Health Psychology

1. Health Psychology Psychology 46.339 (01) Summer 2007 Instructor: Dr. Fuschia Sirois Wednesday August 1: Lecture 8, Prep. Guides 7,8 Chapter 10: Pain and its Management Chapter 11: Chronic illness

2. The Significance of Pain • Obvious significance • Pain hurts and so it disrupts our lives • Pain is critical for survival • Minor pains provide low-level feedback • Medical consequences • Pain is the symptom most likely to lead an individual to seek treatment

3. The Experience & Perception of Pain Pain serves 3 functions: • Warns of potential serious injury • survival value; produces withdrawal reflex to prevent further injury 2) Pain that prevents further injury promotes learning to avoid same situations later 3) Certain pains limit physical activity and promote rest  facilitates healing processes

4. The Elusive Nature of Pain:Overview • Pain is a psychological experience • Interpretation of the pain influences • Beecher’s study of WWII injuries • Pain is influenced by

5. The Elusive Nature of Pain:Measuring Pain - Verbal Reports • What words do you use to describe pain? • Large informal vocabulary • Throbbing pain? Shooting pain? Dull ache?

6. The Elusive Nature of Pain:Measuring Pain • Pain Behaviors are behaviors that arise as manifestations of chronic pain • Pain Behaviors are observable • Help define characteristics of different pain syndromes

7. Physiology of Pain • Pain perception is called Nociception • Nociceptors in peripheral nerves first sense injury Afferent sensory neurons (PNS)  spinal cord  brain Two major types of peripheral nerve fibers • A-delta fibers – small, myelinated fibers that transmit sharp pain • small,myelinated fibres  • their activity influence sensory aspects of pain • C-fibers – unmyelinated fibers transmit dull, aching pain • unmyelinated fibres  • influence motivational & affective elements of pain

8. Gate Control Theory(Melzac & Wall, 1965) Pain is not just the result of a linear process from sensory stimulation to brain reception & the experience of pain • Psychological factors can affect the experience of pain. • Neural gate can open and close thereby modulating pain. Spinal cord modulation • small A-delta & C-fibre activity opens the gate  pain • large A-beta fibre activity closes the gate  inhibitspain Descending Brain modulation • central control trigger activates cognitive processes • can open or close gate: e.g. attention, past experiences, anxiety, fear, beliefs, relaxation, mood, all affect gate

9. Gate-Control Theory – (Melzac & Wall, 1965) • Gate is located in the spinal cord. 3 Factors involved in opening or closing of the gate: • The amount of activity in the pain fibers. • The amount of activity in other peripheral fibers • Messages that descend from the brain.

10. Factors that influence the experience of Pain

11. Conditions That …… Open the gate… • Physical conditions • Extent of injury • Inappropriate activity level • Emotional conditions • Anxiety or worry • Tension • Depression • Mental Conditions • Focusing on pain • Boredom Close the gate… • Physical conditions • Medications • Counter stimulation (e.g., heat, message) • Emotional conditions • Positive emotions • Relaxation, Rest • Mental conditions • Intense concentration or distraction • Involvement and interest in life activities

12. Brain Brain To brain To brain From pain fibers From pain fibers Transmission Cells Transmission Cells Gating Mechanism Gating Mechanism From other Peripheral fibers From other Peripheral fibers Spinal Cord Spinal Cord Gate-Control Theory Gate is closed Gate is open

14. Acute vs. Chronic Pain Acute Pain:temporary, < 6 months Chronic Pain: > 6 months;intermittent or constant • Chronic Pain • Typically begins with an acute episode • Pain does not decrease with treatment • Pain does not decrease as time passes • Three types of chronic pain • Chronic benign pain • Recurrent acute pain • Chronic progressive pain

15. Clinical Issues in Pain Management: Acute vs. Chronic Pain • Acute and chronic pain present different psychological profiles • Chronic pain often produces depression • Pain present in 2/3 of patients seeking care from physicians with primary symptoms of depression (Bair et al) • Pain control techniques work well with acute pain but less successfully with chronic pain

16. Pain Control Techniques:Overview • Pain control can mean a person • No longer feels anything in an area that once hurt • Feels sensation but not pain • Feels pain but is no longer concerned about it • Is hurting but is able to stand it

17. Pain Control Techniques Most common method of controlling pain – through drugs • Morphine has been the most popular painkiller for decades Counterirritation • Inhibiting pain in one part of the body by stimulating or mildly irritating another area • E.g., Biofeedback • individual is provided with ongoing specific information about a particular physiological process

18. Pain Control Techniques Distraction: • an element of many effective pain management techniques - redirects attention from pain; e.g. guided imagery, hypnosis, Relaxation Techniques • person shifts his/her body into a low state of arousal Hypnosis • involves relaxation, suggestion, distraction, and the focusing of attention.

19. Pain Treatment & Management Multidisciplinary Pain Management • no single method is completely effective & effectiveness of single treatment modes varies across individuals • Often the aim is to change pain beliefs and behaviors in order to increase functionality & quality of life • program may include pain education, sleep hygiene classes, counseling, exercise, stress management, etc.

20. Quality of Life:What Is Quality of Life? • The degree to which a person is able to maximize his or her • It also addresses disease or treatment related symptomatology • It is an important indicator of recovery from, or adjustment to, chronic illness.

21. QoL and Chronic Illness • How would you rate the QoL of someone with a chronic illness? • 1 = lowest 5 = highest • Now if you were diagnosed with a chronic illness, say arthritis, would you expect your QoL to decrease, stay the same or increase? • WHY?

22. Quality of Life: Why Study Quality of Life • Documentation helps improve interventions for those who are chronically ill • Research helps pinpoint which problems are likely to emerge for particular patients • Impact of unpleasant treatments can be seen and reasons for poor adherence identified • Therapies can be compared • Decision-makers have information about long-term survival and quality of life

23. Quality of Life and Chronic Illness • Health-related Quality of Life (HRQOL) • represents the functional effects of an illness and its consequent therapy upon a patient, as perceived by the patient • important if treatments aim is to make a patient feel better and function better in their day-to-day activities, e.g., well-being, vitality

24. Coping & Chronic Illness • Avoidant strategies • Positive illusions and coping • impact of disease on goals, coping resources, and identity • social resources key in adaptation

25. Emotional Responses of Chronic Illness: Denial • A defense mechanism involving the inability to recognize or deal with external threatening events • Denial is believed to be an early reaction to the diagnosis of a chronic or terminal illness • Can serve a protective function • During the rehabilitative phase, denial may have adverse effects. WHY? • examples

26. Emotional Responses of Chronic Illness: Anxiety • Anxiety is common after diagnosis:It increases when people • Are waiting for test results • Are anticipating adverse side effects • Are awaiting invasive medical procedures • Anxiety is high when • Substantial lifestyle changes are expected • People feel dependent on health care professionals

27. Emotional Responses of Chronic Illness: Depression • When the acute phase of chronic illness has ended • Then full implications begin to sink in • Depression is common • Often is debilitating • Assessing depression in individuals with chronic illness is problematic • WHY?

29. Chronic Illness, Depression & Control Emotional adjustment: depression is more prevalent in those with chronic illnesses 25-33% vs 10-25% in the general population • CI depression, & depression can exacerbate the CI • loss of control is major cause of depression in CI Control beliefs tend to be lower in individuals with CI than in healthy populations Age is an important determinant of depression in chronic illness • depression & other psychological problems are more common in younger vs. older people WHY?

30. Positive Effects of Chronic illness Many individuals report positive outcomes from their chronic illness • Benefit finding • Life improved overall • Increased joy • Increased value in family, personal hobbies • Improved relationships • Enhanced spirituality • QoL reports of those with chronic illness are often higher than those of non-ill samples

31. Cognitive Adaptation & Well-being Cognitive Adaptation Theory (Taylor 1983) Adjustment to threatening events (including illness) relies upon 3 themes: 1) a search for meaning in the experience 2) attempts to regain a sense of mastery or control over the event 3) efforts to restore self-esteem • When individuals experience setbacks they respond with cognitively adaptive efforts to help them return to or go beyond their initial state of functioning

32. Coping with Chronic Illness: Patients’ Beliefs • People develop theories about where their illness came from • Stress • Physical injury • Bacteria • God’s will • Self-Blame? Another person? Environment? Fate? • Research on the consequences of self-blame is inconclusive

33. “Learning to live with what you can’t rise above”: Control beliefs and adjustment to tinnitus Fuschia M. Sirois University of Windsor Christopher G. Davis &Melinda S. Morgan Carleton University Sirois, F. M.,Davis, C. G., & Morgan, M. (2006). “Learning to live with what you can’t rise above”: Control beliefs, symptom control, and adjustment to tinnitus. Health Psychology, 25(1), 119-123.

34. Control beliefs and adjustment Control beliefs • An individual’s beliefs about how much control they have over a situation. Chronic health condition as a stressor • Opportunities for control are limited • Perceptions of control may help offset the feelings of helplessness • But perceived control over uncontrollable aspects of health may diminish well-being • Meaning of control key for understanding its role in adjustment

35. Different meanings of control Are different control perceptions equally adaptive for managing a chronic health condition? • General control over health • Symptom control • Past or retrospective control

36. Symptom severity and control Different types of control beliefs influence how people appraise and cope with a stressor • General control and main effects on appraisals • Situational control as a coping resource that moderates threat appraisals • Role of retrospective control in appraisal and coping process not fully explored

37. Tinnitus • 10-15% of the adult population experience tinnitus • Characterized by the perception of sound in the absence of external stimuli • Incurable • Distressing • Unknown etiology • Adjustment to tinnitus is not directly related to the severity of tinnitus

38. The present study • Examined the moderating role of perceived control in the relation between symptom severity and adjustment to tinnitus • Adaptational benefits of perceived control will depend on symptom severity and type of control • general control over health, symptom control, and retrospective control Two adaptational outcomes: • affective measure (depressive symptoms) • measure of eudaimonic well-being

39. Methods Participants • 319 people with tinnitus, M age 46.5 years (SD = 12.3). • 42% females Procedure Participants recruited via notices posted • on-line through tinnitus support message boards • by email sent by the Tinnitus Association of Canada to its members Participants completed the survey on the Internet

40. Methods Perceived control over health • e.g., “If I set my mind to it, I can improve my health” Symptom control • e.g.,“If I make the effort, I can manage my symptoms” Retrospective control • three questions adapted from prior research on bereavement (Davis et al, 1995, 2000). Adaptational outcomes • Depressed Mood • Psychological well-being • Tinnitus severity Tinnitus severity– index based on several subjective ratings

41. Results Table 1. Zero-order Correlations Between Perceived Control, Symptom Severity, and Adaptational Outcomes.

42. Results General control • main effect for both depression (b = -.22, t(283) = -3.83, p < .001) and psychological well-being (b = .35, t(300) = 6.56, p < .001). Retrospective control • main effect for both depression (b= .31, t(285) = 5.78, p < .001) and psychological well-being (b = -.28, t(300) = -5.27, p < .001). Symptom control • moderated the effects of tinnitus severity for both depression (b = -.15, t(281) = -2.61, p = .01) and psychological well-being (b = .12, t(297) = 2.33, p < .05).

43. Figure 1. Estimated CES-Depression scores as a function of Symptom Control Beliefs (+/- 1 SD) and Tinnitus Severity (+/- 1 SD).

44. Figure 2. Estimated Psychological Well-being scores as a function of Symptom Control Beliefs (+/- 1 SD) and Tinnitus Severity (+/- 1 SD).

45. Conclusions Successful coping with tinnitus is associated with Reinterpreting symptoms as manageable allows people to maintain a meaningful, purposeful, and enjoyable life.

46. Coping with Chronic Illness: Patients’ Beliefs • Patients must integrate their illnesses into their lives • Develop a realistic sense of the illness • Understand restrictions imposed by it • Follow the regimen required • Patients need to adopt an appropriate model for their disorder • Acute models won’t be effective

47. Self-Identity in Chronic Disease Self-Concept • An integrated set of beliefs about one’s personal qualities and attributes Self-Esteem • A global evaluation of one’s qualities and attributes. Body Image • The perception and evaluation of one’s body, one’s physical functioning, and one’s appearance. • Body image plummets during illness • The adjustment process takes a year or more

48. Personal Issues in Chronic Disease: The Private Self • Major threats to self, because illnesses create • Adjustment to chronic illness impeded • Patient’s secret dream seems shattered • Alternate paths to fulfillment need discussing

49. Psychological Interventions and Chronic Illness: Social Support • Social support resources can be threatened by chronic illness • “erosion” of social support • Interventions can teach patients to • Recognize potential sources of support • Draw on these resources effectively • Family support • Enhances the patient's physical/emotional functioning • Promotes adherence to treatment

50. Psychological Interventions and Chronic Illness: Support Groups • Group of individuals who meet regularly • Share some common problem or concern • Support groups are believed to help people cope because • People learn techniques that others have used successfully to combat problems • They provide opportunities to share concerns and exchange information with similar others • Support groups may promote better health and long-term survival