Lecture notes with Health and Medical Psychology at Leiden University - 2015/2016

Lecture 1: Health behaviour explained

Introduction

Health psychology focuses on the relationship between the body and the mind, dealing with chronic diseases, revalidation, eHealth, prevention, promotion of healthy lifestyle, stress and stress-related diseases among many other things.

Primary prevention focuses on healthy people who are not (yet) sick at all and how to keep it that way. Secondary prevention comes after the first few symptoms of a disease have shown, but they are treated in an early stage. Tertiary prevention comes after later, irreversible symptoms have shown and has to do with revalidation.

Views on health

Health has more than one point of view. It can be seen as not being ill, being strong, healthy behaviour, fitness, mental health, being able to function and do what you want, etc. The World Health Organisation defines health as shown on slide 15.

As there are different views on health, there are different models on health as well. For example, the biomedical model is a dualistic model, where psychological and physical illness can be explained by physical factors. However, in this model there is no room for psychological factors causing illness. Becoming ill has to do with the immune system not being able to protect you against contagious agents when exposed to them.

The biopsychosocial model contains three approaches that together form health: biology, psychology and social context (see slide 19). In this model, both body and mind cause diseases or health. There is a lot of interaction between these two. The biopsychosocial model states that there are several factors of a long life. How long your life is depends on: sleep, food, weight, exercise, alcohol use and smoking.

Health behaviours

According to Matarazzo, there are two types of health behaviour: behavioural pathogens are bad for your health, e.g. substance use, whereas behavioural immunogens are good for your health (e.g. exercise).

Why we should change behaviour:

• Health behaviour has a relation with mortality. Lifestyle can decline diseases: the mortality rates for certain diseases declined before the medicine came! This is probably due to lifestyle change!

• Health behaviour is linked to morbidity and life quality.

• The prevalence of unhealthy behaviour is high. Many people show risky behaviour, for example: even though the government discourages smoking behaviour, still 28% of the adults smokes!

• Differences between social economic statuses: differences in health behaviour between social-demographical groups can lead to bigger social-economic differences between these groups. But also: different health behaviour can be due to social economic differences (not every healthy lifestyle is affordable for everyone).

• Is health behaviour an informed choice? Not always. Society makes it hard not to buy unhealthy food etc. Plus, you don’t know about everything that’s bad for you.

However,

• social economic status influences health behaviour as well!

• telling someone not to do something might make them more determined to do it! For example: smoking.

• stigmatising could also be a problem: for example, seeing someone fat eating French fries and saying “no wonder she’s fat” though it might be due to an illness.

Motivation

Motivation determines behaviour. There are many factors involved with motivation. They can all be found on slide 39, but the head categories are (in order of closeness to the individual): individual factors, interpersonal factors, community factors, factors of the health system and structural factors.

The Health Belief model is a social cognition model by Rosenstock et al. It focuses on perceived vulnerability (cognitions focused on the risk to become ill or to get a condition) and perceived severity (cognitions focussed on how severe this risk would be). A schematic overview of this model can be found on slide 43. Fear and response efficacy together determine the chance that the behaviour is shown.

The theory of reasoned action by Fishbein and Alzen has some key terms: attitude (percieved chance “if I do this, this will come out” and how this outcome is thought of by this person), subjective norm (how the person thinks this behaviour will be evaluated by others (referents) and how motivated they are of these norms).

Social norms

• Descriptive norms describe how things are always done.

• Injunctive norms name how things are supposed to be done.

• Group norms describe how things are within a certain group. If you are member of more than one group, these norms might be in conflict.

• Social support can also have an influence, in both a positive and a negative way.

Capability

How capable you are of something and how capable you perceive yourself can influence your health behaviour. The social learning theory by Bandura focusses on this exactly. Behaviour is determined by the person and their efficacy beliefs: am I capable of doing this? Schematic overviews of this model can be found on slide 49 and 50. As you can see, there are several factors that directly influence the self-efficacy and indirectly their behaviour.

The protection motivation theory by Rogers focusses on fear in persuasion: fear influences our decisions. The protection motivation theory states the components of a fear appeal (magnitude of noxiousness, probability occurrence and efficacy of recommended response) leads to the cognitive meditating processing (appraised severity), expectancy of exposure and belief in efficacy of coping response which together lead to protection motivation, which leads to the attitude change of intent to adopt recommended response.

Effective interventions

Interventions are effective if they make people believe that they can get some diseases and this would be bad, following the intervention will decrease the chance to get the disease or make it less severe, doing this will cost less than it gains and they can do this (self-efficacy).

The theory of planned behaviour adds percieved behavioural control (to what extent you can control your behaviour) to the model, as seen on slide 53. Intentions are influenced by perceived behavioural control and also influence behaviour themselves.

Conclusion

These social cognition models focus on attitude, social norms and self-efficacy.

Lecture 2: Health behaviour changed

Last week we learned about why we should try to change health behaviour and the conditions of such changes.

What determines behaviour? When are you motivated to perform a certain behaviour?

1. In the early days, one thought motivation could be generated by saying “It could happen to you!” The Health Belief model and the Protection Motivation theory are part of this. Fear is a big factor within disease and within these models. I could get this, this could happen to me… (perceived vulnerability). How can one induce fear? For example, “smoking kills” signs on cigarette packages, pictures of lung cancer, clips. Could one also induce fear by focussing on anticipated regret? For example, you’ll regret not using this condom later! The Parallel Process model states that fear has two consequences: either controlling the fear or controlling these dangers. When there’s a high threat and a belief that you can do something about it (=efficacy), danger control is very likely. However, when the efficacy is low but the threat is high, there’s a denial reaction: fear control. When both the threat and efficacy are low, there is no response, for the person could not even note the danger of think of it as irrelevant. When the threat is low but the efficacy is high, there is some danger control, but not much, since the threat isn’t really that big.

2. Fear only works in combination with response-efficacy (I can reduce this threat) and self-efficacy (I can control my behaviour). This is why later theories focussed more on “You can do it!”. The key features in the Social Cognitive theory by Bandura are efficacy beliefs (can I perform this certain behaviour?) and outcome expectancies (what will happen if I perform this certain behaviour?). Self-efficacy judgements are based on performance accomplishments, vicarious experience, social persuasion, psychological states and emotional states. These self-efficacy judgements determine behaviour. The Theory of Reasoned Action and the Theory of Planned behaviour have attitude (perceived chance “if I do this, this will come out” and how this outcome is thought of by this person) and subjective norm (how the person thinks this behaviour will be evaluated by others (referents) and how motivated they are of these norms) as key features, as well as perceived behavioural control, intention and behaviour, as you can see on slide 20.

The protection motivation theory has a model of cognitive mediating processes, where one can have a maladaptive response as well as an adaptive response, which can both lead to protection motivation. The maladaptive response starts with extrinsic and extrinsic rewards and a high perceived vulnerability (this could happen to me…) and high perceived severity (…and that would be terrible!), which adds up to threat appraisal. One could also have a coping appraisal: a high response efficacy and a high self-efficacy with low response costs lead to this.

How to increase self-efficacy

Bandura’s social learning theory names a few factors that can lead to self-efficacy: goals, step-by-step-mastery, instruction, specific, realistic, practice and feedback. Include at least one of these in your campaign for changing health behaviour! The threat is helpful and makes people aware, but you also need efficacy to promote changing health behaviour.

How can you increase self-efficacy? You could share success stories ('She quit smoking! Here’s how: ....').

However, motivation is not always the same at every moment, but self-efficacy is only effective when motivation is high. Motivation is not always just high or low though, sometimes it can be ambivalent: “on one side, I should go exercise, on the other side, I want to stay home”.

3. Motivation also depends on how bad you want it: did it become part of your identity? “That behaviour is not who I am”. This is why newer theories thought “If only you want to” would induce motivation. Self-regulation, directing your behaviour to reach your goals, is a key term here. You have to be able to set a goal, monitor your own behaviour, evaluate the outcome of that behaviour, and change your behaviour when the current behaviour does not have the wished outcomes. Behaviour has a goal. This goal is determined and chosen by the self of a person. Goals determines actions and give meaning to behaviour. Contextualisation is the key here: identifying the goals of certain behaviours can help you understand the behaviour. How can you determine underlying motivations though? You could ask: “What do you want to change? Why is that of importance to you? Why is that of importance to you? And why is that of importance to you?”

4. Bagozzi and Edwards did just that and they tried to compare the third layers of underlying motives of losing weight. “Feeling good”, “looking good”, “social comparison” and “self-esteem” were central for females. “Looking good”, “self-esteem”, “being socially accepted” were central for males. See slide 28 for the whole overview. When you want to motivate a group that wants the same, but the people have different motives for this, this is important to take this into account!

5. Carver and Scheier came up with the Control theory, which Gardner took and adjusted. You can see this model on slide 29. Key features here are feedback, action planning and setting goals.

6. Markus’ theory of possible selves compares the Future Possible Selves (Desired Self, Feared Self and Ought Self) with the Current Self. The person needs to be motivated to get the Current Self to the Desired Self as quickly as possible. Differences between these two selves, or changing too slowly can excite emotions.

7. The Health Behaviour Goal Model by Gebhardt et al. can be found on slide 32. It focusses on personal goals.

8. The self-determination theory by Deci and Ryan focusses on the basic needs of autonomy, competence and relatedness. The more the goal of a certain behaviour fulfils these basic needs, the more intrinsic this certain behaviour is. The scale of integrity to extrinsity of motivation can be found on slide 35.

How can one increase intrinsic motivation to perform a certain behaviour? Try to connect to the identity of the target group and try to make it meaningful to them. It has to fit into their identity, goals, values and motives!

Relapses

A few reasons and causes not to perform the wished behaviour are listed on slide 38 and could go from simply forgetting you had to do it to having second thoughts. Temptations to fail can be high, like a donut can tempt you to fail your diet. The violation effect (by Marlatt and Gordon) happens when a person drops their goal or wished behaviour/actions. It can be simply because you don’t like it, you can doubt the goal is really satisfactory, self-efficacy can be too low andthe what-the-hell-effect (“I can’t do anything anyway, why do this”) can demotivate you, competing goals and compensatory beliefs can make you violate your intentions. Make the wished behaviour automatic and keep your intentions in mind! Only then can your goal be accomplished and is it effective to set this goal.

The latest theories came up with “Stick to your plans”. Describe exactly what the wished action is, when to take it, what obstacles might get in your way and how to overcome them. How can you bring the intentions into practice? Describe it very specifically: when and where (the situation) and what (the target behaviour). However, plans that you made yourself are usually not of great quality and you have to be very committed to the plan to make it effective! You have to remember your goal, so remind yourself, make the healthy option easier for yourself (always have the almonds ready in your room so you won’t grab the snack near-by), exclude any unhealthy options (usually this is your habit, so make sure the snack is not nearby) and repeatedly connect the wished actions to the underlying goals.

Conclusion

Changing your behaviour takes will-power, the wished action needs to suit your identity and ideals, it needs to facilitate other goals (and basic needs) and it needs to be easy to remember, so remind yourself. And make it fun! Change is a process, it’s not static. When you fall back, a relapse occurs. Learn from your mistakes! Most theories try to explain behaviour by identifying the underlying motivations. 

Lecture 3: Promotion of health at work

History of worksite health promotion (WHP)

The first initiatives that promoted health were actually for reasons other than health of the employees! For example, smoking was banned because it was not safe, hygienic or good for the products: they payed attention to the quality of the products.

After that, it shifted to top management.

After that, it shifted to medical risk factors, such as risk for cardiovascular diseases etc. At this point, the health promotion focused on work rather than products.

After that, it shifted to health behaviour. A fifth generation will be added later on in the lecture.

Advantages work setting for HP

It is actually profitable to promote health at the worksite? Doing this has several advantages! A healthy employee is a more productive employee (high risk employees are even 12% less productive than low risk employees), is less absent and costs less money for health care and absence.

Not implementing certain WHP’s can even cost you money. There are certain costs associated with unhealthy lifestyles, for example:

• Overweight people are more often absent and therefore less productive. They also have a higher risk of work disabilities.

• People who exercise are less often absent and recover sooner.

• Smoking costs money as well: smokers cost their employers money through more absenteeism, work disability, etc.).

Even though non implementing these WHP’s can cost you loads of money, it also costs money to implement these WHP’s. Do the costs of interventions weigh up to the costs of the unhealthy lifestyle of employees? This depends on the intervention, of course. On slide 10 you can see in which interventions employers invest the most. You can see there are many interventions on wearing your seatbelt, because recovery of accidents without wearing a seatbelt costs a lot and it is a relatively easy intervention (putting on your seatbelt is not much effort): the efforts put into the intervention are lower than the costs of not wearing seatbelts, so yes, this one if definitely profitable.

Terborg listed several reasons to introduce WHP’s: the managers can commit to healthy lifestyles on a personal level, you can respond to what the employees want, you can steer in the directions of a desired corporate image (“here at Google we want the best for our employees!”), you can keep your employees satisfied so they keep working at your company and even attract new employees and improve employee morale.

Prevalence WHP programs

The use of WHP programs has grown a lot in the 1980s. In 1992 81% of all workplaces had implemented WHP’s and in 2000 even 90% of all big workplaces! The popularity of food, weight, fitness, blood pressure and stress has grown. Physical fitness and smoking control are the most prevalent WHP’s.

In the Netherlands, 75% of the large companies have WHP’s. The most popular WHP’s are on smoking, work posture and exercise.

WHP programs that focus on health behaviours and risks

As handled in lecture 1, primary prevention focusses on healthy people who are not (yet) sick at all and how to keep it that way. Secondary prevention comes after the first few symptoms of a disease have shown, but they are treated in an early stage. Tertiary prevention comes after later, irreversible symptoms have shown and has to do with revalidating.

Johnson & Johnson developed the Live for Life program. The goal was to promote healthy lifestyles by showing direction and making recourses available, to eventually keep the costs to a minimum. This program consisted of a health screening and consultation, a seminar, courses and material, feedback and rewards and follow-ups. The guidelines were also implemented in the environment. There were several interventions within this program, as shown on slide 21. The employees were free to choose any intervention and 60% chose at least one. The program had a positive effect on weight, fitness, blood pressure, smoking and absenteeism after one year, and after two years it still had a positive effect on fitness and smoking.

The Staywell program also has several interventions as shown on slide 23. First, they make the employees aware of the behavior and the need to change; then they assess, and then they implement the change and keep it that way. So it’s a three-stage-program. It uses social-cultural processes: action teams are formed, where volunteers and informal leaders create a healthy environment and form support groups. Different kinds of techniques are used in this program, such as sessions with an instructor, self-study, campaigns and booklets.

There are more programs such as Seattle 5 a day, Take Heart and Working Well Trial. The latter focuses on preventing cancer via diet and decreasing smoking. It was not effective against smoking but effective for nutrition!

Again: advantages work setting for HP

Why implement HP’s at a worksite? Because you reach many adults, have the right and a stable target population, the right social context, an organizational structure is available and you could intervene at different levels.

HP’s lead to less health risks! It makes people less risky for tobacco use, eating fat, high blood pressure, high cholesterol levels, drinking at high risk and health care use, while increasing wearing a seatbelt, physical activity and improvement of overall health and wellbeing. There are still some things that need more research and evidence though.

Effectiveness of WHP

How effective are these kinds of programs, in which people are screened and given feedback?

Health-wellness programs

We spoke of a shift in the focus of WHP programs earlier in this lecture, and now a 5^th generation is added: the focus is now on health and wellness, where quality of work is also included in the programs but next to the employee wellness. Your work also determines your wellbeing: for example, with stress! See slide 36 for an overview of environmental theories on stress. An acute stress response to a stressor turns into a chronic one when it lasts to long, which damages your body and reduces your resistance, so you are at a high risk for diseases and illness.

The transactional model by Lazarus (see slide 37) starts with a potential stressor that is being appraised twice (what is this stressor, and can I cope with it?) and coped with. Eventually, this leads to stress in the form of emotional, behavioural, psychological and cognitive responses.

Stress Management Interventions focus on individuals and were mostly used in the 4^th generation of WHP programs. Job stressors also influence physical and mental health via the self-esteem.

The job demand-control model by Karasek and Theorell, as shown on slide 40, state that learning and risk of illness are dependent on job demands and control, whereas Tetrick and Winslow think it’s more about the job demands and resources that are available.

The 5^th generation WHP’s have individual factors (risks, health behaviour, how one copes with things), job factors (demands, support, etc.) and employee health and wellbeing as key factors, which all interact.

Interventions can focus on individuals, like interventions on physical exercise and health education. You can also implement interventions on an organisational and environmental level, like interventions on lifestyle changes (providing facilities and resources, policies, etc.). The latter interventions can use the Participate Action Research approach: employees participate in discussing problems, collecting data, interpreting data and defining, implementing and evaluating interventions. The aim is to improve job control in the employees. And it did, the mental health, absenteeism and performance improved!

Combining interventions on an individual level and a organisational level works best!

Healthier work at Brabantia has some key features that are shown on slide 50.

The Dutch law also has some laws about wellness conditions on a worksite, the “Arbowet”. Since 2007, this law also focusses on the psychosocial strain at work. Interventions can also be based on these work conditions, like training, task groups, reward policies, etc. When this was implemented at Brabantia, health risk was reduced after 1 year, as was absenteeism, work conditions were improved and eventually this had financial advantages as well!

Conclusion

The worksite is a good setting to implement HP programs. Hopefully, WHP programs do more than just improve the employees’ lifestyles: it also enhances wellness of the workers because it improves work conditions!

Lecture 4: Illness & perception of symptom

Symptom perception and illness

1. Symptom perception, interpretation and response

20-50% of all complaints seen by a general practitioner are unexplained. This is surprisingly much. Unexplained means that you cannot find a physical cause or explanation for the symptom(s). In the symptom perception model, as shown on slide 19, you can see that attention is needed to be able to recognize the presence of the pain. Pain is attributed to something (for example, “it might be my migraine”) which can result in a physical symptom. The symptom perception activates certain networks after a while, so when you experience this same pain again, associations will be activated so you will attribute the pain faster to the cause of the previous pain (like migraine). This makes certain networks related to each other. The key terms in this model are attention, interpretation and attribution.

Van Laarhoven et al. researched this model and the role of attentional focus. When you focus on the physical symptoms, like pain or itch, it gets more intense. So distraction can help reduce the symptoms on short term, but it doesn’t help in the long run. Also, negative mood leads to more pain and itch. This was researchedin patients with and without fibromyalgia. Negative moods, both fear and anger, can lower the pain threshold. When one key term is attribution, you must also take misattribution into account. In Pennebakers study was found that people who received information about a disease, reported more symptoms of that disease. Information about symptoms can influence your symptoms!

The placebo-effect was also examined in the research of Benedetti. The placebo-effect is based on expectations about something. In one research, expectations, either bad (this is gonna hurt) or good (I won’t feel a thing) were induced. The effect of placebo’s is dependent on your expectation. The size of the pill, the box of the pill, what you say about the effect, the colour of the pill, the amount of pills you have to take, the kind of placebo (does not have to be a pill), price, brand, how it looks, the frequency of taking it, and even where you live can all influence the effect of the placebo. Placebos can even be addictive! There is only a placebo effect of the treatment when the placebo was applied while the patient was watching.

The nocebo effect, the expectation that nothing will help and/or the disease will get worse, is the opposite of the placebo effect and has about the same amount of influence as a placebo.

How does the placebo effect work neurobiologically? The expectation that something will reduce your symptoms affects the brain network that is involved with pain and pain reduction. Endogenous opioids are released: they kill pain. In particular, Parkinson patients release dopamine in the dorsal motor striatum after receiving a placebo-treatment.

There are two systems related to the placebo (and nocebo) effect: the HPA-axis system and the immune activity system.

Placebo also has to do with some learning principles: a placebo has a short-term effect (through conscious processes) when it comes with verbal suggestions (such as saying “95% of all subjects experience itch when receiving this treatment”). However, conditioning makes you really expect an effect (through implicit processes), so the effect lasts on the long term as well. The placebo (or nocebo) effect is strongest when both conditioning and verbal suggestions have been used.

Can you first induce negative expectations and induce positive expectations afterwards? It looks like yes, you can indeed reverse the nocebo effect you first induced.

Implications of symptom perception in clinical practice

Symptom perception is very important for, for example, diabetes, because you need a very strict overview of your blood levels. The amount of trust the patient has in the treatment and care, the communication between the doctor(s) and the patient(s) and the information the patients receives about the side effects are of importance. A doctor must take into account the placebo effect, which might explain why a patient can have side effect before even taking the pills, for example.

2. Medical consultation

A medical consultation can be short and impersonal. Several factors that contribute to satisfaction about the consultation and even the effectiveness of the consultation are listed on slide 57. A medical consultation usually has 5 phases:

1. A relationship between the doctor and the patient is established.

2. “Why are you here?”

3. Examining verbally and sometimes physically.

4. Consideration of the state (ill or healthy?) of the patient

5. Consideration of treatment or further investigation(s).

In order to have a good consult, the doctor must communicate knowledge to the patient, have a good relationship with the patient, understand where the patients problem comes from, understand how the patient understands his or her problem, making a decision together with the patient and understanding how he or she does that. Although time is short, the doctor must also make sure he or she is not rushed.

In the patient-centered approach, the doctor takes in to account the patients agenda, listens carefully to the patient, encourages the patient professionally and personally and stimulates the patient to participate in the conversation and decision-making. Funny fact is that people would like to share their decision making equally with their doctors. Keep in mind that there is always a patient-doctor interaction! Always be aware of the setting and context. Also, create an open atmosphere in this conversation.

3. Clinical examples

You can see the example case of Yasmin on slide 69 and a hypochondriasis patient on slide 73 and a pain management case on slide 76. There are many e-health programs nowadays that be of help to lots of sorts of patients.

Lecture 5: Stress-related symptoms

Symptoms of stress

Stress has an association with performance (Yekes-Dodson law: performance is dependent on the level of arousal) and is an important factor in health and illness. The more stress you have, the higher the chance of getting disease and the more severe it often is. What is stress? It’s hard to describe, definitions are subjective. The book defines stress in three different ways:

1. Stress as a physiological response

There are two stress systems: the sympathetic nerve system, which works through catecholamines and the HPA-axis, which works through the release of glucocorticoids.

Stress: functional?

Stress can be functional: it is a physiological response to threats or threatening situations. A zebra needs to feel a stress response in order to run away from the lion. But that doesn’t last very long (acute reaction). Nowadays in humans, a stress response can last for weeks to even months (chronic stress). On the long run a stress response is very unhealthy to have, neglecting many parts that the body needs, but shuts off during a stress response. So acute stress can be functional, but chronic stress can even be damaging.

Allostactic load: Allostatis is your body adapting to changes. Your body can handle quite big changes actually! The allostatic load is what happens when there’s a lot of stress over a long period of time: the damages build up. Eventually you cannot go back to your old state and systems (mostly your cardiovascular system) can even shut down.

Homeostasis is something like stability or balance, and your body will always strive to reach this. Allostatis is used for this.

Seyles’early model of stress states the body is driven to reach and maintain homeostasis. In the first stage, alarm, there’s an increased arousal. Resistance comes after this, the body adapts to the stressor and defences itself, using all of its recources, and the third stage is exhaustion, where the resources are used almost entirely. However, critics say the response can depend on the stressor.

Psychoneuroimmunology states stress (psychological) and the immune system (physical) can influence each other in a bi-directional relationship.

Stress has an important link to the immune system. An acute stressor enhances the immune system response. But when the stress is chronic, the immune system actually decreases. On the long run, this response will wear out your body. Can we then boost the immune system? Following some research, the answer is yes. They gave individuals a brief training with many techniques for stress management. After this, they were stimulated to use these in a stress task. It can actually boost the immune system! But we still have a long way to go.

Stress and the brain

Stress affects the hippocampus, amygdala and frontal cortex. There can really be a loss of volume! These areas can reduce cortisol: so when these areas are affected more cortisol is released, which again affects the brain, which increases cortisol, etc. The amygdala however has more activity: a lot more danger is perceived: more stress. Cognitive performance is affected by stress as well: mostly memory and attention, which explains not remembering something during an exam and not being able to concentrate.

Cortisol is a main regulator here. It gives negative feedback to the HPA-axis, damages certain brain areas and decreases the adaptation skills to stress. However, it also makes you feel like you have more energy!

2. Stress as a stimulus

In this definition, stress is related to certain events, like traumatic events, big life events or even the small problems that come in life everyday (‘daily hassles’). Cumulative life stress even indirectly influences the chance of getting a depression and PTSD after being hospitalized, but it is mediated by some certain steps. Trait anxiety and life events are big factors here, but gender, age and HPA-axis-variations play a role too.

3. Stress as a subjective experience (the transactional model of stress)

The transactional model of stress by Lazarus focusses on an interaction between stressors and personal characteristics. The key idea here is cognitive appraisal: interpretations of situations and considering if it’s stressful. Primary appraisal focusses on harm-loss, threat and challenge. Secondary appraisal has more personal factors: do I have the resources and can I do it? This was extended from just cognitions to emotions as well, as you can see on slide 30.

Many of the concepts are still researched nowadays! So remember that this distribution of demands and resources is important. But how can demands and resources interact? Are they separate entities? Are they both needed? Do you need more resourses than demands or does it not work that way? We still don’t know that yet.

Losing resources can induce stress – states the Conservation of resource model by Hobfoll. Losing something you have is stressing. The meaning of this loss is not personal (unlike in Lazarus’ theory), it does not differ per individual. In Lazarus’ theory, not just the situation of the loss counted, but also the personal appraisal.

Stress and illness

Burn-out and PTSD are (direct) stress-related disorders; more indirect stress-related disorders are chronic pain, depression and cardiovascular diseases. When a situation (like a job) doesn’t fit with the persons resources, there’s a mismatch. The job demand control theory states occupational stress is determined by demand, if you can control it, if you can predict it, and the ambiguity.

Measurement

You can measure stress during specific stress tasks and measure people’s responses, or on self-report questionnaires, or even saliva- and blood samples. Look for (mediators and) moderators too!

(Inter)personal influences on the stress response and the appraisal are the following:

1. Coping dimensions: most people think problem-focused coping (face the problem itself and reduce components of the problem) is more effective than emotion-focused coping (managing your own response to the problem), but this depends on the stressor – they could also co-occur! Approach-oriented coping (going to the stress source) versus avoidance (like distracting yourself). Coping styles are more like a trait: unchangeable. That’s unrelated to a stressor. However, coping strategies can be changed and can be dependent on the kind of stressor and the context. Coping goals mean having plans or ideas and goals of how you want to cope and what you want to reach – these are not researched very often yet.

2. Personality: of the five traits (that you can see on slide 43), neuroticism is most the most studied trait, because it is related to illness. All the other traits are positively related to health (e.g. being an extravert makes you more resistant to illness). Negative affectivity is a tendency to interpret everything very negatively and feel more distressed.

3. There are four personality types:

   • Type A = hostile, angry, impatient, easily aroused. Weakly predisposed to coronary heart disease (mostly explained by hostility).

   • Type B = the healthy type, other types are compared to this one.

   • Type C = passive, suppression of emotions. There’s a weak association with cancer.

   • Type D = distressed, negative affects and socially inhibited, few social support. Linked to cardiac events, more than type A.

4. Perseverative cognitions: repeating thoughts on emotional states and their consequences. When it’s about the future, we call it worry. When it’s about the past: rumination.

3. Cognitions: the perceived locus of control (the extent to which you think you have control over situations). Internal locus of control: thinking you are responsible for outcomes; this is linked to better outcomes. External locus of control: thinking external factors determine outcomes; this is related to illness. It’s related to self-efficacy, but the distinction between the two is that locus of control is about how changeable a situation is, and the self-efficacy is about of you can do that.

4. Emotions: stress can act directly (via physical symptoms) and indirectly (via appraisals, unhealthy behaviours, direct physiological ways and not feeling able to look for social support). Emotional disclosure, like keeping a diary, can moderate coping.

5. Social support: social support is a very important resource and can affect coping and appraisal:

6. Instrumental support: like needing money.

7. Emotional support: like care or listening.

8. Informational support: like advice .

People can perceive the amount of social support different than the amount they actually get. They can get tons of help but feel like they don’t get any at all. This is why the perceived amount of social support is a better predictor than the actual amount of social support. Social support can boost your ego and reduce blood pressure and cortisol levels influence cognitive appraisal and make your coping response more proactive. Social support from parents also counts: prenatal stress can cause health problems in the baby, like breathing problems and more. Stress and age combined can cause illnesses: your immune system functions decrease with age.

Gender: overall, females experience more stress than men, and in particular females experience more interpersonal stress and men task-related stress and stress for achievements.

Negative moderators are shown on slide 59. Keep this in mind to get better follow-ups! Positive moderators are shown on slide 60. Keep this in mind for good therapies!

Lecture 6: Coping with chronic disease & its psychosocial consequences

Chronic diseases and illnesses

Chronic disease lasts long, has more than one causes, not one definite cure and changes gradually over time. Chronic illness is a health disturbance over a longer period of time, that is related to a disease (probably chronic disease).

Psychosocial, physical and psychological consequences

You can feel pain, weakness, tired (fatiqgue), dizzy, less libido and less hungry, and the list goes on. You can have trouble concentrating, remembering, word-finding, multitasking, etc. Psychological challenges are found on slide 15.

Which condition has the most effect on quality of life?

The anwer can be found on slide 21. But can you really compare these groups? Yes and no. It has its limits: it just measures certain limitations. Don’t forget the importance of the timing: how long has it been since the diagnosis at the moment you’re testing? Someone who’s just heard the diagnosis scores differently from someone’s who been coping with the disease for six years.

An interesting question is: is permanent loss easier to adapt to than loss where you can recover from? Interestingly, a research found that people with a permanent stoma had better quality of life than people with a temporary stoma.

Models of adjustment

The idea behind stage models of adjustment is that loss of health is like losing a loved one:

• First there is a stage of uncertainty

• In this disruption there is clarity: this is the diagnosis (and this is the plan)

• Striving for recovery

• Restoring your well-being.

However, criticists say it’s not dynamic and some stages can co-occur at the same time. You can also cope with the disease in different ways for different areas: acceptance at work, but not in your personal life (for example, not being able to have children).

The model of Lazarus and Folkom says you appraise something on more than one level:

1. First – what does this mean to me.

2. Second – what can I do.

But it lacks the influence of the environment (social support for example).

This is where the model of Maes, Leventhal and De Ridder comes in: it’s more than appraisal, but also the characteristics of the disease, the influence of major life events, etc. This model also tells you what the eventual effect is and how effective the adjustment is.

They don’t explicitly talk about the positive effect of disease: some people (50-80%) state a disease made them stronger: we call it “benefit-finding” or “posttraumatic growth”. This is what adaptational models say: the main idea here is people search for a meaning: they ask “why?” or “what did I do wrong?”. Eventually this will serve to restore self-esteem. So it serves as a way to get better.

Some say this benefit-finding is a delusion. Research shows mixed findings but the research on this topic is quite young. But you could call this idea stigmatising: like you’re sending the message that you must feel stronger after battling cancer, cause if you dealt with it well, you should feel stronger. If you don’t, you haven’t fought hard enough.

Stanton et al. created a model on adjustment:

1. mastery of adaptive tasks – self-management (being good at disease-related tasks like taking meds, not neglecting the illness.)

2. absence of psychological disorders

3. presence of low negative affect and high positive affect

4. so you participate in the society.

5. whether you have a good quality of life.

Denial and non-expression

It can actually be quite adaptive to deny the diagnosis shortly after your diagnosis, but after a while this can be damaging. There is one exception: it depends very much on the cultural context: some Asian cultures don’t value emotional expression very much so it might be better to not express the emotions. So whether denying is good for you depends on the stage of illness and the cultural context.

Adaptation to chronic disease

Are you more vulnerable to illness by ignoring emotions or even symptoms? If you’re depressed, you are more likely to get chronic disease. And people who have chronic diseases are about 2.5 times more likely to get depression after their diagnosis. Being depressed after a heart attack makes you more likely to die.

Challenges related to: social context

Stigmas: chronically ill people say it’s hard to be ill because it’s so unpredictable and it is hard for people to understand that one day you can do anything and the next you’re bedridden (and also because you cannot always see the disease).

People are sympathetic at first but after a while the patient gets socially isolated due to people getting bored because of cancellations of social dates etc.

Also, it is very hard for people to accept they need intense help, and it is also hard for the caregivers to give up so much time of their life.

In the US 29%of adults is an informal caregiver: helping someone without financial compensation. Like the Dutch “Participation society” or “participatiemaatschappij”. Take into account that this puts a strain on the social relationships! This is hard to research because the amount of burden depends on the relationship, timeline, stability of the disease and the disease itself (e.g. Alzheimers, where the personality can change), etc.

Caregivers can experience distress because of the high demands, financial situations, anger, guilt, grief, being worried and therefore overcaring, which puts an extra big strain on both the patient and themselves.

Lecture 7: Pain

Pain occurs in a lot of different medical conditions, but can also occur without a physical problem. From practice we can conclude that pain is experienced a lot, because 50% of all physical symptoms are pain.

The definition of pain

Pain: ‘’an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’’ (ISAP, 1989). The definition is developed by the International Association of Pain. Pain is not only sensory, it additionally always has an emotional component (people suffer from the pain they experience). Tissue damage (or injury to the body) is not necessary for pain, it is possible to experience pain without a physical problem. Pain can be described as a subjective experience, because it contains sensory information and a subjective interpretation of physical sensations. The severity or intensity of pain is determined by an interaction process (social, psychological, behavioural factors and physical pathology).

Headaches and low back pain are the most common reasons for consulting a physician. In most of these cases no clear (physical) cause is found. There is no one-on-one association of physical problems and pain, so psychology does matter!

Some examples of pain are: headaches, muscle or joint pain, abdominal pain (like irritable bowel syndrome or Crone’s disease), post-surgical pain or cancer related pain (can be caused by a tumour or as a result of therapy).

The prevalence of experiencing pains varies. Gender plays a role in the life time prevalence of headaches: For women it is 83% and for men it is 62%. The definition of life time prevalence is the number of people who experience a certain type of pain at least one time in their life.

The classification of pain

There are two ways pain can be classified, namely:

• According to cause;

• According to duration.

Classification of pain according to cause

Nociceptive (or musculoskeletal) pain: this kind of pain is caused by tissue damage (like damage in the muscles or bones). An example of a cause that can lead to nociceptive pain is a bone fracture or a burn wound. Nociceptors are specialised pain receptors, activation of these receptors leads to nociceptive pain.

Neuropathic pain: this kind of pain is caused by any type of pain or disease in the nervous system. For example Multiple Sclerosis: the formation of plaques leads to the development of pain, this is a pathology of the nerves. Neuropathic pain is very difficult to treat. Most of the time it becomes chronic and gets worse. Patients give a very typical description of this kind of pain, for example the feeling of freezing, burning or a sensation of needle pricks.

Patients report sensory changes that are due to the pain, for example allodynia and hyperalgesia. If patients experience pain in a situation that normally doesn’t cause pain it is called allodynia. If patients experience disproportional pain in the case of experiencing a ‘normal’ or subtle pain, it is called hyperalgesia. For example: getting an injection can be unbearable. These patients have a lower threshold, so they experience a lot of pain.

Mixed pain: this kind of pain contains both nociceptive and neuropathic elements. For example in the situation of a herniated disc.

Idiopathic pain: this kind of pain is experienced when no clear organic cause can be found. There is no clear diagnosis that refers to a physical (organic) problem. So there is no structural abnormality that can cause the pain.

Patients who are suffering from Fibromyalgia experience pain all over their body. An assumption of this diagnosis is that the pain is experienced in 11 out of the 18 pressure points (which are divided in the four quadrants of the body). The pain needs to be experienced with a pressure of 4 kg. This diagnosis is only based on the symptoms that patients experience. Fibromyalgia has a high co-morbidity (70-80%) with Chronic Fatigue Syndrome.

Classification of pain according to duration

According to the duration of pain you can distinguish between acute and chronic pain.

• Acute pain: Pain that lasts for less than 3-6 months. Acute pain has different types:

  • Acute pain as a consequence of for example an injury. This type occurs only once. In this situation the pain will stop once the injury or the damage has healed.

• Acute pain that is recurrent, for example episodes of migraine headaches.

• Chronic pain: is the opposite of acute pain andcontinues for more than 3-6 months. There are two types of chronic pain:

  • Chronic pain with an identifiable cause (for example RA or in cancer patients.). This kind of pain is more progressive.

  • Chronic pain with no identifiable cause underlying it (for example fibromyalgia and chronic back pain).

Consequences of chronic pain

Economical consequences

Economical consequences can be divided into direct and indirect consequences. Some examples of direct consequences are related to visiting doctors, medication, taking a lot of exams, etc. Indirect consequences are disability (a patient is not be able to work fulltime) or sickness absence (not be able to go to work at all).

Psychological consequences

Examples of psychological consequences are anxiety, frustration (if a cure is not available), sleeping difficulties (constant having pain leads to sleeping difficulties and vice versa) and depression (there is a reciprocal relationship between being sick and being depressed, if people are depressed they are more attentive, they become more sensitive to the development of pain and of chronic pain. This is like a vicious circle.).

Social consequences

Some examples of social consequences of chronic pain are social isolation (or problems in the social network) and problems in the relationship with the partner or children of the patient.

Explanatory models

Explanatory models can be divided into biological, psychobiological and psychological models.

1. Biological models make a clear distinction between body and mind. A pain stimulus activates specialised pain receptors. These receptors send a signal through the spinal cord to the brain. This model assumes that the experience of pain is a direct effect of an injury or wound (a physical problem). But people experience pain if there is no physical cause, so this model is not complete.

2. Psychobiological models

3. Gate-Control theory (Melzack & Wall, 1965): this theory uses an analogy of a gate to explain the pain experience. The essence is that pain is a result of two different processes. The first process is the same as the process in the biological model; namely that the pain signal travels to the brain. The second process takes place in the brain; namely the cognitions and emotions that are related to the pain. The activation of system one and two result in substances, like endorphins. These substances can open (increase the pain experience) or close (decrease pain) a ‘gate’. The level of pain that you experience is a result of the interaction between process one and two. The Gate-Control theory explains why psychological factors can influence a pain experience. For example: paying attention to the pain and a negative mood increase the pain experience. This theory is important to psychologist, because it made the influence of psychological factors upon pain credible.

4. Onion model (Loeser, 1980): consists of four different layers:

5. Nocicetion: this is the centre of the union. This part contains the pain stimulusand the activation of pain receptors.

6. Pain perception: the pain receptors send the pain signal to the brain, so in this phase people are consciously aware of the pain.

7. Pain suffering: this phase includes the suffering from the pain experience. The perception of pain can lead to negative emotions (like feeling sad or anxious).

8. Pain behaviour: this phase contains the behaviour as a result of the experience of pain. For example showing or expressing the pain, complaining about it or trying to get rid of the pain (seeing a doctor, taking medicines or avoiding physical activity). Psychologists focus on layer 2, 3 and 4.

3. Psychological theories:

4. Psychodynamic theory: the importance of unconscious processes is central. The pain prone personality (Engel, 1959) contains an inability to cope with problems such as anger. It also contains the denial of other emotional or interpersonal problems. If a patient has a pain prone personality, he or she is more sensitive to experiencing persistent pain.

5. Learning theory: in 1898 Thorndike formulated the Law of Effect. This theory says that that anything that is followed by a positive consequence will happen again. According to Skinner’s Operant Conditioning people learn on the basis of consequence (punishment or reward) of the behaviour.

   • Learning theory and chronic pain: Fordyce was the first who applied the paradigm of operant conditioning to pain. He thought that pain responses are the result of a learning process and are maintained by reinforcement. His theory explains why the use of medication leads to pain relief (this is called negative reinforcement). The Learning Theory is restricted to just the behaviour component, it does not take cognitive and emotional factors into account.

6. The Cognitive-Behavioral model: this model takes the role of behaviour, cognitions and emotions into account. Some examples of cognitive factors that could play a role in the process of pain experience are: attention (distraction from the pain can be very helpful for some patients. Distraction is possible by watching a movie or playing a videogame), attribution (the process of making attributions about the pain someone is feeling. There is a big difference in pain perception between thinking your arm hurts because of a bruise instead of a bone fracture. If someone made an attribution as something very bad, this leads to much more pain.), expectations (expectations about for example tolerating, controlling the pain and about pain relief. The placebo effect plays an important role in pain relief). The C-B model takes also emotions into account. Anxiety, depression and frustration (if the pain does not go away that easily) can play an important role. Anxiety leads to rumination, worrying and for example pain-related fear). Emotions, cognitions and behaviour influence each other: it can be seen as an vicious circle.

Pain assessment

It is important to measure pain because it can result in a clear picture of the pain problem. Pain is a complex phenomenon. Multidimensional assessment is needed. Pain cannot be observed directly because it is a subjective experience, so the use of self-reports are necessary. Important dimensions to take into account while assessing pain patients:

1. Pain perception: perception of the pain contains different factors, like intensity, duration, quality and frequency of the pain. It can be measured with the visual analogue pain scale or another scale (1-5/ 1-7). It is also possible to keep a pain diary. It is important that this is especially used at the end of treatment.

2. Psychological dimension: contains an emotional and cognitive dimension. This dimension can be measured using the Symptom Checklist-90 R (SCL –90R), which contains nine subscales. The Pain Catastrophing Scale (PCS) can be used to measure the cognition component. It contains the subscales rumination, helplessness and magnification. The Pain Coping Strategies Questionnaire (CSQ) can be used to measure the coping component. This questionnaire has six subscales, namely: diverting attention, reinterpreting the pain sensation, catastrophizing, ignoring sensations, praying or hoping and coping self-statements.

3. Behavioural dimension: for example verbal, non-verbal expression of the pain or behaviours to reduce the pain. The McGill Pain Questionnaire is multidimensional, it contains four key questions:

4. Where is your pain?

5. What does it feel like?

This dimension can be measured using 20 word groups that each describe a specific pain, with increasing intensity.

• How does it change with time?

Try to get to know more about which situations or objects increase the pain and which relieve it. Ask about the pattern of the pain as well; is it constant?

• How strong is your pain?

Treatment of Acute Pain

Can be divided in medical treatment (pain killers) and psychological treatment.

1. Psychological treatment: some examples of psychological treatment are distraction (watching a movie or reading a book), relaxation and hypnosis. These three types of treatment are demonstrated to be effective after operational pain and in children who suffered from cancer (and experienced a lot of painful and invasive procedures, like punctures). In the case of distraction by making use of a virtual reality a patient enters an immersive virtual environment. This can serve as a good distractor from the pain. Spiderworld is shown to be effective in adolescent who suffered from a burn wound. They rated the pain as less high in comparison with patients who played the Nintendo. Snowworld is also shown to be effective in adults who suffered from a burn wound. The effect of Snowworld or Spiderworld on the experience of pain can be explained using the gate control theory. The conscious attention of the patient was necessary to experience pain, so by entering a virtual reality, the attention of the patient is distracted from the physical (body) pain and payed to the virtual world. But we have to keep in mind that the patients used in this study used a lot of pain killers. So the effect of a virtual reality can be seen as an extra effect, on top of the pain reducing effect of medication. Psychological treatment techniques: Relaxation, biofeedback, meditation, hypnosis, behavioural intervention (using techniques based on the principle of operant conditioning and learning theory), cognitive behavioural models.

2. Relaxation influences the pain directly (change in muscle tension and blood perfusion reduce pain) and indirectly (feeling more relaxed, being better able to cope with pain).

3. Biofeedback comes close to relaxation. Relaxation is focussing on one muscle (group). Biofeedback is giving objective information about tension of muscles. Show the patient that the tension has gone down.

4. Mindfulness Based Stress Reduction is a form of Mindfulness meditation, developed by Jon Kabat-Zinn.

Kabat-Zinn: it is about being aware of the surrounding and focussing attention on one thing. Observe sensations, but don’t try to get them away.

A study showed good results of this intervention. After one year there was still an effect, but not on pain (there was an effect on the way people cope with the pain).

• Hypnosis is based on the assumption of deep relaxation. It works because patients have the expectation that it will ease the pain (suggestion). Patients reinterpret the pain and are given a distraction (cognitively things do change).

• Medical treatments work because they interrupt the transmission of a pain signal through the spinal cord to the brain. All medical treatments are based on the biological model. Surgical intervention prevents transmission of pain signals, because it blocks the neural pathways that guide these signals. It works on the short term, but on the long term it does not. It doesn’t work that well on the long term because receptors find another way to reach the brain. A side effect of a surgical intervention is that it can damage the nervous system, what leads to neuropathic pain. An example of a neurophysiological intervention is the use of Trancutaneous Electrical Nerve Stimulation (TENS). In this case small electrodes send electrical pulses, they block the pain signals. Studies showed that it is effective, but it seems to be for a short term. In this case there is also the problems of the pain signal that finds another road. Examples of pain medication are: painkillers, narcotics, anxiolithics, corticosteroids, NSAIDS and antidepressants (stress, muscle tension and pain go down). In psychological treatment it is important to make a distinction between factors that caused the pain initially and factors that maintain the pain. If muscles have become weaker this could lead to a lack of physical activity.

Behavioural interventions

The goal is to increase healthy behaviour. This can be reached by reinforcing healthy behaviour and extinction of the bad and unhealthy behaviour. This intervention is shown to be effective in patients who suffer from chronic low back pain. In Cognitive Behavioural Therapy irrational catastrophic beliefs, pain related fears and avoidance behaviour are central.

Rational Emotive Therapy (Albert Ellis) is a CBT model. RET challenges irrational automatic thoughts using the ABC (actual situation, irrational belief and consequences) scheme. The irrational thoughts are changed in thoughts that are more functional and rational. CBT seems to be effective for chronic pain.

Group therapy for treating different chronic pain problems is as effective as individual therapy. Group therapy is cost-effective and group dynamics can have positive effects. The ideal group size is 5-7 patients.

Another example of therapy is a self-help program (using a book or the internet). An advantage of self-help programs is that they are cost-effective. But an intervention needs to include some sort of contact to be effective.

Summary

Pain is complex and subjective, it needs a multidimensional assessment. Often no clear organic cause is found for the pain people have. CBT is effective, it focuses on realistic goals, self-efficacy and thoughts.

Lecture 8: Chronic disease & psychological interventions

Structuring interventions in chronic illness

We can structure interventions with a model Maes developed, which exists of three dimensions:

• Aim (goal of intervention): doing something about quality of life (QoL) or self-management (both is also possible)

• Level (individual, group (with or without partners) or environment (community or physical environment)

• Channel (how is it offered to patients). There is a distinction between direct (face to face contact) and indirect (not offered by a psychologist, other health care professionals or by lay people (trained and supervised by psychologist), or self-help interventions).

This model is the basis of this lecture.

Intervention aims

1. Quality of life interventions (Qol): one can distinguish physical training programs, stress management programs (the majority of QoL-interventions), social support (always supervised by a psychologist) and palliative care (if recovery is not possible). Qol-interventions focus on restoring or improving the QoL. They focus not only on the physical environment, but also on psychological, emotional and social well-being. QoL focuses on:

• reducing stress

• reducing pain (because it is very prevalent)

• problems that are related to performance of everyday activities (limitations on social, emotional or physical component).

• Physical training programs: in most cases these programs are part of much larger programs. Physical training programs have beneficial effects on co-morbidity (don’t develop other problems on top of the first problem) and mortality in CHD patients and diabetes patients. If people keep doing this program, they feel emotionally better. However, this effect is not huge and also temporary. People have to continue participating in physical exercise to keep the effect.

• Stress management programs: these programs have a positive effect on QoL, progression and mortality in patients (for example cancer, CHD or HIV). The program affects disease management and coping, this way it influences mortality and morbidity. Stress management programs use intervention techniques like life skills training, time management, (mindfulness) meditation, relaxation and cognitive restructuring.

• Cognitive restructuring: the main idea is that the perception of a situation has an impact on how you feel and behave. If you want to do something about how you feel and behave, change your cognitions. ‘The Hook’ is an example of a program that focuses only cognitive restructuring. The goal was to help post-MI patients in gaining control over experiences stress and emotions in daily stressor situations. The program focuses on type A personalities, people who score very high on hostility. In the beginning of the program participants had to think about an incident where they became very angry, irritated or impatient. After describing this, the group discusses three questions about the incident (see lecture slides 9-10). It is important that participants come to the understanding that they have a choice when they are confronted with a stressful situation, namely: changing the situation or changing your perception about the situation. It is also important to make participants aware of the type of stressor that influences their emotions and moods and leads to irritation, anger and frustration. If the perception of the situation changes, the level of emotional arousal goes down, this leads to higher feelings of control about your own emotions.

• Relaxation: in its simplest form, breathing exercises. In most interventions: in a group setting (but exercising at home is very important). Deep breathing exercises help feeling more relaxed at a daily basis. There are different types of relaxation, like guided imagery, progressive relaxation and breathing techniques. Studies concluded that relaxation was effective for treating hypertension, it was as effective as medication to get the blood pressure down. An example of a relaxation program to reduce stress is the Ornish Program, especially for CHD patients. It is a very strict program and patients have to exercise one hour a day.Be careful with a program that is too strict, this can be demotivating.

• Mindfulness (meditation): this program focusses on mental and physical relaxation. The patient observes thoughts and emotions and accepts them as they are. Mindfulness has gained growing attention in practice and scientific literature.

• Time management: managing the patients time (taking into account the limitations they experience). Focus on what you have to do (your obligations) and personal goals (things you like to do).

• Life skills training: acquiring socials skills (so that you can communicate about you disease and are able to ask for help when it is necessary). Problem-solving is also a part of life skills training; this is important in case of practical problems.

2. Social Support Interventions: are very important. There are two different types: social support groups (not a self-help group, but under supervision of a psychologist) and assertiveness training.

• Obtaining social support is important because people with a good social network (quantity and quality) seem to cope better with their disease (influences how you feel, disease management, adherence with medical advice etc.). The family is an important factor in adherence with medical advice. Identifying your social support network (which people can I count on?) and really using the sources (communication skills) are very important. The need for a certain sort of help can be different from time to time. Some patients need practical support, others just need the emotional support. Family members also need social support, for example, when they are caregivers (like partners from an Alzheimer’s disease patient).

• Assertiveness training: can be helpful for patients suffering from symptoms of social anxiety (talking about the anxiety reduces being ashamed of it). Training in assertiveness can have a positive impact on the QoL and on disease management.

• Social support groups: these are groups in which patients can exchange information and support each other. This can be helpful in overcoming feelings of shame. Some research shows a beneficial effect on morbidity and mortality.
  Spiegel (1989) developed a social support group for patients suffering from breast cancer. His intervention was effective, directly after the intervention pain experiences were reduced and mood was improved. After 10 years the invervention had an effect on survival.
  Studies tried to replicate the results Spiegel found, but were not successful.
  Fawzy (1993): developed a social support group for melanoma patients. He added education, stress management and coping skills training to the program. He found an effect on well-being, immune function and survival (but the sample size was very small). After 6 years the survival rates in the intervention group were increased.

• Palliative care: this kind of interventions focus on the acceptance of the disease if the disease is not curable or recovery is not feasible. The care is focused on patients who are terminally ill. It contains self-help groups doing psychotherapy (focused on anxiety and depression).
  Lutgendorf et al. (1995) is an example of a QoL intervention. This program was designed to reduce feelings of anxiety and depression in HIV-seropositive homosexual men (after their first diagnosis). The program consisted of a 10 week cognitive-behavioural stress management group program. The program contained the following components: cognitive-behavioural therapy (the aim was to improve the way of coping by increasing the sense of control participants experienced), relaxation exercises (progressive relaxation) and assertiveness training (learning how to communicate about HIV, improving and keeping the social network intact). CBT focused on the perceptions that influence coping, replace the dysfunctional thoughts for more functional thoughts and influence maladaptive coping strategies. The results showed reduction in anxiety and depression and improvement in coping strategies, immune functioning and social support. This multi-component intervention not only improved QoL, it also influenced the physiological status and psychological well-being of the patients.

3. Self-management interventions: having a chronic disease sometimes means that you have to change your lifestyle and improve your adherence to medical advice. It is important to change unhealthy behaviours and adopting healthy behaviours. In case of for example diabetes, self-management behaviours can be very important (like monitoring blood sugar level). Some behavioural techniques to increase self-management are:

• Self-monitoring: observing your own behaviour, the consequences of the behaviour and the antecedents (all the different aspects).

• Goal setting: Using this technique, patients determine their own health goals (which they want to obtain).

• Shaping the process of change: using small (behavioural) steps can be helpful in reaching the final goal.

• Self-reinforcement: giving yourself a reward if you reach a goal.

• Stimulus control: controlling the stimulus, for example by adapting to the environment (removing all the ashtrays in your house if you want to quit smoking).

• Behavioural contracting: setting a contract between the health professional and the patient (which contains goals, rewards, punishments etc.).

• Modelling: also called observational learning.

Self-management interventions combine different intervention techniques. These interventions result in stronger effects on the outcomes than just educational interventions (education interventions are limited to giving information about the disease and consequences etc.).

Example of self-management program:

• Arthritis Self-Management Program (ASMP) (Lorig et al., 1993)

• A lot of interventions are based on ASMP, it serves as a blueprint for other interventions.

Rheumatoid Arthitis (RA) symptoms

Autoimmune disease: inflammation of the joints. Also pain, fatigue and stiffness of the joints.
There was an intervention that focused on mild – moderate RA patients. The goal of the intervention was to improve health behaviour and health status.
Duration: 6 weeks (6-10 is normal). It was supervised by lay people (some of them were RA patients themselves). Patients set a weekly goal and self-monitored this goal.

Components/ techniques in ASMP

• Psychoeducation (giving information during lectures)

• Goal setting and feedback (weekly goals)

• Modelling and role playing

• Cognitive techniques (controlling pain by means of distraction)

Results

One-year follow-up showed a positive effect on pain (not immediately after the intervention). Immediately after the interventions the results showed positive effects on self-efficacy, health behaviours, depressed feelings and general mood. So it can be concluded that a multi-component self-management intervention influences self-efficacy, health behaviours, health status and (psychological) well-being (especially on depression).

Intervention level

Individual, group or environment?
Most psychologist think that an intervention needs to be a direct, face-to-face and individual to be effective. But this implies that you have to do a lot for a very small number of patients, so it is not cost-effective. This led to the development of group interventions (sometimes patients and partners), who are more cost-effective.

The Dutch heart and Health program

The aim of the program was to improve QoL and health behaviour. The groups contain about 8 patients (with or without partners) during cardiac rehabilitation. The program lasts 8 weeks and consists of weekly session (2 hours per session). Each session pays attention to a specific topic, but is structured in the same way.

• Part I sessions: this is the informational part (giving information, answering questions the participants have etc.)

• Part II sessions: focuses on irrational thoughts that negatively influence rehabilitation goals. These thoughts are identified, challenged and replaced by more functional and rational thoughts.

The results of the program show a positive effect on QoL, smoking cessation, use of health care resources and eating habits (so it has an influence on both QoL and self-management).

Interventions focused on the environmental level

• Social engineering: the goal of social engineering interventions is to modify environments of the patient (for example at home, at work etc.) to facilitate normal functioning in the daily life of the patient. Psychological expertise can be very important and relevant, for example in the case of accepting changes in the environment. Accepting changes in the environment means accepting that a disease is progressive, so one might need help from a psychologist (help in accepting that the disease is progressive, you can’t do what you did in the past). Daniel (1999) developed a community level intervention for diabetes control. The results showed a positive effect on blood pressure (but not on the blood glucose level).

Intervention channel

It is possible to make a distinction between direct and indirect interventions. Indirect interventions consist of face-to-face contact between a psychologist and a patient. Direct interventions consist of fore example contact with another health care professional, a lay person, internet or a book (intervention is offered by someone else than a psychologist).
Giving a group intervention is more cost-effective than giving individual interventions. Not all patients need intensive interventions or direct interventions (who are giving by a psychologist). Health care professionals, who offer an indirect intervention, need to be supervised and trained in psychological principles.

Motivational interviewing and self-regulation in RA patients

This intervention contains: psycho-education and motivational interviewing (both offered by a physical therapist). It also contains self-regulation coaching (which is offered by a specialized nurse). The self-regulation coaching consists of two face-to-face sessions (which use a workbook), increasing self-efficacy, learning self-management techniques and helping the patient to integrate activity into the everyday life. Interventions for improving physical activity can be helpful, but most of the time the results weaken if time passes by (see slide 42).

Weight Watchers movement (founded by Stunkard) is an example of a training program offered by lay people. Mantovani (1996) also developed a program focused on increasing the QoL in elderly cancer patient, who also suffered from anxiety and depression while having chemotherapy treatment. Volunteers were able to give the patients practical help, information and emotion support. The intervention showed positive results on pain control, stress and functional limitations experienced in life. But the effectiveness of interventions given by volunteers is dependent on the supervision of the volunteers and how complete the training was.

An example of an intervention based on a manual is The Heart Manual (Lewin et al., 1999). This intervention was a six week during self-help program. It was based on goal setting & pacing, cognitive restructuring and relaxation. The participants had every other week telephone contact with a trained nurse (to evaluate the progress and motivating the patient). The results of the intervention show that one year after discharge participants experienced less anxiety and depression and also used health care resources less.

Source

These lecture notes are based on the subject 'Health and Medical Psychology' - 2015-2016.