6b - Coping with Illness and Disease (28.02.2020) Flashcards
WHO definition of health
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
WHO model
Describes the consequences of disease & suggests causal links between them:
- impairment refers to a problem with a structure or organ of the body
- disability is a functional limitation with regard to a particular activity
- handicap refers to a disadvantage in filling a role in life relative to a peer group, as a result of impairment and disability
Links:
Disability strongly correlates with handicap.
BUT research shows a very low correlation (r=0.19)
between impairment and disability in 763 CHD patients.
Suggesting other factors in addition to impairment (structural problem), influencedisability (functional limitations)…
- individual differences as well as the social circumstances play a role.
Crisis Theory of Coping with Illness (Moos, 1977)
• Similar to homeostasis, we have a need for social and psychological
equilibrium.
• Serious illness presents ‘a crisis’ and our usual, habitual ways of coping are inadequate.
• A state of disorganisation, feelings of fear, guilt, sadness etc .
• A crisis by definition is self-limited because we cannot remain in an extreme
state of disequilibrium.
- Adaptive responses personal growth and adjustment to the illness. (e.g. either appreciation of life)
- Maladaptive responses poor adjustment (psychological problems, low functioning etc).
Crisis theory of coping with illness
Moos & Schaefer, 1984
- the theory was developed into a more complex model
coping process consists of
coping process is influenced by:
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Illness related factors
- Unexpected
- Cause & Outcome/Prognosis (e.g. self blame, guilt, depression)
- Disability
- Stigma (e.g. HIV or obesity)
- Disfigurement
- Prior experience (e.g. someone in the family suffered a disease)
Background/Personal Factors
- Age of onset (e.g. teenagers find it more difficult to adjust to diabetes than e.g .younger children because there is more responsibility on the parents)
- Gender (women are more likely to seek support)
- SES & occupation
- Pre-existing illness beliefs
- Pre-existing personality
What are the big 5 personality traits
- Openness – no clear link to health
- Conscientiousness - +2 years life expectancy
- Extraversion – lower rates of CHD, protective respiratory disease
- Agreeableness – Hostility associated w/ CHD
- Neuroticism – higher use of alcohol and smoking; higher symptom reporting
The Impact of Agreeableness
Big Five Personality Traits: Different adaptation for high and low agreeableness
‘I see myself as someone who has a forgiving nature’
May be explained by more agreeable individuals…
Having more social support & better quality of friendships
More likely to follow self-care instructions & have positive, active coping strategies
disagreeable: moderate decline in life satisfaction
Physical and Social Environment
- Hospitalisation (incl. feeling institutionalised)
- Accommodation and physical aids/adaptations
- Societal attitudes
- Social support & social role
The Social Network (Brummet et al, 2001)
- worse social network higher risk of cardiac death
- sociaal isolation is a robust predictor of cardiac mortality.
Meta-analysis: Social Relationships and Mortality Risk (Holt-Lunstad et al, 2010)
• 148 studies with 308,849 participants.
• Findings indicated a 50% increased likelihood of survival for
participants with stronger social relationships.
• Consistent across age, sex, health status and follow up period.
• Conclusions: The influence of social relationships on risk for mortality is comparable with well-established risk factors for mortality.
-> This is also a very important factor, has a strong effect, smoking is also a RF but both are important
Illness representations
- thoughts and beliefs about illness
- (Leventhal et al. 1980)
- Definition: “A patients own implicit, common sense beliefs about their illness”
1) Identity
2) Cause
3) Consequences
4) Time line
5) Curability/controllability
What are the specific components of illness representatuin
• Identity: the label of the illness and symptoms
• E.g. “I have a cold, with a sore throat and runny nose”
• Cause: what may have caused the problem, such as genetics, circumstances, trauma, etc.
• E.g. “My cold was caused by being stressed and run down”
• Consequences: expected effects from the illness and views about
the outcome
• E.g. “My cold will prevent me from going out tonight”
• Time-line: how long the problem will last and whether it is seen as
acute, chronic or episodic
• E.g. “My cold will be gone in a few days”
• Cure/control: expectations about recovery or control of the illness • E.g. “If I rest my cold will resolve quickly”
Illness Perceptions Questionnaire
-> useful clinical tool
- Identity – What symptoms are e.g. pain, tiredness
- Cause – “A germ or virus caused my illness” “Pollution of the environment caused my illness”; “Stress was a major factor in causing my illness”
- Timeline - “My illness is likely to be permanent rather than temporary”
“My illness will last for a long time” - Consequences - “My illness has major consequences on my life” “My illness is a serious condition”
- Cure-Control - “There is little that can be done to improve my illness”
“My treatment will be effective in curing my illness”
A Picture of Health: Conclusions
Patients who drew damage to their heart perceived that their heart had recovered less at 3 months, that their heart condition would last longer and had lower perceived control over their heart condition
Extent of damage drawn correlated to slower return to work
Peak troponin-t not related to 3-month outcomes or return to work
“Drawings (and the associated illness beliefs) of damage predict recovery better than medical variables”
Adaptive tasks
1) Tasks related to illness or treatment
• Coping with symptoms or disability
• Adjusting to hospital environment/medical procedures
• Developing and maintaining good relationships with healthcare professionals
2) Tasks related to general psychosocial functioning
• Controlling negative feelings and retaining a positive outlook
• Maintaining a satisfactory self image and sense of competence
• Preserving good relationships with family and friends
• Preparing for an uncertain future (e.g. conversations about will and end-of-life-care)
Coping Skills
- Coping: ‘Cognitive and behavioural efforts to master, reduce or tolerate external and internal demands and conflicts’ (Strauss, 1988).
- Problem Focussed coping: Efforts directed at changing the environment in some way or changing one’s own actions or attitudes.
- Emotion focussed coping: Efforts designed to manage the stress-related emotional responses in order to maintain one’s own morale and allow one to function.
2 types of coping with health problems
Problem-Focused
• Seeking relevant information about an illness
• Learning specific illness related procedures eg pacing
activities
• Changing behaviour eg diet
Emotion-focused
• Seeking reassurance and emotional support
• Learning relaxation strategies
• Meditation
- Many studies have found that use of emotion focussed coping strategies associated with poorer adjustment and greater levels of depression.
- However, circular reasoning (i.e. those who are more distressed may need to engage in more emotion- focussed coping).
- Optimal coping depends on the individual and the situation- flexibility is the most beneficial.
2 types of coping with health problems
Problem-Focused
• Seeking relevant information about an illness
• Learning specific illness related procedures eg pacing
activities
• Changing behaviour eg diet
Emotion-focused
• Seeking reassurance and emotional support
• Learning relaxation strategies
• Meditation
- Many studies have found that use of emotion focussed coping strategies associated with poorer adjustment and greater levels of depression.
- However, circular reasoning (i.e. those who are more distressed may need to engage in more emotion- focussed coping).
- Optimal coping depends on the individual and the situation- flexibility is the most beneficial.
What stress?
- Transactional definition of stress:
- Stress is a condition that results when the person / environment transactions lead the individual to perceive a discrepancy between the demands of the situation and the coping resources available.
Why are medical situations stressful?
patients feel threat
- will it hurt?
- will I die?
Why is patient distress a bad thing?
- Moral/ethical responsibility to minimize suffering if possible.
- Distress during treatment related to longer term psychological morbidity.
- Distress during treatment related to wide variety of treatment outcomes, eg, patients not complying.
Is it helpful to prepare patients?
- 97 patients undergoing abdominal surgery randomly allocated to receive:
- ‘preparation’ – detailed info about location, severity and duration of pain • ‘normal care’ – not informed about post-operative pain
• Prepared group reported less pain, used less analgesic medication and their post-operative stay in hospital was an average of 2.7 days shorter.
Procedural vs sensory information
- Procedural information – Information about the procedures to be undertaken
- Sensory information – Information about the sensations that may be experienced
participants given sensory information reported significantly less distress during the procedure.
Dual process hypothesis
- Proposes that procedural and sensory information are both helpful because they work in different ways.
- Procedural information works by allowing patients to match ongoing events with their expectations in a non- emotional manner.
- Sensory information works by “mapping” a non- threatening interpretation on to these expectations.
How much information is enough?
- depends on the patient’s preferances
- some people are more distressed with general info and others are distressed with specific info
Communication in informing patients
- Prepare patients with information – not all patients like/know to ask questions
- Try to gage patient preference for level of information and involvement
- Check patient’s understanding – anxiety can block information being heard.
- Try to avoid medical jargon
- Provide written information as an well as verbal
Increasing control in medical situations
• A device for patient to signal their
pain/discomfort during dental treatment can
reduce distress
• Patient can squeeze a buzzer during an MRI to halt the procedure
• Control over treatment options for fertility procedures related to greater well-being
patients having more control, better health outcomes.
Preparing children for treatment
- Preparatory information should be specific and include procedural & sensory information.
- Older children (> 7yrs) benefit most from information presented about a week before a procedure, younger children closer to the procedure.
- Modelling and coping skills interventions can be helpful
- eg. Film ‘Ethan has an operation’ depicting a child in hospital using positive coping strategies reduced anxiety in children undergoing operations (Melamed & Siegal, 1975)
How do children cope?
- Children use the same types of coping as adults, but preference for problem-solving increases with age, whilst avoidant coping declines.
- Distraction is the most effective coping strategy for younger children.
- For older children (>9yrs) matching coping strategy to child’s preferred coping strategy is more effective.
Match coping approach to the childs preferences.
Combined Show –Tell – Do Approach
1) Tell: Using simple language and a matter-of-fact style, the child is told what is going to happen before each procedure (comparisons the child understands are used and negative, emotive words avoided).
2) Show: The procedure is demonstrated using an inanimate object (eg a doll), a member of staff or the clinician.
3) Do: The procedure does not begin until the child understands what will be done.
The impact of parents’ behaviour
Children’s distress during a routine immunization was correlated with the amount of distress shown by parents but not to subjective anxiety (Frank et al, 1995)
Maternal interaction study
- different in boys and girls
• Mothers randomly allocated to training in one of three interaction styles:
• Pain promoting (reassurance & empathy etc) • Pain reducing (distraction, humour etc)
• No training
All children underwent a cold pressor task
Girls more sensitive to the mothers interaction styles
parents haave an impact on the children’s pain experience.
Summary - take home messages
• The Crisis theory of coping with illness provides useful framework for understanding the factors which influence adjustment to illness.
• Illness Representations can shape patients’ coping responses and recovery – the IPQ is a useful clinical tool.
• Preparing patients for treatment can reduce distress.
• It’s important to gage patient preference for information and
their preferred coping style.
• Increasing perceptions of control during treatment can reduce
patient distress.
• Important to adapt preparation with children.
