Download The Relationship Between Physical and Psychological Health

The relationship between physical
and psychological health
Russell Jones
15/03/2016
15/03/2016
THE LINK BETWEEN PHYSICAL
& MENTAL HEALTH
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People react to illness in different ways, most
going through a dynamic process which
changes over time. There may be initial
worry about its cause, followed by the shock
of diagnosis and a period of adjustment as
coping strategies are formulated.
Families and carers may also enter a period
of adjustment.
Most people given time and appropriate help
can adjust to the most serious of conditions.
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DEVELOPING MENTAL HEALTH PROBLEMS
AS A CONSEQUENCE OF A PHYSICAL
CONDITION
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Approximately one quarter of people may develop
depression, anxiety, panic disorder by failing to
adjust to their physical condition.
Depression is characterised by persistent and
severe low mood, qualitatively different from ‘normal
distress’
Anxiety is characterised by severe agitation and
apprehension which is qualitatively different from
‘normal worry’.
Both have major effects on function such as sleep,
concentration, socialisation, work and normal daily
activities.
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WHAT HAPPENS WHEN DEPRESSION &
ANXIETY DEVELOP IN THE CONTEXT OF
PHYSICAL ILLNESS?
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Recovery from the physical condition is
impeded
Pain can become more difficult to control
Confidence to participate in rehabilitation
programmes is reduced
In extreme cases, the patient can come to
believe they are a burden to family or staff
and have suicidal thoughts.
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STRESS &
PSYCHONEUROIMMUNOLOGY
The study of how the body’s immune system is
affected by stress.
 The immune system protects the body from diseasecausing micro-organisms by means of specialised
lymphocytes.
 The system affects the individual’s susceptibility to
infectious diseases, allergies, cancers, and
autoimmune disorders [e.g rheumatoid arthritis, in
which the immune system attacks normal tissue].
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It is generally accepted that the mind as an organ,
processes information and interacts with the body
by producing chemical changes that initiate chain
reactions, determining both our physical and mental
health.
Nerve endings are found in the tissues of the immune
system
CNS changes alter immune response and vice versa
An immune response alters hormone and
neurotransmitter levels and vice versa
Irwin 2008.
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Some patients experience internal conflicts and struggle to express
emotions such as anger, fear, frustration, sorrow.
They develop physical symptoms that are concomitants of the
emotion but once the emotions are expressed directly, the
somatising decreases.
Positive affect is thought to release endomorphins that have a tonic
effect on organs which may contribute to health by diminishing
autonomic and endocrine activity that otherwise may diminish
immune function.
Harvard 35 year longitudinal study 1988 – students with more
positive attitudes within personality tests experienced better health
and longevity.
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EXAMPLES
Marucha 1998, dental wounds in students took 40% longer to
heal if obtained days before a stressful exam, compared to
wounds in the summer vacation. Slow healing wounds was
associated with poorer immune system functioning.
 Watson, 1999, breast cancer patients found that those more
pessimistic about future events, were more likely to develop new
tumours over a 5 year period.
 Baum, 1999, metastatic breast cancer study. Weekly support
groups versus standard care. Four years later, those not in the
group had all died whilst one third of the intervention had
survived. There was no difference in illness severity at outset
There is a strong link between neurotransmitters and the immune
system. Negative emotional states such as anxiety or
depression affect transmitter levels.
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Schleifer et al [1983] looked at the immune
system of partners of women with breast cancer,
and found significant suppression of lymphocyte
function lasting 14 months after bereavement,
and not due to pre-existing conditions.
Kiecolt [2002] observed that negative emotions
were related to poorer response to vaccines,
increased susceptibility to illness, and longer
lasting infections.
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In patients assessed with abdominal pain, fewer than 50% have a
specific diagnosis. Kroenke 1990.
Patients interpreting their gastroenteritis condition pessimistically
and expressing anxiety were more prone to developing IBS. Spence
2007.
When diabetic patients are exposed to a stressor, they can
experience a delay in glucose metabolism after eating. Wiesli 2005.
There is a relationship between depressive symptoms and
enhanced inflammatory response which can be a potential pathway
for cancer, stroke and diabetes. Fagundes 2013.
In later life, late onset depression is linked to dementia. Diniz 2013.
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WHY IS ILLNESS PERCEPTION SO
IMPORTANT?
Those who perceive their illness as more threatening
are at higher risk of depression.
Self care and management of chronic illness can also
be affected by depression.
Even a mild mental health problem in patients with
physical illness can have major effects. For example a
mild eating disorder in a diabetic patient may have
serious long term consequences disproportionate to
the nature of the severity of the eating disorder.
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HOW WELL DETECTED ARE MENTAL
HEALTH PROBLEMS IN LONG TERM
CONDITIONS
Over half of all case of depression in the general
hospital setting go unrecognised
There is an overlap of symptoms, e.g. People
with COPD may experience decreased appetite,
tightness of chest and fatigue – symptoms also
associated with anxiety and depression.
Depressed people attending general practices
usually present with non-psychological
symptoms such as pain or poor sleeping. When
a chronic physical disease is found to be
present, there is the risk of overlooking the
depression.
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Clinical barriers such as lack of time, lack of
knowledge about depression can prevent
detection of mental illness.
 Even if symptoms are discussed, staff might
reasonably regard depression and anxiety as
‘normal’ reactions to being unwell.
 In turn, patients may be reluctant to seek help
because of stigma or guilt.
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Communication…..
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Effective communication is essential to ensure
that patients’ problems and concerns are
understood by those providing care, and that
relevant information, advice and treatment are
understood and acted upon by patients.
The most common challenges reported include
imparting complex information, eliciting and
dealing with psychosocial concerns, dealing with
individuals who may lack capacity.
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Benefits of good communication
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Studies have shown that no more than half of
the information given to patients is recalled.
Patients may not have understood or recalled
the advice given or they may have beliefs
which conflict with the advice which were
never elicited by the clinician.
A common problem is the use of jargon and
technical terms. Verbal information should be
backed up by written information, easy to
follow.
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Essentials of communication
Developing trust through clinical competence
and sincerity.
 Expressing genuine interest in the patient
 Eliciting patients’ beliefs & concerns
 Acknowledging and responding to distress
 Avoiding overly complex information
 Using a collaborative, empowering approach
 Respecting privacy & confidentiality
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Empowerment
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Individual empowerment is about people having a sense
of control over their lives through building people’s
confidence, boosting their self-esteem, developing their
coping mechanisms or enhancing their personal skills.
Having a sense of control is important as it has a direct
effect on mental and physical health.
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Empowerment strategy EXAMPLES
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Dose Adjustment For Normal Eating [DAFNE] is a way of
managing Type 1 diabetes and provides people with the
skills necessary to estimate the carbohydrate in each
meal and to inject the right dose of insulin.
DAFNE Mission Statement
Our vision is to improve outcomes for people with Type 1
diabetes through high quality structured education which
is embedded in the Health Service.
The DAFNE Programme is a working collaborative of 75
diabetes services from NHS Trusts and Health Boards
across the UK and Southern Ireland.
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QUESTIONS TO ELICIT
SYMPTOMS OF DEPRESSION
Have your symptoms got you down at all?
 Do you ever get the feeling that you can’t be
bothered to do things?
 Are there things you look forward to, or does
your illness stop you?
 Has this illness affected your confidence?
 Do things ever get so bad you can’t see a
future?
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COMMON SCREENING TOOLS
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Patient Health Questionnaire
Hospital Anxiety and Depression Scale
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MEDICALLY UNEXPLAINED
SYMPTOMS
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Physical symptoms unexplained by organic
process are extremely common.
An estimated 20% of new illnesses in primary
care, and as many as 40% of all new medical
outpatient referrals are accounted for by
patients with MUS.
The more bodily complaints a person reports,
the more likely they are to report
psychological distress.
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HELPING DURING INITIAL
CONSULTATION
Patients tend to feel empowered if:
They feel understood and respected, not
dismissed.
They receive an explanation of their
symptoms
Their psychological issues are acknowledged
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Patient: are you telling me it’s all in my mind?
Nurse: no, not at all. What I think is that your body is
maybe telling you that you are under a lot of stress
and really hurting….I’m asked to see lots of patients
in this hospital and I’m yet to find an illness which
isn’t worse with stress and worry.
Making the psychosocial history part of the initial inquiry
is necessary to avoid possible hostility in a patient by
showing a sudden interest in psychological factors, after
physical investigations reveal unremarkable results.
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Those with MUS show an abnormal amplifying
perceptual style, restrictive assumptions about
health and body functions, and a tendency to
over-interpret physical sensations as possible
signs of organic disease.
Some show a memory bias for illness-related
stimuli
In other words patients with MUS have a
tendency to worry and focus upon symptoms
which may not be helpful and result in an
increase in the severity of symptoms.
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The emotional impact of being
admitted to hospital
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Admission is stressful !
The environment is alien and people have to share toilet and bedroom
facilities.
Identity is affected as outdoor clothes and belongings are removed.
Access to relatives and loved ones is restricted and people may have to
interact with many different professionals.
Those who smoke, drink, eat certain foods will find restrictions imposed.
Older people may become easily confused by a new environment and
moving to another ward can cause further disorientation.
Not all wards have interview rooms for personal conversations…the curtains
around the bed can diminish intimacy
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In the last decade, the average length of stay in acute hospital has
fallen from 14 to 6 days!
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The physical health of people with
mental illness
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Major depression doubles the lifetime risk of developing type 2
diabetes
Depression is a risk factor for developing heart disease
People with schizophrenia are 3 to 4 times more likely to develop
bowel cancer
People with schizophrenia have a 52% increase risk of developing
breast cancer
Long term use of antipsychotic drugs increases the risk of
developing metabolic syndrome which is characterised by weight
gain, high blood pressure and glucose intolerance which can lead to
diabetes.
Sudden death in schizophrenia increases incrementally with each
additional psychotropic medication taken.
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