Exam 2: Part 2 Flashcards
forms of communication (3)
1) Person-person ⇒ direct communication
2) Print media
- Brochures
- Posters
- billboards
3) Short video (PSA ⇒ public service announcement)
- Television
- Internet
message framing (2)
gain frame: something you gain either positive or negative (usually benefit)
loss frame: something you loose either positive or negative (usually threat)
fear appeal
assumes fear will bring about behavior change
- Can be effective to motivate
- Needs to be coupled with useful information to help guide behavioral change
what can too much fear do?
it can be counterproductive and lead to defensiveness
- this is likely for people very involved in the issue
what framing method is better for producing change?
loss frame is preferred and more effective for people such as experts who understand the topic well
what 3 things does behavior change depend on?
- Level of knowledge
- Certainty of outcome
- Risk taking ⇒ prevention or deal with it when it arises
when people have certainty vs uncertainty which framing is better?
when people are certain of the consequences of a behavior a gain frame works best
- If they are uncertain a loss frame works better
when are preventative behaviors vs detection behaviors used in framing?
preventive behaviors help avoid risk but detection behaviors involve risk because there is a risk of finding disease
- To push people for detection behavior the loss frame works better
what is risk averse vs risk tolerant?
- risk averse prefers a gain frame
- risk tolerant prefers a loss frame
what is message sending vs receiving
experts who create health messages may use frames that work for them but not well for their audience
health literacy
the degree to which individual can obtain, process, and understand the basic health information and services they need to make appropriate health decisions
what are skills needed in health literacy? (3)
- Print literacy ⇒ read and write
- Numeracy ⇒ understand information with numbers
- Oral literacy ⇒ speak and understand speech
→ may help or hurt understanding of health literacy
what % of Americans in 2003 have limited health literacy?
36%
- Rates higher for elderly, minorities, people who have not completed high school, people who spoke a language other than english before starting school, people living in poverty
what are health literacy meta analysis study outcomes? (4)
- Lower literacy associated with higher emergency room and hospital visits and lower influenza immunization
- Lower literacy among senior was associated with higher mortality and poor overall health status
- Lower health literacy was also associated with poorer ability to take medications appropriately or interpret labels and health messages
- Not enough data to look at numeracy ⇒ more work is needed
health literacy interventions (3)
- Comprehension can be improved if essential information is presented alone or first,and if reading level is lowered ⇒ videos and images also help
- Interventions that teach self management and treatment adherence reduce emergency room and hospital visits
- Interventions work best if they are pilot tested before implemented, emphasize skill building, and are delivered by a health professional
levels of prevention providing treatment (3)
- primary prevention
- secondary
- tertiary
primary prevention
when a treatment is provided to prevent an illness from occurring
No symptoms or signs of illness are present
secondary prevention
treatments designed for use early in an illness when the illness is reversible or curable
tertiary prevention
treatments designed to contain the illness and prevent progression while minimizing symptoms
- such as cancer or diabetes
levels of intervention in health changes
- Individual ⇒ clinical providers or health care providers
- Proximate environment ⇒ community level
- Distal environment ⇒ interventions at the federal or state level
commonalities of treatment definition
make it difficult for a particular treatment to be determined better than a comparison treatment
commonalities of treatment in therapy (3)
- therapist characteristics
- Therapeutic process: respond to success or setback, opening up about certain issues, etc.
- Client characteristics: expectations of success or failure for themself or therapy, motivation, personality, communication skills, etc.
cognitive behavioral methods
complementary techniques that target thoughts and behaviors
cognitive behavioral method subsections (6)
- self monitoring
- cognitive restructuring
- behavioral contracting
- stimulus control
- relaxation training
- modeling
self monitoring definition
monitoring oneself usually through journaling by paying attention to thought, emotions, behaviors, and their environmental context
cognitive restructuring definition
use information gathered during self monitoring to challenge the person’s thoughts
- What is the evidence for a belief
- What are alternative explanations
behavioral contracting definition
creating a contract in which desirable behavior is rewarded and undesirable behavior is punished
- Operant conditioning principles
- Behaviors can be reinforced/strengthened when reworded and diminished when punished
- Rewards should be supportive of behavior to be strengthened
stimulus control definition
the environment is explored for triggers of undesirable behaviors
- built on principles of classical conditioning
- Once they are identified by self monitoring they can be modified or avoided
relaxation training definition
can help with stress that may be playing a role in triggering an undesirable behavior or anxiety
modeling definition
involves identifying people who can serve as role models for the behavior a person is trying to change
- Familiar or unfamiliar but visible in practice of their target behavior
relationship building objectives in the therapeutic process (and 3 components)
begins in the first meeting and objectives are to understand reasons and degree of motivation to achieve cooperation and negotiate a treatment agreement (action oriented)
- Understanding
- Motivation
- Negotiate a contract
assessment in the therapeutic process (2 components)
the therapist will attempt to understand the clients current health behaviors
- Personal: personality, health beliefs, knowledge, attitudes toward illness, etc.
- Contextual: family of origin, social groups, community, and cultural norms
reorientation in the therapeutic process
use of various techniques to being about changes in thoughts and behaviors ⇒ targeting the client but may also involve family members
- Social connections can help increase compliance and minimize the risk of relapse
3 parts of the therapeutic process
- relationship building
- assessment
- reorientation
Elanor case study
had weight issues and met with a physician as well as a behavioral medical counselor who helped her to re-percieve her inner self and not overeat or conform to other expectations (including her husband and inlaws)
- she eventually reached her goals and her husband also began to collaborate with her and include himself in her meal plans
- also had a friend to keep her accountable
treatment issues (4)
- health education
- adherence
- relapse education and prevention
- anxiety and depression
health education
includes psychoeducation, brochures, videos, etc. to provide information and motivation for client to understand factors promoting or threatening their health
- Health literacy affects the success of education
psychoeducation
any materials or experience planned by both a provider and a client to affect behavior
adherence
sticking with the program (30-70% of clients drop out)
- Problem for everyone
- Failure to begin treatment, premature termination, minimal completion
relapse education and prevention
1) Relapse can happen any time but is most likely during maintenance
- Slips shouldnt be considered failures ⇒ rehearse relapse what happens and how to respond
2) Prevention includes self efficacy and coping and continued self monitoring
- Revising techniques learned when originally making the change and providing continuous support
digital methods for treatments
cognitive behavioral therapy is open access to many people and can reduce costs while keeping a personalized treatment plan
- Phone apps
- Internet
sham knee surgery results
veterans have pain with their knee and all decide to undergo surgery to reconstruct their knees
- 2 would be to perform a debridement
- 3 perform a lavage
- 5 would say to make some cuts in the skin and leave the knee joint alone
→ none would know the difference in what they got
- All 10 had decrease in pain and improved function
placebo vs nocibo in latin
I shall please vs I shall harm
placebo effect
beneficial health outcome resulting from a person’s anticipation that an intervention (pill, procedure, or injection) will help them
nocebo effect
detrimental health outcome resulting from a person’s anticipation that an intervention (pill, procedure, injection) will
what influences nocebo effect
- A clinicians style in interacting with patients also may bring about a negative response that is independent of any specific treatment
- we are often told about the possibility of negative side effects from procedures may influence a patient’s outcome
what influences placebo effect independent of treatment
A clinicians style in interacting with patients also may bring about a positive response that is independent of any specific treatment
- The placebo effect is the patient improvement due partly to the patient’s beliefs about the surgery
placebo-nocibo effects are due to what?
due to a substance
- pill, injection, acupuncture, surgery, etc.
placebo-nocibo response
includes both the placebo effect and all other influential treatment factors
- Expectations, conditioning, relationships, environment
- It is difficult to determine what else is included in the intervention
- effect is also likely due to the interactions with the doctor and the medical environment (response)
what is different about the placebo-nocibo response
effects are attributed to only the patients interaction
- this is distinguished from other reactions in the environment which contribute to changes in the outcome and are important
general placebo effect factors
- invasiveness => the more invasive a procedure is, the more the placebo effect works
- feature associations => associations with features of the intervention (such as blue pill = sleep over red pills)
- expense => with more expensive interventions there are larger effects and brand named products have a larger effect than generic names
- classical conditioning => prior experiences with interventions which can trigger the effect of the placebo (sometimes purposefully done before a placebo)
factors affecting the placebo response
- expectancy
- classical conditioning
- changes in thoughts and motions and behaviors
- personality
- patient provider relationship
- clinical environment
- social environment
expectancy definition
what the patient or participant expects to happen
Influenced by what they are told by the provider or experimenter
- If they are told they will get relief, then they do (placebo)
- If they are told they will get a headache this increases the likelihood they will get one (nocibo)
classical conditioning in placebos
factor in placebo and nocebo responses ⇒ we often have experiences with medical environments and these experiences can trigger +/- responses
changes in thoughts/emotions/behaviors with placebos
getting treatment of any kind can change our feelings and behaviors
personalities with placebos
placebo prone personalities have not been identified but people have individual differences
- Some people are more likely to respond than others
- Traits associated are optimism and self efficacy
- Traits likely interact with the particular symptom context
patient provider relationship and placebos
relationship between the patient and provider can affect responses to treatment
- Warm, empathetic practitioner is associated with better placebo responses
- Cold practitioners are related with lower placebo effect and more nocibo effect
clinical environment and placebos
medical setting can influence our responses through classical conditioning or cognitively by making us feel anxious/threatened or protected/cared for
social environment and placebos
social environment beyond the clinic influences us so if your family and friends believe in the treatment, then we are more likely to have a placebo effect
placebo by proxy
children and others are more likely to have a placebo effect when their parents or family believe it will too
levels of placebo-nocebo responses (5)
- Biology
- Psychology
- Social relationships
- Clinical environment
- Home environment
what influences you when you take something?
Pill features, previous experiences, personal traits (optimism), if a friend/family gives it to you, where you take it, etc.
double blind study design with placebos
placebo treatment is randomly assigned so some get the real treatment vs the fake ⇒ neither the person or the provider knows
- One of the best designs
- Easy for something like a pill but harder for surgery
2-arm studies vs 3-arm
2: treatment vs placebo ⇒ used the most
3: real treatment, placebo, and no treatment studies ⇒ allows us to study the effects of the actual treatment itself when we have a group who does not get anything
ethical concerns of 3-arm studies?
concern to assign people to no treatment
- some studies that aren’t interest in a treatment may use only a 2-arm design (placebo or nocibo)
how does waitlisting affect placebo studies?
Using waitlisted people as part of the no treatment group is supposed to help with the ethicality
- Waitlisting people show 33% of the improvement of treatment group and 40% of the placebo group
- Suggests there is a placebo response for being on a waitlist for the treatment
T/F 4 arm studies have been done?
false but could be done
- Treatment, placebo, no treatment or waitlist with clinical interactions, no treatment or waitlist without clinical interactions
who was Henry Beacher?
WW2 physician influenced expectancy and soldiers responses to pain medication
- led him to study placebos experimentally
- Important to compare a treatment to a placebo ⇒ ability of a practitioner to make a patient feel better regardless of the science
- Recently it is more important to figure out how much treatment (real or placebo), compared to no treatment at all is needed to feel better
what was assumed prior to Henry Beacher?
Prior to his work any change in outcome has been attributed to treatment
bias definition
non random change in the outcome due to factors other than those being studied
types of bias (4)
- perceptual
- response
- hawthorne effect
- publication bias
perceptual bias definition
when participants perceive their symptoms more readily because they are paying more close attention to their body
- Anticipating changes or recording their feelings
- Intentional shift not a real change in health status
response bias definition
patients report their symptoms differently even though they may not have changed
- may be due to social desirability
social desirability definition
behavior in ways that are thought to be desired by others
- Patients are motivated to please the provider or researchers by telling them what they think they want to hear
what types of bias can inflate treatment effect?
perceptual and response
hawthorne effect
changes behavior because of participating in a research study
- Includes perceptual and response bias and also participants may reduce poor health decisions and increase healthy behaviors due to monitoring that can affect treatment
publication bias
studies with positive results are more readily published than those with small or null effects ⇒ makes treatment effects look larger and more consistent than they actually are
what comparisons let us look at what factors are influencing the treatment not just due to the placebo response?
- no treatment group: influenced by hawthorne, interactions with provider and researchers, research environment, etc.
- placebo group: influenced by all these things and features of the no treatment group plus the placebo
- a known treatment: all factors influencing no treatment and placebo but also factors specific to the treatment such as the drug or the procedure
what would happen if we only compared treatment and placebo groups? (wouldn’t include a no treatment group)
we wouldn’t know the size of the placebo response but only that the treatment effect is bigger
additional issues with research studies (5)
- spontaneous remission
- regression to the mean
- concomitant treatments
- drop out rates
- inadequate blinding
spontaneous remission definition
when patients get better but it has nothing to do with treatment
regression to the mean definition
when patients who have really bad symptoms desperately want a treatment even if they may get a placebo, so they join a study ⇒ change from an extreme
- Its likely their symptoms just got better over time as they are enrolled in the study
- Patients symptoms don’t remain constant and sometimes they improve/worsen
concomitant treatment definition
no treatment groups are more likely to seek out other treatment during the study
- They may be getting a treatment during the time so this affects their results in the other study they participate in where they aren’t getting a treatment
drop out rates
dropout rates are higher for a no treatment group
- Maybe they are more sick or more responsive to hawthorne effect
inadequate blinding definition
the participant is able to figure out if they are getting the real treatment or placebo which can alter the study’s result
if a treatment provides more pain relief than the placebo but the placebo provides more pin relieve than no treatment what should you do?
use the treatment or if the treatment is associated with negative side effects then we could cut down on the dosages to help reduce this
placebo controlled drug reduction definition
cutting down on a drugs dosage by using a placebo for a portion of the treatment
if the placebo is no better than the non treatment group but the active treatment is very effective what should you do?
the treatment is the best course and non of it is due to placebo effect/response
if both the treatment and placebo result in similar pain relief what should you do?
may be better to use the placebo alone when the treatment is associated with negative side effects
if neither the drug or the placebo is effective with pain relief what should you do?
neither treatment should be used
active placebos
if the placebo produces the same sensations or side effects as the active drug it will enhance the placebo even more
characteristics of placebo-nocebo responses (9)
- Subjective (self reported) and objective (measurement by researchers)
- Dose responses ⇒ more placebo or nocibo given the greater the response
- active placebos enhance
- Found in healthy and ill ⇒ placebo and nocibo responses are found in both healthy and patient groups
- Global and localized symptoms ⇒ placebo and nocibo responses are found in both
- Open disclosure ⇒ placebo responses can still be found when participants are told they are getting a placebo (usually also told the placebo has some effectiveness for ailments)
- Placebos are not curative ⇒ found to be effective for symptoms like pain, weakness, or depression but have never cured a disease
- Can be short term or long term ⇒ usually studies look over hours or days but sometimes effects last longer for weeks or months (debated)
- May be specific to outcome and intervention types ⇒ placebo effects and responses are rarer and smaller than many people believe
what did meta analysis find with placebos?
only helpful for pain relief or device use
amygdala
cluster of cells important for fear and anxiety feelings
Periaqueductal gray
when stimulated this reduces pain
analgesia
pain relief, loss of sensations
hyperalgesia
pain increase
what is the analgesic pathway in the brain
Placebo (positive expectations) → brain prefrontal cortex → endorphins → midbrain (PAG) and amygdala = pain relief
what are the 2 dopamine pathways in the brain? (+/-)
- Placebo (positive expectations) → brain prefrontal cortex → dopamine → brain reward center (nucleus accumbens)
- Nocebo (negative expectations) → brain prefrontal cortex → decreased dopamine → no stimulation of the brain reward center (nucleus accumbens)
what is the hyperalgesic pathway in the brain?
Nocebo (negative expectations) → brain prefrontal cortex → cholecystokinin (CCK) → midbrain (PAG) = pain increased
what is an endorphin?
a morphine like chemical which triggers the PAG to quiet pain signals from the body and the amygdala
- Results in feelings of calm and lessening and release of pain
what is Naloxone?
an endorphin blocking agent helps us observe the cessation of the placebo effect
- Confirmed the analgesic pathway
what are the nucleus accumbent involved in?
the pleasure pathway for reward in the brain
- triggered by dopamine
what does CCK do?
heightens the pain signals in the PAG
what does Proglomide do?
is a CCK blocking agent which allowed us to observe the cessation of the nocebo effect caused by CCK
- why we know this is the hyperalgesic pathway
what is the overview for our biological mechanisms (2)
- Biological mechanisms of placebo and nocebo can be the same (but with opposite activity)
- One stimulates and one inhibits ⇒ dopamine reward pathway - Biological mechanisms of placebo and nocebo can be different
- Each expectation using its own pathway ⇒ endorphins and CCK
what happened in the dental placebo study?
researchers told the patients they would receive morphine, saline, and something that would increase their pain
- Placebo responders were given an endorphin blocker and these patients had a reduced placebo effect from an endorphin blocker which increased pain
what is Parkinson’s disease?
difficulty with movement and as the disease progresses someone may have a shaky head/limbs due to insufficient dopamine production
- due to the basal ganglia being affected
- dopamine is important for the motor network affecting the basal ganglia
what is Parkinson’s disease treated with?
apomorphine which acts on dopamine receptors
what procedure was used in the Parkinson’s disease study?
parkinson’s patients were given a placebo and changes in rigidity of risk and firing of neurons in basal ganglia were recorded
what are the results of the Parkinson’s placebo study?
Placebo did not produce any changes alone
- If a patient was given the drug apomorphine with the placebo before the test day then there was a placebo response ⇒ stronger the more times the conditioning happened before the test day
- After 4 pairings the placebo response was as high as the drug response
what did the Parkinson’s disease placebo study demonstrate?
demonstrates classical conditioning of the placebo response
- cannot replace the drug apomorphine but could work as placebo based drug reduction
what are the factors of placebo response in clinical settings? (5)
- patient provider relationship
- expectations
- previous experiences
- route of administration
- increased follow up
patient provider relationship in clinical settings
warm empathetic provider is more likely to contribute to a placebo response while a cold and distant provider is less likely for the patient to be relaxed and trusting with less of a placebo response
expectations of patients in clinical settings
when providers show enthusiasm this shapes their expectations toward a placebo response but if they are uncertain or emphasize side affects the patients will more likely have a nocebo response
results of previous experiences for patients in clinic settings
may produce classical conditioning but if they are positive this increases the placebo response while if it is negative this leads to a nocibo response
route of treatment administration in clinical settings
the more invasive the greater the response
- Ex: injection > capsule > pill (color matters due to association by culture of the person)
increased follow up results in clinical settings
associated with a larger placebo response ⇒ rather than a single visit the patient will come back multiple times and receives additional support
what are the 2 types of placebo?
pure placebos and impure placebos
pure placebo vs impure placebo
pure is considered to have no known medical effects (like a saline injection or sugar pill) whereas an impure placebo is an active treatment for something but not the condition it is being given in
