- to maintain trust
- to reduce uncertainty
- to prevent unrealistic expectations
- to promote open communication
- most pts wish to know their diagnosis and to be informed about their prognosis and treatment
- doctors find it easier to treat an care patients if they know their diagnosis
- lack of information can increase patient uncertainty, anxiety, distress and dissatisfaction
4
Q
What are the implications for patients if bad news is not delivered well?
A
- doctor patient relationship
- emotional well being i.e. distress and depression
- adjustment to their ability to cope with the illness for patients and their relations
5
Q
Why is it difficult to break bad news?
A
- fear of patients reaction
- desirer to protect patient
- fear of being blamed i.e. shooting of the messenger
- lack of confidence in ability to communicate
- sense of failure in the doctor
- lack of time
- reminds them of their own mortality and mortality of family and friends
6
Q
What are blocking behaviours?
A
Are behaviours that doctors can use when giving bad news such as..
- tell patient distress is normal
- change the subject
- giving information/advice before concerns aired
- focus on a particular aspect
- asking leading/closed/multiple questions
7
Q
What is the Spikes Model?
A
S = setting and listening skills P = patients perception I = invitation from patient K = knowledge E = empathy S = strategy and summary
8
Q
Give a good example of S: setting and listening skills in the spikes model?
A
- break the news face to face not telephone/letter
- avoid given information to relatives first
- ensure privacy with no interruptions
- find out who the patients want present
- tissues
- introduce yourself and any colleagues (only a few!)
- listening mode: silence and repeption
9
Q
Give a good example of P: patients perception in the spikes model?
A
What does the patient know already?
- before you tell ask?
- start consolation with general question i.e. what do you know so far?
10
Q
Give a good example of I: invitation from the patients in the spikes model?
A
- don’t assume that the patients will want to know everything
- if patients declines any information at this time respect it
- allow for denial and offer future opportunity for further discussion such as written appointment further down the line
11
Q
Give a good example of K: knowledge in the spikes model?
A
- give a warning shot
- incorporate key terms used by the patients
- lead patient to diagnosis: give small chunks of information at a time
- avoid jargon, align your language with the patient: use clear and simple explanations
12
Q
Give a good example of E: empathy in the spikes model?
A
- empathetic response
- listen to the patients concerns as you might be able to reassure them
13
Q
Give a good example of S: strategy and summary in the spikes model?
A
Summary: summarise main discussion points and check their understanding
Strategy: discuss strategies, agree on next step, be optimistic but avoid inappropriate premature response
Closure: signal closure, future availability, opportunity to ask questions, if still upset ask if they would like a member of staff to stay with them
14
Q
Define sexual orientation
A
term used to describe what gender you are attracted to : lifelong or vary over a lifetime
15
Q
Define sexual attraction
A
Includes feelings, behaviours and identity (may not all coincide)
16
Q
Identity?
A
Gay, lesbian, bisexual, are terms of identity however most people prefer no labels or wish to define themselves
17
Q
MSM?
A
men who have sex with men
18
Q
WSW?
A
women who have sex with women
19
Q
What is the gender binary model?
A
That there are two separate categories male and female which are clearly distinguished by anatomy so men should look and act masculine and women should look at act feminine
20
Q
Gender identity?
A
Someones internal perception and their experience of their gender
21
Q
Gender role/expression
A
The way the person lives in society and interacts wiht others
22
Q
Transgender status
A
Umbrella term for those who gender identity and gender expression differ from their birth sex e.g. transexuals, transvestites, cross dressers, gender queer
23
Q
transexual person?
A
Someone who feels a consistent and overwhelming desire to transition and fulfil their life as a member of the opposite sex
24
Examples of how stereotypes about LGBT patients can affect their healthcare? Assuming......
- a patients has an opposite sex partner or not
- a same sex partner is not next of kin
- a butch looking women doe snot need contraception
- a masculine looking man does not have anal sex
- a married man does not need an STI text
- a lesbian does not what children
25
Who can LGBT patients be discriminated by?
school, family, neighbours, if old other older people, hate crime, health care provision
26
So what can happen to LGBT patients?
- job loss and social isolation = norm
- rejection by family is common
- high risk of violence if fail to pass in public
- mental health: depression, self harm, suicidal
- gender reassignment is long, difficult to access and unsupported
27
How the discrimination of LGBT patients can lead to poor health?
- increased stress
- low self esteem
- isolation
- increased conflict
- sub culture
- distrust of authorities
- discriminatory healthcare
28
Give some examples of stereotypes for LGBT people
- gay men are effeminate, promiscuous and well groomed
- in lesbian relationships one person wears the trousers
- bi people are indecisive and greedy
29
Define homophobia
prejudices and discrimination against gay people
- giving patient poorer care
- ignoring or isolating LGBT colleague
- homophobic comments and jokes from other patients and staff
30
What is institutional homophobia?
is many ways in which government, business, religious institutions, and other institutions and organizations discriminate against LGBT people
- only having paternity care for male colleagues
- failure of organisation to tackle homophobia inside the work place
31
What are the specific health needs that are prevalent in the LGBT community?
- mental health: stress and seems worse in them
- Substance abuse: smoking, alcohol, recreational drugs
- cancer: HPV between women, MSM more likely to have anal cancer, HIV positive doubles risks
- sexually transmitted infections:
For MSM, HIV & syphilis more common amongst MSM but this depends on lifestyle and condom use
For WSW can still contract an STI even if have only slept with women in past 5 years
32
What do LGBT patients want?
- Validate the patients identity, more than being neutral
- confidentiality, don't out them without their consent
- respect, their lifestyle and identity do not show inappropriate interest
- knowledge, don't rely on patient for information, be able to distinguish between a patients problems and their identity
33
What are the ethical and legal requirements of doctors in providing good care for LGBT patients?
- be pro active to build trust
- don't make assumptions
- language
- confidentiality
- reflect upon and think about own feelings
- challenge homophobia
GMC = do not let your views prejudice treatment, challenge colleagues behaviour
Tomorrows doctors: respect all patients, colleagues and others regardless of sexual orientation
The law: equality act 2010: illegal to discriminate on grounds of sexual orientation or gender identity, in provision of goods and services in education and workplace
34
Define sexual dysfunction
Sexual dysfunction is characterised by a disturbance in sexual desire and in the psychological changes that characterise the sexual response cycle and cause marked distress and interpersonal difficulty
35
Describe the sexual response cycle?
- Desire
- Arousal
- Orgasm
36
Give examples of how the male sexual response cycle can be affected: Desire, arousal, orgasm
```
D = lack or loss of sexual desire
A = erectile disorder
O = rapid ejaculation, inhibited organism
Other = sexual aversion and lack of sexual enjoyment, dyspareunia/painful sex
```
37
Give examples of how the sexual response cycle can be disrupted in women: Desire, Arousal and Orgasm
```
D = lack or loss of sexual desire
A = sexual arousal disorder
O = organism dysfunction
Other = sexual aversion/lack of sexual enjoyment, dyspareunia, vaginismus (goes into involuntary spasm)
```
38
Describe the possible problems in sexual dysfunction..
- occur irrespective of sexual orientation
- more than one problem can oc-exist
- are often present in both partners
- lifelong or acquired
- generalised/situational
- physical or psychological difficulties
- may present overtly or covertly i.e. reported negative investigations for pain or discharge, never being happy with an method of contraception
- reluctance to raise a sexual problem
39
Examples of precipating factors in sexual problems..
- physical
- life events
- pschological
- partner problems
40
Examples of predisposing factors in sexual problems..
- false beliefs/concepts
- physical vulnerability
- unrealistic expectations
- poor communication skills
- early sexual trauma
41
Examples of perpetuating factors self in sexual problems..
- lack of confidence
- spectating
- guilt and shame
42
Examples of perpetuating factors (partner) in sexual problems..
- breakdown communication
- pressure to perform
- criticism and hostility
- guilt and self blame
43
What are the main treatments of psychosexual therapy
- educative counselling: individual or couple
- modification of attitudes/beliefs
- facilitation of communication/assertiveness
- specific directions for sexual behaviour: foreplay, dilator therapy, stop start
44
Give specific examples of male psychosexual therapy
- oral: viagra, testosterone
- local therapy e.g. emula cream
- self injection therapy
- mechanical therapy e.g. pumps and rings
- surgery e.g. penile implant
45
Give specific examples of female psychosexual therapy
- testosterone e.g. if post menopausal
- lubricants
- oestrogen
- clitoral therapy device, EROS
- zestra gel
46
Points to consider when discussing sexual issues with patients
- empathy and reasurement
- embarrassment
- stigma
- privacy and confidentiality
- open and specific questions
- avoid labels and value judgements do not make assumptions!
- terminology
- religious and cultural issues
- interview partner
47
Structured clinical interview for sexual problems
- detailed description of the problem, its onset progression including behaviour, effective and cognitive functioning
- relationship with partner
- relevant past relationships
- medical history and drug use
- mental health history
- family and psychosexual history
- significant life events
- cultural aspect
- coping mechanism and support networks
48
Why terminology around sexual behaviour can be a problem in talking to patients and the implications of this for practise
- term sex maybe different things to different people
so can be difficult getting accurate information from patients (sexual history, discussing sexual behaviours)
- use specific terms for sexual behaviour
- check patient understanding to make sure that they understand it in the same way that you do
49
The NATSAL survey what was reported?
| survey done in 1990/1991, 1999/2000, 2010/2012
- increasing average number of heterosexual partners
- more people reporting anal and oral sex
- more people experiencing same sex relationships
- more acceptance of same sex relationships
- higher incidence of consistent condom use in the past 4 weeks
- more HIV tests and visit to STD clinics
50
Why is it difficult to get accurate information about sexual behaviour?
- embarrassment or reluctance to report their sexual behaviour to the interviewer
- may not be able to recall all their sexual encounters
- sampling problems, those who did not respond and those 75
51
What are the implications of diversity in sexual behaviour?
- problem about getting reliable data means we cannot say what is normal statically
- not such thing as normal sexual behaviour
- what maybe thought as normal sexual behaviour is actively quite common i.e. anal sex in heterosexual couples
- whats normal for 1 person may not be for another
- can reflect stereotypes and overlook diversity
- behaviour and norms about sexual behaviours change over time: culture, age group, sexual orientation and social context
52
Why sexual issues may not be raised in medical consultations from the healthcare professionals perspective?
- not their area of speciality so might not mention it
- may feel uncomfortable about talking about it to a patient
- may have not thought it was relevant to their consultation
- didn't think it was there place to say
- were focusing on the patients other issues/problems
- might not have the knowledge to do so
- might not be time
53
Why sexual issues may not be raised in medical consultations from the patients perspective?
- don't want to seem stupid in front of the doctor/ think doctor thinks that it will be obvious
- think might be judged if they thought it was a priority
- women might feel uncomfortable if the professional male or female does not feel open to talk about their sexual issues and vice versa for men
- might stereotype different specialties
54
Examples of how to facilitate discussion about sexual issues?
- ensure staff have had appropriate training and are confident in dealing with sexual issues even though it it not their area of speciality
- have regular assessment to show that staff are able to talk about sexual issues
- might provide leaflets with written information for the patient to take home
- make it clear that information/clinic are available for sexual issues
55
What are the three main patterns in dying?
Gradual death: slow decline in ability and health
Catastrophic death: through sudden and unexpected events
Premature death: in children and young adults though accident/illness
56
Diversity in patterns of dying...
- fewer people die at home
- medicalisation of death
- death rates are falling in England and Wales
- women on average live longer
- death rates higher in older age groups but people can still die at any age
- less wealthy on average experience poorer health and die sooner
- causes of death include CVS, cancer, respiratory, mental, behavioural, suicide, accidents, NS disorders, GI, GU
57
The five stages of grief model of adjusting to the idea of dying?
1. Denial
2. Anger: search for 2nd opinions/alternative treatments, blame someone
3. Bargaining: appeal to higher powers to save them
4. Acceptance: accept death, peace with friends and relatives
58
The positive aspects to denial?
- coping mechanism
- respect desire not to know
- written information can be given to be looked at by patient/their family
59
The negative aspects to denial?
Can be a barrier to good care as patients can refuse to discuss concerns or think about future
60
Symptoms that are often experienced following bereavement
Grief:
- set of psychological and physical reactions to bereavement
- a normal reaction to overwhelming loss
- a reaction in which normal functioning no longer holds
- common elements include anger, blame, guilt and depression
61
Describe the grieving process...
- disbelief and shock in early stages
- developing awareness
- resolution
Each person experiences stages differently
62
What is mourning?
- process of adapting to loss
- role of funeral rituals (mark passing of loved person, show grief, social support, celebrate lost person, marking their death and the future)
63
What is bereavement?
is associated with increased risk of illness and mortality particularly in older people who have lost their spouse.
- physical: sob, palpitations, fatigue, digestive symptoms and decreased immune function
- behavioural: insomnia, irritability, crying, social withdrawal
- emotional: depression, anxiety, guilt, anger
- cognitive: lack of concentration, memory loss, hopelessness, disturbance of identity, visual and auditory hallucinations
64
What are the risk factors for poor outcome of bereavement? (risk factors for chronic grief)
- prior bereavement
- mental health
- type of loss (young person, nature of death, caring status)
- lack of social support, stress fro others arises
65
What are the risk factors which lead to complications in the grief process? (risk factors for chronic grief)
- expression of grief discouraged
| - ending of grief discouraged
66
Examples of good practice in communication with patients who have the following barrier: Language
- interpreters: family, friend or a professional
- risk of confidentiality, patient being embarrassed, miscommunication, translating medical jargon
- in emergency situations where there are not translators can use picture books
- interpreters often need briefing before medical consultation
67
Examples of good practice in communication with patients who have the following barrier: Learning Disability
Is a reduced intellectual ability and having difficulty with every day activities such as household chores, socialising, managing money.
- good online resources and visual aids available i.e. easy health website
- might not have best lifestyle, difficulty communicating illness, do not understand precautions that they need to take
68
Examples of good practice in communication with patients who have the following barrier: deaf
- having working hearing aid loops
- visual aids
- interpreters but need good understanding of BSL
69
Examples of good practice in communication with patients who have the following barrier: sight loss
- increase accessibility by telephone appointments, home visits, slopes and hand rails
- specially designed appointment cards
- apply good communication skills with patients
- have specialised written documents available: braile, big spaced out texts, clear fonts, avoid italics/underline, black font on yellow paper, audio files/cd
70
Define cultural diversity
- culture is defined by each person in relationship to the groups or groups with whom he or she identifies
- an individual culture may be affected by such factors of rate, ethnicity, age, language, country of origin, auscultation, sexual orientation, gender, socio-economic status, religious/spiritual beliefs, physical abilities, occupation among other
- these factors may impact behaviours such as communication styles, diet preferences, health beliefs, family roles, lifestyles, rituals and decision making processes
- all of these beliefs and practises in turn can influence how patients and health care professionals perceive health and illness and how they interact with each other
71
Examples of ways in which culture can impact on patients presentation to health services:
- way they think about the illness/problem
- the way they make sense of certain symptoms and behaviours
- the view of potential services and the services they choose to accept
- the way in which those who have illness are perceived
- issues of access
- experience of service user
- visibility of services
72
Reasons why organisations and delivery of health care needs to take diversity into account
- increased diversity of populations
- increasing but limited evidence to show that taking a patient centred approach improves outcomes
- huge disparities in care accessed
- differential outcomes
- legislation; everyone should receive equal care regardless
73
How problems can arise in organisations delivery of health care needs to diversity
- lack of knowledge = inability to recognise differences
- self protection/denial = attitude that there differences are not significant enough to outweigh our humanity
- fear of the unknown = because this is challenging and it is intimidating to understand something new that does not fit into greta worldwide view
- feeling of pressure due to constraints = feeling rushed so do not look at patients individual needs
74
What problems in delivery of diversity in health care may lead to
- patients provider relationship are affected when understanding of each other expectations is missing
- miscommunication
- non compliance
- rejection of health care provider
- provider not understanding patients perspective
- conflict or isolation within staff groups
75
The concept of attachment in child devlopment
- a strong affectional tie felt for another
- a biological based system that functions to maintain proximity to the infants care giver
So infants are predisposed to exhibit proximity seeking and contact maintaining behaviours
- infant will form first mental model of a relationship based on interaction with their primary care giver
- critical point for attachment in 1st year and problems may result is separated in first 4 years
76
What is a secure attachment worth?
- love and care
- idea that other will be available to them in times of need
- influences brain development
- better social competence, peer relations, self reliance, physical and emotional health
77
What are the stages of social development in infancy?
1. Newborns: show prefrences for human faces over inamite objects, 1st socail smile = 6 weeks
2. 3 Months: distinguish strangers from non strangers, but show preference for non strangers but will still allow any caring adult to handle them without being unduly upset
3. 7 to 8 months: specific attachments are formed and children will miss key people and show signs of distress in their absence, will be wary of strangers picking them up even with key people present
78
What is a secure attachment style?
- mother is quick to respond to physical and emotional need of child, this helps the child cope with stress
so if mum leave the room child distressed but calms down quickly when she returns and explores
79
What is a secure attachment predicted by?
- carer is sensitive to child's signals
- rapid, appropriate responses emitted consistently
- interactive synchrony with carer
- carer accepts role of parent/carer
- carer has higher self esteem
80
What are the types of insecure attachment?
1. Avoidant, child explores the environment and is not bothered by mums return. the mum does not respond when the child is upset. Tries to stop child crying and encourage independence and exploration
2. Ambivalent, child gets upset when mother leaves the room but can be comforted by a stranger, when mother returns child acts ambivalently or appear angry, mum is inconsistent so varies between responding quickly or not at all. So child is occupied when mother is available but can sue her for a secure basis
3. disorganised, can be one of each 3 but child shows difficulty coping when mum returns i.e. freezing so mum can be withdrawn, negative, be giving inappropriate care with roles not be clearly defined.
81
The behavioural changes that can occur if an attachment figure is absent
- separation anxiety
- bed wetting
- increased aggression
- detachment
- clinging behaviour
82
The phsycial changes that can occur if an attachment figure is absent
- depression
- slower movement
- less sleep
- changes in HR and body temperature
- > seen in pre school children hospitalised for chemo
83
What are the three stages when an attachment figure is absent?
1. Protest: child is distressed, looking for mother and clinging to substitute, for countless days
2. Despair: sign of helpless ness, withdrawn, cry only intermittently
2. Detachment: more interested in surroundings, may smile, be sociable but when carer returns they are remote and apothetic
84
What are the criticism of attachment theory?
- too simplistic
- overly focuses on mother, father are marginalised
- multiple attachment figures may be formed
- quality of substitute care has not been considered
85
The implications of separation for the hospitalised child
- lack ability to keep image of carer in their mind
- limited language so do not understand tomorrow
- lack ability to understand abstract concepts
- often feel abandoned and may attribute this to their own failings i.e they have gone because I was naughty
86
Complications to health outcomes in hospitalised children
- adherence to treatment maybe adversely affected and this in turn may impede recovery
- patients experience of pain maybe worse if anxiety levels are higher
- patients may suffer from adverse effects of stress on health
87
Examples of good practise in the organisation of hospital care for children
- allow parental/carer access
- allow attachment objects such as teddy
- reassure the child that they are not being punished/abandoned
- make environment more like home
- use stimulating toys/activities
- high quality substitute care and specialised nurses
- continuity of staff
88
What are the 4 features of Piagets stages of childhood development?
1. Sensor-motor (0-2)
2. Pre-operational (2-7)
3. Concrete Operational Stage (7-12)
4. Former Operational Stage (12+)
89
What in the Sensor-motor stage in Piagets stages of child development?
- 0 to 2
- experience world through senses
- develop motor coordination
- no abstract concepts
- develop body schema
- develop understand permanence at 8 months i.e. continued existence of out of sight objects
90
What in the Pre-Operational stage in Piagets stages of child development?
- 2 to 7
- language development, symbolic thought, able to image things
- egocentrism
- lack concept of conservation e.g. water in different glasses
- can only classify by a single feature
- do not understand reversibility
91
What in the concrete-operational stage in Piagets stages of child development?
- 7 to 12
- think logically but concrete rather than abstract
- difficulty with complex reasoning i.e. not metaphors
- achieve conservation of number, mass and weight
- classification by multiple features
- able to see things from others perspective
92
What in the Formal operational stage in Piagets stages of child development?
- 12+
- abstract logic
- hypothetic deductive reasoning
93
Criticisms to Piagets model of child development
- focuses too much on what the child cannot do not what they can achieve
- if child deemed too young for a certain concept and therefore are only given partial information this can be damaging as a child will try and make sense of the situation anyway
94
What is Vygataky's theory of social development?
- cognitive development requires social interaction
- child is an apprentice and learns through shared problem solving
- with able instruction child can achieve some increase in understanding
- focus on zone of proximal development
95
The implication of theory about childhood cognitive development for communicating with children about illness and treatment
- don't assume average ability, need to asses each child's level of understanding and their zone of proximal development and tailor communication for this
- young children lack theory of mind, so may think that other know how they feel
- difficult to articulate feelings due to language constrictions
- difficulty thinking about future
96
Examples of good practise in communicating well with children
- adjust consultation style to the capacities of children i.e. language and complexity of ideas
- explain things to children in age appropriate way i.e. dolls and actions
- age appropriate information booklets can increase child's understanding of illness, treatment and recovery
- where applicable use parents to communicate with children
- social referencing: initial contact with parents/carers which rapidly instals confidence and draws the child in
- remember different levels of understanding with parents
- for special needs need an understanding of the child's communication, visual clues, altered communication
97
in adolescents for communication
- increased independence
- increased risk taking
- increased self awareness
- increased conflict with parents
- decreased communication
- see with or without parents/carers
98
Do's for communicating with children
- smile if appropriate
- eye contact
- calm
- acknowledge and greet child
- simple and clear information
- give child choice were possible: examine on mummy's lap or on bed
- play!
- distract them so talk about their interests
- quick fixes such as stickers
- acknowledge child's feeling
- say positive things about the child to the child
99
Don'ts for communicating with children:
- stand over child
- use force
- promise things you cannot deliver
- express your frustration
- rush or ask too many questions
100
define Pschology intervention
psychotherapy is the systematic use of a relationship between a patient and a therapist as opposed to physical(medication( and social (not looking at individual) methods to produce changes in feeling, cognition and behaviour
101
What is psychodynamic therapies?
- aims to resolve the unconscious conflict that underlies symptoms
- exposes feelings using experience of therapist and the relationship
- attempts to enhance insight difficulties and help incorporate painful previous experiences
102
Who is psychodynamic therapy suitable for?
- inter personal difficulties and personality problems
- those who have the capacity to tolerate pain
- interest in self exploration
103
What is systemic therapy and family therapy?
individuals, couples or families with the focus on rational complex. address patterns of interaction and meaning
- aims to facilitate resources in system as a whole
104
who is systemic therapy and family therapy suitable for?
- child psychiatrists use
105
What are humanistic therapies?
no universal definition but relies on general counselling i.e. warmth, empathy and unconditional positive regard
- can help with coping in intermediate crisis where already motivated and willing to problem solve
106
Who is humanistic therapies (client centred) suitable for?
mild to moderate difficulties relating to:
- life events
- substantial depression
- mild/anxiety or stress
- martial/relationship difficulties
- those with a recent onset so less than a year
107
Who is CBT suitable for?
- patients who are keen to participate
- engage together with the therapist/collabritevly
- those who can articulate their problem and are practically seeking solutions rather than just wanting to be happy
108
What are the core principles and methods of CBT?
- relief symptoms by changing maladaptive thoughts, beliefs and behaviours
- pragmatic combination of concepts and techniques from cognitive therapy and behavioural therapy
109
Cognitive therapy rational
- not passive recipients of stimuli
- interpret the world via value, beliefs and expectations
- use cognition to make sense of the world
- not the situation that upsets us but our view of it
- change in mood state are directly related to the way we make sense of the events
110
Diagrams in CBT
think thoughts, emotion, psychology and behaviour are all linked to our environment.
And that we also go through the stage of early experience, core beliefs, assumptions and eradicate incidence.
111
What is the negative cognitive triad in CBT?
1. negative view of self
2. negative view of world around
3. negative view of future
112
What are the techniques that can be used in CBT?
- graded exposure to feared situations
- activity scheduling
- reinforcement and reward
- role play/remodelling
- education
- monitoring of thoughts, behaviours and feelings to develop awareness of their interpersonal relationships
- behavioural experiences, so put them in a feared situation
- cognitive reversal of coping with difficult situations
- schema work on core beliefs
113
What are the limitations to CBT?
- findings of efficacy derived from homogenous populations with limited co-morbidities
- delivered by expert practitioners, this is difficult in clinical practise
- limited benefits when problems are complex and diffuse
114
The mental health conditions that CBT is likely to be effective for
- depression
- eating disorders
- sexual dysfunction
- anxiety states e.g. phobias, OCD, panic, PTSD, body morphic disorder, GAD/generalised anxiety disorder
115
Define pain
an unpleasant sensory and emotional experience which is associated with actual and potential tissue damage or is described as in terms of such damage
116
What are the limitations of the biomedical model of pain?
- people report continuing to experience pain are the tissue damage has healed
- people report feeling pain when no physical damage has been identified
- people report no pain despite severe injuries
- amputees experience phantom limb pain
- placebo effect
- variations in pain reported form people with different injuries
117
What is the biomedical model of pain?
- physical damage in the sole, direct cause of pain and it explains the full extent of the pain after the tissue damage has healed
- more damage = more pain
- any role for Psychology is the aftermath of pain
118
What are the differences between acute and chronic pain?
Acute=
- short term, attracts our attention and warms of tissue damage, pain lasts for as long as there is healing, action to take is rest and medication, injury is short term
Chronic =
- pain >12 weeks, long term and is dehabilitating, pain is not useful so does not indicate any tissue damage, prolonged rest and medication is not helpful like in acute pain, arises from variety of conditions/disease and can have nor know cause
119
What is the gate control theory of pain?
- pain is experienced in the brain through a complex 2 way pathway in the body from damage/disease source
- different pain fibres: fast, slow, hot, cold, blunt, sharp
- important neural relays or gates for messages to pass through are located in the dorsal horn of the spinal chord
- pain is the result of a 2 way process between the brain and tissue damage
- the extent to which the gate is opened or closed affects the number of pain message that are received
120
Examples of what opens the pain gate?
```
injury
over/under active
sensitivity of NS
stress and tension
focus on pain expectation
negative emotions
negative beliefs
minimal involvement in life
```
121
Examples of what closes the gate of pain
```
medication
counter stimulation i.e. mummy rubs it better
regular exercise
regular relaxation
distraction (children!)
positive emotions
positive beliefs/control
active life
```
122
How biological, psychological and social factors affect the experience of pain
- operant conditioning i.e. smell of hospital/dental drill
- classical conditioning, viscous cycle
- meaning
- self efficacy, give patients as much control as possible
- attention
- catastoihpsing i.e. negative beliefs
- pain behaviour can become part of identity
- secondary gains i.e. get attention
- fear = higher levels of pain
- anxiety
123
The aims of pain management programmes
- reinforces an acceptance of reality of chronic pain
- improves fitness, mobility and posture
- address fears of consequences of movement
- develop ways to cope with stress, anxiety and depression
- improve ability to relax
- graded return to activities to daily living
- facilitate appropriate medication use
- improve communication skills
- reduce use of unhelpful aids/equipment
- improve quality of life, working towards optimum function and self reliance in managing their persistent pain
124
What are the principles of pain management programmes
1. managing thoughts and feelings
2. active but pacing self
3. realistic goal setting
4. relaxtion
125
Other parts to pain management programmes
- hurt does not mean harm
- sleep hygiene
- communication
- anger managemtn
- relationships
- voluntary change
- planning for bad days
- introducing physiology of pain and the pathways
- exploration of difference between acute and chronic pain
- Pschology of stress response
then believe that pain is real, part of a group who have shared experiences, social comparison theory of that you judge that others are worse off
- action/side effect of drugs
126
What are the problems with pain management programmes?
- not all patients can work in groups
- do not know the key aspect of success
- practicalities of follow up
- how long will people maintain their improved ability to manage their pain
- need specialist training for pain management programme teams
127
What is mindfullness?
Focuses on the experience, the present moment, do not get suck in unproductive worrying over the past or over the future
- self compassion with kindness stance
- different from traditional CBT
128
What are the range of factors that patients with chronic illness have to cope with
- diagnosis: emotional response
- physical impact: pain, limited mobility other symptoms
- treatment: anxiety, discomfort, impact on body image
- hospitalisation: loss of autonomy, privacy/status, possible removal from support network
- adjustment: biographic disruption, change in identity, chronic nature of illness, with terminal illness
- socioeconomic impact: financial, social, relationship
129
What is emotion focused coping?
- change the emotion
so behavioural = talking to friends, alcohol, finding distraction
so cognitive = change how you think about the situation such as denial, focus on positive aspect of the situation
130
What is problem focused coping?
change the problem or your resources
- reduce demand of stressful situations i.e. find out how you can cope with it
- expand resources to cope with it making do: physiotherapy exercises, mobilised wheelchair
131
What are the ways to aid patient coping?
1. increase/mobilise support
- paints have impoverished social network so help recognise and mobilise support, suggest formal services of support
2. increase personal control
- pain management, self management programmes, give patient choices, taking cognitive control
3. prepare patients for stressful events by reducing ambiguity and uncertainty
- effective communication, peer contact, responsiveness to individual preferences, special cases
4. stress management techniques
132
Why patients with chronic illness are at increased risk of mental health problems?
ANXIETY=
is a response to a threat
- to identity, well being
- threatening events such as surgery
unpleasant emotional state
occurs at various stages off illness
sustained anxiety associated with unhelpful thinking patterns
- increased vigilance to threat
- interpret anything ambiguous as threatening
- increased recall of threatening memories
disorders include: phobia, panic attacks, PTSD
DEPRESSION:
higher risk = severity of illness, pain and disability, other negative life events, lack of social support
comorbid depression = exacerbate the pain and distress associated with physical health outcomes
Physiological distress has an effect on health directly or indirectly (poorer self management, compromised quality of life, risk factors, health related behaviour)
133
What are the barrier to identifying psychological difficulties in patients
illness and treatment factors = pschological response changes over time and symptoms maybe attributed to illness and treatment
patient factors = think inveitable result of disease and it cannot be avoided, want to avoid sounding as it complaining or presenting additional burden, avoid being judged of inadequate/unable to cope, time, poor relationship with doctors
health care professional factors = outside psychiatric setting so believe not within their role or fear of overwhelming distress of patient, if patient volunteers might steer them back to physical condition, reluctance of HCP to label patients as having psychological problems, uncertain of how to help, short consultations
134
Nice guidelines for managing depression?
- support in coping/prevention
- counselling and psychological therapies
- medication
Anxiety:
generalised anxiety disorder = medication and low intensity psychological interventions e.g. groups
If more severe/persistent then high intensity psychological interventions
Depression:
mild to moderate = low intensity psychological interventions e.g. individual guided self help, group peer support, group based CBT
moderate to severe depression = combined with antidepressants and high intensity psychological interventions
135
The physiological response to stress
- flight or fight response (short term change to mobile for activity, mainly triggered by catecholamines, hypothalamus organises response to tress, triggers adrenal medulla and anterior pituitary gland to secrete ACTH to adrenal cortex to release cortisol.
- increased oxygen availability
- increased fuel availability
- preparation for tissue damage/fatigue
- enhancing mental function
- conservation of energy resources e.g. GI
- enhancing physical function e.g. CO, BP
136
Why stress can have positive consequences?
- survival advantage
137
Why stress can have a negative consequence?
- have frequent daily hassles and chronic stressors and physiological response is il suited to these forms of stress
- long term stress is damaging -> general adaptation syndrome (so body continues to operate at a higher level so it resets to this, leading to exhaustion i.e.damage, adrenal glands will be exhausted
138
What are stressors?
an external or internal event that triggers a stress response
-> stressors were developed as objective measure of stress
139
Give examples of stressors?
```
Stressful life events:
- divorce
- death of spouse
- jail time
- marriage
- retirement
- vocation
- boss at work
- change in financial state
- moving house/school
- change in sleeping habits
Daily:
- losing house/car keys
- missing the bus
```
140
What is the transactional model of stress?
Helps us understand how and why stressors have an impact on health but must account for:
- differences between individuals
- different impact of different stressors
- stress response in absence of direct threat
-> process of interaction between a person and what is going on in the outside world
- stress is a result of how people appraise events and their ability to cope with them.
Demands/stressors = life events, daily hassles, chronic stressors
Resources = personality, social support, coping skills
We appraise these both together to give a stress response = exceeding resources to much to cope with?
141
What is the subjectivity of stress?
different things maybe stressful for different people at different times
142
What is primary appraisal?
Is this event a threat/how bad could it be?
143
What is secondary appraisal?
Do i have the resources or skills to cope?
144
What is reappraisal?
reconsider situation one you have tried to cope with it and may decided if more or less stressful than you thought
145
Important factors that modify the impact of stress?
Control:
if the situation is in our control we are less likely to feel stressed where as if you feel like you are not in control you are more likely to get stressed
Social support:
big buffer for stress and can have a protective impact on health
146
Th physiological response that stress can have on health?
- physical damage
- CVS
- mechanical trauma due to increased BP and HR
- attracts inflammatory and coagulation = atheroscleorosis
- liberation of glucose if stressed -> insulin resistance and possible type 2 diabetes
147
The effects of stress on the immune system
Short/long term stress = up regulated, prepare for damage and resist infection and cell mediated immunity
long term stress = depressed immune system and inflammation, feedback loop gets disrupted as continually high = immune supression
148
The effects of coping efforts on health due to stress
- see an increase in unhealthy behaviours: smoking, drinking, chocolate, slopping out in front of telly.
- immediate relief but damaging long term
149
What are the negative impact that stress can have on mental health?
Thinking become more rigid and extreme under stress.
- prone to cognitive disorders (overgeneralisation = always bad, catastrophsing = expecting the worst, personalisation = thinking its your fault)
- rumination, so become completely focused on ones symptoms of distress
- lack of control, helplessness, leads to anxiety, depression, low motivation and a downward spiral of illness
150
What are strategies for managing stress?
1. cognitive strategies: CBT, hypothesis testing
2. behavioural strategies: skills training, time management
3. emotional strategies: counselling, emotional disclosure, social support
4. physical strategies: relaxation training
5. non cognitive strategies: drugs
Best approach = combination of all strategies
151
Define compliance
the extent to which an individual patient complies with medical advice
152
Define adherence
the extent to which patient behaviours coincides with medical advice
153
Define concordance
negotiation between patient and doctor over treatment regimes
- patients beliefs and priorities are respected
- patient is active and more decisons in the partnership
154
The relationship between concordance and adherence
- patient is involved in and has shared ownership of the decisions about treatment
- patient beliefs, expectation, lifestyles and priorities can be taken into account
- barriers to adherence e.g. practical information, perceptional can be addressed
- promotes patients trust and satisfaction with care therefore making adherence more likely
155
The extent of non adherence across patient groups
- in chronic illness 50% not adherent
- medication regime = 20.6%
- exercise = 28%
- health behaviour = 31.3%
- diet = 41.7%
Highest rates of adherence in HIV, GI disorders, cancers
Highest rates of non adherence in pulmonary disease, diabetes, sleep disorders
156
What are the problems with measuring adherence?
- what counts as adherence
- treatment not usually a one off event in continues over a period of time
- lack of consistency in measures
- hard to compare studies for different medications or treatments
157
What are some direct measures of adherence, including there strengths and limitations?
Urine/blood test:
+ provides most direct measure of consumption/adherence
- expensive
- limited use in clinical practise
- invasive
- affected by metabolism, non adherence may still be masked
Observation e.g. of consumption:
- see above
158
What are some indirect measures of adherence, including there strengths and limitations?
Pill count:
+ more objective than self report
- subject to inaccuracies such as lost pills
Mechanical or electrical measures of dose:
+ objectively measured whether a dose have been dispensed
+ more accurate than other indirect mechanisms
- doesn't measure if medication has been taken
Patient self report:
+ easy to obtain and inexpensive
- prone to inaccurcies/bias with tendency to over report adherence, wants to be good pt
Second hand reports:
see above and depends on familiarity with patient
159
Unintentional adherence?
- capacity and resource limitations
| - individual constrains such as memory and dexterity or ability to access prescriptions
160
Intentional non adherence?
- arises from beliefs, attitudes, expectations that influences patients motivation to begin and persist with regime
161
Factors influencing adherence with examples of each
Illness factors:
- symptoms, better if symptoms so problems if asymptomatic i.e. HT
- severity, with less serious disease patients in poorer health are more like to adhere but with more serious disease patients in poorer health are less likely to adhere
Treatment factors:
- preparation: setting, waiting, time, time of referral/inconvenience
- immediate character: complexity of regime, duration of regime, degree of behaviour changes, expense, container design
- consequences: side effects actual or fear of them
Patient factors:
patients understanding of: treatment, illness, satisfaction with consultation/treatment regime
recall: influenced by anxiety, knowledge, importance,
know how to take
Health care factors: so setting
- organisation: primary/secondary care, in/outpatient, follow up, appeal, accessibility of venue, waiting times
- prescriber: belief and attitudes towards them, who prescribes doctors/nurses
Doctor patient interaction:
- perceived manner
- positive behaviour
- communication
- perceived importance
162
the nature and effective of problems with improving adherence
approaches: addressing practical barrier,
problems: lack theoretical input is it truly patient centred
effectiveness: broadly but small effects
health belief model: severity and susceptibility of disease and benefits and barrier to treatment
163
The complexity of reasons for drug and alcohol abuse
pleasure, entertainment, social lubricant, enhanced creativity, enhanced other experiences such as dancing, music or sex, peer influence, relieve boredom, relieve anxiety, depression or stress, forget worries, relief from pain, spiritual request
164
Low risk drinking
drink within sensible drinking guidelines and are at low risk of harmful effects
165
hazardous drinking
drink over the sensible drinking limits but who have avoided significant harm so far from alcohol.
A pattern of behaviour that increases the risk of harmful consequences for the user that are of public health significance despite absence of current disorder to the individual user
166
harmful drinking
drinking at above levels recommended for sensible drinkers, typically at higher levels that hazardous drinkers and show clear levels of alcohol related harm. Might not have understood link between their drinking and range of problems that they maybe experiencing.
A pattern of drinking which is already causing damage to health, the damage maybe physical or mental
