B.

Sc PSYCHOLOGY

5th SEM CORE COURSE

UNIVERSITY OF CALICUT

PSY5B05-HEALTH PSYCHOLOGY

2019 ADMISSION

Prepared by
Linitha Zerin K
Assistant Professor
Department of Psychology
 CPA College of Global Studies, Puthanathani
COURSE CODE PSY5B05

TITLE OF THE COURSE HEALTH PSYCHOLOGY

SEMESTER IN WHICH THE 5

th

COURSE TO BE TAUGHT

NO. OF CREDITS 3

NO. OF CONTACT HOURS 48 (3hrs/week)

Objectives of the course:

 To understand the Psychological, behavioural and cultural factors contributing to

physical and mental health
 To study the management of different illnesses

 Course details

MODULE NAME OF MODULE MODULE HOURS

NO.

1 Introduction to health psychology 12

2 Health behaviour and primary 12

prevention

3 Stress and coping 12

4 Psychosocial issues and management of 12

advancing and terminal illness
 MODULE 1: Introduction to health psychology

HEALTH

WHO defined health as “a complete state of physical, mental and social well- being and not

merely the absence of disease or infirmity.”

HEALTH PSYCHOLOGY

 Health psychology deals with the psychological and behavioral processes contributing to

overall individual’s well -being and health.

 It deals with the subject of health and illness by merging all knowledge of biological,

behavioral, social and psychological sciences.

 Health psychology is basically applying the psychological theory to health related practices.

 Health psychology can be defined as the aggregate of specific educational, scientific and

professional contributions of the discipline of psychology to the promotion and maintenance

of health, the prevention and treatment of illness and the identification of etiologic and

diagnostic correlates of health, illness and related dysfunction.” (Matarazzo,1980)

The Mind-Body relationship

 The Greeks: They were among the first to identify the role of bodily functioning in health and

illness. They developed humoral theory of illness, in which specific personalities were

associated to four humors.

 Middle ages: Mysticism and demonology dominated the concepts of disease, which was

“God’s punishment of evildoing". Throughout this time, the church was the guardian of

medical knowledge.
 Renaissance: Great strides were made in the technological basis of medical practice, such as

Leeuwenhoek’s microscopy and Morgagni’s contributions to autopsy.

 For the next 300 years, physical evidence became the sole basis for diagnosis and treatment of

the illness.

 Beginning of modern psychology: Sigmund Freud’s work on conversion hysteria.

 In 1930, unlike Freud’s, Flanders Dunbar and Franz Alexander linked patterns of personality

to a specific illness. Their works helped the emerging field of psychosomatic medicine.

NEED AND SIGNIFICANCE OF HP

 Changing patterns of illness

 Acute illness

 Chronic illness

 Advances in Technology and Research

 Role of epidemiology in Health Psychology

 Morbidity – Numbers of cases of a disease

 Mortality – Numbers of death

 Expanded Health Care Services

 Increased Medical Acceptance

 Demonstrated Contributions to Health

 Methodological Contributions to Health

 BIOPSYCHOSOCIAL MODEL

 Interactions between individual genetic makeup (biology), mental health and personality

(Psychology) and sociocultural environment (social world) contribute to their experience of

health or illness.

 Theorized by Psychiatrist George L. Engel.

 Biological Influences on Health: It include genetics, infections, physical trauma, nutrition,

hormones and toxins.

 Psychological factors: The psychological component looks for potential psychological

explanations for a health problem, such as lack of self-control, emotional turmoil, or negative

thinking.

 Social factors: Social and cultural factors are conceptualized as a particular set of stressful

events that can differentially impact health depending on the individual and his or her social

context.

BIOMEDICAL MODEL

 Focuses on the physical or biological aspects of disease and illness. It is a medical model of

care practised by doctors and/or health professional and is associated with the diagnosis, cure

and treatment of disease.

 Emphasis on diagnosis and treating individuals separately from their lifestyle/living

conditions.
 Receives the majority of government healthcare funding.

 Played a large role in prolonging life expectancy.

 Eg: X-rays, Scans, Blood test, Ultrasound, Surgery

 MODULE 2: health behaviour and primary prevention

HEALTH BEHAVIOURS

 Behaviors undertaken by people to enhance or maintain health.

 A health habit is a health behavior that is firmly established and often performed automatically,

without awareness.

 These habits usually develop in childhood and begin to stabilize around age 11 or 12.

Changing Health Habits

 Attitude change

 Educational appeals: Educational appeals make the assumption that people will change their

health habits if they have good information about their habits

 Fear appeals: This approach assumes that if people are afraid that a particular habit is hurting

their health, they will change their behavior to reduce their fear.

 Message framing: A health message can be phrased in positive or negative terms. Messages

that emphasize problems seem to work better for behaviors that have uncertain outcomes, for

health behaviors that need to be practiced only once, such as vaccinations and for issues about

which are fearful.

Cognitive Behavioural Approach

 Cognitive behavior approaches to health habit modification focus on the target behavior itself,

the conditions to elicit and maintain it, and the factors that reinforce it. The most effective

approach to health habit modification often comes from CBT.

 CBT interventions use several complimentary methods to intervene in the modification of a

target problem and its context.

 CBT may be implemented individually, through therapy in a group setting,or even on the

internet, and so it’s a versatile as well as effective way of intervening to modify poor health

habits.

 Self- monitoring

Self -monitoring assesses the frequency of a target behavior and the antecedents and the

consequences of that behavior .The first step in self -monitoring is to learn to discriminate the

target behavior. A second stage in self -monitoring is charting a behavior.Each of these

condition can be a discriminative stimulus that is capable of eliciting the target behavior.

Stimulus control

 Once circumstances surrounding the target behavior are well understood, the factors in the

environment that maintain poor health habits such as smoking, drinking and overeating can

be modified.

 Stimulus control interventions involve ridding the environment of discriminative stimuli that

evoke the problem behavior and creating new discriminative stimuli, signaling that a new

response will be reinforced.

The self-control of behavior

 CBT focuses heavily on the beliefs that people hold about their health habits.

 The person acts as his or her own therapist and together with outside guidance learns to

control the antecedents and consequences of the target behavior.

 Cognitive restructuring trains people to recognize and modify their internal monologues to

promote health behavior change.

Self- reinforcement
Self- reinforcement involves systematically rewarding oneself to increase or decrease the

occurrence of target behavior.

Behavioral assignments

A technique for increasing client involvement is behavioral assignments, home practice

activities that supports the goals of a therapeutic interventions. Behavioral assignments are

designed to provide continuity in the treatment of behavioral problem.

Social skills and relaxation training

Some poor health habits develop in response to the anxiety people experience in social

situation. Many health habit modification programs like social skills training or assertiveness

training are trained in methods that help people deal more effectively with social anxiety.

Relaxation training

Many poor health habits are caused or maintained by stressful circumstances and so managing

stress is important to successful behavior change. A mainstay of stress reduction is RT

involving deep breathing and progressive muscle relaxation

Motivational interviewing

MI is increasingly used in health promotion interventions.Originally developed to treat

addiction.MI is a client centered counselling style designed to get people to work through any

ambivalence they experience about changing their health behaviors. In MI, the interviewer

adopts a known judgmental, non-confrontational, encouraging and supporting style.

Relapse prevention

One of the biggest problems faced in health habits modifications is the tendency for people to

relapse. Following initial successful behavior change, people often return to their old bad
 habits. Abstinence violation effect – a feeling of loss of control that results when a person has

violated self- imposed rules. Relapse prevention should be integrated into treatment programs

from the outset.

Health belief model

According to this model, whether a person practices a health behavior depends on two factors:

whether the person perceives a personal health threat and whether the person believes that a

participant health practice will be effective in reducing that threat.

Perceived health threat

The perception of a personal health threat is influenced by at least three factors: general health

values, which include interest in and concern about health; specific beliefs about personal

vulnerability to a particular disorder and beliefs about the consequences of the disorder such

as whether they are serious.

Perceived threat reduction

Whether a person believes a health measure will reduce threat has two subcomponents:

whether the person thinks the heath practice will be effective, and whether the cost of

undertaking that measure exceeds its benefits.

Theory of planned behaviour

• According to this theory, a health behavior is the direct result of a behavioral intention.

• Behavioral intentions are themselves made up of 3 components:

1. Attitude toward the specific action

2. Subjective norms regarding the action

3. Perceived behavioral control

• Attitude toward the action center on the likely outcomes of the action and the evaluations of

those outcomes.

• Subjective norms are what a person believes others think that person should do and the

motivation to comply with those normative beliefs.

• Perceived behavioral control is the perception that one can perform the action and that action

will have the intended effect; thus component of the model is similar to self- efficacy.

• These factors combine to produce behavioral intention and ultimately behavior change.

Trans theoretical model

J.O.Prochaska and his associates developed the trans theoretical model of behavior change, a

model that analyzes the stages and processes people go through in bringing about a change in

behavior and suggested treatment goals and interventions for each stage.

Precontemplation

 This stage occurs when a person has no intention of changing his or her behavior. Many people

in this stage are not aware that they have a problem, although families, neighbors, or coworkers

may well be.

Contemplation

 Contemplation is the stage in which people are aware that they have a problem and are

thinking about it but have not yet made a commitment to take action.

Preparation

 In this stage, people intend to change their behavior but have not yet done so successfully. In

some cases, they have modified the target behavior somewhat, such as smoking fewer
 cigarettes than usual, but have not yet made the commitment to eliminate the behavior

altogether.

Action

 The action stage occurs when people modify their behavior to overcome the problem. Action

requires commitment of time and energy to making real behavior change. It includes stopping

the behavior and modifying one’s lifestyle and environment to rid one’s life of cues associated

with the behavior.

Maintenance

 In this stage, people work to prevent relapse and to consolidate the gains they have made.

Protection motivation theory

• The protection motivation theory deals with how people cope with and make decisions in times

of harmful or stressful events in life. These decisions are a way of protecting oneself from

perceived threats. The theory attempts to explain and predict what motivates people to change

their behavior.

• The theory is used mainly as a model to explain decision making and action about health.

• PMT examines how people appraise their abilities to manage threats.

• The theory proposes the variable motivation to protection to explain health behaviors.

• Protection motivation theory was developed by R.W. Rogers in 1975 in order to better

understand fear appeals and how people cope with them. However, Dr. Rogers would later

expand on the theory in 1983 to a more general theory of persuasive communication.

 Social cognitive theory

• Social cognitive theory is a learning theory developed by the renowned Stanford psychology

professor Albert Bandura. The theory provides a framework for understanding how people

actively shape and are shaped by their environment. In particular, the theory details the

processes of observational learning and modeling, and the influence of self-efficacy on the

production of behavior.

• The theory states that when people observe a model performing a behavior and the

consequences of that behavior, they remember the sequence of events and use of this

information to guide subsequent behaviors.

• Social cognitive theory considers many level of social ecological model in addressing behavior

change of individuals.SCT has been widely used in health promotion given the emphasis on

the individual and the environment ,the latter of which has been become a major of focus in

recent years of health promotion activities.

Attribution theory

The origins of attribution theory lie in the work of Heider (1944, 1958), who argued that

individuals are motivated to understand the causes of events as a means to make the world

seem more predictable and controllable.

Attribution theory has been applied to the study of health and health behavior. The issue of

controllability emphasized in attribution theory has been specifically applied to health in terms

of the health locus of control. Individuals differ in their tendency to regard events as

controllable by them (an internal locus of control) or uncontrollable by them (an external locus

of control).
 Models of prevention

Prevention strategy: types of prevention in general, preventive care refers to measures taken

to prevent diseases instead of curing or treating the symptoms. The three levels of preventive

care— primary, secondary, and tertiary care—are detailed below:

• Primary prevention—those preventive measures that prevent the onset of illness or injury

before the disease process begins.

 Secondary prevention—those preventive measures that lead to early diagnosis and prompt

treatment of a disease, illness or injury to prevent more severe problems developing. Here

health educators such as health extension practitioners can help individuals acquire the skills

of detecting diseases in their early stages.

 Tertiary prevention—those preventive measures aimed at rehabilitation following significant

illness. At this level health services workers can work to retrain, re-educate and rehabilitate

people who have already developed an impairment or disability.

 MODULE 3: Stress and coping

STRESS

Stress is a negative emotional experience accompanied by predictable biochemical,

physiological, cognitive and behavioral changes that are directed either toward altering the

stressful event or accommodating to its effects.

STRESSOR

An event or situation that causes stress.

APPRAISAL OF STRESS

• Stress is the consequence of a person's appraisal processes:

• Primary appraisal occurs as a person is trying to understand what the event is and what it

will mean. Events may be appraised for their harm, threat, or challenge. Harm is the assessment

of the damage that has already been done, as for example being fired from a job.

• Secondary appraisals assess whether personal resources are sufficient to meet the demands

of the environment. When a person's resources are more than adequate to deal with a difficult

situation, he or she may feel little stress and experience a sense of challenge instead.

• Stress, then, is determined by person-environment fit .It results from the process of appraising

events (as harmful, threatening, or challenging), of assessing potential resources, and of

responding to the events. To see how stress researchers have arrived at this current

understanding, we examine the origins of stress research.

Fight or Flight

The earliest contribution to stress research was Walter Cannon's (1932) description of the

fight-or-flight response. Cannon proposed that when an organism perceives a threat, the body
is rapidly aroused and motivated via the sympathetic nervous system and the endocrine system.

This concerted physiological response mobilizes the organism to attack the threat or to flee;

hence, it is called the fight-or-flight response.

At one time, fight or flight literally referred to fighting or fleeing in response to stressful events

such as attack by a predator. Now, more commonly, fight refers to aggressive responses to

stress, such as getting angry or taking action, whereas flight is reflected in social withdrawal

or withdrawal through substance use or distracting activities. On the one hand, the fight-or-

flight response is adaptive because it enables the organism to respond quickly to threat. On the

other hand, it can be harmful because stress disrupts emotional and physiological functioning,

and when stress continues unabated, it lays the groundwork for health problems.

Selye's General Adaptation Syndrome

Another important early contribution to stress was Hans Selye's (1956, 1976) work on the

general adaptation syndrome. Selye exposed rats to a variety of stressors, such as extreme cold

and fatigue, and observed their physiological responses. To his surprise, all stressors,

regardless of type, produced essentially the same pattern of physiological changes. They all

led to an enlarged adrenal cortex, shrinking of the thymus and lymph glands, and ulceration of

the stomach and duodenum.

From these observations, Selye (1956) developed the general adaptation syndrome. He argued

that when a person confronts a stressor, it mobilizes itself for action. The response itself is

nonspecific with respect to the stressor; that is, regardless of the cause of the threat, the person

will respond with the same physiological pattern of reactions. Over time, with repeated or

prolonged exposure to stress, there will be wear and tear on the system.

The general adaptation syndrome consists of three phases. In the first phase, alarm, the person

be-comes mobilized to meet the threat. In the second phase, resistance, the person makes
efforts to cope with the threat, as through confrontation. The third phase, exhaustion, occurs if

the person fails to overcome the threat and depletes physiological resources in the process of

trying.

Tend-and-Befriend

In response to stress, people (and animals) do not merely fight, flee, and grow exhausted. They

also affiliate with each other, whether it is the herding behavior of antelope in response to a

predator or the coordinated responses to a stressor that a community shows when it is under

the threat of a hurricane.

S. E. Taylor and colleagues developed a theory of responses to stress termed tend-and-

befriend. The theory maintains that, in addition to fight or flight, people and animals respond

to stress with social affiliation and nurturant behavior toward offspring. These responses to

stress may be especially true of women.

During the time that responses to stress evolved, men and women faced somewhat different

adaptive challenges. Whereas men were responsible for hunting and protection, women were

responsible for foraging and child care. These activities were largely sex segregated, with the

result that women's responses to stress would have evolved so as to protect not only the self

but offspring as well. These responses are not distinctive to humans. The offspring of most
 species are immature and would be unable to survive, were it not for the attention of adults. In

most species, that attention is provided by the mother.

Tend-and-befriend has an underlying biological mechanism, in particular, the hormone

oxytocin. Oxytocin is a stress hormone, rapidly released in response to some stressful events,

and its effects are especially influenced by estrogen, suggesting a particularly important role

in the responses of women to stress. Oxytocin acts as an impetus for affiliation in both animals

and humans, and oxytocin increases affiliative behaviors of all kinds, especially mothering.

In addition, animals and humans with high levels of oxytocin are calmer and more relaxed,

which may contribute to their social and nurturant behavior.

Research supports some key components of the theory. Women are indeed more likely than

men to respond to stress by turning to others. Mothers' responses to offspring during times of

stress also appear to be different from those of fathers in ways encompassed by the Tend-and-

befriend theory. Nonetheless, men, too, show social responses to stress, and so elements of the

theory apply to men as well.

Negative Events

 Negative events produce more stress than do positive events. Shopping for the holidays, coping

with an unexpected job promotion, and getting married are all positive events that draw off

time and energy. Nonetheless, these positive experiences are less stressful than negative or

undesirable events, such as getting a traffic ticket, trying to find a job, coping with a death in

the family, getting divorced or experiencing daily conflict. Rejection targeted at you

specifically by an-other person or group is particularly toxic. Negative events produce more

psychological distress and physical symptoms than positive ones do.

Uncontrollable Events
 Uncontrollable or unpredictable events are more stressful than controllable or predictable ones

especially if they are also unexpected When people feel that they can predict, modify, or

terminate an aversive event or feel they have access to someone who can influence it , they

experience less stress, even if they actually can do nothing about it .Feelings of control not

only mute the subjective experience of stress but also influence biochemical reactions to it ,

including catecholamine levels and immune responses.

Ambiguous Events

 Ambiguous events are more stressful than clear-cut events. When a potential stressor is

ambiguous, a person cannot take action, but must instead devote energy to trying to understand

the stressor, which can be a time-consuming, resource-sapping task. Clear-cut stressors, on the

other hand, let the person get on with finding solutions and do not leave him or her stuck at

the problem definition stage. The ability to take confrontative action is usually associated with

less distress and better coping.

Overload

 Overloaded people experience more stress than people with fewer tasks to perform. For

example, one of the main sources of work-related stress is job overload, the perception that

one is responsible for doing too much in too short a time.

Personality and coping

The personality characteristics that each person brings to a stressful event influence how he or

she will cope with that event.

Negativity, stress and illness

• Research has especially focused on negative affectivity: a pervasive negative mood marked

by anxiety, depression and hostility.

• People high in negative affectivity (also called neuroticism) express distress, discomfort and

dissatisfaction in many situations.

• Negative affectivity is related to poor health, including such chronic disorders as arthritis,

diabetes, chronic pain and coronary artery disease.

• Negative affectivity is also related to all-cause mortality.

• Taken together this research suggests that psychological distress involving depression, anger,

hostility and anxiety may form the core of a disease prone personality.

• Negative affectivity is related to elevated levels of stress indicators such as cortisol, heart rate,

inflammation and risk factors for coronary heart disease.

• A second link is poor health.

• Negative affect leads people to worry, be more aware of their symptoms and attribute their

symptoms to poor health.

• People who are high in negative affect are more likely to get sick, but they also are distressed,

experience physical symptoms and seek medical attention even when they are not sick.

Positivity and illness

 Positive emotional functioning promotes better mental and physical health and a longer life.

 Positive emotional states have been tied to lower levels of stress indicators such as cortisol and

better immune responses to challenges such as exposure to flu virus

 When people are feeling positive, they also invest time and effort to overcome obstacles in

pursuit of their goals, which may accordingly affect their mood and lower their stress levels.

 In addition to promoting general well-being, positivity promotes several specific

psychological resources that improve coping to which we next turn.

 SOCIAL SUPPORT

 Defined as information from others that one is loved and cared for, esteemed and valued and

part of a network of communication and mutual obligations.

 Social support can come from parents, a spouse or partner, other relatives, friends, social and

community contacts (such as churches or clubs) or even a devoted pet.

 Social support helps people thrive.

 People with social support experience less stress when they confront a stressful experience,

cope with it more successfully and even experience positive life events more positively.

 Social support can take any of several forms.

 Tangible assistance: Involves the provision of material support, such as services, financial

assistance or goods. Eg; the gifts of food that arrive after a death in a family mean that the

bereaved family members will not have to cook for themselves and visiting friends and

family.

 Family and friends can provide informational support about stressful events. For example,

if an individual is facing an uncomfortable medical procedure, a friend who went through the

same thing could provide information about the exact steps involved, the potential

discomfort experienced and how long it takes.

 Supportive friends and family can provide emotional support by reassuring the person that

he or she is a valuable individual who is cared for. The warmth and nurturance provided by

other people can enable a person under stress to approach the stressful event with greater

assurance.

 Research suggests that when one receives help from another but is unaware of it , that help is

most likely to benefit the recipient- Invisible support

 Social support can lower the likelihood of illness, speed recovery from illness or treatment

and reduce risk of mortality due to serious disease.

 Social support also typically benefits health behaviors.

STRESS MANAGEMENT PROGRAM

 Identifying Stressors: In the first phase of the program, participants learn what stress is and

how it creates physical wear and tear. In sharing their personal experiences of stress, many

students find reassurance in the fact that other students have experiences similar to their own.

They learn that stress is a process of psychological appraisal rather than a factor inherent in

events themselves.

 Identifying Stress Antecedents

Once students learn to chart their stress responses, they are taught to examine the antecedents

of these experiences. They learn to focus on what happens just before they experience feelings

of stress.

 Avoiding Negative Self-Talk

Students are next trained to recognize and eliminate the negative self-talk they go through

when they face stressful events.

 Completing Take-Home Assignments

In addition to in-class exercises, students have taken home assignments. They keep a stress

diary in which they record what events they find stressful and how they respond to them. As

they become proficient in identifying stressful incidents, they are encouraged to record the

negative self-statements or irrational thoughts that accompany the stressful experience.

 Acquiring Skills

The next stage of stress management involves skill acquisition and practice. These skills

include cognitive-behavioral management techniques, time management skills, and other

stress-reducing interventions, such as exercise. Some of these techniques are designed to

eliminate the stressful event; others are geared toward reducing the experience of stress

without necessarily modifying the event itself.

 Setting New Goals

Each student next sets several specific goals that he or she wants to meet to re-duce the

experience of college stress. For one student, the goal may be learning to speak in class without

suffering overwhelming anxiety. For another, it may be going to see a particular professor

about a problem. Once the goals are set, specific behaviors to meet those goals are identified.

In some cases, an appropriate response may be leaving the stressful event altogether.

 Engaging in Positive Self-Talk and Self-Instruction

Once students have set realistic goals and identified some target behaviors for reaching their

goals, they learn how to engage in self-instruction and positive self-talk. Self-instruction

involves reminding oneself of the specific steps that are required to achieve the goal. Positive

self-talk involves providing the self with encouragement.

 Using Other Cognitive-Behavioral Techniques

In some stress management programs, contingency contracting and self-reinforcement are

encouraged. Several other techniques are frequently used stress management interventions.

Time management and planning helps people set specific goals, establish priorities, avoid

time-wasters, and learn what to ignore. Most stress management programs emphasize

practicing good health habits and exercise at least20-30 minutes at least 3 times a week.

Assertiveness training is sometimes incorporated into stress management.

.
 MODULE 4: psychosocial issues and management of advancing and terminal

illness

EMOTIONAL RESPONSES TO CHRONIC HEALTH DISORDERS

• Immediately after a chronic health disorder is diagnosed, a patient can be in a state of crisis

marked by physical, social, and psychological disequilibrium.

• If the patient's usual coping efforts fail to resolve these problems, the result can be an

exaggeration of symptoms and their meaning, indiscriminate efforts to cope, an increasingly

negative attitude, and worsening health. The uncertainty and ambiguity inherent in many

chronic disorders (e.g., Will it get worse? If so, how quickly?) affects quality-of-life

adversely.

• People with chronic health disorders are more likely to suffer from depression, anxiety, and

generalized distress.

• These psychological changes are important because they compromise quality of life, predict

adherence to treatment, and increase the risk of dying early.

Denial

• Denial is a defense mechanism by which people avoid the implications of a disorder,

especially one that maybe life-threatening. It is a common early reaction to chronic health

disorders.

• Patients may act as if the health disorder is not severe, it will shortly go away, or it will have

few long-term implications. Immediately after the diagnosis of the health disorder, denial

can serve a protective function by keeping the patient from having to come to terms with

problems posed by the health disorder when he or she is least able to do so.
• Over time, however, any benefit of denial gives way to its costs. It can interfere with taking

in necessary treatment information and compromise health.

Anxiety

• Following the diagnosis of a chronic health disorder, anxiety is also common.

• Many patients are over-whelmed by the potential changes in their lives and, in some cases, by

the prospect of dying.

• Anxiety is especially high when people are waiting for test results, receiving diagnoses,

awaiting invasive medical procedures, and anticipating or experiencing adverse side effects of

treatment.

• Anxiety is a problem not only because it is intrinsically distressing but also because it interferes

with treatment.

• For example, anxious patients cope more poorly with surgery;

• Symptoms of anxiety may also be mistaken for symptoms of the underlying disease and thus

interfere with assessments of the disease and its treatment

Depression

• Depression is a common reaction to chronic health disorders. Up to one-third of all medical

inpatients with chronic disease report symptoms of depression, and up to one-quarter suffer

from severe depression.

• Depression is especially common among stroke patients, cancer patients, and heart disease

patients, as well as among people with more than one chronic disorder.

• At one time, depression was regarded only as an emotional disorder, but its medical

significance is increasingly recognized.

• Depression predicts death from all causes.

• People who have intermittent bouts of depression are more likely to get heart disease,

atherosclerosis, hypertension, stroke, dementia, and chronic disorders, most notably coronary

heart diseases and Type II diabetes at younger ages.

• Depression exacerbates the course of several chronic disorders.

• Depression complicates treatment adherence and medical decision making.

STAGES TO ADJUSTMENT TO DYING

Kübler-Ross's Five-Stage Theory

• Elisabeth Kübler-Ross, a pioneer in the study of death and dying, suggested that people pass

through five stages as they adjust to the prospect of death: denial, anger, bargaining,

depression, and acceptance.

• Although research shows that people who are dying do not necessarily pass through each of

these stages in the exact order, all of these reactions are commonly experienced.

1. Denial

 Denial is thought to be a person's initial re-action on learning of the diagnosis of terminal

illness. Denial is a defense mechanism by which people avoid the implications of an illness.

 They may act as if the illness were not severe, it will shortly go away, and it will have few

long-term implications.

 In extreme cases, the patient may even deny that he or she has the illness, despite having been

given clear information about the diagnosis.

 Denial, then, is the subconscious blocking out of the full realization of the reality and

implications of the disorder.

 Denial early on in adjustment to life-threatening illness is both normal and useful because it

can protect the patient from the full realization of impending death.

 Usually it lasts only a few days. When it lasts longer, it may require psychological intervention.

2. Anger

 A second reaction to the prospect of dying is anger. The angry patient is asking, "Why me?

Considering all the other people who could have gotten the illness, all the people who had the

same symptoms but got a favorable diagnosis, and all the people who are older, dumber, more

bad-tempered, less useful, or just plain evil, why should I be the one who is dying?“

3. Bargaining

 Bargaining is the third stage of Kübler-Ross's formulation. At this point, the patient abandons

anger in favor of a different strategy: trading good behavior for good health.

 Bargaining may take the form of a pact with God, in which the patient agrees to engage in

good works or at least to abandon selfish ways in exchange for better health or more time.

4. Depression

 Depression, the fourth stage in Kübler-Ross's model, may be viewed as coming to terms with

lack of control.

 The patient acknowledges that little can now be done to stay the course of illness. This

realization may be coincident with a worsening of symptoms, tangible evidence that the illness

is not going to be cured. At this stage, patients may feel nauseated, breathless, and tired.

5. Acceptance

 The final stage in Kübler-Ross's theory is acceptance.

 At this point, the patient may be too weak to be angry and too accustomed to the idea of dying

to be depressed.

 Instead, a tired, peaceful, though not necessarily pleasant calm may descend.
 Some patients use this time to make preparations, deciding how to divide up their remaining

possessions and saying goodbye to old friends and family members.

THE MANAGEMENT OF TERMINAL ILLNESS IN CHILDREN

• Working with terminally ill children is perhaps the most stressful of all terminal care. As a

result, family members, friends, and even medical staff may be reluctant to talk openly with a

dying child about his or her situation.

• Nonetheless, terminally ill children often know more about their situation than they are given

credit for. Children use cues from their treatments and from the people around them to infer

what their condition must be. As their own physical condition deteriorates, they develop a

conception of their own death and the realization that it may not be far off.

• It may be difficult to know what to tell a child. Unlike adults, children may not express their

knowledge, edge, concerns, or questions directly. They may communicate the knowledge that

they will die only indirectly, as by wanting to have Christmas early so that they will be around

for it Or they may suddenly talking about their future plans.

• Counseling with a terminally ill child may be required and typically follows some of the same

guidelines as is true with dying adults, but therapists can take cues about what to discuss from

the child, talking only about those issues the child is ready to discuss.

Parents, too, may need counseling to help them cope with the impending death. They may

blame themselves for the child's illness or feel that there is more they could have done.

CONTINUED TREATMENT AND ADVANCING ILLNESS

• Advancing and terminal illness frequently bring the need for continued treatments with

debilitating and unpleasant side effects.

• For example, radiation therapy and chemotherapy for cancer may produce dis-comfort, nausea

and vomiting, chronic diarrhea, hair loss, skin discoloration, fatigue, and loss of energy. The

patient with advancing diabetes may require amputation of extremities, such as fingers or toes.

• The patient with advancing cancer may require removal of an organ to which the illness has

now spread, such as a lung or part of the liver.

• The patient with degenerative kidney disease may be given a transplant, in the hope that it will

forestall further deterioration.

• There may, consequently, come a time when the question of whether to continue treatments

becomes an issue. In some cases, refusal of treatment may indicate depression and feelings of

hopelessness, but in many cases, the patient's decision may be supported by thoughtful choice.

THE ISSUE OF NONTRADITIONAL TREATMENT

• As both health and communication deteriorate, some terminally ill patients turn away from

traditional medical care.

• Many such patients fall victim to dubious remedies offered outside the formal health care

system. Frantic family members, friends who are trying to be helpful, and patients themselves

may scour fringe publications for seemingly effective remedies or cures; they may invest

thousands of dollars in their generally unsuccessful search.

• Some patients are so frantic at the prospect of death that they will use up both their own savings

and those of the family in the hope of a miracle cure.

• In other cases, turning to nontraditional medicine may be a symptom of a deteriorating

relationship with the health care system and the desire for more humanistic care.
• This is not to suggest that a solid patient-practitioner relationship can prevent every patient

from turning to quackery. However, when the patient is well informed and feels cared for by

others, he or she is less likely to look for alternative remedies.

MEDICAL STAFF AND THE TERMINALLY III PATIENT

• Unfortunately, death in the institutional environment can be depersonalized and fragmented.

• Wards may be understaffed, with the staff unable to provide the kind of emotional support a

patient needs.

• Hospital regulations may restrict the number of visitors or the length of time that they can stay,

thereby reducing the avail-ability of support from family and friends.

• Pain is one of the chief symptoms in terminal illness, and in the busy hospital setting, the

ability of patients to get the amount of pain medication they need may be compromised.

• Death in an institution can be a long, lonely, mechanized, painful, and dehumanizing

experience.

ALTERNATIVES TO HOSPITAL CARE FOR THE TERMINALLY ILL

 Hospice Care

 The idea behind hospice care is the acceptance of death, emphasizing the relief of suffering

rather than the cure of illness.

 Hospice care is designed to provide palliative care and emotional support to dying patients and

their family members.

 Patients are encouraged to personalize their living areas as much as possible by bringing in

their own familiar things. Thus, in institutional hospice care, each room may look very

different, reflecting the personality and interests of its occupant.

 Patients also typically wear their own clothes and determine their own activities. Hospice care

is oriented toward improving a patient's social support system.

 Restrictions on visits from family or friends are removed as much as possible. Staff are

especially trained to interact with patients in a warm, emotionally caring way.

 Usually, counselors are available for individual, group, or family intervention.

 Home Care

• Recent years have seen renewed interest in homecare for dying patients.

• Home care appears to be the care of choice for most terminally ill patients and for many

patients, it may be the only economically feasible care.

• The psychological advantages of home care are that the patient is surrounded by personal items

and by family rather than medical staff.

• Some degree of control can be maintained over such activities as what to eat or what to wear.

Although home care is often easier on the patient psychologically, it can be very stressful for

the family.

• Even if the family can afford around-the-clock nursing, often at least one family member's

energies must be devoted to the patient on an almost full-time basis.

• The designated caregiver must often stop working and also face the additional stress of

constant contact with the prospect of death.

• The caregiver may be torn between wanting to keep the patient alive and wanting the patient's

and their own suffering to end.

 INDIVIDUAL COUNSELLING

• Counselors working with terminally ill individuals work in a multi-disciplinary team to

provide psychological comfort to the dying and their family. They may normalize emotions

during a difficult time, provide spiritual support, educate about normal physical, emotional,

and social changes, and assist in managing practical problems.

• Counseling Tasks of counselors include helping the dying individual prepare for the reality of

death. This is done through education and supportive therapeutic interventions about the dying

process that address the physical, emotional, social, spiritual, and practical needs.

FAMILY THERAPY

• The family responds in many ways to this anxiety, but will often not express these feelings;

the therapist has to try to discover at which stage of mourning the family has arrived.

• The patient too must be encouraged to express his feelings; this will relieve tension, and make

it easier for the family to accept the reality of what is going to happen.

• It is important to keep the family informed about the medical requirements of the treatment.

• These should be explained very clearly, so that all members understand, accept and cooperate

in such tasks as ensuring attendance at out-patient consultations, laboratory investigations and

taking the medicine prescribed.

• We find that often only one member of the family, usually the mother, carries the whole

responsibility of caring for the patient.

• All these matters need to be discussed with the whole family, together with such matters as

the patient's school attendance, any problems of family relationships, and plans for the future.