Chapter 7 Chronic and Life-Threatening Illnesses PDF

Chapter 7 Chronic and Life-Threatening Illnesses Chronic condition – a condition that doesn’t go away or get better; life-threatening an often accompanied by severe symptoms Acute illness – an illness with a defined beginning and end - health psychology has dedicated a great deal of research effort...

Chapter 7 Chronic and Life-Threatening Illnesses Chronic condition – a condition that doesn’t go away or get better; life-threatening an often accompanied by severe symptoms Acute illness – an illness with a defined beginning and end - health psychology has dedicated a great deal of research effort. To understanding chronic conditions accompanied by emotional distress - cancer and cardiovascular diseases are now the main culprits unlike viruses and bacteria in 1900s Cancer Not one disease but many; one form of cancer is different from another form in a patient Oncology – the study and treatment of cancer Sites of cancer – types of cancer as defined by the location of the tumour Involves uncontrolled growth of abnormal cells, which often form a tumour – when abnormal cells spread from original site to other parts of the body; uncontrolled growth of abnormal cells, general cell growth is common throughout the body – when abnormal cells form a mass, results in a tumor, when adhering tightly together we say that the cancer is localized – spread to other parts of the body through blood or lymphatic system – when spreading occurs it refers to as metastasized, metastasized is harder to treat since the treatment cannot be localized – early detection reduces the likelihood that the cancer will have metastasized Many forms, with different symptoms – Most common types are lung, breast, prostate, and colorectal Leading cause of death worldwide and in Canada, having killed 10 million people in 2020 in world In Canada, 30% of all deaths due to cancer; 617 diagnosed with cancer and 228 Canadians die from cancer each day In women, 25% of cancer cases are breast cancer and in men 20% are prostate cancer Economic costs of cancer rise from $2.9 billion to $7.5 billion in 2012, although most costs are covered by government medical plans in Canada there are still out of pockets for the patient and families Illness burden for Cancer Cancer diagnosis: Response may be denial or perception as death sentence Patients have to cope with aggressive treatments with unpleasant side effects Stigma: e.g., blame the victim  – Stigma has been decreasing – because of reports in the media of celebrity health issues and deaths; media coverage may educate and motivate people to engage in cancer prevention measures – Number of cancer survivors hold stereotypically negative view towards cancer – If people hold negative views, they are far less likely to disclose their diagnosis to others – Others have identified the experience of cancer as a time for reflection on priorities – Long term effects of childhood or adolescent cancer are mixed; those who experienced cancer during adolescence demonstrated health-related quality of life to be on par with or even greater than those who had not experienced cancer Economic burden (out of pocket costs) Suffering may occur in two areas: 1. Physical – fatigue, pain, side effects of treatment - chemotherapy - types: illness-caused and treatment-caused - 60% of cancer burden is related to physical factors - pain management is a major challenge for patients and for those providing treatment - frustration is cancer pain tends to be undertreated - more than 90% of cancer pain can be controlled by current treatments, however these treatments are underused. This is due to three types of explanations: issues related to health-care system, issues related to health care practitioners, and issues related to patients and their families - pain-related analgesics for their cancer pain include forgetfulness. Belief that pain should be tolerated and concerns regarding side effects - patients may be unwilling to report mild or moderate pain making it difficult for practitioners to prescribe adequate medication, related to health-care practitioners they may be reluctant to prescribe opioids 2. Psychological - fear and depression – for patients and families most common and most distressing ▪ Depression rates are four times higher in those with cancer ▪ - those who were already depressed at the time of diagnosis are more likely to maintain a lower quality of life after treatment than those who were not already depressed ▪ Fear and depression can become chronic even if treatment is proceeding successfully ▪ Links between psychological distress and immunocompromise – depressed patients also greater pain intensity ▪ Patient’s depression is positively correlated with family caregivers’ depression - intrusive cognitions - coping style Cancer and Physical Distress Pain management is a major challenge – More than 90% of pain can be controlled by current treatment, but tends to be underused Patients’ attitudes and behavior a major influence – Fear drug tolerance or addiction, so hesitant to seek treatment – Believe pain must be tolerated, so hesitant to report pain Cancer and Psychological Distress Depression and anxiety are common Negative consequences of depression – Poorer quality of life, reduced adherence, longer hospital stays, higher mortality rates, greater reported pain Cancer related depression Linked to intrusive cognitions: unwanted thoughts often visual in nature, related to the patient’s ideas about cancer and death – 48% of anxious cancer patients experienced intrusive thoughts – Results in poorer coping due to anxiety, sense of hopelessness, helplessness Cancer and Coping Style Psychological response influenced by coping style o Emotion-focused coping: focus on reducing the emotional impact of disease without trying to cure it ▪ One tendency to avoid thinking about possible stressor because to address them would be upsetting ▪ Avoidance-oriented strategy ▪ Possible to use approach-oriented to emotion-focused strategies – patients address their emotions, vent them and deal with them o Problem-focused coping: focus on addressing stressors, typically through action (e.g., adherence, increasing knowledge ▪ Approach-oriented strategy ▪ Can lead to state anxiety – patients engage in self-blame believing they should be able to control something that in fact they cannot ▪ Self-blame contributing to psychological distress in breast cancer patients o Emotion-approach coping: coping by facing emotional responses to a disease and dealing effectively with those responses Table 7.2 A Comparison of Emotion-Focused and Problem-Focused Coping  o Optimism and having a sense of purpose in life positively associated with coping Treatment of Cancer Typically, treatment involves one or a combination of the following: – Surgery: to remove tumour(s) – Radiation Therapy: to shrink or destroy tumour(s); side effects depend on the extent to which the radiation hits neighboring cells and organs ▪ Surgery and radiation therapy are treatments intended to deal with specific sites as precisely as possible – Chemotherapy: to treat metastasized cancer or prevent it from spreading ▪ Called adjuvant therapy when used in conjunction with other therapies ▪ Side effects cause by unavoidable harm being done to healthy cells, also include hair loss, fatigue, nausea ▪ Fatigue is reported most patients who undergo chemotherapy and radiation; cancer-related fatigue can last for years after treatment ▪ Exercise can significantly reduce fatigue in chemotherapy and physical and psychological interventions more effective than pharmacological options ▪ Recreational activity linked to improve survival in cancer patients ▪ Side effect alopecia (both men and women difficult to treat); gives a new identity of cancer patient so willingness to pursue treatment ▪ Other may pursue a program such as “Look Good… Feel Better” ▪ Promising new strategy to reduce hair loss that is proving to be quite effective: scalp cooling ▪ Anticipatory nausea – nausea that is felt before a chemotherapy treatment begins, explained in terms of classical conditioning  ▪Antiemetic medication – medication intended to reduce nausea and vomiting; side effects include hiccups – Hormone Therapy: to reduce presence to tumour-stimulating hormones, used for prostate and breast cancer ▪ Prostate cancer patients on hormone therapy can experience persistent fatigue, their sex drive may be diminished and start developing secondary female sex characteristics such as breast enlargement and they are at increased risk for Alzheimer’s disease Treatment of Cancer: Responses Radical surgery: requires removal of considerable amount of normal tissue – Can impact appearance and autonomy (e.g., radical breast mastectomy – part or all of the breast is removed, can experience depression and disruptions in sexual activity) – Depression unaffected whether or not breast reconstructions occurs immediately after mastectomy – Disfigurement – a potential physical result of cancer surgery that can have serious psychological consequences. Ex: cancers of head and neck may require surgery that changes facial shape – Colorectal cancer is one of the four most common cancers in Canada – Decision regarding surgery are easier for young than elderly who do not have many years left to live Side effects of chemotherapy and radiation therapy do harm to healthy cells – Fatigue (can last years), nausea, vomiting, hair loss, pain, increased risk of infection – Fatigue better treated with physical activity than pharmacological options – Anticipatory nausea Helping People Cope: Social Support Includes companionship, practical help (e.g., drive to medical appointment) - we know having a partner increase survival rates Family-oriented care – family becomes the patient because virtually for every cancer patient there is a family and a collection of close friends who are also affected by the disease Help-intended communication: attempts to alleviate (reduces) emotional distress – Advantage to use pre-existing communication patterns and preferences as guide – When we become preoccupied with “saying the right thing”, we may become paralyzed and thus entirely unhelpful, support providers should acknowledge the person’s concerns and fears as being legitimate while trying to help effective ways of dealing with them Support groups: members can provide empathy, knowledge from shared experiences  ▪ Empathy is an important element of support, for cancer patients this means interacting with other individuals who have had similar cancer experiences ▪ Support groups are of considerable benefit for prostate cancer patients; support groups provide good opportunities for problem-focused coping ▪ Online support groups have higher depression scores ▪ Support groups often emphasize education and so they suit people who cope best by being informed called monitors while other block out information called blunters Survivors may report posttraumatic growth: positive psychological or lifestyle outcome resulting from an experience with a life-threatening illness; benefit-finding: finding “silver lining in the cloud” which appears to aid in posttraumatic growth Navigator: often a nurse, social worker or community health worker, this person helps patients find their way through complicated world of hospitals and treatment Social comparison: Monitoring the opinions and experiences of others to determine what is right and wrong, normal or abnormal and use of this information in decision making; upward comparison by looking at people better off than us or downward who are worse off ▪ Support groups should include people at similar stages of cancer to reduce the risks of maladaptive upward and downward comparisons Psychotropic Medications and Psychotherapy Antidepressants: Possible negative or positive interactions with other cancer-related treatment(s), antidepressants such as Prozac – not only helps people deal with depression but it also enhances the effectiveness of drugs indicating a positive drug interaction Psychotherapy: Can be used to help patient adopt a problem-focused approach to coping with cancer – Focus on thoughts and behaviors (cognitive-behavioral approaches) – Useful as a method of pain management – Helpful for family caregivers who also experience emotional and physical distress – series of steps to follow when developing a psychotherapeutic treatment strategy for working with people who are chronically ill: obtain sufficient medical information, access person’s psychological status and response to the illness and must integrate a theoretical orientation – match orientation with the patient’s most pressing needs – psychotherapy also provided for families of cancer patient – more common for a family member to not be there for provision of care; those who are not family member but are taking on this role are more prevalent Diabetes Affects ~ 5% of Canadians and increasing People with diabetes have mortality rates twice as high as those without  Diabetes occurs when pancreas produces too little insulin which is needed to help the body use sugar for energy – Type I (“insulin dependent”): little to no insulin produced; take insulin by self-administered injection ~ 10% of cases ; more prevalent among people of indigenous, African and Latin- American; symptoms frequent urination, unusual thirst, extreme hunger, unusual weight loss and extreme fatigue – Type II (non-insulin-dependent diabetes): insulin insufficiently produced or used, ~ 90% of cases; more prevalent over the age of 45 if they are obese; frequent cuts and bruises that take a long time to heal - Over 65 years of age, Canadians are must diagnosed with diabetes - children with supportive parents who do not use nagging tend to control their diabetes better – Gestational Diabetes: Temporary condition, affects 10% of pregnant women Treatment may include insulin injections, controlled diet, blood sugar monitoring Diabetes and Psychological Distress Fear and depression most prevalent psychological problems for people with diabetes Fear may relate to – possible long-term consequences of disease (amputation, blindness, stroke) – self-testing and self-injection May lead to decreased self-efficacy, affecting disease management because stress-related hormones interfere with insulin action Type 1 fear self-injection or self-testing; low blood sugar condition called hypoglycemia; hypoglycemia physical symptoms such as fatigue; extreme cases lead to seizures or loss of consciousness After their blood sugar stabilizes, they feel guilty about blowing up to someone who was trying to help saying that these are hypoglycemic symptoms Type 1 diabetes often occurs in childhood – parents become very involved in disease management Diabetes and Psychological Distress Depression 3 times more common among people with diabetes type I (2 times for diabetes II) than those without – May cause difficulty in communicating emotions and accepting help; feel isolate or unsupported Depression and blood sugar linked bidirectionally: affecting each other in both directions – Low blood sugar worsens depression and depression reduces the likelihood that people with diabetes will monitor their blood glucose levels regularly Hypoglycemia: when blood sugar levels drop and as a result other psychological symptoms occurs such as mood changes o Basically low blood sugar -> affects moods -> depression – Depression impacts disease management Coping with Diabetes Interrelated goals of diabetic education programs Two major goals: ensure cooperation with the disease management regimen and second to treat psychological distress; two goals are closely related i.e. psychological distress decreases cooperation with the disease management regimen - Ensure compliance with regimen - Treat psychological distress Support for diabetics may include - Cognitive behavior therapy (CBT) – reduce depression and help improve glycemic control - Education and support groups – information regarding efficacy – how disease can be controlled, emotional coping that can come from other patients - Support from social network (family, friends) – hypoglycemia have mood changes and disorientation but this does not mean help shouldn’t be offered Cardiovascular Diseases In Canada, cardiovascular deaths have declined by 40% in the last 10 years In Canada, every 7 minutes someone dies from stroke or heart disease Health psychologists focus on: o Myocardial infarction (heart attack) – caused by lack of blood flow to the heart - when people stop doing exercise o Coronary artery bypass graft (bypass surgery)- healthy arteries from other parts of the body, often legs are grafted into the coronary artery system to bypass blocked arteries o Angioplasty – a bubble-like device is inserted into the artery at the point of blockage, thus expanding the artery and allowing for better blood flow ▪ Bypass surgery and angioplasty are used to treat a condition called myocardial ischemia in which there is a lack of blood flow to the heart muscle ▪ MI and CABG represent coronary heart disease (CHD) Cardiovascular Disease and Psychological Distress Psychological distress puts them at a greater risk for developing coronary heart disease Anxiety and fear of future attacks Leads to cardiac invalidism: anxiety regarding a subsequent heart attack causes limited activity more than is necessary by disease status - negatively impacts quality of life - unhealthy sedentary lifestyle Anxiety strong for people with cardiac arrest in which their heart actually stops beating and they must be resuscitated Depression extremely common (- 40%)  - Increases risk for future cardiac problems and health - Worse for women and people over 65 Depressed people do not think that they should exercise and ignore the importance of it due to their fluctuating moods and hence it makes them at risk for cardiovascular disease ▪ Bidirectional relationship between depression and cardiovascular disease, more problematic for women especially those who are older, women twice as likely as men to suffer post-MI depression Coping with Cardiovascular Disease Support from social network Rehabilitation programs - Holistic: addressing all aspects of life, from diet and exercise to mental health - peak benefit at ~ 9 months - reduce mortality by up to 47% who had myocardial infarction and 27% for cardiac rehabilitation Psychotherapy - Cognitive reappraisal and restructuring to promote healthy anger management ▪ Anger risk factor for coronary heart disease; especially when expressed as hostility, one episode of intense anger can trigger a fatal heart attack for CHD patients ▪ Cognitive reappraisal and restructuring – therapy sometimes used with cardiac patients in which they learn to think differently about the things that make them angry and to make to make behavioral changes such learning to control their breathing Rehabilitations programs are not enough so antidepressants sometimes used such as selective serotonin reuptake inhibitors (SSRIs) HIV and AIDS Human immunodeficiency virus (HIV) - Gradually breaks down immune system - Prolonged HIV infection results in acquired immune deficiency syndrome (AIDS) ▪ AIDS: caused by HIV; after infection the body’s compromised immune system makes it susceptible to a host of other infections ▪ Between 2014 and 2018, the rate of new cases of HIV increased at a drastic rate by more than 25% ▪ Prolonged HIV infection results in AIDS ▪ HIV is so-called slow virus, with a long delay between initial infection and when serious symptoms start to surface ▪ Progression of HIV infection includes three stages: first, acute infection period which begins 2-4 weeks after initial exposure and persist for a month or two; people are unaware that they contracted HIV, individuals are also extremely  contagious during this stage; symptoms include persistent chills and fever, frequent fatigue, diarrhea, sweating during sleep and yeast infections in vagina, ears or on the tongue. Second is clinical latency period lasts years or decades with appropriate treatment and the final stage in AIDS – cancer such as non- Hodgkin’s lymphoma or Kaposi sarcoma takes advantage of compromised immune system Certain populations at greater risk - Men who have sex with men – gay and bisexual men – 25% not aware of their HIV+ status – 40% of cases of men sleeping with men in Canada - people who use injection drugs - people receiving blood and blood products – person-to-person involving the exchange of bodily fluids, primarily semen and blood; North America principal mode are vaginal or anal sex and sharing of needles by intravenous drug users - Indigenous persons – 20% of all HIV diagnoses in Canada - heterosexual accounts for 28% cases and IV drug use for 22% - heterosexual relations are responsible for greater percentage today compared to early days; male-to-female transmission is much more likely than female-to-male - Diagnostic rates are higher for males than females - mothers can transmit HIV to her child during pregnancy, childbirth and even breastfeeding HIV/AIDS and Psychological Distress Important differences from other illnesses: no cure, attached social stigma, myths about infectivity Unique psychological challenges that negatively impact self-esteem and quality of life - Personal responsibility of guilt - Rejection and alienation by others - Anxiety about uncertain future – common problem - trigger symptoms of PTSD related to major depression Depression twice as high in those with HIV compared to those who do not have this condition; 54% of people living with HIV or AIDS in Canada experience depression Coping with HIV/AIDS Drug regimen – antiretroviral treatment (ART) – a treatment for HIV/AIDS that has been shown to significantly increase life expectancy; initiation of this therapy leads to life expectancy of 65 years of age in Canada; side effects such as reduced bone density and heart, kidney and liver damage Pre-exposure prophylaxis (PrEP) – a prophylactic ART drug regimen taken to reduce the risk of acquiring HIV; not 100% effective and a long list of side effects Best course of action is to engage in safe sex by using condoms and to do so with few partners Unique challenges in coping  - Social support often lacking due to stigma and alienation – lower levels of support related to faster progression to AIDS - Antidepressants may worsen symptoms Medications available to prolong life - Antiretrovirals and protease inhibitors - Many adverse side effects Group therapy found to be effective – cognitive focus help participants put a stop to intrusive thoughts or address irrational beliefs that lead to depression and anxiety; there is some evidence that therapy improves endocrine levels and immune system functioning Quality of Life Quality of life: impact of symptoms and treatment on physical, social, cognitive and emotional functioning of a person ▪ Primary concern in the treatment of people with serious or chronic illness – Treatments that alleviate medical symptoms may negatively impact other areas of life Trade-off between duration and quality of life must be recognized ▪ Those providing treatment must be sensitive to the trade-off between duration of life and quality of life ▪ Patient must be an integral member of the decision-making team ▪ With surgery their life will prolong by years and without the surgery by 1 year, of course after the surgery it will involve removal of patient’s larynx and prosthetic device will be needed to talk; patient’s voice will sound mechanical with lots of pain versus one year of life with own voice and much less pain. Decision is made on the quality of life such as an opera singer will have difficulty in thinking about this surgery as opposed to a father who wants to attend his daughter wedding Phenomenologically, according to the patient’s own report, therefore patient must be involved in all decision-making - phenomenologically – according to a person’s own report on the phenomenon, for a physician someone would rather not live than live without tennis is unthinkable but this is irrelevant according to what physician or third person thinks as it is a quality life decision which is subjective Death and Dying A dying person may experience some or all of these reactions: – Denial: coping strategy refuse to acknowledge seriousness; people deny distressing events exist or that negative emotions are felt/ Ex: news about one is going to die faced with extreme novel or severe trauma – Anger: a reaction that follows denial when people are confronted with novel and severe trauma, ex: being angry at medical incompetent and for all its fancy equipment and pills being unbale to prevent patient from dying; get mad at unfairness if it all. Anger can spread to family and friends, might get angry with them for not being helpful – Bargaining: trying to “buy more time”, volunteer for research or make strong commitments in terms of religiosity or spirituality – Depression: feelings of hopelessness and helplessness – patient gives up, thus unduly hastening death – Acceptance: being at peace with one’s situation of their own death, perhaps they view death as a relief, patient might be more peaceful than family and friends not accompanied by a sense of despondency - death doulas – someone who provides varied roles to those who are dying and to their family members; provide care that traditionally be taken on by family members but because of changes in family structure and because families are becoming more geographically dispersed there is a gap in such care Bereavement and Grief Friends and family must cope with bereavement - Grief: psychological response to bereavement - bereavement – emotions attendant upon the loss of a close friend or loved one - grief – deep sorrow usually in response to bereavement Bereaved are a high-risk group - Higher suicide and death rates - Higher incidence of depression and substance abuse - More medical problems May attend grief therapy – six R’s of mourning Death doulas