Session 4 Flashcards

Question

Explain about depression

Answer 1

Depression is an emotional state characterised by persistent low mood, sadness, loss of interest, despair, feelings of worthlessness Tends to be long-term (in the future depression could become the second most leading cause of disability, after ischaemic heart disease) Higher risk of developing depression: * Severity of illness (Moody et al 1990) * Pain and disability (Wulsin et al 1999) * Other negative life events * Lack of social support Comorbid depression can * Exacerbate the pain and distress associated with physical health problems * Adversely affect illness outcomes (NICE 2010)

Answer 2

Direct pathways of psychological distress on health: see stress learning objectives e.g. impact on immune system, functional impairment (Januzzi et al., 2000, Katon 2003) Indirect pathways (Ziegelstein et al, 2000, Katon 2003, 2004) Risk factors and health related behaviour e.g. smoking, drinking, sedentary lifestyle * Compromised quality of life * Impact on coping (e.. with treatment) * Poorer self-management, e.g. depressed patients 2x less likely to adhere to treatment (DiMatteo et all, 2000)

Answer 3

**Illness and treatment factors:** * Psychological responses change over time e.g. depression may set in after patient goes home * Symptoms may be attributed to illness or treatment **Patient factors:** * May believe psychological problems are inevitable result of illness and can’t be alleviated * May wish to avoid sounding as if they are complaining or presenting an additional burden to healthcare professionals * May wish to avoid being judged as inadequate or failing to cope * Stigma associated with mental health problems **Healthcare professional factors:** * Outside psychiatric settings, HCPs may avoid asking about psychological problems: believe they are not within their role/ fear overwhelming distress of patient * If patients volunteer information concerning psychological health, HCPs may tend to steer them back on topic of physical condition * Reluctant of some HCPs to label patient as having psychological difficulties

Answer 4

* Recognising possibility of psychological problems: listen/ask about/opportunity to raise problems * Offer help for psychological symptoms: such symptoms are a source of distress in themselves * There are clear links between the psychological and physical health of patients * A concern to all healthcare professionals regardless of their speciality.

Answer 5

Support in coping (prevention) Counselling and psychological therapies Medication (antidepressants under-prescribed in the chronic illness)

Answer 6

Recognition, assessment and management Mild to moderate depression * Low-intensity psychological interventions * Individual guided self-help (based on CBT – Cognitive Behavioural Therapy - principles); CCBT (Computerised CBT); structured group physical activity; group based CBT; (+group peer support for those with comorbid chronic illness)) Moderate to severe depression * Combine with antidepressants * High-intensity psychosocial interventions – individual CBT; interpersonal therapy, other therapies

Answer 7

Generalised Anxiety Disorder * Low-intensity psychological interventions * Individual self-help (based on CBT principles); psychoeducational group * Medication (SSRI) If more severe or persistent * High-intensity psychosocial interventions * Individual CBT; applied relaxation

Answer 8

Is pain a sensation or emotion? Physical or mental? – Relates to mind-body dichotomy Opposite of pleasure – an emotional experience Early bio-medical theories of pain: * Cut knee (tissue damage) leads to message to brain (feel pain) * Physical damage is sole, direct cause of ‘real’ pain and explains the full extent of the patient experience, more damage causes more pain * Only role for psychology in this model is with aftermath of pain (e.g. anxiety, fear, depression)

Answer 9

* Some people report continuing to experience pain after tissue damage heals * Some people report experiencing pain when no physical damage can be identified * Some people report not feeling too much pain despite severe injuries * Some (but not all) amputees experience phantom limb pain * Placebo effect * Variation in pain reports from people with similar injuries (early research e.g. Beecher 1956, WWII patients) * Positive mood/mindset makes pain experience seem less intense whilst negative mood/mindset makes pain experience seem more intense

Answer 10

WHO definition of pain: an unpleasant sensory and emotional experience which is associated with actual or potential tissue damage or is described in terms of such damage **Acute Pain** * Short term e.g. burn finger, break leg * Attracts our attention – so we can do something about the pain - warns of tissue damage * Pain lasts for as long as there is healing (pain is useful, performing a function) * There is action to take: rest, see doctor, medication Chronic Pain (Persistent Pain) * Pain for \>12 weeks, long term, debilitating * Pain is not useful – does not indicate on-going tissue damage * Prolonged rest and medication is not helpful unlike acute pain * Arises from a variety of conditions/diseases or NO KNOWN CAUSE

Answer 11

Assessing Pain directly and objectively is difficult because pain is so subjective. Consider * Self report * Assessing behaviour * Psychophysiological measures through observation e.g. sweating, muscle state (rigid, tense) * Measuring effect of pain on other areas of life e.g. mood, daily living * Clinical assessment is important – getting an all-round picture is important

Answer 12

* Pain is experienced in the brain through complex pathways in body from damage / disease source * Different types of pain fibres have been identified: fast, slow, hot, cold, blunt, sharp * Important neural relays or gates for messages to pass through are located in dorsal horn of spinal cord * Pain is a result of a 2-way process of communication between the brain and the tissue damage or nerve messages * The extent that the gate is open or closed affects the number of pain messages that are received. (The more open the gate, the more pain is felt and vice versa) * Psychological factors e.g. thoughts, beliefs, interpretations, expectations, fear and anxiety interact with physiological events e.g. physical stimuli, tissue damage, nerve messages, medication * Pain is a perception, not just a physical sensation * The same physical event may be perceived differently in different people (or even the same person at a different time). * Pain is never entirely ‘physical’

Answer 13

Examples of what Closes the gate * Medication * Counter stimulation * Exercise * Relaxation * Distraction * Positive emotions * Positive beliefs – control * Active life (less time to worry or think about pain) Examples of what Opens the gate: * Injury * Over/under active * Sensitivity of neural system * Stress and tension * Focus on pain – expectation * Negative emotions * Negative beliefs * Minimal involvement in life NEED TO CONSIDER BIOLOGICAL, SOCIAL AND PSYCHOLOGICAL FACTORS

Answer 14

* Evidence is consistent with GCT but no actual physical structure has been identified * There is an assumption that there is still some organic basis of pain * Allows that physical and psychological processes interact but still seems them as separate – dualistic thinking * Despite limitations, it has been an enduring theory as it works well to explain how people experience pain in practice * Developments of GCT: neuromatrix theory of pain (the idea that the physical structure is more widely distributed in the whole nervous system, not just at a single location)

Answer 15

* E.g. classical conditioning – sound of a dentist’s drill could bring pain * Self-efficacy – sense of control e.g. patients gain more self-efficacy if they are given pain medication pumps they can administer themselves * Negative emotions are associated with more intense experiences of pain * Pain behaviour such as limping or grimacing signal to other people you are in pain and attract sympathy however this makes you more aware of the pain – goes round in a cycle.

Answer 16

Pain Management Programmes (PMP) – British Pain Society June 2006 * A PMP aims to improve the physical, psychological emotional and social dimensions of quality of life in people with persistent pain using a multidisciplinary team working according to behavioural and cognitive principles rather than consider pain as a disease or damage in biomedical terms (biopsychosocial approach to treating pain, to improve quality of life for patients with chronic pain) * Problems formulated in terms of effects on physical and psychological wellbeing rather than as disease or damage in biomedical terms or as deficits in the individual’s personality or mental health * Central message is that the programme is about helping the patient take control of their pain, rather than the pain being in control. It is not about cure. * For some this is a difficult message to accept, however many people will have already realised that medication or surgery has not been able to ‘fix’ their problem and so they are enthusiastic about something else they can try.

Answer 17

Guided, Supported Practice on a PMP * Reinforce an acceptance of reality of chronic pain * Improve fitness, mobility and posture * Address fear of consequences of movement * Develop ways to cope with stress, anxiety, depression, anger – show them different methods, give them choice * Improve ability to relax * Graded return to activities of daily living * Facilitate appropriate medication use * Improve communication skills * Reduce use of unhelpful aids and equipment

Answer 18

Programme Topics: 4 main parts * Managing thoughts and feelings (CBT – over arching framework, plus ‘new wave’ CBT e.g. Mindfulness) * Active, but pacing self – not over or under active and understanding posture and biomechanics, building achievements (so that you don’t overdo a good day and end up relapsing) * Goal setting * Relaxation Other topics: ‘hurt does not mean harm’, sleep hygiene, communication including assertiveness and anger management, relationships, stress management, maintaining change, including planning for ‘bad’ days, anatomy and physiology of pain and pathways, explanation of differences between acute and chronic pain, physiology of stress response, action and side effects of other drugs

Answer 19

* Learning to focus on all of the experiences in the present moment, not get stuck in unproductive ruminating over the past or worrying about the future * Instead of trying to change or fight negative thoughts, accept them as ‘just thoughts’ and return attention to the present moment * Take a stance of self-compassion, act with kindness * Can use mindfulness for managing stress, and that in turn helps with pain * MBPM differs from traditional CBT – encourages learning to tolerate focusing attention on pain sensations, but to detach the negative thoughts and related unpleasant emotions from the experience * Pain is inevitable, suffering is optional – John Kabat-Zinn

Answer 20

* Being believed that the pain is real * Being part of a group – may be different causes of pain, but shared experience of the effect of pain on their lives * Social comparison theory – people often judge others as worse off

Answer 21

* By the time of referral to PMP patients will on average have had 5 years of pain. They will almost always have exhausted all other medical methods of pain relief. * 40% have pain due to an accident, 20% have pain of unknown cause * They are often angry, depressed, anxious, disabled, out of work, have no family difficulties and will have withdrawn from usual social activities e.g. due to combination of mood, finances and pain * Social isolation “You don’t believe you can go out and meet people any more. You don’t believe you have anything to offer them. In a sense your pain becomes your identity. There is nothing else to speak about. All your experience is about pain and being in bed surrounded by 4 walls. It becomes a self-perpetuating cycle.

Answer 22

Inclusion/exclusion criteria to consider * Communication/language * Mental health * Cognitive ability * Willing to be in a group environment * Level of physical functioning * Social/psychological obstacles that need addressing first Issues with PMPs * Not all patients able to work in groups – need to have language, cognitive and social skills * We know PMPs are effective from systematic reviews but what are the key aspects? * Maintaining the changes that people make – how long will people maintain their improved ability to manage their pain? * Practicalities of follow-up * PMP approach ideally belongs at the beginning of an episode of pain * Specific training for PMP team to ensure consistency

Session 4 Flashcards

(46 cards)