Heart Disease, Stroke, Cancer, and Aids: Causes, Management, and Coping Summary PDF

1 CHAPTER 14 HEART DISEASE, STROKE, CANCER, AND AIDS: CAUSES, MANAGEMENT AND COPING CHAPTER OUTLINE I. Coping With and Adapting to High‑ Mortality Illness A. Adapting while the prospects seem good 1. Early concerns following diagnosis...

1 CHAPTER 14 HEART DISEASE, STROKE, CANCER, AND AIDS: CAUSES, MANAGEMENT AND COPING CHAPTER OUTLINE I. Coping With and Adapting to High‑ Mortality Illness A. Adapting while the prospects seem good 1. Early concerns following diagnosis a. mortality is the main issue that concerns patients and families b. patients often show optimistic attitudes but tentative future plans c. coping often switches from avoidance to problem-focused approaches 2. Developing regular activities a. activities provide a respite from thinking about condition b. patients may over-estimate abilities and become discouraged c. patients need to develop reasonable plans and carry them out 3. Family dynamics a. a cycle of dependence can emerge due to patient helplessness and family nurturance 4. Cognitive adjustments to high-mortality illness a. three themes to cognitive adjustment i. finding meaning in illnesses ii. gaining a sense of control over illness iii. restoring self-esteem, sometimes by comparing themselves with less fortunate people b. effects of cognitive adjustments i. greater positive reappraisal after cancer diagnosis is related to better perceived health and psychosocial functioning ii. many individuals do not achieve high adjustment, particularly when social support is perceived as low B. Adapting in a recurrence or relapse 1. High-mortality diseases are marked by relapses a. relapse presents as an additional crisis a. is perceived as a bad sign b. patients tend to use similar coping strategies but may be less hopeful II. Heart Disease A. Section introduction 1. Coronary heart disease a. results from narrowing and blocking of coronary arteries b. types of heart disease i. atherosclerosis ‑ blood vessels become narrowed by plaques ii. angina pectoris - painful cramps caused by brief or incomplete blockage iii. myocardial infarction - part of heart muscle is  2 destroyed by severe or prolonged block - symptoms of heart attack: uncomfortable pressure, fullness, squeezing or pain in the center of chest that lasts for more than a few minutes; pain spreading to shoulders, neck, or arms; chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath - congestive heart failure - condition in which heart is enlarged, pumping capacity is reduced, and person gets shortness of breath upon little exertion - prevalence of heart attack: 1.2 million Americans suffer heart attack each year, 40% of whom die - heart damage increases when patients delay seeking help; 1/3 delay help seeking for 3 or more hours B. Who is at risk of heart disease, and why? 1. Age, gender, and sociocultural risk factors a. age and gender i. risks for heart disease higher for men and those over 45 ii. American men have far higher rates of heart disease than women at all ages b. sociocultural factors i. death rates are three times higher for African- Americans than Asian-Americans, with whites, Native American, and Hispanics being intermediate 2. Lifestyle and biological risk factors a. risk factors i. hypertension ii. family history of heart disease iii. cigarette smoking iv. high blood pressure v. high LDL and total cholesterol levels vi. physical inactivity vii. diabetes viii. obesity ix. stress b. effects of reducing risk factors i. high LDL and low HDL cholesterol is the strongest risk factor; smoking is the second ii. risk gets cut in half after stopping smoking and reducing cholesterol and blood pressure 3. Negative emotions and heart disease a. research indicates people who experience chronic high levels of hostility, depression, and anxiety are more likely to develop heart disease and hypertension i. have less healthy lifestyles ii. negative emotions have physiological effects that promote heart disease b. type A people have chronically high levels of catecholamines and corticosteroids, especially when under stress i. these chemicals damage heart and blood vessels and increase formation of platelet clots ii. heart attacks are more likely on Monday mornings for those who are working  3 C. Medical treatment and rehabilitation of cardiac patients 1. Section introduction a. many cardiac patients have not had a heart attack, but tests show they have heart disease b. may receive one of two invasive procedures for atherosclerosis i. balloon angioplasty opens the vessel and his held open by a stent ii. bypass surgery shunts blood flow around the diseased section of an artery with a piece of healthy blood vessel 2. Initial treatment for heart attack a. emergency medical treatment i. clot-dissolving medication frees blocked arteries ii. coronary care unit may closely monitor functioning iii. other procedures such as angioplasty or bypass may be necessary b. emotional state of cardiac patients i. high anxiety occurs in first few days of coronary care ii. denial may be used by some patients, who are typically less anxious iii. greatest difficulty coping is seen generally by those who had distress/social problems before attack. iv. excessive denial, depression, anxiety impairs recovery. 3. Rehabilitation for cardiac patients a. programs are designed to promote recovery and reduce risk factors. i. common program features - information provided on symptoms, medications and lifestyle changes - lifestyle change advice includes: quitting smoking, losing weight, exercise, reducing dietary fat and cholesterol, reducing high alcohol consumption, and stress management b. adherence to programs i. some find adherence easy whereas others may resent the restrictions ii. less adherence is found in those with low self-efficacy or who perceive low social support c. exercise as a part of the intervention program i. introduced gradually and tailored to physical capability ii. begins with supervised short-distance walking and becomes more vigorous iii. adherence brings about substantial benefits iii. exercise adherence is related to psychosocial adjustment. - 50% discontinue in six months - compliance is higher if there is a special place to exercise d. adherence to other lifestyle changes i. dietary changes are difficult due to the impact on family life ii. only 30 - 40% quit smoking  4 iii. higher self-efficacy is related to following cardiac regimen D. The psychosocial impact of heart disease 1. Importance of work a. valued as a sign of recovery i. may need to cut back on work or change jobs ii. negative interpersonal relationships with co-workers due to shift in job capability iii. not going back to work is associated with lasting emotional difficulty 2. Family relationships a. cardiac patients with strong social support recover faster and survive longer b. prior family problems may be exacerbated by the heart attack i. cycle of guilt and blame may develop ii. sexual relations may decline c. families may promote cardiac invalidism i. family members can increase estimates of patient’s physical functioning by personally experiencing the feats they can perform ii. more similar beliefs between spouse and patient about heart disease are related to increased functioning months later d. long-term emotional consequences of heart disease i. most adjust fairly well ii. poor adaptation, compliance, and greater likelihood of another heart attack occurs if very high levels of anxiety/depression E. Psychosocial interventions for heart disease a. programs with education and psychological counseling i. meta-analysis study results 1. interventions reduced mortality and recurrence of heart problems 2. programs reduced risk factors 3. addressing fear and anxiety led to far greater psychosocial adjustment 4. studies on psychotherapy have had mixed results b. stress-management programs i. programs reduced angina pectoris by 40%, Type A behavior, and lowered blood pressure c. Ornish's multi-component program i. combined dietary, exercise, and stress management approaches ii. program improved atherosclerosis, reports of chest pain, and later cardiac problems III. Stroke A. Section introduction a. definition and prevalence i. damage that occurs in some area of the brain due to  5 deprivation of blood supply and oxygen ii. in US, 600k new or recurrent strokes annually with 160k deaths b. common symptoms of stroke i. sudden weakness or numbness of face, arm, or leg ii. sudden confusion, trouble speaking, or understanding iii. sudden trouble seeing in one or both eyes iv. unexplained dizziness, loss of balance, or fall v. sudden, unexplained, severe headache B. Causes, effects, and rehabilitation of stroke 1. Section introduction a. causes of blood disruption i. ischemic stroked caused by thrombus or embolus in cerebral artery - tends to occur more slowly ii. hemorrhagic stoke is a ruptured blood vessel - tends to occur rapidly and cause loss of consciousness - occurs less frequently but more likely to cause extensive damage and death 2. Age, gender, and sociocultural risk factors for stroke a. incidence rates are higher for men, African Americans, and middle-aged persons i. differences probably lies in biological and lifestyle variations 3. Lifestyle and biological risk factors for stroke a. risk factors include: i. smoking ii. hypertension iii. heart disease, diabetes and their risk factors, obesity, physical inactivity, high cholesterol iv. family history v. high red blood cell count vi. occurrence of transient ischemic attacks vii. drinking more than two alcoholic drinks per day b. role of negative emotions i. depression is linked to incidence of stroke and mortality 4. Stroke effects and rehabilitation a. extent and type of impairment depends on amount and location of lesion i. receiving immediate treatment with clot-dissolving medications reduces damage b. although stroke is one of the most disabling chronic illnesses, improvement of deficits is possible, especially for the young, and those with strokes due to hemorrhages i. motor impairment is the most common deficit - biofeedback and physical therapy reduce disability ii. cognitive impairment may include deficits in language,  6 learning, memory, and perception - language disorders include: - receptive aphasia (difficulty understanding verbal information) - expressive aphasia (problems producing language) iii. visual disorders are common with right brain stroke. - example: visual neglect which results from processing only part of visual field and can be treated by teaching patient to turn head to scan full visual field iv. emotional effects may depend on area of the brain damaged - left hemisphere damage is related to depression - right hemisphere damage is related to interpretation and expression of affect - emotional lability may occur B. Psychosocial aspects of stroke a. common coping strategies i. denial occurs more than for heart disease or cancer patients b. emotional adjustments i. depressed individuals show less improvement and remain in the hospital longer ii. depression may result when recovery slows and full extent of impairments becomes known c. occupational effects i. less than half of stroke sufferers return to work within 6 months ii. may not be able to return to work at all which may be emotionally and financially stressful d. social effects i. families often do not adjust well, and marital harmony often declines ii. social contacts and activities may decline and be a source of stress IV. Cancer A. Section introduction 1. Fear associated with cancer diagnosis a. anxiety from false positive breast cancer tests can last for months after tests b. physicians recognize patients' fear of cancer, but are becoming more likely to share details about serious medical conditions B. The prevalence and types of cancer 1. Cancer involves unrestricted cell proliferation which may form a malignant neoplasm (tumor). a. cause of growth unclear but may be due to oncogenes, which regulate cell growth  7 2. Five types of cancer a. carcinomas - malignant neoplasms of skin cells or cells lining body organs i. constitute 85% of human cancers b. melanomas -neoplasims of the skin cells that produce melanin b. lymphomas - cancers of the lymphatic system c. sarcomas - malignant neoplasms of the muscle, bone, or connective tissue d. leukemias - cancers of the blood-forming organs 3. Cancer cells do not adhere as strongly and therefore more easily spread or metastasize through blood or lymph systems. 4. Prevalence a. leading cause of death worldwide i. second leading cause of death in US - 550,000 deaths and 1.4 million new cases annually - 60% of new cases can expect to live at least 5 years, most will be cured - almost all the increase in cancer cases since 1950 is due to lung cancer C. The sites, effects, and causes of cancer 1. Section introduction a. physical effects of cancer i. growth of tumor interferes with normal development and functioning ii. pain may be caused by pressure on normal tissue or nerves or blocking of flow of body fluids b. cancer as a direct or indirect cause of death i. direct cause - spreads to a vital organ and competes for nutrients; causes organ failure ii. indirect cause - weakens victim and, along with treatment, impairs appetite and ability to fight infection 2. Common cancer sites a. skin cancer i. prevalence = 1 million cases annually ii. types of skin cancer - basal cell carcinoma - squamous cell carcinoma - melanoma b. prostate cancer i. prevalence = 230,000 cases annually ii. survival rate can be 100% with early detection c. breast cancer i. prevalence = 217,000 cases annually ii. 5-year survival rate of 97%, 79% if cancer has spread d. lung cancer i. prevalence = 174,000 cases annually  8 ii. 5-year survival rate of 49% if cancer is localized but only 15% overall e. colorectal cancer i. prevalence = 147,000 cases annually ii. 5 year survival rate of 91% when detected early, 62% overall f. uterine and cervical cancer i. prevalence = 51,000 cases annually ii. 5 year survival rates of 92% 3. Prognosis and causes of cancer a. prognosis depends on how early it is detected and its location b. causal agents i. cancer is caused by interplay of genetic and environmental factors ii. environmental factors include stress, smoking, diet, ultraviolet radiation, chemical hazards, and viral infections 4. Age, gender, and sociocultural factors in cancer a. age factor i. risk for cancer quadruples from ages 40-80 b. gender factor i. incidence rates of cancer are much higher in males than females ii. most common diagnoses are prostate cancer in men and breast cancer in women c. sociocultural factors i. cancer incidence and mortality rates highest for African Americans - survival rates are probably lower due to late detection ii. national differences in cancer prevalence occur D. Diagnosing and treating cancer 1. Knowing warning signs for cancer and having regular examinations increases early detection. a. sites for early detection physician or self-examination include breast, skin, colon or rectum, testes, prostate and uterus or cervix b. warning signs for cancer (CAUTION) i. change in bowel or bladder habits ii. a sore that does not heal iii. unusual bleeding or discharge iv. thickening or lump in breast or elsewhere v. indigestion or difficulty swallowing vi. obvious change in wart or mole vii. nagging cough or hoarseness 2. Diagnosis a. typical medical procedures i. blood or urine tests may reveal unusual levels of certain hormones or enzymes ii. radiological imaging, such as X‑ ray, that reveals  9 presence of tumor iii. biopsy to remove and examine suspect tissue 3. Types of Medical Treatment a. goal of treatment is cure i. since possibility of metastasis exists, 5 year survival rate is gauge of treatment success ii. type of treatment determined by size and site of neoplasm, effect of treatment on patient's life, age of patient b. types of treatment i. surgery is a preferred treatment to eliminate localized cancer and may be used to remove portion of large tumors - tissue near neoplasm may be removed due to concern of spreading cancer, although this process is changing - for breast cancer either the entire breast is removed (mastectomy) or just the tumor is removed (lumpectomy) ii. radiation may involve external beam therapy or internal radiation therapy - side effects such as irritation, burns, hair loss, nausea, loss of appetite, sterility, and reduced bone marrow function may occur iii. chemotherapy involves the use of powerful drugs that kill rapidly dividing cells - side effects include reduced immunity, sores in the mouth, hair loss, nausea and vomiting, and damage to internal organs, but most effects are temporary c. treatment side effects i. two common side effects - severe and long-lasting fatigue - nausea during and soon after treatment ii. side effects learned through classical conditioning - anticipatory nausea - learned food aversions d. demands of treatment i. cancer treatment is complex and demanding - requirements to take medications at home - needs to return to clinics for on-going treatments ii. studies of adherence produce mixed findings. - adults tend to adhere well but adolescents and minority groups have lower adherence E. The psychosocial impact on cancer 1. Cancer involves a series of threats and unique stresses. a. treatment decisions i. must decide between benefits of treatment and side effects ii. adjustment problems may occur if outcomes aren't as  10 expected b. threat of recurrence i. threat of recurrence is a concern for those in remission ii. if recurrences occurs the distress can be worse than the initial illness c. adjusting to treatment i. medical procedures can be as aversive as disease itself ii. adjustment has medical consequences and affects disease progression iii. high levels of hopelessness and depression are associated with poor prognosis iv. high levels of stress and poor coping are associated with poor immune system activity d. incidence of emotional problems i. less than half of cancer patients show emotional difficulties ii. most problems are transitory iii. patients with cancer often cope by using positive reappraisal iv. study comparing cancer patients and general public found similar levels of depression, happiness, optimism, and perceived health 9 months after diagnosis and treatment 2. Adjustment depends on patients' physical condition and age a. severe depression is associated with disability or pain 3. Site of cancer, age, and gender influence adjustment a. men with prostate cancer react differently depending on age and child-bearing experience b. women with breast, cervical, or uterine cancer affected by degree of disfigurement or impact on sexual functioning 4. Psychosocial problems a. changes in relationships with family and friends may occur. i. withdrawal from social contact because of awkward feelings about discussing disease ii. physical condition and treatment may interfere with social activities iii. others may avoid patient due to fear or own emotions F. Psychosocial interventions for cancer 1. Psychosocial approach begins with physician's diagnostic interview. a. providing information about treatment is helpful 2. Types of psychosocial interventions a. relaxation and systematic desensitization may be used to treat anticipatory nausea b. cancer pain can be treated with relaxation and problem- solving training c. cognitive-behavioral stress management improves adjustment by reducing depression and increasing positive reappraisal strategies d. family therapy and support groups benefit patients and family through education and group discussion  11 G. Childhood cancer 1. Leukemia is the most common cancer in children a. 2,700 new cases annually b. 5-year survival rate is 78% 2. Treatment programs for leukemia a. phases of treatment i. induction phase - patient receives combinations of high doses of drugs to bring disease into remission, radiation may be used to prevent development in the brain ii. maintenance phase - continued chemotherapy treatment over the next 2-3 years on an out-patient basis b. treatments include extremely painful procedures such as bone marrow transplants i. use of distraction and modeling used as intervention 3. Psychosocial adjustment a. initial trauma is difficult but adjustment improves over time b. adjustment is better with earlier diagnosis and longer survival c. patients may lag behind peers in academic progress due to illness V. AIDS A. Section introduction 1. Ways in which AIDS differs from other high-mortality chronic illnesses a. a new disease that was unknown until 1980 b. an infectious disease caused by HIV and spread through shared contact with blood/semen c. prevalence i. death rate is low in developed countries ii. a worldwide epidemic with high annual mortality and millions of people infected B. Risk factors, effects, and treatment of AIDS 1. Section introduction a. risk factors i. sexual activity that exposes body fluids ii. sharing contaminated needles iii. birth by an infected mother 2. Age, gender, and sociocultural factors in AIDS a. worldwide prevalence is 38 million, 800k are children b. in the US, infection rates are highest among 20-45 year olds c. infection rates are 3 times higher in men, and have constituted 80% of all AIDS cases in the US d. sociocultural i. death rates are many times higher in African Americans and Hispanics ii. largest concentration of cases in sub-Saharan Africa  12 C. From HIV infection to AIDS 1. Section introduction a. several years may pass following HIV infection before immune system is impaired b. the diagnosis of AIDS i. originally was made following development of opportunistic diseases such as pneumocystis carinii pneumonia or Kaposi's sarcoma ii. current diagnosis includes low level of helper T cells -new blood tests can determine amount of viral load b. AIDS-related complex i. occurs during time of infection and development of AIDS ii. characterized by fever, night sweats, diarrhea, fatigue, and swollen lymph glands 2. Medical treatment for people with HIV/AIDS a. many opportunistic diseases may be treated with antibiotics i. some victims become hypersensitive or allergic to medications ii. many patients develop encephalopathy b. main treatment i. antiretroviral agents - from 1980s to mid-1990s, main drug was azidothymidine (AZT) which suppresses HIV reproduction - from mid 1990s, protease inhibitors used to interfere with HIV reproduction and reduce viral load ii. problems with medicines - regimens may not work on all strains - must strictly adhere to regimen - treatment is expensive - can have serious side effects - adherence low because of treatment complexity and side effects c. survival patterns i. most AIDS victims die within 3 years ii. 5-10% survive for 15 more years with HIV iii. some long survivors explained by genetic processes iv. HIV victims with high reactivity to stress and poor coping show poor immune function and faster disease progression iv. starting treatment early after infection with brief interruptions allows body to develop immune defenses C. The psychosocial impact of AIDS 1. In the mid-1980's, people with AIDS were ostracized. 2. AIDS still arouses fear and discrimination a. many Americans believe it is punishment from God for misbehavior b. often associated with homosexuality and drug abuse  13 c. concern that family, friends, neighbors, and coworkers will reject 3. Health effects of stigma a. countries that resist acknowledging disease foster its spread b. stigma leads to delay in testing and treatment c. revealing serostatus slows disease progression 3. Adaptation to HIV/AIDS a. adaptation depends on access to medications i. using effective treatment reduces distress ii. as symptoms decrease, adaptation increases b. experiences of those who don't adapt well i. fear of abandonment, pain, debilitation, and disfigurement ii. feelings of hopelessness, helplessness, and depression - treating depression is critical since it related to faster disease progression D. Psychosocial interventions for AIDS 1. Counseling at the time of testing a. information needs i. information is needed to reduce anxiety while waiting for results. ii. for HIV-positive, counseling is needed regarding illness, treatment, and resources 2. Interventions for people living with HIV/AIDS a. intervention needs i. assistance with complex regimen ii. intervention for emotional distress, pain management, and sleep disorders iii. reducing anxiety and depression for those who do not have effective drugs b. studies on intervention effectiveness i. intervention reduces anxiety/depression and enhances immune function ii. HIV patients who wrote about a traumatic experience had lower viral loads than those writing about a neutral topic VIII. The Survivors: And Life Goes On A. Adapting to bereavement 1. Bereavement is the state of having lost someone through death. a. grief is the characteristic feeling b. mourning is the expression of these feelings B. Physical and psychosocial impact 1. Adapting to bereavement a. each grieving person adjusts at their own rate - no rule of thumb on time needed to adjust - spousal grief is similar before and after death, remains high for about a year, and is greater for middle-aged  14 individuals - individual therapy or group support may help with adjustment 2. Adjusting to bereavement in AIDS cases for gay men. a. many experience long series of bereavements without time to adjust in between b. gay men who have lost lovers may receive less social support from others 3. Adjusting when a child dies a. death of a child may result in years of grieving for the loss i. the loss of a child is one of the most tragic events that can happen to a family ii. surviving siblings need special attention, it is not uncommon for them to show little grief C. Psychosocial interventions for Bereavement 1. Individual therapy and support a. group discussion and role playing b. systematic densensitization D. Reaching a positive adaption 1. Long-term adjustment a. most people are able to build new lives with social support b. although surviving spouses usually receive a great deal of attention, eventually this changes and they must return to their daily lives c. some bereaved individuals are never able to adjust, but new and enriching lives can be built