GOVERNMENT COLLEGE OF NURSING

JODHPUR

Topic: - Pathophysiology and Psychodynamics

of disease causation

Subject: - Advance Nursing Practice

Submitted to: - Submitted by: -

Mrs. Monika Solanki Bhanwar Lal Dewna
Nursing Lecturer M.Sc. (N) Previous
GCON, Jodhpur GCON, Jodhpur

Pathophysiology and Psychodynamics of disease causation

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Introduction to health
Health is the level of functional or metabolic efficiency of a living being.
In humans, it is the general condition of a person's mind, body and spirit, usually meaning to be free from
illness, injury or pain.
When the body is threatened or suffers an injury its response may involve functional that the body can
mount will determine between adaptation and maladaptation.

Definition of health
The term health has been defined in a variety of ways.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease
or infirmity” - WHO

Health is a state of dynamic balance of an individual’s ability to perform personally valued roles and
responsibilities, to deal and cope with physical, biological, psychological and social stresses and challenges
thought the life while continuing to maintain sense of well-being” - According to ICN

Determinants of health
 Human biology
 Environment
 Lifestyle
 Health and health allied resources

Human biology
 Genetic inheritance and physiological factors- Physiological factors involve the physical functions of
the body. Certain physical condition such as being pregnant or overweight place an increased risk of
stress on physiological system increasing susceptibility to illness in that area.
 Hereditary or genetic predisposition to specific illness is a major physical risk factor. Eg. A family
history of diabetes mellitus is at risk of developing disease later in life. Other genetic risk factor
includes family history of cancer, heart disease or mental illness.
 Age –Age increases or decreases susceptibility to get illness. Eg: An infant born prematurely and
neonates are more susceptible to infection. The risk of heart increases with age for both sexes.

Environment
 Micro-environment-Refers to immediate environment or personal environment usually include home
environment, occupational environment, socio-cultural environment.
 Macro-environment-External environment which is outside the home environment.
 Physical environment-It includes housing; building structures and wide variety of physical substances
which directly or indirectly regulate body mechanism and affect heath.
 Social environment-It includes other people and social institutions, socio-cultural events, religious
beliefs, moral and ethical values and social rules and regulations pertaining to living in the society. The
individuals develop certain practices which will have positive and negative impact on heath.
 Biological environment-It is comprised of plant and animal kingdom which help in maintaining the
ecosystem and thereby heath of people.

Life style
Life style refers to the people’s ways of living which is reflective of their knowledge, attitude and
practices. It is composite of daily living activities, behavioral and cultural practices including customs
and traditions. e.g.-unhygienic practices, nutritional deficiencies, smoking, alcoholism etc .
Health and health allied resources
 Socio-economic conditions-It includes economic status, education, occupation and living standard.
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  Political system-It has a very strong role in promotion of people in the country. The health care
delivery system is determined by the political system through there is constitutional control.
 Heath related services-It includes education, food and agriculture, industry, rural and urban
development, social welfare and manpower development, communication and broadcasting and
transportation etc.

Patho-physiology and psychodynamics of disease causation

Disease
Disease is just the opposite of the health “Disease is a condition in which body health is impaired, a
departure from the state of health, an alteration of human body interrupting the performance of vital
functions” Webster.
The Oxford English Dictionary defines decease as, "a condition of the body or some part or organ of the
body in which its functions are disrupted or deranged.”
Pathophysiology
It is the physiology of altered health. The term combines pathology and physiology. Pathology deals with
the study of structural and functional changes and physiology deals with the functions of the human body.
Psychodynamics
 It is a systematized study and theory of the psychological forces that underlie human behavior,
emphasizing the interplay between conscious & unconscious motivation.
 It is defined as human behavior, either external or internal which can lead to its state of health or disease.
 The original concept of psychodynamics was developed by “Sigmund Freud”. Psychodynamics also
known as dynamic psychology. It is the study of the interrelationship of various part of mind, personality
or psyche in relation to mental, emotional or motivational forces.

Concept of disease causation-

Includes theories of disease causation, pathogenesis and iceberg phenomenon.

Theories of disease causation:

 Old theories
 Germ theory of disease
 Biomedical model
 Theory of multifactorial causation
 Epidemiological triad
 Lazaro’s theories of stress response
 Wolff’s theory of stress, organ maladaptation and disease
 Holmes and Rahe’s theory of life change and the onset of illness

Old theory
 Old Theories- Till the end of 18th century, various theories were in vogue, e.g. supernatural theory of
disease (e.g. curse of God; an evil eye).
 The Ayurveda considers that the disease is due to imbalance of the “tridoshas.” These are Vata (air),
pitta (bile) and kapha (mucus).
 The Chinese medicine believes that the disease is caused due to imbalance of male principle (yang) and
female principle (yin).

Germ theory
 The discoveries in microbiology became a turning point in the etiological concept of disease.
 Louis Pasteur (1860) demonstrate the presence of bacteria in the air.
 Robert Koch (1877) showed the anthrax was caused by bacteria.
 These theories of Pasteur and Koch confirmed the germ theory of disease
 Thus, the emphasis has shifted from empirical causes (like bad air as cause in malaria) of the old theories
to microbes of Germ theory.
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 But now, it is recognized that a disease is rarely caused by a single agent alone, but depends upon a
number of contributory factors.

Biomedical model
 This model explains disease as a result of malfunctioning organs or cells. e.g. diabetes is caused by
malfunctioning of pancreas.
 But the drawback with it is that it focuses on cause and effect relationships, tends to ignore the
psychosocial component of the disease.

Theory of multifactorial causation

 This theory of multifactorial causation was put forth by Pettenkofer Munich (1819-1901).
 Disease is not caused by an organism but predisposed by many factors contributing to its occurrence,
specially “modern diseases” of civilization
 These predisposing factors are: -social, economic, cultural, genetic, psychological factors, etc. (including
poverty, illiteracy, ignorance, poor living condition, over-crowed)
 This theory de-emphasizes the “Germ theory” (or single cause idea).
 It is now known that most of these factors are so much linked to life-style and human behaviour, that
they are considered as “Risk-factors”, in the web of causation of the disease.

Web of causation
 It was suggested by MACMAHON and PUGH.
 This model is ideally suited in study of chronic diseases where disease agent is not known but is
outcome of interaction of multiple factors.
 It considers all predisposing factors of any type and their interrelationship with each other. E.g
Myocardial infarction.

Epidemiological triad
Environment which are equally important to determine whether or not disease will occur in the exposed
host. This demanded a broader concept of disease that synthesized the basic factors of agent, host and
environment.

Lazaru’s theories of stress response

According to him, in the process of coping, the individual shapes as well as responds to a demand or
stress which can have an impact on the client’s resistance to disease

Wolff’s theory of stress, organ maladaptation and disease

He studied people’s responses to chronic stressors, like a frustrating job or an unhappy home life. He
believed that a person’s total life situation, profoundly affects a person’s susceptibility to disease

Holmes and Rahe’s theory of life change and the onset of illness
 They explored the relationship between the amount if change in a person’s life and subsequent illness.
 They discovered that the higher a person’s life change score, the greater the likelihood that an illness
would develop

Pathogenies of the disease

 Pre-pathogenesis phase
 Pathogenesis phase

Pre-pathogenesis phase

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This phase refers to the period before the onset of disease. During this phase, interaction is taking place
among the three components of epidemiological triad namely agent, host and environment, each
representing the angle of triangle respectively.

As long as there is equilibrium among these three interacting factors, so long the person will be healthy.
Once the equilibrium is disturbed, disease process starts. In other words, potentially we are all in pre-
pathogenesis phases of many diseases, both communicable and non-communicable.

Agent factor
 Physical agent-heat, cold, radiation, humidity
 Chemical agent-endogenous: urea, uric acid, calcium oxalate
 Exogenous: dust, allergens, gas
 Biological agent-viruses, bacteria etc
 Mechanical agent-friction, injury, accidents
 Nutritional agent

Host factor
 Age
 Sex
 Ethnicity
 Occupation
 Literacy rate
 Income
 Marital status
 Nutritional status
 Lifestyle factor

Environment factor
 Physical environment-air, water, soil, food
 Biological environment-plants, animals, insects, microbes
 Socio-cultural environment-death or divorce of parents, loss of employment, etc.

Pathogenesis phase
 The pathogenesis phase begins with the entry of the disease "agent" in the susceptible human host.
 The further events in the pathogenesis phase are clear-cut in infectious diseases, i.e., the disease agent
multiplies and induces tissue and physiological changes, the disease progresses through a period of
incubation and later through early and late pathogenesis.
 The final outcome of the disease may be recovery, disability or death.
 The pathogenesis phase may be modified by intervention measures such as immunization and
chemotherapy.
 The infection may be clinical or sub clinical, and when the sub clinical, the person will not have a
recognizable signs and symptoms but may spread the disease agent to others, acting as a “carrier”, as in
typhoid, diphtheria.
 When the person develops clinical signs and symptoms, he is called as a “clinical case”.
Iceberg phenomenon
 To this disease can be closely related with an iceberg. The floating tip of iceberg represents what
physician sees in the community i.e clinical cases.
 The vast submerge portion of the iceberg represents the hidden mass of disease i.e latent, unapparent,
pre-symptomatic and undiagnosed cases and carrier in the community. The waterline represents the
demarcation between apparent and unapparent diseases.

Role of nurse in prevention of disease

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 Participation in early diagnosis and treatment.
 Notification of certain specific diseases
 Identification of source of infection and method of spread
 Health education of people in general
 Control of communicable diseases.

Stress
Definition
Stress is an internal state that can be caused by physical demands on body (disease conditions, exercise,
extremes of temperature etc.) or by the environmental and social situations which are evaluated as
potentially harmful, uncontrollable or exceeding our resources for coping.
The physical, social and environmental causes of stress state are termed as stressors. One induced by
stressors, internal stress state can lead to various physical bodily responses and psychological responses like
depression, anxiety or hopelessness.

Stressors
A little stress is helpful in coping and to adjust but beyond the limit it becomes ‘distresses. Main stressors
causing distress are: -
 Physical stressors such as injury, infections, exercise, noise and climatic changes
 Social stressors are family, social activities, health and financial conditions
 Psychological stressors include frustration, conflicts etc.

General adaptation syndrome

Body’s response to stressors is called “general adaptation syndrome”. It consists of three stages: -
1. Alarm reaction
2. Stage of resistance
3. Stage of exhaustion

1. Alarm reaction
It is essentially the emergency response of body. In this stage, prompt responses of the body, many of them
mediated by the sympathetic nervous system, preparing the body to cope with stressors.

2. Stage of resistance
 If stressor continues to be present, stage of resistance begins, where body resists the effect of continuous
stressors /stimuli.
 During this stage, certain hormonal responses of the body are important line of defence in resisting the
effects of stressors or stimuli.
 Mainly ACTH (adrenocorticotrophic hormone) is important and more active among hormonal response.
 Secretion of ACTH is controlled by CRF (corticotrophin releasing factor), made by cells of brain
structure (hypothalamus).
 Stressors/stimuli stimulate hypothalamus to release more CRF, in turn increasing the secretion of ACTH
from pituitary glands.
 ACTH stimulates adrenal gland to secrete steroid hormones such as cortisol into the blood.
 Cortisol adaptively deal with stressors or stimuli for long period of time but maintenance for long period
of time may be harmful.
 Prolonged elevation of cortisol levels results in elevated blood
pressure and other hormones in excess may have their own harmful actions which may worsen the
body’s response to stimulus.
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3. Stage of exhaustion
Final stage of general adaptation syndrome is the stage of exhaustion. In this stage, the body’s capacity to
respond to both continuous and new stressors/stimuli is seriously compromised. For eg: - due to actions of
cortisol, person may not be longer able to ward off infection and becomes sick and die.

Sources of stress
There are many sources of stress. They are broadly classified a
 Internal stressors, which arise from within the body like infection, feelings of depression.
 External stressors originate outside of individual like transfer to another city, or death in family or any
pressure from peer.
 Developmental stressors occur at predictable times throughout individual’s life.
 Situational stressors are unpredictable and may occur at any time. Examples are: Death of family
member, Marriage or divorce, Birth of child, New job, Illness.

Effects of stress
Stresses have physical, emotional, intellectual, social and spiritual consequences. Usually effects are mixed
as stress affects whole of the body.
 Physically, stress can threaten person’s physiologic homeostasis.
 Emotionally, it can produce negative or self-destructive feelings about self.
 Intellectually, stress can influence person’s problem-solving abilities and perceptual abilities.
 Spiritually, stress can challenge one’s beliefs and values.

Manifestations
 Pupils dilate to increase visual perception when serious threats to body arise.
 Diaphoresis increases to control elevated heat due to increase metabolism.
 Heart rate and cardiac output increases to transport nutrients and by products effectively
 Pallor skin due to vasoconstriction of blood vessels due to effect of nor epinephrine.
 Sodium and water retention increase due to release of mineral corticoids, which increases blood volume,
 Respiratory rate increases in rate and depth due to vasodilation causing hyperventilation.
 Urine output decreases.
 Dry mouth
 Decreased peristaltic movements
 Mental alertness improves.
 Increased muscle tension.
 Blood sugar increases due to release of glucocorticoids and gluconeogenesis.

Coping with stress

Coping may be described as dealing with change-successfully or unsuccessfully. Coping strategies is a
natural or learned way of responding to a changing environment or specific problems or situation. Or
coping is cognitive and behavioural effort to manage specific external and/or internal demands that are
appraised as exceeding or taxing the resources of the person. Coping strategies can be long term and short
term.
 Long term coping strategies can be constructive and realistic. For example, in any situation talking
with others or trying to find out more about situation.
Others include changes in lifestyle pattern such as eating a healthy diet, exercising regularly, using
problem solving in decision making instead of anger etc.
 Short term strategies can reduce stress to a tolerable limit temporarily but are ineffective ways to
permanently deal with reality. They may have destructive effects on the person.
Examples are using alcoholic beverages or drugs, daydreaming, etc.
Coping mechanisms can be adaptive or maladaptive.
 Adaptive coping helps the person to deal effectively with stressful events and minimizes distress
associated with them.

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 Maladaptive coping can result in unnecessary distress for person.

Nursing management
Nurse needs to remember that coping is always purposeful. The effectiveness of person’s coping is
influenced by number of factors. Including
 Number, duration and intensity of stressors
 Past experiences of individual
 Personal qualities of individual.
 Support systems available to individual.

1. Assessment: - Assessment includes

Nursing history: - It includes questions related to client perceived stressors or stressful events, past and
present strategies and signs of stress.
Physical examination for indicators of stress like nail biting, nervousness, weight changes or stress related
problems like hypertension, dyspnoea.

2. Diagnosis: - It includes
 Anxiety due to stressors
 Compromised family coping
 Fear related to perceived threat
 Impaired adjustment to situation
 Ineffective coping
 Post trauma syndrome

1. Planning: -Nurse must develops plans in collaboration with patient and significant support people
according to client’s health state, level of anxiety, support resources, coping mechanisms.
2. Implementation: - Nurse can choose one of these methods of intervention that will be effective for
client.

Health promotion strategies: - it includes: -

• Exercise helps to relieve tensions, promotes a feeling of well-being and relaxation
• Optimal Nutrition helps in increasing the body’s resistance to stress. People need to avoid excess of
caffeine, salt, sugar and fat and deficiencies in vitamins and minerals.
• Sleep helps in restoring the body’s energy levels and managing stress.
• Time management helps in less stress situations.

Minimizing anxiety: - nurses must carry out measures to minimize anxiety and stress of patient for
example, encourage the patient to take deep breaths before giving injections or massaging the client to
relax.

Using relaxation techniques: - several relaxation techniques are used to relax the mind and tension.
Nurse should encourage the clients to use these techniques in stressful situations like during child birth,
before and during painful procedures or postoperatively to cope with pain. These techniques include: -
 Breathing exercises
 Massage
 Progressive relaxation
 Yoga
 Meditation
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 Music therapy
 Humour and laughter therapy.
These are the various strategies which can be used to deal with stress and person will be able to prevent and
minimize the effects of stressors on the body.
Hormonal response
Sympathetic nervous system response:
Its response is rapid and short-lived. Nor-epinephrine is release at nerve endings that are in direct contact
with their respective organs to cause and increase in function of the vital organs and state of general body
arousal. Increase heart rate, Peripheral vasoconstriction, raising blood pressure, blood glucose is increased,
pupils dilated. The purpose of this response is to provide better perfusion to the vital organs.
Sympathetic-adrenal-medullar response:
In addition to its effect on major end organs, sympathetic nervous system also stimulates the medulla of the
adrenal gland to release the hormones epinephrine and nor epinephrine into the blood stream. The action is
similar to the sympathetic nervous system and has the effect of sustaining and prolonging its actions. These
catecholamines stimulate the nervous system and produce increase in blood glucose level and increase
metabolic rate.
Hypothalamic-pituitary response:
The longest-acting phase of the physiologic response which occur in persistent stress, involves the
hypothalamic pituitary path way. The hypothalamus secretes corticotrophin releasing factor which
stimulates anterior pituitary to produce ACTH, which in turn stimulates adrenal cortex. Cortisol stimulates
protein catabolism releasing amino acids, stimulates liver uptake of amino acids and their conversion to
glucose and inhibit glucose uptake by many body cells but not those of the brain and heart. This cortisol
induced metabolic effects provide body with a ready source of energy during a stressful stimulation.

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Summary: -
During the session we discussed about: -
 Introduction & Definition of health
 Determinants of health
 Definition of Patho-physiology, psychodynamics and disease
 Theories of disease causation
 Pathogenies of the disease
 Role of nurse in prevention of disease
 Stress & Stressors
 General adaptation syndrome
 Sources, effect & manifestations of stress
 Hormonal response

Conclusion: -
Disease is just the opposite of the health “Disease is a condition in which body health is impaired, a
departure from the state of health, an alteration of human body interrupting the performance of vital
functions. As long as there is equilibrium among agent, host & environment factors, so long the person
will be healthy. Once the equilibrium is disturbed, disease process starts. In other words, potentially we
are all in pre-pathogenesis phases of many diseases, both communicable and non-communicable. A little
stress is helpful in coping and to adjust but beyond the limit it becomes ‘distresses. Body’s response to
stressors is called “general adaptation syndrome”. It consists of three stages: - alarm reaction, stage of
resistance & stage of exhaustion. Relaxation techniques help to relive from stress.

Bibliography: -
 Park K.Textbook of Preventive and Social Medicine, 19th Edition, Bhanot, pp. 29-36, 80-82.
 Basheer S P, A concise textbook of advanced nursing practice, 1st ed, Emmess publisher, Pp- 190-97
 Gupta Piyash and Ghai O.P., "Textbook of Preventive and Social Medicine" 2nd Edition, C.B.S.
Publishers & Distributors, New Delhi, pp 10-11
 Brunner, Sudharath, "Text Book of Medical Surgical Nursing" 11th edition, William Wilkins Lippincott.
 Navdeep kaur Brar & HC Rawat, textbook of Advanced Nursing Practice, published by Jaypee the
health science publisher, edition 1st, page no. 763-817.

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