HEALTH PSYCHOLOGY lectures.docx

Building Blocks of Behavior 1- Learning Types of ASSOCIATIVE learning Classical conditioning Link to stimuli to illicit a specific reaction Pavlovian dogs Little albert (white rat and loud noise) Apply to the clinical setting – limit negative experiences to be associated with the procedure/ the...

Building Blocks of Behavior 1- Learning Types of ASSOCIATIVE learning Classical conditioning Link to stimuli to illicit a specific reaction Pavlovian dogs Little albert (white rat and loud noise) Apply to the clinical setting – limit negative experiences to be associated with the procedure/ the environment Operant conditioning Changing behaviour and voluntary choices in response to consequences Positive and negative reinforcement increase the behaviour +VE= increase the reward -ve= removes the punishment (action either results in award or removal of punishment) Decrease behaviour Likelihood of the of the behaviour being Punishment: negative behaviour and negative response to decrease the response Spontaneous recovery: fear response triggered out of the blue Cognitive learning Acquiring new behaviours and information through observation and information rather than direct experience Observational learning Alfred bandura No direct experience necessary – see what happens to others Either through punishment or Absence of rewards Observing models, social situations and is based on human perception of the situation occurring in front of them Therapies based on learning theory Systematic desensitization CBT Behavior modification BUILDING BLOCKS OF BEHAVIOUR 2- MEMORY Hippocampus- responsible for memory. Transfers short term memory to long term memory Types of memory: Episodic memory– an event happens, and it is remembered. Procedural memories – taught through repetition. Types of amnesia Retrograde Antero-retrograde Components of memory Encoding What Is important for encoding to happen: Attention to the event/ info is critical “focusing awareness.” Divided attention reduces memory. Types: Shallow: structural—physical appearance Intermediate: phonemic – sound Deep: semantic – meaning Storage Multi-store model of storage: like a computer analogy by Atkinson and Shiffrin Sensory memory – like the CD put in, and can be taken out, temporary Dependent on stimuli Info lasts millisecs or secs depending on stimuli Auditory, tactile, visual Short term memory – like a central process system Rehearsal is necessary to maintain the info (verbally repeating it) Limited capacity- only lasts 20-30 sec Dependent on attention 7+/- 2 units of info (i.e phone numbers) chunking numbers helps remember increased numbers Hard to multitask, distractions make you forget it Long term memory – like a hard drive Unlimited capacity to remember. “Working Memory Theory” Baddeley – short term memory theory Memory can work despite distractions Eavesdropping on convos in a busy room Proves that we pay attention surroundings, and can divert attention as necessary (name, gossip, smoke) Format of working memory theory: a central executive control system enables us to focus on one or two things in our environment – it is essentially responsible for attention; and it is supported by 3 subsystems: the visuospatial sketchpad eaves dropping monitors our visual environment all the time, in case an important visual stimulus arises that needs attention diverted to it The phonological loop is used in everyday conversation –thinking or rehearsing what we are going to say conversation taking a few seconds to work out what they are going to say. “active listening” in clinical where you try to suppress the phonological loop to an extent, so that you listen to exactly what the patient says. The episodic buffer a temporary and limited capacity store that allows the various components of working memory and LTM to integrate information and serves as an interface between working memory and LTM essentially integrates the information in working memory, but also is responsible for retrieving information from long-term memory (situationally) responsible for passing rehearsed information into long-term memory. Retrieval recovering info from memory can be faulty/not perfect- misinformation/ false memories affected by time meaningfulness connectedness retrieval cues retrieval methods: recall recognition relearning reconstruction Forgetting ineffective encoding: problems with encoding due to lack of attention “pseudo forgetting” never a true memory to begin with because it didn’t reach storage step decay of memory memory fades over time due to decay in physiological mechanisms interference with other info new information impairs retention of old – retroactive interference old information interferes with retention of new – proactive interference retrieval failure on the tip of the tongue difficulty retrieving note that retrieval is best when the context is similar to the encoding context motivated forgetting unpleasant/embarrassing/traumatizing memories repressed “Freudian theory” Memory Disorders AMNESIA retrograde amnesia inability to remember events that happened prior to onset retrieval failure anterograde amnesia inability to take in new info/ difficulty remembering day to day events consolidation failure post traumatic amnesia combo anterograde and retrograde – cannot store new memory, cannot remember past events onset due to a traumatic head injury – classified as mild, moderate, severe causes traumatic brain injury drugs encephalitis ECT Alcohol – Korsakoff syndrome Lack of stimulation of neurons – age amnesia Emotional trauma Alzheimer’s Clinical implications Understand factors that affect recall Factors affecting encoding Working memory capacity – chunk info together when presenting it Be aware of how the info is presented most important given early and summarized at the end primacy and recency effect facilitate encoding from working memory to long term memory rehearsal of info make info meaningful via examples, rationales, and the usage of visual aides deep encoding and elaboration is promoted facilitate recall recall cues, diagrams, leaflets, instructions written down personal implications maximize encoding capacity by reducing distractions chunk the info – be aware of working memory capacity don’t shallowly process- not just read/re-read, draw diagrams, make examples, paraphrase, build connections with existing knowledge recall techniques HUMAN DEVELPOMENT 1: INFANCY TO CHILDHOOD HUMAN DEVELOPMENT includes: emotional physical cognitive motor language Motor development continuous development gradual progressive discontinuous development – by stages progress in particular order because each stage builds on the last; progress through them is strongly related to age; development is marked by major disruptive changes cephalocaudal: head to foot motor development upper body development before lower body proximodistal development center to outward motor development control of trunk before control of extremities gross motor skills – large muscle groups moving arms, grab toys fine motor skills – small muscle groups holding a pencil, finger movements Cognitive development Erik Erickson’s Stages of cognitive development landmark stages of cognitive development healthy/ unhealthy growing Age Stage Achieved Not achieved 0-18 months Trust v mistrust basic needs are met by the caregiver. Optimistic personality Trust is developed for the caregiver optimism later on Mistrust is formed insecure personality 2-3 years Autonomy v shame & doubt Autonomy self sufficiency TOILET TRAINING. Encouragement for children to do tasks on their own promotes autonomy Shame & Guilt disbelief in own abilities. Doesn’t think they can do it 3-6 years Initiative v guilt Initiative develops increased self esteem and confidence through socialization acts all grown up Guilt excess conflict because of responses from others when trying to achieve goals = feelings of guilt 6-12 Industry v inferiority Industry acquiring new skills, academically and socially functioning outside of family Inferiority negative experiences at this stage can develop inferiority Emotional development: ATTACHMENT bonding bw infant and caregiver reflective of parenting styles mirrored in how one acts in the future in other relationships different from culture to culture Japan has very little avoidant attachment instances whereas Germany has very many as they try to push independence early on ATTACHMENT STYLES: Ainsworth Strange situation procedure Secure (75% of children) Child is distressed when parent is gone Not comfortable around strangers w/o parents When mother is present is more open to strangers Comforted by parent’s presence Typically means that the child has trusting relationships and good self esteem Anxious-Ambivalent Child is distressed when parent is gone Wary around strangers, even when parent is present Not comforted when parent returns ”how could you do this to me” Distrusting relationships, worry their partner doesn’t love them Avoidant Avoids parents Doesn’t seek comfort or contact from parents No preference bw parent and stranger Problems with intimacy, invest very little emotion, cannot share thoughts/feelings Main and Solomon Adapted attachment tyles: Emotional Development: Temperament Temperament: Innate aspect of personality Natural way of acting/ reacting to the world Nature vs nurture 3 types: Easy/ flexible - calm, happy, adaptable, regular in sleeping and eating habits, positive in mood and interested in new experiences Difficult/feisty/active- fussy, irregular in feeding and sleeping habits, low in adaptability, fearful of new people or situations, easily upset, highly strung and intense in their reactions Slow/cautious – relatively inactive, reflective, tend to withdraw or react more negatively to novelty, but their reactions gradually become more positive with experience COMBO Piaget Theory of Cognitive Development Stage 1: sensorimotor period Object permanence develops Stage 2: preoperational period Lacking conservation – if an object’s appearance changes, to the child it is no longer the same object Centration- focus on one thing only, not the other aspects Irreversibility – can’t take back what has been done Animism- all things are living creatures Egocentrism Stage 3: concrete operational Develop conservation understanding – decentration Reversibility Declined egocentrism Implications for HCPs Concept of illness in children Can observe child’s behavior and understand needs of the child What influences children behavior Understand developmental milestones and educate parents on them to see if their children are meeting those milestones and support them in their development 0-2 yrs: Incomprehension as a result of sensorimotor period Irrelevant answers and evades the question 3-5 yrs: phenominism as a result of preoperational Particular objects cause illness but no reasoning behind them Monsters cause illness because they just do 5-7 yrs: contagion as a result of the preoperational period Illness is caused by objects/people related/near the child, no understanding of the cause You get measles waling near people 7-9 yrs: contamination as a result concrete operational Illness is understood to be through contact Illness is viewed as a punishment for being bad You’re outside without a hat when it is cold causes a cold because you start sneezing 9-11 yrs: internalization as a result of the concrete operational period Illness is caused by many external factors – swallowed / inhaled = internalized These children can differentiate between body organs and function and can understand specific simple information about their illness. They can also see the role of treatment and/or personal action as returning them to health Post partum depression 13% new mothers Stigma in women voicing difficulties after birth undetected cases Predictors/Risk factors: Prenatal depression Low self-esteem Childcare stress Prenatal anxiety Life stress Low social support Poor marital relationship History of depression Difficult infant temperament Maternity blues Single marital status Unplanned pregnancy Low socioeconomic status Diagnostic criteria 2 weeks of dysphoric (low) mood lacks pleasure in normal activities + 4 of the following: Appetite disturbance Sleep disturbance Psychomotor activation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive guilt Impaired concentration Suicidal Ideation Effects on infants and children Cognitive problems such as lower cognitive performance, less creative play as a toddler Emotional and behavioural problems such as anger, withdrawal, less mature expression of autonomy, passive noncompliance, lower levels of interaction Negative impact on cognitive development This is resultant of withdrawn/ lack of affection from mother Human development: adolescence Adolescence key features: Synapse formation in the prefrontal cortex Increased control over impulse and decision making Adaptive life stage, prepared for change from home to outside world Erickson’s cognitive development: Identity vs confusion Who am I and where am I going Healthy resolution of earlier conflicts serve as foundation for search for identity Adolescents struggle to make decisions Healthy: experiment with identity and roles in society Unhealthy: Lack of confidence: A lack of self-identity can make it difficult for people to have confidence in themselves and their abilities. PIAGET: FORMAL OPERATIONAL Abstract thinking (not concrete) Understand hypotheticals Capable of abstract logic and debate Understanding of illness: Physiological Good understanding of physiological causes and nature of illness (internal organs effected by different illnesses; cancer is when cells grow too fast); age 11+ Psychophysiological Illness can result from and be aggravated by physiological and psychological causes Social development Peers play a huge role in the social development of Nature of relationships Early adolescence – non-romantic friendships, ‘cliques’, groups, clubs Late adolescence – establish sexual identity. Parenting style Parental responsiveness (acceptance) vs demandingness (control) Need a balance of control and autonomy- give opportunities for growth meanwhile giving guidance, standards, limits Important for developing independence, self-esteem indulgent/neglectful substance abuse, conduct disorder “acting out” authoritarian associated with demonstrate insecurity, anxiety, depression and eating disorders. Impact of chronic illness/ disability Physical effects Physical deformity, noticeable, makes them seem different from their peers, results in lowered self-image/ self-esteem Emotional effects Alienation Low levels of emotional well being Social/educational/ vocational effects Social isolation d/t frequent hospitalization Low education Difficulty getting job/ Financial independence Implications for HCPs Adherence to treatment – conflicting priorities: teenagers care about here and now while drs care about long term Meet them half way See adolescent alone / confidential setting Be non-judgmental When asking about meds, indicate poor adherence is normal Explore knowledge base of the teenager; correct misunderstandings Educate about illness Negotiate short-term goals as opposed to long term ones Sexual behaviors in adolescence Partners have a role in behavior in general Condoms can be stigmatizing Social expectations and behavior – societal penalty and reward (i.e. culturally) Perception of men vs women partaking in sexuality, and sexual behavior Mental health in adolescence Severe depression Difficulties in mental health found to impact teens-young adults MWS (my world survey risk index for mental health) Increased trend in depression and anxiety protective factors related to mental health such as self-esteem, optimism and resilience have decreased – especially in females sleep, physical activity, social media use and pornography use were strongly associations Risk factors: Experience of health, work and relationship stress Family difficulties Experience of being in an abusive intimate relationship Having a bisexual or homosexual orientation Human development: Adulthood & Ageing Adulthood No major changes in development – calm in comparison Patterns of behavior and psychological states morbidity/mortality Erickson’s Stages of Development Age Stage Met Unmet 20-40 Intimacy vs isolation Develops intimate and healthy relationship with others Empathy Understanding of others, love and companionship If sense of identity is undeveloped – fear of commitment and retract into isolation if unable to form friendships 40-65 Generativity vs isolation Grandparent mentality Adult ability to care for another person, guide the next gen Have children, nurtures them or guidance for the next gen put current issues and their resolution at the forefront or it can lead to stagnation in later life 65+ Integrity vs despair Look back on life positively with sense of accomplishment Life has been wasted, many regrets Baltes theory of successful ageing – SOC model theoretical framework that explains how individuals can utilize their inner resources to transform negative situations into positive ones = increased satisfaction in life S= SELECTION : reconstructing goals to prioritize those that are most important or meaningful to the individual. The selection process is important because it allows individuals to allocate their limited resources, such as time and energy, to the goals that matter most to them. O= OPTIMIZATION: engaging in goal-directed actions and means to achieve one's goals. This involves investing time and energy into the acquisition, refinement, and application of goal-relevant means. acquisition of new skills/resources, and practice of skills, taking advantage of the right moment C= maintaining a given level of functioning in the face of loss and decline in goal-relevant means. This involves investing in compensatory means to address the declines and losses that occur. Examples of compensation strategies include modifying behaviors, using external aids acceptance altering and getting help in order to meet those goals Implications for HCPs Elder abuse Financial and material Physical/ sexual Psychological Neglect MUST REPORT Care giver burnout Affects women more than men; more often the caregiver, although there is an increase in male caregivers of family >40 hrs/ week of care Decreased health, mental and physical Depression, social isolation, stress and anxiety manifest into somatic symptoms DEATH Kubler-Ross 5 Stages of grief: DABDA DENIAL, ANGER, BARGAIN, DEPRESSION, ACCEPTANCE Risk perception Risk perception is the subjective assessment we make about the probability of an event/accident happening and how concerned we are with the consequences Processing of risk information influences risky behavior influenced by heuristics= cognitive bias advertising uses cognitive bias and emotions Availability heuristic overestimating frequency of vivid or easily recalled events – e.g., fear of flying versus fear of travelling in car? Representativeness heuristic if something is similar to things in a certain category, it belongs to that category Omission bias – avoid taking action because of too much information the thought that harm from inaction as less severe than harm from action. implications in situations where both acting and not acting carry potential risks Unrealistic optimism/Optimistic bias – some behavior is more risky for others than for self (unrealistic optimism) leads individuals to underestimate their personal risk of experiencing negative events compared to others Public health strategies to increase risk awareness: Posters with acronyms FAST for stroke assessment and action = decrease in mortality rate for stroke because people know how to identify and react \ Communicating risk Accurately communicating risk to patients: Communicating numbers quantifying risk being consistent, clear and using precise numbers rather than “low risk/rare” Use positive and negative stats Use visual aids to represent data, and show risk in perspective Express encouragement and hope Relative risk vs number needed to treat vs absolute risk RR RR is the comparison of the ARs of two groups, such as the intervention group and the control group “what are my chances of getting infected relative to a vaccinated person?” Relative risk stats can be misleading – used by companies e.g., 5/100 die if given no treatment, 4/100 die if given treatment = 20% reduction in mortality rate NNT NNT is the number of people who need to be treated with an intervention to prevent one harmful event Best way to communicate to people stats AR AR is the probability of an event occurring in a population Provides context absolute risk reduction compares how much your risk reduces by getting a vaccine. Social context Conformity: Yielding to real or imagined social pressure fear of being disliked/ made fun of assumption that the group collectively is smarter who were the whistle blowers conformity/lack of reporting criminal proceedings/ gov’t report obedience Definition: form of compliance that occurs when people follow direct commands, usually from someone in direct authority Milgram’s Experiment Shock each time mistake made, increasing by 15v each time Agonised protests of “Learner” audible through partition after 150v 300v - “Learner” yells and pounds partition 315v - “Learner” groans, swears and pounds partition 315v+ - no further sound from “Learner” Bystander effect People less likely to provide help to those in need when in groups than when they are alone Diffusion of responsibility: which the responsibility for an action is shared among a group of people, making it less likely that any one person will take action Someone else will Pluralistic ignorance: majority of people privately believe something, but assume that most others believe the opposite. This can lead to a situation where people are reluctant to act, even if they believe that something is wrong, because they think that no one else cares. Nazi soldiers in Nazi Germany ALCOHOL USE DISORDER Quantifying: Criteria: Alcohol Use Disorder DSM-5: Single construct: distinguished on number of criteria Mild = 2-3 points Moderate= 4-5 Severe = 6+ Criteria includes: Recurrent use in failure to fulfil obligations Recurrent use in hazardous situations (inebriated at work, drunk driving) Continued use despite alcohol-related social or interpersonal problems Tolerance to alcohol Withdrawal or substance use for relief/avoidance of withdrawal Alcohol craving Drinking in larger amounts or for longer than intended Persistent desire or unsuccessful attempts to stop/reduce drinking Great deal of time spent obtaining, using, or recovering from alcohol Important activities given up/reduced because of drinking Continued drinking despite knowledge of physical or psychological problems caused by alcohol Embedded in learning theory operant conditioning: reward from drinking acts as a positive reinforcement as opposed to the repercussions of the hangover later (delayed negative effect) social learning: self-confidence in social situations; learn by imitating peers Dependence: Genetics vs environmental theories Biology vs social situations High genetic “loading” = highly likely susceptibility to alcohol dependence Environment = peers, societal perception (media, drinking culture), advertising Genetics Variable alcohol metabolism based on genetic background of the individual Negative consequences: Cirrhosis CVD, diabetes, HTN Cancer Low education attainment Getting fired from missing work Financial problems Violent behavior/ involved in bad situations as a victim Memory loss/ blacking out , insomnia Repeat accidents or trauma lack of personal care withdrawal symptoms Assessment Physical conditions Psychiatric problems Frequent consultations with different doctors UNIT consumption, withdrawal symptoms, when the pt first starts drinking in the day Prevention and treatment Consider support groups if: Patient fails to benefit from (extended) brief intervention patients drink more than 30 units of alcohol daily, or show signs of moderate/severe dependence have a history of epilepsy, withdrawal related seizures, or delirium tremens or have comorbid physical or mental health conditions CAGE ASSESSMENT TOOL = ASSESS DEPENDENCE Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticising your drinking? Have your ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? +2 more = problem AUDIT-C TOOL= ASSESS FOR abuse, bingeing, frequency, amount RISKY SEXUAL BEHAVIOR SEXUAL HEALTH and Health care Contraceptives STI Prevention and Tx Fertility management: pregnancy, planning, abortion HCPs need to know how to address these concerns with pts, build rapport and develop a safe environment for self-disclosure HCPs need to be educated in concerns, and understand where their role comes in (recommendations for tx, referrals, etc.) RISKY SEXUAL BEHAVIOUR Sex work Sex with strangers Unprotected sex with a partner: genital and oral Early sexual activity Having a high risk partner (has multiple partners, is an IVDU) Implications for Safe sex practices Contraception Need to understand the cultural, societal beliefs that influence personal behaviors Promote STI testing, pap smears, OBESITY Obesity: Increased body fat as opposed to lean body mass Adverse health outcomes resultant Physical and mental health implications High heritability of BMI from bioparents Epigenetics is involved Obesogenic factors: Measured by BMI: Weight (kg) Height (m2) normal= 18.5-24.99; overweight >25 BMI DOESN’T ACCOUNT FOR EVERYTHING AND IS NOT FULLY ACCURATE Age Gender Body frame Sleep, stress, coping style, financial issues, pain, medication side effects Waist circumference more accurate in determining risk factor for CVD Waist:hip ratio Adipose tissue around abdomen TREATMENT Explain health risks Explore reasons for obesity Identify barriers to weight loss Develop weight loss targets with the individual Training – brief behaviour change interventions Information on supportive services – written information, community based groups, online resources. Monitor any weight changes (safe/unsafe/ineffective) Provide pharmacological support if necessary (~BMI>30) Refer to bariatric surgery service if necessary (~BMI>40) Behavioral therapy Not specific to obesity- seen in smoking and alcohol cessation: 5As Ask Advise Assess Assist Arrange follow up Involves: Diet, physical activity, lifestyle modification Pharmacological therapy To be used when behavioral therapy has not worked Orlistat – acts on GI and reduces fat absorption Criteria: a BMI of 28.0 kg/m2 or more with associated risk factors a BMI of 30.0 kg/m2 or more First line tx therapy should be continued beyond 3 months only if the person has lost at least 5% of their initial body weight since starting drug treatment otherwise d/c the decision to use drug treatment for longer than 12 months (usually for weight maintenance) should be made after discussing potential benefits and limitations with the patient the co-prescribing of orlistat with other drugs aimed at weight reduction is not recommended Phentermine – reduces appetite Surgery to be used when behavioral therapy AND pharmacology has not worked Gastric bypass surgery Complications post- op: pneumonia, infection, leakage from re-shaped intestine 15%+ of cases fail (e.g., patient snacks continuously, fails to lose weight) Helpful in tx of T2DM, hyperlipidemia , HTN, associated sleep apnea Gender Based Violence UN definition: "Gender-based violence is violence that is directed against a person on the basis of gender or sex. It includes acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty…. While women, men, boys and girls can be victims of gender-based violence, women and girls are the main victims*.” Violence against women (VAW) Intimate partner violence (IPV) Several levels to GBV, encompassed and normalized by: Family Community State/ Institutions Sexual Health Positive, healthy experience No coercion, discrimination, violence (WHO) Sexual rights, are engrained in human rights: Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination the rights to life, liberty, autonomy and security of the person the rights to equality and non-discrimination the right to be free from torture or cruel, inhuman or degrading treatment or punishment the right to privacy the rights to the highest attainable standard of health (including sexual health) and social security the right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolution of marriage the right to decide the number and spacing of one’s children the rights to information, as well as education the rights to freedom of opinion and expression, and the right to an effective remedy for violations of fundamental rights. TYPES OF SEXUAL VIOLENCE non-contact = sexual harassment, revenge porn contact = nonconsensual touching penetrative abuse = oral, anal, vaginal penetration forced marriage denial to use contraception female genital mutilation, compromised sexual integrity of women forced prostitution/ trafficking, exploitation key features of GBV harassment – women more than men, and most often in public violence- from family member many woman worry about crimes – limiting where they go and who they go with underreporting- disbelief in the victim, victim retaliation child sexual abuse = <17 yrs old, children and adolescents adult sexual abuse= >17 yrs old Intimate partner violence abuse continuum pattern of increasingly abusive behaviour leading to emotional/ psychological abuse control of the partner IPV consequences- short term/long term physical injuries IBS – induced by stress Gynecological disorders, infertility, PID STIs Unwanted pregnancy, unsafe abortions Unhealthy coping mechanisms Poor mental health Fatality Acute tx of victim of SA SATU – treatment unit, works in collab with the police Tx of the victim Collection of forensic evidence Emergency Dept Emergency Contraception HIV prophylaxis Hep b Evaluation of safety at home (child) STI follow up Offer collab with SATU to collect forensic evidence – this has to have consent obtained by adult pts Implications for HCPS Advocacy of the pts Comprehensive and holistic treatment of the pt Encourage HCPs sensitivity training So that they may effectively treat and provide support Effective assessment make the environment safe for disclosure Active listening, emotional support Referral and support – stop the recurrence of violence; police, shelters etc. Sex ed to young people – importance of understanding positive sexuality Look towards the population to see what works (evidence based) Work with the patients. Consent consent consent Do not stereotype Educate on access to services, and culturally competent services Complementary and Alternative Medicine What to ask as a HCP: Have you ever been to a CAM practitioner? Did you wait long to be seen? How long was the visit? Did it work? Have you ever spent money on self-care? Complementary: used with western/modern medicine Alternative: used as a replacement Goal = treatment/cure/pain management Applies to biopsychosocial model biomedicine model: what is the best treatment for everyone (overall) Examples: Mind-body interventions (Ex: prayer, art therapy, yoga) Biologically-based therapies (Ex: Chinese and ayurvedic medicine) Manipulative/Body-based methods (Ex: massage, acupuncture, osteopathy) Biofield/Energy therapies (Ex: Reiki, craniosacral therapy) Alternative medical systems (Ex: Homeopathy, Chinese medicine) not conventional medicine sought d/t the limitations of conventional medicine Principles: Lacks evidence to support Tailored to individual and their problem Relationship between medicine and CAM Integrative; A concept that describes the integration between western and alternative forms of medicine to offer a more holistic and individualized approach to healing complementary + conventional Monopoly: only modern medicine is legally recognized Tolerance: state funding goes to medicine, where pts can seek out CAMs privately Parallelism: both are equally recognized and available for pts Implications for HCPs Evaluate if harmful or not Opportunity to enhance physician-patient communication, create a safe space Recognize importance and legitimacy of patient experiences Not be dismissive of what is outside conventional medicine Encouraged to look into CAMs Not prescribe it unless formally trained Understand the cultural context Healthcare Ethics 4 principles: Respect for Autonomy Patient ability to choose for themselves Nonmaleficence Do no harm Opposite: negligence, professional malpractice Imposing risks, intentionally/unintentionally Beneficence: Principle of Beneficence refers to a statement of moral obligation to act for the benefit of others. Non-maleficence Paternalism = taking control, infringing on the pt Manipulation of information Nondisclosure of information Deception Lying Coercion and justifying this action by: Reference to the patient’s best interests; Preventing harm to the patient; Mitigating harm to the patient. Justice Punishment for malpractice Rationing necessities based on who deserves it more, and deciding who deserves it more Ethical decision making: 4 QUAD METHOD Based on: type and severity of the illness presence of comorbidities and frailty impairment of the other organs and systems, can the impairment be alleviated with ICU treatment how long the pt needs ICU care for, can they withstand the treatment survival does the patient, informed of the treatment and what it entails, still what to follow through with it Ethical decision making: Pandemic minimizing public harm restrict individual liberty: self-isolate, access to services, limiting visitors to hospitals/residential facilities, restricting public gatherings. proportionality measures to restrict individual liberty should not exceed more than what is necessary solidarity collaborative approach that sets aside self-interest for the greater good. Applies to every level of society. fairness healthcare resources are distributed fairly, and effectively, representative of equality in terms of accessibility for all duty to provide care code of ethics of all hcps hcps need to weigh their jobs and obligations with their own health and personal obligations reciprocity privacy depending on necessity, a person has a right to contingent privacy and confidentiality Procedural Values to Guide Pandemic Time Decision Making reasonableness openness and transparency inclusiveness responsiveness There should be an opportunity to revisit and revise decisions as new information becomes available, as well as mechanisms to address disputes and complaints accountability Placebo RCT- placebo: the pt, through random allocation, does not know whether they have the placebo or not Double-blind RCT- placebo: placebo is given to participants through random allocation, both participant and experimenter do not know the allocation Recent findings: the blinding doesn’t matter as much simulating the therapeutic environment> hiding the fact there is a sugar pill placebo effect: placebo follows the same trajectory as actual medication not as strong as the medication placebo users may increase dosage to achieve the same affect= habituation behavioral and physiological responses can be seen can cause dependency, withdrawal symptoms as well Theories on why placebo works: Non-interactive theories Interactive theories Treatment characteristics sham surgery injection pills: quantity: more>less size: bigger>smaller color: green>red/yellow brand names: well known name over generic new> old. more expensive Experimenter bias: impact of experimenter’s expectations have on the study Patient characteristics emotional dependency extraversion neurosis Reporting error confabulation: symptoms are the SAME, pt reports getting better biased perception of the pt and the doctor= spontaneous improvements HCP characteristics: better reputation of the HCP the more the placebo effect more enthusiasm interpersonal skills: warm, empathetic Anxiety reduction theory: any treatment reduces one’s anxiety gate control theory: anxiety reduction may close the gate and reduce pain, whereas increased anxiety may open the gate and increase pain Physiological theories Learning theory: classical conditioning treatment is associated with conditioned stimulus elicit a response Patient expectations: seeing administration over hidden adherence Non-interactive theories: only looks at the pt, tx, professional INDEPENDENTLY does not look at interactions bw physiological theories placebo activates endogenous opiate release and decreases pain can be countered by naloxone placebo can cause habituation, withdrawal and dependency Nocebo: the drug will harm, pt reports side effects of a treatment drowsiness, nausea, fatigue, insomnia women>men Pain Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage Note: Subjective Sensation and emotion Pain without injury Injury without pain Cost: Personal cost: Associated with extended hospital stay lost working days increased use of social welfare benefits Debilitating and distressing Healthcare system cost High population incidence Major reason people see a doctor Gate control theory of pain: PERIPHERY Nociceptors: (receptors of pain)Injury/irritation activate nerve endings at the site of damage. A-delta fibres: – these react to sudden mechanical or heat damage they are myelinated fibres, and therefore activation results in very quick transmission. trigger reflex: These fibres rapidly transmit impulses and terminate in the cerebral cortex. They therefore result in very quick perception and action – e.g., putting hand on hot plate and hand is withdrawn very quickly, before we realise we’re burned C polymodal fibres – these are slow acting fibres. They’re not myelinated, and transmit message slowly, dull, aching pain They terminate below the cerebral cortex in the thalamus and hypothalamus these are the centres in the brain associated with mood, and so prolonged activation of c-polymodal fibres results in alterations to mood and motivation. A-beta fibres- are also large myelinated fibres BUT they are essentially anti-pain fibres, that are activated by touch or temp, such as rubbing, or a hot water bottle, and they counteract the pain message. Gate Control Theory of Pain: Cognition And Mood : Mood Anxiety and depression – reduced pain tolerance and increased reporting of pain Cognitions: Attention: focusing on pain increases experience of pain = increased pain Expectations of increases or reductions in pain can be self-fulfilling. Also: Attributions of the cause of pain Beliefs about the ability to tolerate pain Beliefs about the ability to control pain Expectations of relief from pain – the placebo effect. Summary: factors that influence pain perception Increase pain (open gate) Decrease (closed gate) Physical : injury inactivity drug/alcoholism Physical : medication Massage Heat/cold Behavioral: Poor sleep Busy life Behavioral: Excersizing Relaxing Good sleep habits Emotional Anxiety/depression Stress Helplessness/hopeless Emotional: Humor Optimism Enjoyable activities Cognitive: Focus on pain Worry about the pain Expect the worst Cognitive: Distraction Coping skills Duration of pain Acute: limited duration, likely to get better pain management: Coping skills distraction, relaxation, hypnosis Pharmacological intervention PCA, Chronic: long term disease, >6months Management: Behavioral strategies, cognitive strategies (CBT) address negative thinking, reinforce adaptive behaviours ASESSMENT SOCRATES/OPQRSTUV, survey Stress and Health Affects of Stress Chronic mental and chronic physical health problems Depression Anxiety Lowered immunity Causes physical and mental health problems Worsens pt outcomes Greater use of healthcare services Defining stress: 3 models stimulus, transaction, reaction Stimulus: Objective and measurable Types: Major life events Assessed by rating scale in Life Change Unites Frequency, timing, duration of stressors Can precede some disorders, mostly people do not develop psychological problems suggesting many variables are involved Catastrophes Countered by enjoyment Transaction The external or internal event (stressor) environment Individual’s characteristics and appraisals (perception of the stressor) The internal or external resources a person has available\ Stress will occur when demand or appraisal is greater than coping ability Subjective Variable to pt coping mechanisms Social context of appraisal Dynamic constant reappraisal (re-evaluate) Theories in Transaction: Positive linear theory stress and anxiety present challenges to the individual, which, in turn, improve performance stress motivates you to study, so you perform better The Negative Linear Theory stress at any level consumes an individual’s time, energy, and attention, taking away from the task at hand and consequently inhibiting performance Inverted-U Theory of Stress / Yerkes-Dodson Law (YDL) This is the idea that a certain amount of stress is good for you and leads to better performance because it acts as a motivator. However, when stress gets beyond the point where we can cope with it, or goes on too long, it can become a negative force Response: Behavioural responses/ coping mechanism Adaptive (healthy)/maladaptive (unhealthy) Maladaptive: Poor nutrition Lack of exercise Alcohol and drug use Risky sexual behaviour Smoking Learned helplessness Adaptive coping: Constructive strategies Problem-focused coping: dealing directly with the stressor Emotion-focused coping: changing our feelings about the stressor (e.g. cognitive reappraisal) Factors that improve coping: Social support: correlates with better physical and mental health Optimism: appraise events in a less threatening way; less susceptible to illness Perceived control: perception of control over our circumstances Physiological response Flight or fight response Stress management Increase Sleep, sleep hygiene: Stress fatigue Decrease caffeine intake Caffeine release of stress hormones, affects sleep; high doses can increase anxiety and risk of panic attacks Low doses may have protective effects on psychological stress and cognitive functioning during stress Regular exercise: Redirect energy/high level of arousal; releases endorphins Time-out/Pacing and maintaining a good work-life balance Venting/Support system Expressive writing (Seligman, Pennebaker Changing triggers Identifying situations that contribute to stress and changing them Behavioural techniques Identify triggers and practise behavioural responses Plan responses to stressors rather than reacting Relaxation techniques: Skills to: lower BP, slower pulse, slower breathing Meditation – incorporating set periods of relaxation or “time-out” Cognitive techniques: Restructuring/Reframing: Doesn’t change the external reality but changes perspective Identifying and challenging stress-evoking cognitions e.g. CBT, positive self-talk Maintaining realistic expectations : more predictable greater control “Third wave therapies” Tolerating rather than challenging responses Predicting Measure Health Behaviors Public health measures understand health behaviors Continuum models (i.e. A leads to B leads to C) The Health Belief Model (HBM) do people believe they are at risk do people believe in the benefits of taking action to avoid it Pros: common sense Cons: assumes people will make logical decisions about health neglects social factors Stage models (can move between stages) The Transtheoretical Model (TTM) different people have different stages of readiness if health programmes match the stage that people are at, it will increase retention/recruitment alternative stage 6: relapse, if they cannot maintain Pros: tailored to the stage of change, recognized the difficulties in adherence and allows for failure Cons: assumes logical and rational thinking; does not address context Dynamic models (integrated) Behaviour change wheel (I.E. COM-B) Brings different models together Capability, opportunity, motivation Accounts for context Most behaviours influenced/dependent on, others EXAMPLE= COM-B model Capability Physical capability: having skills/strength to do the behavior Psychological capability: having the psych. Skills to perform behavior regulation Opportunity Physical Opportunity: environment provides u the opportunity Social Opportunity: social acceptance, cultural supports self-regulation change routine and environment Motivation (Head) Reflective motivation: self-conscious planning, analysis, decision making. Internal belief and intention (Heart) Automatic motivation: Emotions and impulses that arise from associative learning or innate disposition (i.e. pleasure of eating a cake) supports engaging in the desired behavior Pros: comprehensive approach with many options; takes context into consideration (COM) Cons: evidence is still emerging on efficacy of this model Personality and Illness Personality: internal factors that are relatively constant accounting for individual behavior 4 theories: Psychoanalytical Behavioural Humanistic Biological Psychoanalytical Freudian theory Sigmund Freud Observational theory, based on women subjects All behavior is d/t the subconscious mind ID: primitive, behavior according pleasure Unconscious EGO: decision making, according to making it reality Conscious SUPER EGO: moral component -> social standards of right and wrong VERY unconscious balance of all 3= dynamic equilibrium imbalance= conflict anxiety/neurosis defensive behavior Results in defense mechanisms Defense mechanisms: Repression Traumatic experience, try to forget Regression Retreat to early stage of development Older child pees bed when sibling is born Denial Refusing to acknowledge smthg unpleasant is happening Displacement Divert emotions from one thing to another Rationalisation Creating a false but plausible excuse to justify unacceptable behavior Reaction formation Behaving in an opposite way to how you actually feel Sublimation Transforming a socially unacceptable impulse into an admired and socially valued goal Projection Attributing OWN negative qualities to others Intellectualization Avoiding the emotions associated with anxiety-provoking experiences by focusing on abstract/impersonal thoughts Pros to Freudian theory: Includes child development Considers nature and nurture in personality development Cons: The sample group was emotionally disturbed people that this theory was based on, very UNTESTABLE Biological Big 5 theory of personality Eysenck Suggests that genetics and a person’s physiology translates to the type of personality they have A highly aroused person introvert because social unease 3 dimensions Extraversion v introversion Neuroticism v emotional stability Psychoticism v self-control 5 big personalities: Openness: open to new experiences, eccentric Conscientiousness: organized, self-directed, controlling Extraversion: outgoing, enthusiastic, active Agreeableness: trusting, compliant, empathetic Neuroticism: prone to stress, worry, negativity can be high or levels of any of these domains PERSONALITY TYPES Idea that personality can influence illness vulnerability and progression Independent of hereditary/ family history of the disease Type A: Associated with CORONARY HEART DISEASE Very competitive and ambitious Sense of urgency and timelyness Strong achievement drive Hostile, angry, aggressive linked to smoking and drinking Type B: laid back Opposite to type A Not competitive, no hostility/anger No care for time Type C: CANCER Cooperative, appeasing Compliant, passive Suppress negative emotion Type D: Tendency to experience negative emotions Anxiety, depression Socially inhibited crazy outgoing to avoid disapproval Social alienation Does not cause CHD, prognostic risk factor for CHD Other personalities : Optimism Depression: risk factor for death after MI Pessimism/ fatalism low survival time in AIDS/ cancer Implications for HCPs: Personality may predict disease onset Personality may also change because of an illness (gained helplessness) Personality may have indirect link to unhealthy behaviors Personality may influence illness progression/outcome because it influences individual coping responses understanding of individual differences , and that everyone requires a different approach Can tailor treatment to the individual if you understand their personality Adherence Adherence: A BEHAVIOUR Patient and HCP engagement in a treatment regime Not entirely on the pt NOT COMPLIANCE – compliance suggests that the pt has nothing to do with their treatment and is just passively following the doctor’s orders Professional non-adherence (to do better for the patient): Adherence doesn’t just apply to pts HCPs ethical implications of what is necessary for the pt Prescribing antibiotics for viruses Not adhering to professional guidelines Concentrating on procedures which pay most Not recording patient information e.g. smoking status 3 elements: Initiation: when the first dose is taken Implementation: does dose taken = prescribed dose? Until the last dose Persistence: time bw initiation and discontinuation (end of therapy) Measuring adherence Measurement should be (guidelines): Reliable Valid Immediate results Safe, practical, non-invasive Applicable to a variety of treatments Measuring tools Subjective Pt reporting Objective methods: Measuring drug concentration, tablet counting, therapeutic outcome achieved, electronic measuring systems Should they be categorical OR dichotomous? Categorizing measurement of what is good or bad levels of adherence Dichotomous = good/bad Continuous measuring adherence as a percentage (i.e. pt was adherent to % of the regimen) EMERGE guidelines to measure adherence 4 domains for measuring adherence domains 17 dedicated to adherence reporting Non-Adherence Types Intentional = Choosing not to Pt beliefs/ cognitions towards: Cause of the disease Duration/timeline Consequences of the disease Curability Emotions towards it Treatment Addiction to medication Is the treatment worth it Worried about side effects balancing the pros and cons (necessity v concern) translates to increased adherence Unintentional Forgetfulness/ distraction Inability to adhere- i.e. being physically unable to maintain a fitness regime because of the difficulty CAUSES Consequences of non-adherence Longer tx time Poor health outcomes Rehospitalization/ longer stay Increased dosing dt tolerance/ drug resistance Increase cost on the healthcare system Implications Ethically – should we stop treating? --> need to find a solution, understand why it is happening Facilitating adherence Understanding of the condition and its treatment Establish concordance Encourage questions, ask pts about their understanding of the treatment Memory for the info given Avoid jargon, provide opportunity to take notes and give written instructions Simplify when possible Develop systems, like reminders, for long term plans phone reminder to take birth control pill Satisfaction with the process of the treatment strategies to encourage adherence should be tailored to why there was non-adherence in the first place Access to Quality healthcare Resource allocation Microallocation = bw pts Macroallocation= divide the healthcare budget Problem of resource allocation Changes in demographic i.e. ageing population changes in the perception of health dynamic need for the healthcare system = sudden increase in need during COVID investing in health vs healthcare health think social determinants of health environment life-style societal support genetics research healthcare medical care – weighting in SDH is very LOW questionable importance – would we need this as much if we had a healthy society? Rationing of resources and principle of Justice and Equity remember rationing falls under Justice principle Aristotle formal principle of Equality: equals should be treated equally, and unequals treated unequally in proportion to the relevant inequalities John Rawls “theory of justice”: we should allocate resources to ensure that those in poorest health, or greatest need, are as well off, in terms of health, as they can be 2 competing ethical theories: Utilitarianism: allocation towards treatment s that provide the greatest benefit i.e. $1mil going to flu vaccine distribution vs hereditary disease tx looks at QALYs quantifying benefit of intervention compared to other interventions pros: cost effectiveness> need for the healthcare intervention cons: Deontology: allocate resources to give pts the tx they want Supply and demand Who decides resource allocation? Medicine profession/HCP bodies Government Individual doctors Influences on who gets treatment: Market forces Ability to pay Desert: treatment according to merit Contribution to society: social value Lottery Needs principles: Distribution in proportion: to degree of immediate threat to life to degree of immediate ill health to lifetime of ill-health to immediate capacity to benefit to cost of exhausting the capacity to benefit Maximizing principles: maximize health max well being Egalitarian principle equalize lifetime health expectancy equalize the opportunity for lifetime health expectancy combination principles combine maximize health w/ equalize lifetime and health expectancy combine needs w/ maximizing Medical neediness criterion for selection: those in most urgent need are given priority, with the provision that there is a reasonable chance of success if there were multiple people affected by the same thing: random selection Treat equally w/ resources available Prioritization protocols may be put in place i.e. during COVID 19 Considering frailty, comorbidities for ICU treatment – benefit to them and survival time post Access to quality health care- disability Classifying Intellectual disability DSM 5: 3 domains of impairment BEFORE AGE 18 Conceptual: limits in intellectual functioning: language, math, problem solving Social: limits in empathy, social judgement Practical: self-management, personal care, responsibilities + IQ test Examples: Fragile X Prader-willi Down syndrome Lesch-nyhan CAUSES OF INTELLECTUAL DISABILITY Prenatal: obstetric complications FASD Drug/toxin Pre-eclampsia Birth complications Perinatal factors Cerebral palsy Hydrocephalus Neural tube deficit Spina bifida Postnatal: Infections/ head injury/ hypoxia HEALTH RISKS FOR THOSE WITH AN INTELLECTUAL DISABILITY Primary secondary Epilepsy - obesity Mobility problems - fractures Hearing - poor health Visual -constipation Mental health disorders - GERD Psychosis - STIs ALZHEIMERS often rely on health management by proxy (cant make decisions by themselves) Health promotion and screening Disease prevention measures Management for existing problems Continuous assessment necessary to identify any other concerns Classifying Physical disability Impairment, activity limitation and participation restriction Total/partial loss of body/ body function Can be life-long Categorizing disability ICF (international classification of functioning) framework by WHO Shared system for communication, common language, categorizing disability Related health information systems FRAMEWORK : BODY FUNCTION ACTIVITY PARTICIPATION ENVIRONMENT PERSONAL FACTORS IMPLICATIONS FOR HCPS: Understand there is attention defecit May be unable to communicate pain or distress HCPs need to communicate directly to the pt, (where possible) they are not incompetent (someone with quadriplegia for example, still can speak and make their own decisions) Stigma “less than” because of differences Stereotyping Prejudice Discrimination Discreditable stigma – for those who you cant see their disability Discredited- for those whose disability is more obvious \ Felt Individual expects negativity Enacted Actual behavioral discrimination Accessibility of quality healthcare: Palliative Care What is palliative care: Focus of reducing pain and increasing comfort, (NOT CURE) usually in the context of chronic disease. Does not focus only on the patient, but their family too. Holistic approach: spiritual, social, psychosocial needs are cared for Interdisciplinary input affirms life and regards dying as a normal process neither hastens nor postpones death Contrast with euthanasia and physician assisted suicide provides relief from pain and other distressing symptoms integrates the psychological and spiritual aspects of patient care offers a support system to help patients live as actively as possible until death offers a support system to help the family cope during the patient’s illness and in their own bereavement Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated Will enhance quality of life, and may also positively influence the course of illness LEVELS OF PALIATIVE CARE: LEVEL 1: PALLIATIVE CARE: mindset adopted and demonstrated by all hcps and all care facilities LEVEL 2: GENERAL PALLIATIVE: special training LEVEL 3: SPECIALIST PALLIATIVE : fully focused and limited to the provision of palliative care Hospice: Typically associated with end of life care/ pt prognosis is poor No curative treatment Importance: Aging population Increase in chronic illness amongst children Need for diversification as these are no longer accessed by people with terminal cancer There is also a dissatisfaction in those who die hospital deaths (lack of training is clear, and pts needs while alive are clearly unmet) Understanding that family must also be considered in the patient’s care, even after death they need support too In-hospital specialized team can be implemented If these needs aren’t met, or if the pt dies suddenly, feelings of grief and mourning/ dissatisfaction will exist Goals of Care: levels of intervention DNACPR (DNR): do not resuscitate Should be clearly established with doctor and patient Doctors should probably discuss resuscitation with any patient at clear risk of cardiorespiratory arrest, regardless of whether DNACPR is being considered Bereavement, grief and mourning Bereavement: the processes occurring after death or loss during which the individual learns to adjust Grief: the subjective feeling (emotional response) caused by the death of a loved one or object Normal grief does not respond to antidepressants Abnormal grief: Delayed/absent Chronic Masked grief somatic symptoms Exaggerated psychiatric illness Responds to antidepressants r