Psychology Flashcards
Theories of Pain
**Specificity Theory
Presence of dedicated pathways for each somatosensory modality
4 types of sensory receptor controlling 4 types of sensory modality
- heat, cold, touch, pain
Nerve responds to only one modality
Nerve continuous from periphery to brain
**Gate Control Theory
(Melzack and Wall)
Allows physical distraction by a different stimulation closing the gate
- Large fibre stimulation – normal somatosensory input – gate closed
- Small fibre stimulation – pain – gate open
Explains why if we rub our leg after hitting it the pain lessens
Acute vs Chronic pain
* Acute A warning system Represents tissue damage Message – do something about this! Short duration Care and relief likely Suffering recognised
*Chronic
May or may not be associated with tissue damage – pain itself is disease
Long duration
No end in sight
Care and relief not likely
‘Psychosomatic’
Suffering may be dismissed – its all in your head!
Psychological methods of pain control
*Hypnosis
- Chronic Pain Psychological Therapy
- > Cognitive Behavioural Therapy
- Thoughts, beliefs, distorted thinking, catastrophising responsible for the consequences of events
- Identify and challenge distorted cognition
- Cognitive restructuring
- Coping skills training
- Imagery and relaxation
- Stress management
2 Main Classification systems of psychiatric disorders
- ICD-10 - WHO international classification of diseases
- Diagnostic and Statistical Manual of Mental disorders (DSM-V) - American Psychiatric Association
Purpose: Standardises diagnoses, enhancing ability to research disorders and build an evidence base for practice
Psychosis
Severe mental disturbance, loss of contact with external reality
Neurosis
Mental distress, but can still distinguish between symptoms originating in their own mind and external reality
Mood Affective disorders
Depression
o Dysthymia
Pt experiences chronic depressive symptoms, but not severe enough to warrant a diagnosis
o Mild
o Moderate
o Severe
Severity usually based on number of symptoms and impact on person’s life
Bipolar Disorder Episodes of depression and elation o Cyclothymia Episodes of mood swings but not severe enough for diagnosis o Bipolar I o Bipolar II
How depression diagnosed
At least 2 core symptoms + 2 other symptoms identified
Core symptoms of depression
- Depressed mood most of the day nearly every day
- Markedly diminished interest and pleasure in all or nearly all activities most of the day nearly every day
- Decreased energy or increased fatiguability
Other symptoms associated with depression
Decrease/increase appetite
Reduced self esteem and self confidence
Insomnia/hypersomnia
Psychomotor agitation/retardation
Fatigue/loss of energy
Feelings of worthlessness or excessive guilt
Decreased concentration or indecisiveness
Recurrent thoughts of death or suicidal ideation
[Do Rats In Prison Feel Fatigued During Races]
Biological features of depression
- Altered sleep patterns; usually decreased
- Early morning wakening; mood typically worse am
- Appetite reduced with weight loss
- Libido reduced or absent
- Motor activity agitation or retardation, including speech
Cognitive features of depression
- “Beck’s cognitive triad” = negative, pessimistic thoughts about: self, the world, the future
- ‘all or nothing’ thinking, personalising, focussing on negatives, catastrophising, jumping to conclusions
- Reduced attention, concentration, decisiveness
- Guilt, worthlessness, death or suicide
- Delusions and hallucinations can occur
Aetiology of depression
Combination of genetic factors and stressful life events
Also linked to some drugs
- steroids, OCP (contraceptive), chronic pain, terminal illness
Types of depression
SAD:
Seasonal affective disorder – lack of natural light
Abnormal grief reaction:
Delayed grief/excessive grief years later
Adjustment disorders:
Abnormal responses to big life changes
Instruments designed to measure anxiety and depression
Screening –
The 2 Question Test
1. During the past month, have you often been bothered by feeling down, depressed or hopeless?
2. During the past month, have you often been bothered by little interest or pleasure in doing things?
Yes to both – 96-97% sensitivity, 57-67% specificity
→ problem with detection of false positives
Hospital Anxiety and Depression Scale (HADS)
• 14 item self-rating scale for severity of depression and anxiety symptoms.
• 90% sensitivity, 86% specificity
Patient Health Questionnaire – 9 (PHQ-9)
• 9 item self rating scale measures proportion of time in past 2 weeks depressive symptoms present
• 80% sensitivity, 92% specificity
Psychological treatments of depression
CBT or interpersonal psychotherapy
(Defined very broadly)
• Cognitive – perception of events/ thinking errors
• Behavioural – changing behaviours
• Psychotherapy – how your past effects now
Pharmacological treatments of depression
Antidepressants
• SSRIs
= Selective Serotonin Reuptake Inhibitors
– Most commonly prescribed
– Block re-uptake of serotonin
• SNRIs
= Serotonin Noradrenaline Reuptake Inhibitors
• Tricyclics – older drugs
• Monoamine oxidase inhibitors – older drugs
*Developed based on Monoamine deficiency theory
Monoamine deficiency theory
Monoamine deficiency theory
• Imbalance in brain neurotransmitters – monoamines
• Depression caused by deficiencies of the MOAs: serotonin, dopamine, noradrenaline
• Theory supported by effects of antidepressants which increase monoamine levels
SSRIs
SSRIs
SSRIs block reuptake of serotonin so that it has a chance to activate its receptor for longer
• Serotonin - also known as 5 hydroxyl tryptamine - and its corresponding GPCR
• GPCRS are 7 transmembrane domain receptors – large family – ligand binding pockets – protein cascades
• Study of proteins and knowledge of their function is challenging, and compared to genetics, our knowledge is limited (but is growing rapidly)
• GPCRS everywhere – side effects
• Expression goes up and down drastically (downregulation) on rapid basis – moment to moment. Drug effects vary by:
• Individual
• Time
P11 may have a critical role, and may represent a new therapeutic target for depression
Efficacy of SSRIs
• Recent meta-analyses show selective serotonin reuptake inhibitors have no clinically meaningful advantage over placebo
• Claims that antidepressants are more effective in more severe conditions have little evidence to support them
• Methodological artefacts may account for the small degree of superiority shown over placebo
(Moncreiff and Kirsch 2005)
SSRIs Side Effects:
SSRIs Side Effects:
Headache, anorexia, nausea, indigestion, anxiety, sexual dysfunction
Increased risk of GI bleeding (especially elderly)
Increased agitation in first few weeks
Range of unpleasant withdrawal effects
Increased suicidal ideation and aggression (esp. under 18s)
Bipolar Disorder
Recurrent episodes of altered mood and activity
Major depressive, manic, hypomanic or mixed
Clinical features of manic episodes:
Elation (maybe irritable)
Increased psychomotor activity, including speech
Exaggerated optimism, inflated self esteem
Decreased social inhibition with no regard for safety
Insight absent, possible psychotic features
Bipolar 1
One episode of mania (don’t need to have experienced depressive episode)
Socially disinhibited
Increased risk taking
Complete disruption of normal activities
Bipolar 2
History of depressive episodes and hypomania
Hypomania – experience elation but can still engage in normal activities
Experience depressive episodes
Biopolar Aetiology
Genetic (evidence clear)
Neuroendocrine abnormalities
Triggers (severe stress post-partum, life events)
Biopolar Treatment
Nice Guidelines → Stepped Care Model
Model provides a framework for organising the provision of services, and helps patients, carers and practitioners to identify and access the most effective interventions.
The least intrusive, most effective intervention is provided first.
If a person does not benefit from that intervention, or declines an intervention, they should be offered an appropriate intervention from the next step.
Talking interventions first – exercise, diet
Psychoanalytical Theory
Psychoanalytical Theory – Freud Personality composed of 3 components: 1. Id – Pleasure driven – Unconscious urges & desires – well below surface of awareness 2. Superego – Morality driven – Ego ideal 3. Ego – Self – Reality principle – Conscious ideas/thoughts/feelings
Behavioural Psychology
Behaviourism = learning through association = stimulus – response
Emphasises responses observable and measurable .’. focuses on influence of environmental factors excluding innate or inherited factors
Behaviourism → observation the focus
Learning inferred from observed behaviour
Building connections between stimuli and response (conditioning) forms habits
Reinforcement shapes learning and therefore behaviour
➢ Classical conditioning
– Can have extinction (response weakened until no longer elicited by conditioned stimulus) + spontaneous recovery
Pavlov
With repeated pairings the neutral stimulus becomes a conditioned stimulus → elicits the conditioned response.
Patient associates dentist with negativity (pain) or reward (out of pain/sticker)
Baby Albert – shows stimulus generalisation
➢ Operant conditioning
Learner operates on the environment and receives a reward for certain behaviour (operations). Eventually bond between operation and reward stimulus is established.
Skinner – behaviour reinforced by reward/punishment
Principle = behaviour shaped and maintained by consequences
Pigeons rewarded randomly, repeated whatever they were doing when rewarded
Patient praised for improved plaque-free score, more likely to return for more treatment
Reinforcers:
1° = whatever strengthens behaviour (food, water, sex)
2° = associated with primary reinforcers (money, certificates, prizes, praise)
HIERARCHY OF NEEDS
Abraham Maslow derived hierarchy of need to achieve full potential
= Humanist psychology, disagreed with Freud’s psychoanalytical theory
Studied successful people –
Why do people who’s needs are met seek self-actualisation? = Metamotivation, desire to reach full potential
Metamotivation is a term coined by Abraham Maslow to describe the motivation of people who are self-actualized and striving beyond the scope of their basic needs to reach their full potential. Maslow suggested that people are initially motivated by a series of basic needs, called the hierarchy of needs.
- Physiologic Needs
- Safety Needs
- Love Needs
- Esteem Needs
- Self-actualisation needs
If basic need not met, won’t strive for self-actualisation. E.g. a homeless patient won’t prioritise oral health.
Personality Theory
Personality theory builds on work of Muslow
Concerned with self-actualisation
Effect of external environment on internal view of self
Personal choice, feel good about teeth can smile at world
General Theories of Anxiety
Beck 1976
Humans have an adaptive mechanism of anxiety = protective and modified by how individual thinks about a threat
The emotional reaction (anxiety or fear) triggered when size of the threat is larger than the individual’s perception of their ability to cope.
Selective Attention
Selective Attention
• Orientation
• Fight/Flight
Attention to – Threatening words (written or spoken) – People, Faces, Body language – Pictures and objects – Internal experiences – Novel neutral stimuli
→ Threat Avoidance
people will go to great lengths to avoid a potentially dangerous situation
Memory Alteration
• Selective remembering of –ve information
E.g. Remember one negative experience over countless positive/uneventful ones
• Intrusive memories
• Flashbacks
Very vivid memories
Feel as though reliving experience, esp. with traumatic experiences
May be triggered by anything related to stimulus e.g. a letter to attend dental appointment etc.
• Schema
= Your own personal framework of ideas
Can manipulate new info to fit our schema - even if it doesn’t
How dental anxiety arises in patients
Psychoanalytical…
➢ Dental phobia is the product of unconscious processes such as false connections and displacement = defence mechanism, superego acts to protect ego by viewing situations as totally unacceptable and dangerous
➢ Dentist/patient relationship governed by the treatment alliance (working with pt, overcoming obstacles i.e. eye contact, take mask off) and transference phenomena
How dental anxiety arises in patients
Behavioural
➢ Conditioning of dental anxiety:
Pairing of a bad experience (US) with a dental visit (CS) → CR – Anxiety. So the on the CS – dental visit needed to initiate the CR – anxiety.
➢ Generalisation:
Fear of dental visit -> fear of dentist -> picture of dentist/person in white coat → CR – Anxiety
➢ Reinforcement:
Attend dentist -> Anxiety
Avoidance -> No anxiety (reward)
Reward - > Behaviour reinforced
Attend dentist -> Anxiety
Behaviour (crying) -> Dentist stops treatment, mother comforts child
→ Behaviour reinforced
➢ Extinction:
Extinction -> remission of anxiety
Latent Inhibition
Many pain/trauma free visits -> no anxiety
Bad experience -> no anxiety
.’. prior good experiences have a protective effect against the conditioning process.
How dental anxiety arises in patients
Cognitive
➢ Catastrophising – thinking the worst, raises anxiety levels
➢ Imagery – seeing yourself in a catastrophic situation
➢ Memory – harking back to a (perceived?) bad experience
➢ Self-efficacy and locus of control – feeling of helplessness, not able to control or predict outcome
How dental anxiety arises in patients
Other
• Biological preparedness
• Social learning theory (Albert Bandura) = Bobo doll experiment; Observational learning + Imitation/modeling -> learning is a cognitive process that takes place in a social context – fear can be learnt from the fear of others.
o Live model – actual person demonstrating desired behaviour
o Verbal – individual describes the desired behaviour in detail
o Symbolic – modelling occurs via media e.g. movies, TV, Internet, literature, radio… stimuli can be either real or fictional characters.
• Personality differences
How dental anxiety arises in patients
Pain & Anxiety Cycle
• Increased anxiety may make it difficult to discriminate between sensation and pain (Dworkin & Chen, 1982)
Dworkin & Chen (1982) – Subjects served as their own control when tooth pulp shock was delivered in laboratory and clinical situations. Significantly heightened pain was observed in the clinical dental setting. The dental setting proved more anxiety-provoking and associated with reduced tolerance for pain, suggesting that cognitive contexts of a dental setting may elicit heightened subjective pain responses.
• Many studies have found that painful and traumatic dental visits are cited as the cause of their anxiety by anxious and phobic patients.
• Some believe that a second episode is necessary for the development of fear and anxiety.
• Now understood that cognitive factors important in process.
• No single aetiology identifiable
• Conditioning in combination with other factors most common cause
• Some anxious patients haven’t had a bad experience
• Some patients with a bad experience aren’t anxious
…which means….
• A good understanding of the multi-factorial causes of anxiety should help clinicians to recognise anxiety and tailor treatment accordingly
Recognition of stressed patient
Body language, idiosyncratic behaviour
- Closed body language
- Shaking/fidgeting
- Holding a part of their body – clutching hands / holding stomach
Sweating – brow / hands / arm pits / all over
Levels of speech
No eye contact / talking very fast / agreeing to anything / agreeing to nothing / saying nothing
Aggression
Hyperventilation – fast, shallow breathing
May tell you feeling stressed/anxious/nervous
Crying
Needing the toilet excessively
Won’t sit down / trying to leave
Making excuses
Reducing anxiety - Communication
Communication vital –> informed consent, pt satisfaction
Open body language Listen Open questions Don’t use dental jargon Speech Tone Pitch Speed Quantity & relevance of info Pain control STOP signal Length of procedure Can take breaks Describe sensation
Anxious pts often have external locus of control – feel lack control over situation, good communication involving them in decision making process, empower them.
methods of helping anxious patients to accept treatment
Gentle reassurance
Counselling/complex cognitive behavioural methods
Chemical Management
• IV sedation
• GA
** But neither eradicate anxiety – no memory of dental procedure so does nothing to help overcome fear of dentist
short vs long term – BM takes time but longer lasting effect .’. can save time in future
Anxiety in children
Not all badly behaved children are anxious (Arnrup & Bodin 2003)
- However: Treat all behavioural problems as if the child is anxious
Some children need sedation in addition to behavior management
Integrated use of sedation increases acceptance of dental treatment particularly in fearful children
Children → Eye level Appropriate age vocabulary Tone of voice Understanding level (child development)
Threats and bribes are not helpful
Reward when appropriate – compliance, not an incentive
Teenagers →
Gillick competence
➢ Used in medical law to decide whether individuals 16 years and younger are able to consent to medical treatment without parental consent/knowledge.
Advanced techniques that could be useful in behavioural management of dental anxiety
Tell-show-do Modelling Distraction Desensitisation Cognitive Behaviour Therapy (CBT) Relaxation Techniques Hypnosis Biofeedback Acupuncture
(Tell Me Doctor Do Cows Really Have Bad Ankles)
Modelling
Social Learning Theory; Bandura (1961) – imitating bobo doll
Can be live or video/computer
Videos
- Most effective if model similar in age, gender, ethnicity to pt – reliability
- Model ‘good’ behaviour -> positive reinforcement
- Positive outcome demonstrated
Distraction
Headset – music, stories TV – cartoons, news Visual distractions - Fish tank Stories Video games
Corah, Gale and Illig,1979 –adults – relaxation and distraction can be effective in alleviating anxiety and reducing stress. Women seem to prefer relaxation, whereas men prefer distraction
Relaxation Techniques
Talk pt through progressive muscle relaxation
Desensitisation
= Reciprocal inhibition
Can’t be relaxed and anxious at same time
1. Teach relaxation and imagery
2. When relaxed imagine anxiety provoking items
3. Progress through hierarchy least – most
4. Treatment
Can combine psychological and physiological = more effective in children
High success rate with adults (Gale and Ayer, 1969), some initiating follow on appointments themselves to complete treatment (thus change in locus of control, reduction/desensitisation)
Long-term effectiveness (Moore, Bordsgaard and Abrahamsen, 2002)
Cognitive Behaviour Therapy (CBT)
– Cognitive restructuring
– Modification of ‘dysfunctional/unhelpful’ thinking
– Directive; action based therapy
E.g. Reframing
She’s prying into my personal life → She needs to know my medical history to devise the best treatment plan
Setting goals:
Next time I’ll sit in the chair when first asked and not wait until asked a second time
Biofeedback
e.g. Lie detector, measures physiological changes
Transference
(Patient)
When reminded in the present of someone from past who aroused strong emotions (may have been forgotten) - feel same emotions in the present related to the person with whom we are interacting.
Feelings are strong and the reasons for them are UNCONSCIOUS
Countertransference
(Clinician)
When transference directed from clinician towards patient.
Can be unhelpful in managing pt’s problem as involves making unhelpful assumptions e.g. high level of understanding, uncooperative, non compliance likely etc. which may not be true for the patient with which you are dealing.
Transactional Analysis
Founded by Eric Berne
3 ego states:
• Parent – authoritative
• Adult – goal of TA to draw people more towards this objective state
• Child – emotional responses
Transactional Analysis
Crossed transactions
one party responds inappropriately; wrong role
Transactional Analysis
Successful transactions
Adult – Adult -> mutuality in consultation, pt centred approach
Models of Dentist/Patient Relationship:
- Paternalistic
- Mutualistic
- Consumerist
- Default
Models of Dentist/Patient Relationship:
Paternalistic
Parent – child interaction
Disease centred
High control by professional
Passive patient; expected to rely on dentist
Models of Dentist/Patient Relationship:
Mutualistic
Adult-Adult interaction
Patient autonomy
Patient centred consultation
Equality of control between professional and patient
Recognises patient as expert on their own problem
Consultation led by pt’s concerns
Models of Dentist/Patient Relationship:
Consumerist
Pt consumer of health service;
makes demands expect to be met –> high levels of investigation, treatment, blaming & litigation
Promoted by government – patient choice and patient charters
Models of Dentist/Patient Relationship:
Default
Neither clinician nor pt has much control.
No one takes responsibility for health outcomes – series of referrals and investigations with no responsibility taken for the patient
No pt education takes place so no learning occurs
