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Stress and clinical psychosomatic problems
Zhejiang University School of Medicine
Ai-Min Bao M.D. Ph. D.
Stress (biological)
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the consequence of the failure to adapt to change.
•
in medical terms, the consequence of the disruption
of homeostasis through physical or psychological
stimuli.
•
the condition that results when person-environment
interaction leads someone to perceive a painful
discrepancy, real or imagined, between the
demands of a situation on the one hand and their
social, biological, or psychological resources on the
other.
•
Stressful stimuli may be mental, physiological,
anatomical or physical.
Stress (biological)
•
The term stress in this sense was first used by
the endocrinologist Hans Selye in the 1930s
specifically in relation to the physiological
responses of laboratory animals.
•
He later broadened and popularized the
concept to include the perceptions and
responses of ordinary people trying to adapt to
the challenges of everyday life.
•
Stress in certain circumstances may be seen
as a positive phenomenon: an evolved
adaptive response prompting activation of
internal resources to meet such challenges and
achieve realistic goals, etc.
Hans Selye, born in
Vienna ( 1907-1982)
A model of stress: General Adaptation Syndrome
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Hans Selye found
all animals exposed
to unpleasant or
harmful stimuli
presented a very
similar series of
reactions, broken
into three stages.
•
The universal
response to the
stressors: the
General Adaptation
Syndrome, or GAS.
A model of stress: General Adaptation Syndrome
Alarm
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the 1st stage, when the threat or stressor is identified or realized, the
body's stress response is a state of alarm: adrenalin will be produced in
order to bring about the fight-or-flight response. There is also some
activation of the HPA axis, producing cortisol.
Resistance
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the 2nd stage, if the stressor persists, it becomes necessary to attempt
some means of coping with it. Although the body begins to try to adapt to
the strains or demands of the environment, the body cannot keep this up
indefinitely, so its resources are gradually depleted.
Exhaustion
•
the 3rd and final stage in the GAS model, all the body's resources are
eventually depleted and the body is unable to maintain normal function. At
this point the initial autonomic nervous system symptoms may reappear
(sweating, raised heart rate etc.). If this stage is extended, long term
damage may result as the capacity of glands, especially the adrenal gland,
and the immune system is exhausted and function is impaired resulting in
decompensation. The result can manifest itself in obvious illnesses: ulcers,
depression (physical or mental illnesses).
A model of stress: General Adaptation Syndrome
Enlargement of the adrenal gland
Atrophy of the thymus
Atrophy of the lymphoid tissue
Gastric ulceration
Before
After
Signs and symptoms of poorly managed stress
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a variety of emotional, cognitive, behavioral and physical symptoms that vary
enormously among different individuals.
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Common somatic (physical) symptoms: sleep disturbances, muscle tension,
headache, gastrointestinal disturbances, and fatigue.
•
Emotional, cognitive and behavioral symptoms: nervousness, anxiety, fear,
depression, anger; distraction, ill-judge; changes in eating habits including making
poor nutritional choices.
•
none of these signs or symptoms means for certain that there is an elevated stress
level since all of them can be caused by other medical and/or psychological
conditions.
•
people under stress have a greater tendency to engage in unhealthy behaviors, such
as escape and avoidance, retrogress and dependant, hostile and aggression,
helpless and self-pity, and substance abuse: alcohol, drugs, cigarette smoking.
•
These unhealthy behaviors can further increase the severity of symptoms related to
stress, often leading to a "vicious cycle" of symptoms and unhealthy behaviors.
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The experience of stress is highly individualized.
Common sources of stress
Both negative and positive stressors can lead to stress.
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Sensory: pain, bright light
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Life events: birth and deaths, marriage, and divorce
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Responsibilities: lack of money, unemployment
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Illness: depression, obsessive compulsive disorder
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Work/study: exams, project deadlines, and group projects
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Personal relationships: conflict, deception, Break up
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Lifestyle: heavy drinking, insufficient sleep
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Environmental: Lack of control over environmental circumstances, such as food,
housing, health, freedom, or mobility
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Social: Struggles with conspecific individuals and social defeat can be potent
sources of chronic stresses
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Adverse experiences during development (e.g. prenatal exposure to maternal stress,
poor attachment histories, sexual abuse) are thought to contribute to deficits in the
maturity of an individual's stress response systems.
Model of psychological stress response in Medical Psychology
start point
factors involved
Cognitive appraisal
Life events
Social support
coping style
Personality traits
end point
Stress
response--psychosomatic
reaction
Health,
disease
When the ability to satisfy one's needs is in imbalance, an adaptation
follows involving a number of physical and psychological factors
Holmes and Rahe stress scale
---Life Events Stress Test
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In an attempt to measure life changes, Holmes and Rahe,
developed the Life Events Scale (also known as the Holmes &
Rahe Social Readjustment Rating Scale, SRRS).
•
The life events are ranked in order from the most stressful (death of
spouse) to the least stressful (minor violations of the law).
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Life events that you have experienced over the past 12 months.
Adults
Life Events
life change units
Life Events
life change units
Death of a spouse
100
Outstanding personal achievement
28
Divorce
73
Spouse starts or stops work
26
Marital separation
65
Begin or end school
26
Imprisonment
63
Change in living conditions
25
Death of a close family member
63
Revision of personal habits
24
Personal injury or illness
53
Trouble with boss
23
Marriage
50
Change in working hours or conditions
20
Dismissal from work
47
Change in schools
20
Retirement
45
Change in residence
20
Marital reconciliation
45
Change in recreation
19
Change in health of family member
44
Change in church activities
19
Pregnancy
40
Change in social activities
18
Sexual difficulties
39
Minor mortgage or loan
17
Gain a new family member
39
Change in sleeping habits
16
Business readjustment
39
Change in number of family reunions
15
Change in financial state
38
Change in eating habits
15
Change in frequency of arguments
35
Vacation
13
Major mortgage
32
Christmas
12
Foreclosure of mortgage or loan
30
Minor violation of law
11
Trouble with in-laws
29
Child leaving home
29
Change in responsibilities at work
29
(continue, Score of 300+: At risk of illness.
Score of 150-299+: Risk of illness is moderate (reduced by
30% from the above risk).
Score 150-: Only have a slight risk of illness.)
Non-adults
Life Events
life change units
Getting married
101
Unwed pregnancy
92
Death of parent
87
Acquiring a visible deformity
81
Divorce of parents
77
Fathering an unwed pregnancy
77
Becoming involved with drugs or alcohol
76
Jail sentence of parent for over one year
75
Marital separation of parents
69
Death of a brother or sister
68
Change in acceptance by peers
67
Pregnancy of unwed sister
64
Discovery of being an adopted child
63
Marriage of parent to step-parent
63
Death of a close friend
63
Having a visible congenital deformity
62
Serious illness requiring hospitalization
58
Failure of a grade in school
56
Not making an extracurricular activity
55
Hospitalization of a parent
55
Jail sentence of parent for over 30 days
53
Life Events
life change units
Breaking up with boyfriend or girlfriend
53
Beginning to date
51
Suspension from school
50
Birth of a brother or sister
50
Increase in arguments between parents
47
Loss of job by parent
46
Outstanding personal achievement
46
Change in parent's financial status
45
Accepted at college of choice
43
Being a senior in high school
42
Hospitalization of a sibling
41
Increased absence of parent from home
38
Brother or sister leaving home
37
Addition of third adult to family
34
Becoming a full fledged member of a church
31
Decrease in arguments between parents
27
Decrease in arguments with parents
26
Mother or father beginning work
26
(continue, Score of 300+: At risk of illness.
Score of 150-299+: Risk of illness is moderate. (reduced
by || 30% from the above risk)
Score 150-: Slight risk of illness..)
Adaptation to stress
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Richard Lazarus (1974): a model dividing stress into eustress and distress.
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When stress enhances function (physical or mental, such as through strength
training or challenging work): eustress.
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When stress is persistent and not resolved through coping or adaptation: distress,
may lead to anxiety or withdrawal (depression) behavior.
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The difference between experiences which result in eustress or distress is
determined by the disparity between an experience (real or imagined), personal
expectations, and resources to cope with the stress.
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cognitive processes of appraisal are central in determining whether a situation is
potentially threatening or harmful.
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Robert B. Zajonc (1984): in opposition to the Lazarus model of stress, argued that
emotional reactions occur before cognitive reactions, and in fact, may be at odds
with cognitive responses.
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consonant with the previous James-Lange hypothesis.
Adaptation to stress
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Responses to stress include adaptation, psychological coping such
as stress management, anxiety, and depression. Over the long
term, distress can lead to diminished health or illness.
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The psychological definition of coping:, the process of managing
taxing circumstances, expending effort to solve personal and
interpersonal problems, and seeking to master, minimize, reduce or
tolerate stress or conflict.
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In coping with stress, people tend to use one of the three main
coping strategies: appraisal focused, problem focused, or emotion
focused coping. (Weiten, Lloyd, 2006)
Adaptation to stress
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Appraisal-focused strategies occur when the person modifies the way they
think, for example: employing denial, or distancing oneself from the problem.
People may alter the way they think about a problem by altering their goals
and values, such as by seeing the humour in a situation.
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Problem focused strategies try to deal with the cause of their problem. They
do this by finding out information on the disease, learning new skills to
manage their disease and rearranging their lives around the disease.
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Emotion focused strategies involve releasing pent-up emotions, distracting
one-self, managing hostile feelings, meditating, using systematic relaxation
procedures, etc.
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People may use a mixture of these different types of coping, and coping
mechanisms will usually change over time.
Men often prefer problem focused coping, whereas women can often tend
towards an emotion focused response.
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Neurobiology
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In response to a stressor: CRH- and AVPexpressing neurons are activated in the
PVN of the hypothalamus and secreted
into the hypophyseal portal system.
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The locus ceruleus (LC) and other
noradrenergic cell groups of the adrenal
medulla and pons, collectively known as
the LC/NE system, also become active
and use brain epinephrine to execute
autonomic and neuroendocrine responses,
serving as a global alarm system.
•
The ANS provides the rapid response to
stress commonly known as the fight-orflight response, engaging the SNS and
withdrawing the PSNS, thereby enacting
cardiovascular, respiratory,
gastrointestinal, renal, and endocrine
changes.
cerebrum
LC
brainstem
Spinal cord
adrenal
kidney
Start of stress
Result of stress
III
nbm
pvn
son
scn
young control, blue: CRH, brick-red: AVP
activated PVN as in aging or depression:
more purple cells (=blue and red in one
cell= arrowhead) and brick-red for AVP
alone (=*). Arrow= blue cell (CRH alone)
Raadsheer et al,
Neuroendocrinology 1994
Raadsheer et al,
Am. J. Psych. 1995
Neurobiology: increased catecholamine
For defence:
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increased catabolism of glycogen and lipids, increased energy supply
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increased function of cardiovascular system, increased BP and blood supply
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redistribution of blood to insure the needs of heart and brain
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expanded bronchium for increasing oxygen supply
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promote the secretion of other hormones for compensation
Disbennifits:
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ischemia of organs
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hypertension
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increased blood viscosity, thrombosis
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over consumption of oxygen
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lipid over-oxidation
Neurobiology: interaction
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Chronic secretion of stress hormones, glucocorticoids (GCs)
and catecholamines may reduce the affect of neurotransmitters,
including serotonin, norepinephrine and dopamine, or other
receptors in the brain, thereby leading to the dysregulation of
neurohormones.
•
Under stimulation, norepinephrine is released from the
sympathetic nerve terminals in organs, and the target immune
cells express adrenoreceptors. Through stimulation of these
receptors, locally released norepinephrine, or circulating
catecholamines such as epinephrine, affect lymphocyte traffic,
circulation, and proliferation, and modulate cytokine production
and the functional activity of different lymphoid cells.
Neurobiology: Psychoneuroimmunology
Stress significantly affect immune systems.
The Immune-Brain Loop: nervous system–immune system interactions
exists at several biological levels.
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The immune system and the brain talk to each other through
signaling pathways, which is essential for maintaining homeostasis.
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Two major pathway systems are involved in this cross-talk: the
Hypothalamic-pituitary-adrenal axis (HPA axis) and the sympathetic
nervous system (SNS).
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HPA axis activity and cytokines are intrinsically intertwined:
inflammatory cytokines stimulate adrenocorticotropic hormone
(ACTH) and cortisol secretion, while, in turn, glucocorticoids
suppress the synthesis of proinflammatory cytokines.
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The activation of SNS during an immune response might be aimed
to localize the inflammatory response.
Neurobiology: Psychoneuroimmunology
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•
•
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Molecules called pro-inflammatory cytokines, which include
interleukin-1 (IL-1), IL-2, IL-6, IL-10, IL-12, Interferon-gamma (IFNGamma) and tumor necrosis factor alpha (TNF-alpha) can affect the
brain.
Immune cells called macrophages, which are the first on the scene
of any infection, create the molecules mentioned above and
experiments showed that they can act directly inside the brain by
creation of microglia and astrocytes. Cytokines are also locally
produced in the brain, especially in the hypothalamus.
Like the stress response, the inflammatory reaction is crucial for
survival.
Recent studies show pro-inflammatory cytokine processes take
place during depression, mania and bipolar disease, in addition to
autoimmune hypersensativity and chronic infections.
Social Psychology: the application in the clinic
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we are all affected by the people we interact with, many of
whom we don't even know personally.
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our social environments play a significant role in how we view
ourselves, and conversely, how we see ourselves impacts our
view of the world.
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the various aspects of social psychology, i.e. the interaction
between our view of self and others, the role of power in social
interactions, and the groups, or the people with whom we
interact, affect our decision making process.
Social Psychology
Our View of Self and Others
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The way we look at ourselves plays an important role in how we see the
world, and vice versa.
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attribution (how we interpret those around us) and attraction (what we seek
in a friend or partner).
Attribution Theory
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Attribution: An idea or belief about the etiology of a certain behavior.
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we tend to explain our own behavior and the behavior of others by
assigning attributes to these behavior.
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There are basically two sources for our behavior; those influenced by
Situational (external) factors and those influenced by Dispositional (internal)
factors. Imagine walking into your boss's office and he immediately tells
you, in an angry tone, not to bother him. your explanation of this behavior
might be...
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Our view of the world, previous experience with a particular person or
situation, and our knowledge of the behavior play an important role.
There are two important errors or mistakes we tend to make
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Social Psychology
Attribution Theory: two important errors or mistakes
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Fundamental Attribution Error: the tendency to over estimate the
internal and underestimate the external factors when explaining the
behaviors of others. This may be a result of our tendency to pay
more attention to the situation rather than to the individual (Heider,
1958) and is especially true when we know little about the other
person. For example, you were driving and got cut off, did you say
to yourself "What an idiot" (or something similar), or did you say
"She must be having a rough day.“?
•
Self-Serving Bias. We tend to equate successes to internal and
failures to external attributes (Miller & Ross, 1975). For example,
when getting a promotion most of us will feel that this success is
due to hard work, intelligence, dedication, and similar internal
factors. But if you are fired… This bias is true for most people, but
for those who are depressed, have low self-esteem, or view
themselves negatively, the bias is typically opposite. For these
people, a success may mean that a multitude of negatives have
been overlooked or that luck was the primary reason. For failures…
Social Psychology
Attraction: Why are we attracted to certain people and not others? Why
do our friends tend to be very similar to each other? And what
causes us to decide on a mate? Many of these questions relate to
social psychology in that society's influence and our own beliefs
and traits play an important role. Research has found five reasons
why we choose our friends:
•
•
•
•
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Proximity - The vast majority of our friends live close to where we
live, or at least where we lived during the time period the friendship
developed (Nahemow & Lawton, 1975).
Association - We tend to associate our opinions about other people
with our current state.
Similarity - The agreement or similarity in between would likely
result in more attractiveness (Neimeyer & Mitchell, 1988).
Reciprocal Liking - We tend to like those better who also like us
back. When we feel good when we are around somebody, we tend
to report a higher level of attraction toward that person (Forgas,
1992; Zajonc & McIntosh, 1992)
Physical Attractiveness - Physical attraction plays a role in who we
choose as friends, although not as much so as in who we choose
as a mate.
Introduction of Social Psychology
Obedience and Power: Why do we obey some people and not others? Why are
you able to influence your patients? What attributes cause a person to be
more influential? These questions are paramount in understanding social
order.
Power is typically thought of has having a certain attribute which gives one
person more influence over another. This attribute could be intelligence or
experience, it could be job title, or perhaps money.
According to most social psychologists, there are five types of power: coercive,
reward, legitimate, expert, and referent.
•
•
•
•
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Coercive power: the power punish. For example, parents are said to have coercive
power because they can place their child in time-out; boss…
Reward power: the power to reward. Parents and bosses have this type of power as
well…
Legitimate power: the power granted by some authority.
Expert power: results from experience or education. Those individuals with more
knowledge tend to have more power in situations where that knowledge is
important. For instance, the physician in a medical emergency, a plumber when the
pipes explode...
Referent power: admiration or respect. When we look up to people because of their
accomplishments, their attitude, or any other personal attribute, we tend to give them
more power over us.
Introduction of Social Psychology
Using Power to Influence Others
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the others (source) influence us (target), or a medical doctor influences his
patient with power. The more types of power and the stronger each of
them is, the more influential he/she will be.
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a person must be believable in order to influence the others, must be
trustworthy, otherwise much more difficult to change the others’ minds.
•
attractiveness plays a role in how influence the others. We tend to be
influenced more by attractive people, including physical and social
attractiveness, likeability, demeanor, and dress.
•
the target or listener plays a role in how he will be influenced as
well. Those with low self-esteem and/or high self-doubt tend to be more
influenced than others.
•
other factors such as age, IQ, gender, or social status do NOT appear to
play a significant role in how we are influenced by others.
•
the relationship between the source and the target plays important role:
similarity, a moderate discrepancy in attitude---the difference must be great
enough that a change is possible but small enough that the listener is open
to the change.
Introduction of Psychopathology
Classifying Psychopathology
Mental illness is classified today according to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM IV), published by the
American Psychiatric Association (1994).
The DSM uses a multiaxial or multidimensional approach to diagnosing because
rarely do other factors in a person's life not impact their mental health.
It assesses five dimensions as described below:
Axis I: Clinical Syndromes: what we typically think of as the diagnosis (e.g.,
depression, schizophrenia, social phobia)
Axis II: Developmental Disorders and Personality Disorders:
Developmental disorders include autism and mental retardation, disorders which
are typically first evident in childhood;
Personality disorders are clinical syndromes which have a more long lasting
symptoms and encompass the individual's way of interacting with the
world. They include Paranoid, Antisocial, and Borderline Personality
Disorders.
Introduction of Psychopathology
Axis III: Physical Conditions which play a role in the development, continuance,
or exacerbation of Axis I and II Disorders
Physical conditions such as brain injury or HIV/AIDS that can result in symptoms
of mental illness are included here.
Axis IV: Severity of Psychosocial Stressors: Events in a persons life, such as
death of a loved one, starting a new job, college, unemployment, and even
marriage can impact the disorders listed in Axis I and II. These events are
both listed and rated for this axis.
Axis V: Highest Level of Functioning: the clinician rates the person's level of
functioning both at the present time and the highest level within the
previous year.
Introduction of Psychopathology
Psychiatric Disorders (the first two axes in more detail as these are what we
typically think of when we think of mental illness or psychopathology).
The DSM IV identifies 15 general areas of adult mental illness.
1. Delirium, Dementia, Amnestic, and Other Cognitive Disorders
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The primary symptoms of these disorders include significant negative
changes in the way a person thinks and/or remembers. All of these
disorders have either a medical or substance related cause.
2. Mental Disorders Due to a Medical Condition
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are directly related to a medical condition.
3. Substance Related Disorders
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two disorders listed: Substance Abuse and Substance Dependence. Both
involve the ingestion of a substance (alcohol, drug, chemical) which alters
either cognitions, emotions, or behavior.
4. Schizophrenia and other Psychotic Disorders
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The major symptom of these disorders is psychosis, or delusions and
hallucinations. The major disorders include schizophrenia and
schizoaffective disorder.
5. Mood Disorders
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The disorders in this category include those where the primary symptom is
a disturbance in mood. The disorders include Major Depression,
Dysthymic Disorder, Bipolar Disorder, and Cyclothymia.
6. Anxiety Disorders
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Anxiety Disorders categorize a large number of disorders where the
primary feature is abnormal or inappropriate anxiety. The disorders in this
category include Panic Disorder, Agoraphobia, Specific Phobias, Social
Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder,
and Generalized Anxiety Disorder.
7. Somatoform Disorders
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Disorders in this category include those where the symptoms suggest a
medical condition but where no medical condition can be found by a
physician. Major disorders in this category include Somatization Disorder,
Pain Disorder, Hypochondriasis.
8. Factitious Disorder
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Factitious Disorder is characterized by the intentionally produced or feigned
symptoms in order to assume the 'sick role.' These people will often ingest
medication and/or toxins to produce symptoms and there is often a great
secondary gain in being placed in the sick role and being either supported,
taken care of, or otherwise shown pity and given special rights.
5. Mood Disorders
•
The disorders in this category include those where the primary symptom is
a disturbance in mood. The disorders include Major Depression,
Dysthymic Disorder, Bipolar Disorder, and Cyclothymia.
6. Anxiety Disorders
•
Anxiety Disorders categorize a large number of disorders where the
primary feature is abnormal or inappropriate anxiety. The disorders in this
category include Panic Disorder, Agoraphobia, Specific Phobias, Social
Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder,
and Generalized Anxiety Disorder.
7. Somatoform Disorders
•
Disorders in this category include those where the symptoms suggest a
medical condition but where no medical condition can be found by a
physician. Major disorders in this category include Somatization Disorder,
Pain Disorder, Hypochondriasis.
8. Factitious Disorder
•
Factitious Disorder is characterized by the intentionally produced or feigned
symptoms in order to assume the 'sick role.' These people will often ingest
medication and/or toxins to produce symptoms and there is often a great
secondary gain in being placed in the sick role and being either supported,
taken care of, or otherwise shown pity and given special rights.
9. Dissociative Disorders
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The main symptom cluster for dissociative disorders include a disruption in
consciousness, memory, identity, or perception. In other words, one of
these areas is not working correctly causing significant distress within the
individual. The major diagnoses in this category include Dissociative
Amnesia, Dissociative Fugue, Depersonalization Disorder, and Dissociative
Identity Disorder.
10. Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders
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These disorders are all related to sexuality, either in terms of functioning
(Sexual Dysfunctions), distressing and often irresistible sexual urges
(Paraphilias), and gender confusion or identity (Gender Identity Disorder. It
should be noted that for these, as well as many other categories, a medical
reason should always be ruled out before making a psychological
diagnosis.
11. Eating Disorders
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Eating disorders are characterized by disturbances in eating
behavior. There are two types: Anorexia Nervosa and Bulimia Nervosa.
12. Sleep Disorders
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All sleep disorders involve abnormalities in sleep in one of two categories,
dysomnias and parasomnias.
13. Impulse Control Disorders
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Disorders in this category include the failure or extreme difficulty in
controlling impulses despite the negative consequences.
14. Adjustment Disorders
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This category consists of an inappropriate or inadequate adjustment to a
life stressor. Adjustment disorders can include depressive symptoms,
anxiety symptoms, and/or conduct or behavioral symptoms.
15. Personality Disorders
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Personality Disorders are characterized by an enduring pattern of thinking,
feeling, and behaving which is significantly different from the person's
culture and results in negative consequences. This pattern must be
longstanding and inflexible for a diagnosis to be made.
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There are ten types of personality disorders, all of which result in significant
distress and/or negative consequences within the individual: Paranoid
(includes a pattern of distrust and suspiciousness, Schizoid (pattern of
detachment from social norms and a restriction of emotions), Schizotypal
(pattern of discomfort in close relationships and eccentric thoughts and
behaviors), Antisocial (pattern of disregard for the rights of others, including
violation of these rights and the failure to feel empathy), Borderline (pattern
of instability in personal relationships, including frequent bouts of clinginess
and affection and anger and resentment, often cycling between these two
extremes rapidly), Histrionic (pattern of excessive emotional behavior and
attention seeking), Narcissistic (pattern of grandiosity, exaggerated selfworth, and need for admiration), Avoidant (pattern of feelings of social
inadequacies, low self-esteem, and hypersensitivity to criticism),
Dependent (pattern of feeling as helpless and fearful), and ObsessiveCompulsive (pattern of obsessive cleanliness, perfection, and control).
Psychosomatic disorders
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illness or disorder whose symptoms are caused by mental processes of the
sufferer rather than immediate physiological causes.
•
Some physical complaints may have a psychological cause: hysterical
paralysis, somatization disorder, and tension myositis syndrome, etc., while
some physical conditions can cause psychological symptoms: vitamin
deficiency, brain injury, etc. Peptic ulcers were once thought to be the result
of stress and are still considered to be psychosomatic, but also have been
proven to have a connection to the H-Pylori bacteria.
•
Often are attributed to a result from stress--- stress management plays an
important role in the development, amelioration or avoidance of
psychosomatic illness.
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Various types of psychotherapy and alternative therapies are used to treat
psychosomatic disorders. In some cases, psychosomatic problems may
improve or disappear following suggestion by a recognized authority.
Evolution of Psychosomatic Diagnosis in DSM
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Recognition of the interaction of "psyche" and "soma" dates from antiquity,
only in modern times have we developed the vocabulary and concepts .
•
The first DSM developed between 1946 and 1951, just after World War II,
with the new rubric: ‘Psycho-physiological Autonomic and Visceral
Disorders," with an explanation: "This term is used in preference to
‘psychosomatic disorders’ since the latter refers to a point of view on the
discipline of medicine as a whole rather than to certain specified conditions.’
The psychophysiological disorders were subcategorized into "reactions" of
various organ systems: musculoskeletal, cardiovascular, gastrointestinal,
genitourinary, endocrine, etc.
•
DSM-II was published 16 years later. By then, psychoanalysis had become
established in American psychiatry, with an emphasis on clinical
observation and the idiographic approach. Psychosomatic conditions
became "Psychophysiological Disorders," with "autonomic and visceral"
dropped.
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Subsequently, questions about psychoanalysis continued to increase,
accompanied by advances in the basic and applied neurosciences relevant
to mental disorders. American Psychiatry became more scientific, with an
emphasis on evidence-based diagnosis and treatment resting on data
derived from appropriately designed research, and it became more
neurobiological. Unfortunately, this new knowledge was applied within the
tired old biomedical model rather than a "bio-psycho-social" model.
Evolution of Psychosomatic Diagnosis in DSM
•
In the vastly changed nature of DSM-III, "Psychophysiological Disorders" was
removed. Instead, there was a new category designated as "Psychological
Factors Affecting Physical Condition.“, the nature of which speaks for itself.
•
A new feature of DSM-III: a "multiaxial" format, in which preexisting
personality disorders or mental retardation, concomitant medical conditions,
stressors, and functional capacity were included. With this incorporation of
psychological, biological, and social factors into a dynamic framework, this
system has the capacity to portray nonlinear psychosomatic causal adaptive
processes.
•
Fourteen years later, DSM-IV, with the same overall design as its
predecessor, continued the same trends. "Psychological Factors Affecting
Medical condition" was substituted for ".... Physical" condition, a further
narrowing. More significant, this rubric no longer had the status of a category
in itself, but became one of a series of subsections within the category "Other
Conditions that May Be a Focus of Attention," grouped with medicationinduced problems, relationship problems, abuse, etc: dilution of the concept
of psychosomatic processes.
•
As we look ahead toward the next DSM, we need to confront a fundamental
and important question: Should there be a category for "Psychosomatic
Disorders" at all? Psychological and biological factors are involved in all
aspects of human function, healthy and disordered.
Theories concern psychosomatic disorders
Psychodynamics: try to bridge the gap
created by mind-body dualism in medicine.
Psychoanalytic theory became the guiding
principle and psychoanalysis was the mode
of treatment.
Freud and his subjective data of
consciousness. Verbal therapy.
It did not provide objectively testable
hypothesis, could not be proven or disproven
scientifically.
It did not make clear the relationships
between behavior and health and illness nor
generate empirical research supporting the
efficacy of talking therapy as an intervention
Theories concern psychosomatic disorders
Psychobiology:
Try to apply the principles of biology to the study of mental
processes, behavior (and psychosomatic disorders), such as seen in
the neurobiology of stress.
Measure some biological variable, e.g. an anatomical, physiological,
or genetic variable, in an attempt to relate it quantitatively or
qualitatively to a psychological or behavioral variable, and thus
contribute to evidence based practice.
The distinguishing characteristic of a biological psychology
experiment is that either the independent variable of the experiment
is biological, or some dependent variable is biological.
---Disabling or decreasing neural function
---Enhancing neural function
---Measuring neural activity
---Genetic manipulations
Theories concern psychosomatic disorders
Social Learning theory:
learned emotional or psychophysiologic responses are a factor in the
causation of psychosomatic disorders, such illnesses lend themselves
to treatment with behavior therapy.
A behavior analysis must be done initially to establish a correlation
between the psychological factors and the somatic illness.
Expectancies can lead to pathology when they are irrationally low:
people have low expectancies---they do not believe their behaviors will
be reinforced---they put little effort into their behaviors---they are likely
to fail---it confirms their low expectancies (a vicious cycle).
Key points of diagnosis of psychosomatic disorders
Determine somatic symptoms that have clear pathophysiological courses
or organic pathological basis.
Search for psycho-social factors that correlate to the somatic symptoms, in
time or with logic of the development and the appearance of disorders.
Exclude somatic diseases and neuroses
Procedures of diagnosis of psychosomatic disorders
Medical history collection: besides common clinical medical history
collection, collect patients’ psycho-social material such as personality
development, temperament, behavior traits, life events and social
support.
Physical examination
Psychological assessment: conversation, interview, observation,
psychological test or even psychobiological tests.
Integrated analysis
Treatment: Treat the body and mind together
Psychological interference:
remove the psycho-social stimulus: social, cultural, and environmental
remove the psychological factors: pre-morbidity personality, mood,
psychological stresses, special life style and behaviors
treat the biological symptoms
Pre-morbidity personality: Type A Behavior Pattern, characterized by
impatience, time urgency, competition and hostility, was originally
developed in relation to coronary heart disease, increased risks in road
traffic accidents; Type B Behavior Pattern, relaxed manner, patience, and
friendliness that possibly decreases one's risk of heart disease.
Mood: depression and ulcer; chronic anxiety, depression, nervous and fear
correlate to tension headache; continuous or discontinuous mood
disorders before outbreak of cerebral vascular diseases
Psychological stresses: negative life events, low-level social support
special life style and behaviors: smoking; over-eating; no exercises;
alcohol abuse; exposure to the toxic, violence or guns; sexual behavior;
drug abuse; speeding…
Clinician-patient communication
Factors involve patients seeing (a) doctor(s)
•
Subjective feeling about a disease or symptom
•
Quality and quantity of the symptoms
•
Effects of psycho-social factors
Psychological needs of patients: being accepted, being respected, being
informed the diagnosis and the treatment, and being safe
Factors involve ‘adherence to medical recommendations’ (the extent to which a
person's behavior coincides with medical or health advice, such as taking
medication regularly, returning to a doctor's office for follow-up
appointments, and observing preventive and healthful lifestyle changes)
•
Subjective feeling of the disease and its severity
•
Treatment regime and its convenience
•
Patients’ obedience
Strategies to encourage adherence
•
intrapsychic factors: knowledge of the regimen, belief in benefits of
treatment, subjective norms, and attitudes toward medication-taking
behavior
•
environmental and social factors: the interpersonal relationship between
the provider and the patient and social support from family members and
friends.
Build clinician-patient relationships
•
when patients take more
responsibility and initiative, put
more effort into improving their
health-related habits and selfmanagement skills, things usually
improve.
•
many patients still expect medical
interventions and interveners to
fix them.
•
A growing number of providers
seek to alter patient preferences
and expectations by explaining
the advantages of a shift in roles,
however gradual the shift may
need to be in a particular
situation, using concrete
examples that relate to the
patient.
•
•
•
active-passive mode
Guide-cooperative mode
Cooperative mode
Clinician-patient communication: patient role adaptation
•
The patient has to change his role of other social identity into a
patient identity, but if his need/motivation in other social identity is
larger than his motivation pursuing therapy for disease…
•
In the early stage of disease that diagnosed by clinician, the patient
denies it or would not accept it…
•
The other social identities of the patient impact the patient and
make him take actions that he should not…
•
Or the patient is content with the role of patient and wish to enjoy
the benefit of being a patient
•
Pessimistic, disappointed, bad mood; abnormal behavior e.g.
aggressive, stubborn, depressive, suicide.
OLD ROLES
NEW ROLES
Defer to provider’s authority
Share responsibility for own health
Be passive. Be “fixed” by provider
Be active. Self-manage health & condition (Provider
supplies expert coaching, support, and sometimes
direction)
Share history, when asked
Share goals, history, values, beliefs and preferences; If
necessary, be assertive
Follow provider orders
Decide what to do with support from provider
Rely on provider to solve problems
Seek provider support for solving problems
Learn about condition from provider
Learn from provider; inform self, too. Scan environment
for new information
Respond to provider questions about progress during
clinical encounters
Monitor own progress between visits; share during
visits.
Don’t worry about medications (it’s all in the medicine
cabinet)
Share responsibility for keeping medication list up to
date
Build clinician-patient relationships
•
Patients self-Management Support aims for consistent care based
on strong respectful relationships among patients, families, and
health care providers, that can grow over time with the providers
and patients making them stronger.
•
Patients who report that their clinicians know them as people, who
experience trust, empathy and respect, and who are provided with
choices and options are more likely to participate actively in
treatment and self-management and, as a result, experience
improved outcomes.
•
Physicians must be:
Altruistic―compassionate, empathetic, trustworthy, truthful,
professional, and aware of personal limits;
Knowledgeable―biomedical knowledge related to diseases
pathogenesis;
Skillful―eliciting histories and performing physical examinations,
technical procedures, critical care, communicating, relieving pain;
Dutiful― includes knowledge of nonbiological determinants of poor
health (social, psychological, and behavioral factors are relegated
to this "nonbiological" category).
Build Relationships
The following specific communication skills can help clinicians and other
team members build effective collaborative relationships with
patients and families:
Ask open-ended questions – invite the patient to share their “story,” not
just about immediate health problems. For example: “What is most
important to you now?” “Tell me about…”
Use reflective listening – seek to understand the meaning of the story.
Express empathy – seek to comprehend the patient’s perspective
Respond to and reflect feelings, concerns, beliefs, values - “You are quite
frustrated and upset about...”
Normalize – “Many people experience…”
Affirm – “You have been doing what you can…”
Self-disclose (when appropriate).
Psychological Aspects of Coping with Cancer
•
A diagnosis of cancer often brings up one of people’s worst health fears.
•
Most adults and children are actually psychologically resilient in coping with
cancer.
•
Resilience does not mean that one is forced into thinking positively all of the
time. Most studies show that feigning a positive attitude may actually become
an added stressor.It may be perfectly OK to be sad and angry.
•
For many, a good coping strategy is to find out as much information as one can
about the specific cancer.
•
It is also a good idea to put together two support teams, the first a support and
comfort team, and the other a medical and psychosocial team, the former may
be family and close friends while the latter might consist of oncologists,
surgeons, nurse practitioners, bedside nurses, a psychologist, a psychiatrist, a
social worker and clergy.
•
A close working relationships between the medical-psychosocial team
members will be extremely important for purposes of coordinating treatments
and for communicating and addressing an adult’s or a child’s needs throughout
treatment.
Psychological Aspects of Coping with Cancer
•
•
•
•
Shock - fear period
Deny - doubt period
Anger - depression period
Acceptance - adaptation period
Psychological Aspects of Coping with Cancer
•
Several factors such as how well he/she developed his/her coping
strategies and stress management skills contribute to how well one adjusts
to anything in life, especially cancer
•
Coping strategies and stress management skills can be learned.
•
Psychologists working with cancer patients and their families try to assess
how well people have faired in the past, not only weaknesses, but also
strengths. They try to work with those strengths to come up with good,
compatible coping strategies, help patients develop stress management
skills.
•
Problems concerning cancers can be acute or chronic, e.g., vomiting due
to recent chemotherapy and/or with several courses followed; work security,
insurance coverage, child care, financial pressures, problematic
interpersonal relationships, etc.
•
Children or adults with prior histories of emotional or mental health
problems often face great challenges in coping with cancer and its
treatments..
Psychological Aspects of Coping with Cancer
•
The fear of death, especially true if someone from their family has died of
cancer. While it will not necessarily impact outcome, feeling this way
certainly does not help treatment.
•
Stress and fear may also come from a recent personal loss: having
someone very close die, a loss of functioning (i.e. being unable to walk
straight after years of no treatment), loss of a role, or a loss of a breast or a
limb. Sometimes, psychotherapy and/or medication are indicated, which is
especially true when someone becomes so depressed and begin to
contemplate suicide.
•
Previous experiences often play an important role in determining one’s
adjustment to cancer: serious physical or emotional trauma such as a
history of early childhood abuse, combat experiences, a history of rape, or
even emotional abuse.
•
Three other scenarios related: symptom tolerance, conditioned to being
anxious when going to receive treatments (classically conditioned vomiting),
and treatments associated with changes in mood or mental functioning
(“iatrogenic effects”, a fancy way of saying treatment-related effects).
Psychological Aspects of Coping with Cancer
While it may raise the worst of fears in adults and children,
thanks to modern treatments, a diagnosis of cancer is
not always fatal. But, there is plenty that can be done
psychologically to cope with the medical or
psychological aspects of cancer with humanity,
understanding, courage and dignity.
Sleep and insomnia
•
Sleep is a natural state of bodily rest
observed throughout the animal kingdom. It
is common to all mammals and birds, and
is also seen in many reptiles, amphibians
and fish.
•
Regular sleep is essential for survival.
However, its purposes are only partly clear
and are the subject of intense research.
•
In mammals and birds the measurement of
eye movement during sleep is used to
divide sleep into the two broad types of
Rapid Eye Movement (REM) and NonRapid Eye Movement (NREM) sleep.
•
Each type has a distinct set of associated
physiological, neurological and
psychological features.
Sleepy men in Tehran, Iran
•
Sleep proceeds in cycles of REM and the four
stages of NREM, the order normally being:
stages 1 -> 2 -> 3 -> 4 -> 3 -> 2 -> REM.
•
In humans this cycle is on average 90 to 110
minutes, with a greater amount of stages 3
and 4 early in the night and more REM later in
the night.
•
Each phase may have a distinct physiological
function. Drugs such as sleeping pills and
alcoholic beverages can suppress certain
stages of sleep. This can result in a sleep that
exhibits loss of consciousness but does not
fulfill its physiological functions.
•
Allan Rechtschaffen and Anthony Kales
originally outlined the criteria for identifying
the stages of sleep in 1968. The American
Academy of Sleep Medicine (AASM) updated
the staging rules in 2007.
Stage 4 Sleep. EEG highlighted by red box.
REM Sleep. EEG highlighted by red box. Eye
movements highlighted by red line.
•
•
Stages of sleep
Criteria for REM sleep include not only rapid eye movements but
also a rapid low voltage EEG. In mammals, at least, low muscle
tone is also seen. Most memorable dreaming occurs in this stage.
NREM accounts for 75–80% of total sleep time in normal human
adults, relatively little dreaming, encompasses four stages:
--- stages 1 and 2: 'light sleep',
--- stages 3 and 4: 'deep sleep‘, or slow-wave sleep, SWS.
--- they are differentiated solely using EEG
--- there are often limb movements, and parasomnias such as
sleepwalking occurs here.
--- A cyclical alternating pattern (CAP, occurs in sleep, characterized
as periodic episodes of aroused EEG activity (more Sleep spindles
and K-complexes) followed by a period of more quiet sleep. Both
these periodic activities, when combined, are considered the CAP
period) may occur while does not occur in REM
NREM consists of four stages according to the 2007
AASM standards:
•
During Stage N1 the brain transitions from
alpha waves (having a frequency of 8 to 13 Hz,
common to people who are awake) to theta
waves (frequency of 4 to 7 Hz). This stage is
sometimes referred to as somnolence, or
"drowsy sleep". Associated with the onset of
sleep during N1 may be sudden twitches and
hypnic jerks also known as positive myoclonus.
During N1 the subject loses some muscle tone
and conscious awareness of the external
environment.
•
Stage N2, is characterized by "sleep spindles"
(12 to 16 Hz) and "K-complexes.“, muscular
activity as measured by electromyography
(EMG) lowers and conscious awareness of the
external environment disappears. This stage
occupies 45 to 55% of total sleep.
•
In Stage N3, the delta waves (0.5 to 4 Hz), also called
delta rhythms, make up less than 50% of the total
wave-patterns. This is considered part of deep or slowwave sleep (SWS) and appears to function primarily as
a transition into stage N4. This is the stage in which
night terrors, bedwetting, sleepwalking and sleeptalking occur.
•
In Stage N4, delta-waves make up more than 50% of
the wave-patterns. Stages N3 and N4 are the deepest
forms of sleep; N4 is effectively a deeper version of N3,
in which the deep-sleep characteristics, such as deltawaves, are more pronounced. In a recent ruling by the
AASM, in order to make precision the scoring
guidelines, stage four had been disbanded, and left is
the stage of sleep N3 to describe the delta sleep
attributed to it.
•
Both REM sleep and NREM sleep stages 3 and 4 are
homeostatically driven; that is, if a person or animal is
selectively deprived of one of these, it rebounds once
uninhibited sleep again is allowed. This suggests that
both are essential to the functions of the sleep process.
Sleeping Japanese Macaques.
Sleep stages
SWS
NREM
Ortho-sleep
Shallow sleep
FWS
REM
paradoxical sleep
Deep sleep
↓
↓↓
The
Somatic ↓
Nervous
System
(muscle tone )
↓↓
The
Autonomic ↓
Nervous
System
(viscera)
↖↘
cortex
(consciousness)
FW,EM,glands
secretion,
cardiovascular,
respiratory,
reproduction,
dreaming
Sleep deprivation
•
a general lack of the necessary amount of sleep, may occur as a result of
sleep disorders, active choice or deliberate inducement.
•
Some evidence of effects on the brain: prefrontal cortex displayed more
activity in sleepier subjects. The temporal lobe involved in language
processing was activated during verbal learning in rested subjects but not
in sleep deprived subjects. The parietal lobe was more active when the
subjects were deprived of sleep, associated with better memory. There are
links to more serious diseases, such as heart disease and mental illnesses,
such as psychosis and bipolar disorder. REM sleep deprivation was found
to alleviate clinical depression: sleep deprivation mimics the effects of
SSRI? However it was also indicated that REM sleep was essential for
blocking neurotransmitters and allowing the neurotransmitter receptors to
"rest" and regain sensitivity which in turn leads to improved regulation of
mood and increased learning ability. Non REM sleep may allow enzymes
to repair brain cell damage caused by free radicals. High metabolic activity
while awake damages the enzymes themselves preventing efficient repair.
Animal studies suggest that sleep deprivation increases stress hormones
(such as cortisol and norepinephrine), which may reduce new cell
production in adult brains.
Sleep interpretation
•
Starting around 300 BC, ancient Greece, the
pilgrims flocked to asclepieia to be healed. They
slept overnight and reported their dreams to a
priest the following day. He prescribed a cure,
often a visit to the baths or a gymnasium.
•
In ancient Egypt, priests also acted as dream
interpreters
•
It was taken up as part of psychoanalysis at the
end of the 19th century; the perceived, manifest
content of a dream is analyzed to reveal its latent
meaning to the psyche of the dreamer. One of the
seminal works on the subject is The Interpretation
of Dreams by Sigmund Freud.
•
Freud argued that the foundation of all dream
content is wish-fulfilment, and that the instigation
of a dream is always to be found in the events of
the day preceding the dream.
Statue of Asclepius with his symbol,
the serpent-entwined staff
Ruins of the Askleipion on Kos
Sleep interpretation
•
Freud claimed, small children dream quite
straightforwardly of the fulfilment of wishes that were
aroused in them the previous day (the 'dream day'), while
the dreams of adults have been subjected to distortion
with the dream's so-called 'manifest content' being a
heavily disguised derivative of the 'latent' dream-thoughts
present in the unconscious.
•
in the more refined terminology of Freud later years,
discussion was in terms of the super-ego and 'the work of
the ego's forces of defence'. In waking life, he asserted,
these so-called 'resistances' altogether prevented the
repressed wishes of the unconscious from entering
consciousness; and though these wishes were to some
extent able to emerge during the lowered state of sleep,
the resistances were still strong enough to produce 'a veil
of disguise' sufficient to hide their true nature.
•
Freud's view was that dreams are compromises which
ensure that sleep is not interrupted: as 'a disguised
fulfilment of repressed wishes', they succeed in
representing wishes as fulfilled which might otherwise
disturb and waken the dreamer.
Sleep disorders: Insomnia
A symptom characterized by persistent difficulty falling
asleep or staying asleep despite the opportunity. It is
typically followed by functional impairment while
awake.
Occurs 1.4 times more commonly in women than in men
(the US).
About three types :
•
Transient insomnia lasts from days to weeks, can be
caused by another disorder, changes in the sleep
environment, the timing of sleep, severe depression,
or stress. Its consequences - sleepiness and
impaired psychomotor performance - are similar to
those of sleep deprivation.
•
Acute insomnia is the inability to consistently sleep
well for a period of between three weeks to six
months.
•
Chronic insomnia lasts for years at a time. It can be
caused by another disorder, or it can be a primary
disorder. Its effects can vary according to its causes,
including sleepiness, muscular fatigue,
hallucinations, and/or mental fatigue; but people with
chronic insomnia often show increased alertness.
Sleep disorders: Insomnia
Pattern of insomnia (often is related to the etiology ) :
•
Onset insomnia - difficulty falling asleep at the beginning of the
night, often associated with anxiety disorders.
•
Middle-of-the-Night Insomnia - characterized by difficulty returning
to sleep after awakening in the middle of the night or waking too
early in the morning. Also referred to as nocturnal awakenings.
Encompasses middle and terminal insomnia.
•
Middle insomnia - waking during the middle of the night, difficulty
maintaining sleep. Often associated with pain disorders or medical
illness.
•
Terminal (or late) insomnia - early morning waking. Characteristic
of clinical depression.
Treatment of Insomnia
Cognitive behavior therapy
•
more effective than hypnotic medications,
•
patients are taught improved sleep habits and relieved of counter-productive
assumptions about sleep.
•
Hypnotic medications are equally effective in the short term treatment of
insomnia but their effects wear off over time due to tolerance.
•
The effects of cognitive behavioral therapy have sustained and lasting effects
on treating insomnia long after therapy has been discontinued.
•
Biofeedback: used in conjunction with relaxation training and other behavioral
approaches to controlling anxiety such as cognitive restructuring (which helps
people rethink just how threatening the very real stresses they need to deal
with really are) helps people recognize when they are having exaggerated
physical stress responses and what they are responding to.
Medications
•
Many insomniacs rely on sleeping tablets and other sedatives to get rest.
•
All sedative drugs have the potential of causing psychological dependence.
•
Certain classes of sedatives such as benzodiazepines and newer
nonbenzodiazepine drugs can also cause physical dependence which
manifests in withdrawal symptoms if the drug is not carefully titrated down
•
Placebo for highly suggestibility mild insomnia
Treatment of Insomnia
Benzodiazepines
•
The most commonly used class of hypnotics prescribed for insomnia
•
bind unselectively to the GABAA receptor
•
such as temazepam, flunitrazepam, triazolam, flurazepam, nitrazepam and midazolam.
•
can develop tolerance and dependence, especially after consistent usage over long
periods of time
Non-benzodiazepines
•
such as Ambien (zolpidem), Sonata (zopiclone) and Lunesta (eszopiclone), more
selective for the GABAA receptor and may have a cleaner side effect profile than the
older benzodiazepines
•
controversies over whether they are superior to benzodiazepines.
•
cause both psychological dependence and physical dependence though less than
traditional benzodiazepines; can also cause the same memory and cognitive
disturbances along with morning sedation.
•
belong to the new category of medications called sedative-hypnotics
Antidepressants
•
such as amitriptyline, doxepin, mirtazapine, and trazodone may have a sedative effect
•
The major drawback is that their antihistaminergic, anticholinergic and antiadrenergic
properties
•
can also lead to physical dependence; withdrawal may induce rebound insomnia and
actually further complicate matters in the long-term.
Treatment of Insomnia
Melatonin
•
effective for some insomniacs in regulating the sleep/waking cycle, but there
is little definitive data regarding its efficacy in the treatment of insomnia.
•
Melatonin agonists, including Ramelteon (Rozerem), seem to lack the
potential for abuse and dependence.
•
A relatively mild side effect profile and lower likelihood of causing morning
sedation.
•
Natural substances such as 5-HTP and L-Tryptophan have been said to
fortify the serotonin-melatonin pathway and aid people with various sleep
disorders including insomnia
Antihistamines
•
The antihistamine Benadryl (diphenhydramine) is widely used in
nonprescription sleep aids such as Tylenol PM, with a 50 mg recommended
dose mandated by the FDA.
•
the effectiveness of these agents may decrease over time and the incidence
of next-day sedation is higher than for most of the newer prescription drugs.
Dependence does not seem to be an issue with this class of drugs.
Atypical Antipsychotics
•
Low doses of certain atypical antipsychotics such as quetiapine (Seroquel)
are also prescribed for their sedative effect but the danger of neurological and
cognitive side effects make these drugs a poor choice to treat insomnia. Over
time, Seroquel may lose its ability to produce sedation.
Treatment of Insomnia
Other Substances
•
herbs such as valerian, chamomile, lavender, hops, passion-flower,
and even Cannabis, have been suggested as effective treatment;
relaxing essential oils help induce states of restfulness
Complementary and alternative medicine
•
Some traditional and anecdotal remedies: sleep hygiene
•
Relaxation techniques: meditation
•
Traditional Chinese medicine: acupuncture, dietary and lifestyle
analysis, herbology and other techniques
•
Buddhist tradition: meditate on "loving-kindness", or metta, generating
a feeling of love and goodwill to have a soothing and calming effect
•
Hypnotherapy: self hypnosis and guided imagery can be effective in
not only falling and staying asleep, but also in develop good sleeping
habits over time.
The Psychology of Pain
•
in the sense of physical pain, is a typical sensory
experience ‘the unpleasant awareness of a noxious
stimulus or bodily harm’
•
experience by various daily hurts and aches,
occasionally through more serious injuries or
illnesses, the response involving sensory, behavioral
(motor), emotional, and cultural components
•
For scientific and clinical purposes, pain is defined
by the International Association for the Study of Pain
(IASP) as "an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage“
•
highly subjective to the individual experiencing it, a
major symptom in many medical conditions--Chronic pain may be more debilitating than the
trauma itself, a leading cause of suicide.
•
part of the body's defense system
Components of Pain
PHYSIOLOGY
BEHAVIORAL
SENSORY
PAIN
COGNITIVE
AFFECTIVE
The Cost of Pain
• Pain inflicts significant costs on individuals, their families, the health
•
•
•
•
•
services and society in general.
The economic costs are very high due to extended hospital stays, lost
working days and increased take-up of benefits.
The cost of pain in terms of human suffering is also high.
It is often the most distressing and debilitating aspect of chronic illness.
Its effects on quality of life can be devastating to the individual and their
significant others.
The emotional toll of severe chronic pain should not be underestimated
It is estimated that around
50% of severe chronic pain patients
consider suicide.
THEORIES OF PAIN
Specificity Theory
Pattern Theory
Gate Control Theory
Specificity Theory (Von Frey, 1894)
• describes a direct causal relationship between pain stimulus and
pain experience.
Stimulation of specific pain receptors (nociceptors)
throughout the body, sends impulses along specific
pain pathways (A-delta fibres and C-fibres) through
the spinal cord to specific areas of the sensory cortex
of the brain
Stimulus intensity correlates with pain intensity;
higher stimulus intensity and pain pathway activation
resulting in a more intense pain experience.
NOCICEPTORS
Failure to identify a specific cortical location for pain,
realisation that pain fibres do not respond exclusively
to pain but also to pressure and temperature, and the
disproportional relationship between stimulus
intensity and reported pain intensity.
Pattern Theory
• Proposed stimulation of nociceptors produces a pattern of impulses
that are summated in the dorsal horn of the spinal cord.
• Only if the level of the summated output exceeds a certain threshold is
pain information transmitted onwards to the cortex: pain perception.
• Evidence of deferred pain perception raised questions:
– Soldiers not perceiving pain until the battle is over
– Phantom limb
– Injury without pain perception
• Growing evidence for a mediating role for psychosocial factors in the
experience of pain, including cross-cultural differences in pain
perception and expression.
Gate Control Theory (Melzack & Wall,1982)
Gate Control Theory
•
•
•
the perception of physical pain is not a direct result of activation of nociceptors, but is
modulated by interaction between different neurons, both pain-transmitting and nonpain-transmitting.
activation of nerves that do not transmit pain signals can interfere with signals from pain
fibers and inhibit an individual's perception of pain.
Afferent pain-receptive nerves, those that bring signals to the brain, comprise at least
two kinds of fibers - a fast, relatively thick, myelinated "Aδ" fiber that carries messages
quickly with intense pain, and a small, unmyelinated, slow "C" fiber that carries the
longer-term throbbing and chronic pain. Large-diameter Aβ fibers are nonnociceptive
(do not transmit pain stimuli) and inhibit the effects of firing by Aδ and C fibers.
The firing of the projection neuron determines pain. The
inhibitory interneuron decreases the chances that the
projection neuron will fire. Firing of C fibers inhibits the
inhibitory interneuron (indirectly), increasing the chances that
the projection neuron will fire.
Firing of the Aβfibers activates the inhibitory interneuron,
reducing the chances that the projection neuron will fire,
even in the presence of a firing nociceptive fiber. Inhibition:
blue, excitation: yellow. A lightning bolt: increased neuron
activation; crossed-out bolt: weakened or reduced
activation.
Gate Control Theory
• It explains how stimulus that activates only nonnociceptive nerves can inhibit
pain.
• One area of the brain involved in reduction of pain sensation is the
periaqueductal gray matter that surrounds the third ventricle and the cerebral
aqueduct of the ventricular system. Stimulation of this area produces
analgesia (but not total numbing) by activating descending pathways that
directly and indirectly inhibit nociceptors in the laminae of the spinal cord. It
also activates opioid receptor-containing parts of the spinal cord.
• Afferent pathways interfere with each other constructively, so that the brain
can control the degree of pain that is perceived, based on which pain stimuli
are to be ignored to pursue potential gains. The brain determines which
stimuli are profitable to ignore over time. Thus, the brain controls the
perception of pain quite directly, and can be "trained" to turn off forms of pain
that are not "useful".
• This understanding led Melzack to assert that pain is in the brain.
PSYCHOLOGICAL ASPECTS OF PAIN
• Many psychosocial factors have been investigated in relation to pain
and these appear to exert independent effects on the experience of
pain.
• eight of these factors:
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Cognitions
Self-efficacy
Perceived control
Prior experience and conditioning
Secondary gains
Personality
Mood
Stress
Cognitions
• influence the experience of pain, particularly the appraisal of situations for their
significance and meaning.
• Aspects of cognition that have received attention related to pain are:
– Attention: Increased attention to pain has been associated with increased
pain perception. This may explain why distraction techniques are useful in
combating pain.
– Dysfunctional thinking: Dysfunctional thoughts, attitudes and beliefs
about pain are automatic patterns of thinking that block the attainment of an
individual’s goals.
– Coping styles: strategies used to attempt to deal with the pain. In general,
active coping styles (e.g. keeping oneself busy) have been found to be
associated with improved coping, reduced pain intensity and improved
recovery rates.
Self-efficacy
• There is a relationship between an individual’s self-efficacy beliefs (an
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individual’s beliefs about how well they can handle a given situation) and about
their ability to manage pain (Brekke et al., 2003).
Self–efficacy beliefs may also relate to a second cognitive component that has
been associated with pain - perceived control.
Perceived control
• Bowers (1968) showed that individuals endure more pain when they
control the pain-stimulus on/off switch than when it is controlled by
someone else.
• This concept relates to the development of patient controlled
analgesia (PCA), in the management of post-operative pain and in
palliative care.
• PCA resulted in patients administering less analgesic morphine than
when it was controlled and administered by nurses or through
continuous infusion.
• PCA appears to result in better pain management, less opiate use and
earlier discharge from hospital than intramuscular therapy (Royal
College of Surgeons & Anaesthetists, 1990).
Previous Experience and Conditioning
• Both classical and operant conditioning have been implicated in the
aetiology of chronic pain via the association of behaviour and pain.
In classical conditioning theory a particular situation or
environment may become associated with pain and therefore
provoke increased anxiety and pain perception.
In operant conditioning theory, pain behaviours become
conditioned responses through positive (e.g. attention, medication,
time off work) and negative (e.g. disapproval of others, loss of
earnings) reinforcements.
Secondary Gains
• relates to social rewards accruing from the
demonstration of pain behaviours.
• to reinforce pain behaviours and thus maintain the
condition.
• However, this may actually reflect that those in
receipt of compensation can allow themselves
appropriate time to recover and says nothing
about the quality of life of those who returned to
work earlier.
• For many individuals, pain results in the loss of
jobs, social contact, leisure activities, valued
identities, reduced incomes and concomitant
reduced standard of living.
• Such losses are very real and distressing and are
often associated with substantial hardships,
lowered mood and loss of self-esteem, unlikely to
be outweighed by incidental benefits.
Time off work
Financial benefits
Receiving attention
Personality
• It has been suggested that there is a pain-prone personality
(Engel, 1959):
Features of the pain prone personality include continual
episodes of varying chronic pain, high neurotic symptoms
(guilt feelings, anxiety, depression and hypochondria)
• Generally, empirical support for the pain-prone personality has
not been forthcoming and it has been suggested that the higher
scores for particular personality factors (i.e. neurotic triad) may
be a consequence rather than a cause of long-term pain.
Mood
• There is a relationship between pain and anxiety
– Acute pain increases anxiety. But once pain is decreased
through treatment, the anxiety also decreases, which can
cause further decreases in the pain, a cycle of pain reduction.
– Chronic pain remains unalleviated by treatment and therefore
anxiety increases which can further increase the pain, creating
a cycle of pain increase.
• Depression is also commonly associated with pain.
People who experience severe and persistent pain
often have feelings of hopelessness, helplessness and despair.
• While correlations between mood states and pain have been
found, the causal direction and the nature of the relationships
remains unclear.
Stress
• Chronic pain both exacerbates and is exacerbated by stress.
• Experiencing persistent high levels of pain can itself can be a
substantial stressor, possibly even the most significant stressor in
the lives of many individuals.
• It is also often the source of additional life stresses, like loss of
employment, relationship difficulties and financial hardship.
• Individual, stereotypical physiological responses to stress (e.g.
clenching jaws, migraine headaches) can be a direct source of pain
and the physiological arousal associated with stress may lead to
increased pain and inhibit effective adaptation.
Stress is such a frequent concomitant of pain that stress management
techniques are routinely included as an integral part of pain
management programmes.
SOCIOCULTURAL INFLUENCES ON PAIN
• Several sociocultural factors have also been implicated in the
experience of pain.
• the role of:
Culture
Gender
Age
Significant others and the family
Culture
• Pain experience is expressed differently across cultural groups.
• Social learning influences pain tolerance levels, communication about
pain, pain behaviours and the meaning of pain.
• Cultural influences may encourage avoidance or acceptance of pain,
demonstrable pain behaviours or stoic concealment.
• It may also affect the treatment received within healthcare systems in
terms of cultural expectations and communication traditions.
• Further research is needed on the influence of social factors and
discrimination on the experience of pain treatment for minority
groups.
Gender
• There is much evidence to suggests that women are better at dealing
with pain than men.
• Biology, sex hormones, culture, socialization and role expectations,
psychology, and past experience have been offered as explanatory
variables.
• However, the relationship between pain and gender is complex.
• The particular type of pain, when it occurs, and the researcher’s
gender are all implicated in pain reporting.
• Skevington (1995) argues gender differences may have been
overemphasized and significant similarities exist between the sexes
regarding pain experiences and actual differences may relate to
treatment behavior and pain severity.
• Further research is needed to unpack the relationship between
gender and pain.
Age
• The experience of pain has been found to vary across the lifespan.
• Less is known about pain in children than in adults.
• Chronic pain in children appears to be under represented in the pain
literature, despite the reporting of both persistent and recurring chronic
pain by children.
• For older adults, pain may be a pervasive aspect of their lives differing
qualitatively from that experienced by younger age groups.
• The elderly are also consistently under-represented in the pain
literature and pain in this group is substantially under-diagnosed and
under-treated.
• Health psychologists should work to improve diagnostic techniques and
understanding of the pain across the lifespan, especially among
children, older adults and the way it interacts with other aspects of their
lives.
Significant others and the family
• A common concept in chronic pain research is that subjective pain
and pain related behaviour may be affected by significant others who
are perhaps one of the major reinforcers for pain-related behaviours
and chronicity.
• Spousal solicitousness may inadvertently maintain or increase the
experience of pain and disability.
• Parents are the most significant influence on a child’s pain perception,
modeling behaviours as well as reinforcing them.
• Pain within the family is likely to affect all family members and the
family will affect how they all cope.
• Further research is required with measurement instruments
specifically developed to assess the relevant variables in pain
populations need to be extended to include families and significant
others.
ASSESSMENT
• Assessment of pain is difficult and various techniques are used
singly or in combination.
• These can be grouped under one of four categories:
– Physiological measures
e.g. medical examination, EMG, heart rate, galvanic skin
response, etc.
– Pain questionnaires
e.g. McGill Pain questionnaire
– Mood assessment questionnaires
e.g. Beck’s depression inventory, HADS, etc.
– Observations
• Direct observation
• Self-observation
Issues in assessment
• Many assessment instruments are insensitive to age, disability and
culture.
• For example, for groups who have communication difficulties,
assessment may rely on the reports of significant others (e.g. carer,
interpreter) rather than the individual.
• Research that focuses on pain assessment among under represented
groups is needed.
• Similarly, more work is required to address issues around the impact
of situational context and assessor characteristics on the assessment
process.
• Further investigation is needed of the influence of assessment,
including the impact of compensation claim assessments and of the
need to prove the existence of pain and how it restricts the sufferer’s
daily activities.
MANAGEMENT OF PAIN
• several strategies:
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Behavioural strategies
Cognitive strategies
Cognitive Behavioural Therapy (CBT)
Pharmacological strategies
Physical strategies
Other strategies and approaches
Palliative care
Multidisciplinary Pain Management Centres/Programmes
Behavioural strategies
• Most are based upon operant learning processes.
• Conditioning was integral to contingency management.
This was a 2-6 week inpatient program during which nursing staff
would ignore medication requests, reinforce targeted ‘well’
behaviours, introduce increasing exercise quotas, and employ a
fixed-schedule ‘pain cocktail’.
The pain cocktail delivered medication within a strong tasting
masking fluid that allowed medication dosages to be reduced
without the patient noticing.
• While such programs have had good (even dramatic) short-term
results, they have been less successful in maintaining such gains,
possibly due to non-generalisation outside the hospital environment.
• It is rare for programmes today to focus solely on conditioning
methods.
Behavioural Strategies
• Other behavioural strategies:
– Graded exercise strategies involve setting a starting level of
activity that the person can manage and then developing a
schedule to gradually increase the length of time and intensity of
the exercise.
– Biofeedback and autogenic training teach the individual to
control aspects of their physiology. The individual receives
continuous feedback through visual and audio signals from a
machine that monitors their physiology, through which they learn
to control their response.
– Relaxation probably affects pain perception both directly and
indirectly, through its positive effects on stress and anxiety. This
may involve progressive muscle relaxation or more simply deep
rhythmic breathing. This is often used in conjunction with
meditation or imagery techniques.
Cognitive strategies
aim to help identify and understand the cognitions and the
connection with experience of pain and then change
negative cognitions, or to improve it.
teaching individuals to identify and challenge distorted
thinking – Cognitive restructuring: an active coping
technique that promotes the internal attribution of
positive changes.
--- Distraction and positive self-talk
---Imagery: forming and maintaining a pleasant, calming or coping image in the mind.
In guided imagery attention is guided away from an undesirable sensation or mood (e.g. pain) by another
person who verbally describes the image while the patient relaxes
--- Meditation: forms part of relaxation training and involves the individual focusing their
attention on a simple stimulus, to the exclusion of all other stimuli
--- Information provision: possibly by alleviating the fear and anxiety of not knowing
what to expect for acute and postoperative pain (Williams et al., 2004).
--- Self-help literature, internet information and support groups may be indicative of the
desire of people in pain to understand their experience, what to expect and potential
treatment options.
Cognitive behavioural therapy (CBT)
• utilises the full range of cognitive and behavioural techniques
already described in individualised programmes that emphasise
relapse prevention strategies.
• Stress management training is often included due to the significant
levels of stress implicated in the generation and exacerbation of
pain.
• The literature on CBT and pain suggests it shows considerable
promise as an effective treatment for pain in adults (Eccleston, et al.,
2002).
Pharmacological strategies
• Various analgesics and anaesthetics are prescribed for the
treatment of pain.
• Anaesthetics are used to numb the sensation of pain.
• However, the associated perceived high risk of addiction
has resulted in their use being restricted.
• Non-opioid analgesics, non-steroidal anti-inflamatory drugs
(NSAIDs) and drugs that control pain indirectly (e.g.
antidepressants, sedatives) are also commonly used.
• Another aspect relating to drugs is the placebo effect.
• In addition, many individuals self-medicate with recreational
drugs like alcohol and cannabis to alleviate their pain.
• However, the informal use of cannabis for pain control
and its interaction with other pain control strategies
needs further investigation.
Physical strategies
• Surgical control of pain mainly involved cutting the pain fibres
to stop pain signal transmission.
However, it provided only short-term results and the risks
associated with surgery mean it is no longer viewed as a
viable treatment option (Melzack & Wall, 1982).
• Physiotherapy may be used to increase mobility and correct
maladjusted posture, encourage exercise and movement and
education.
• Other physical strategies include the stimulation of nerves
under the skin (i.e. transcutaneous electrical nerve stimulation/
TENS treatment), massage, spinal cord stimulation, etc.
Other strategies and approaches
• Acupuncture has been around for centuries and while the
mechanisms by which it produces beneficial effects are not well
understood it does appear to exert substantial analgesic effects
(WHO, 2003).
• There is substantial, reliable evidence that hypnosis has
beneficial effects for the treatment of acute (e.g. childbirth) and
chronic pain (e.g. cancer-related) conditions.
• Individuals frequently use complementary or alternative
therapies (e.g. aromatherapy, Chinese medicine) to combat pain
and there is growing support that they help chronic pain control
(e.g. NIH, 1997).
• The widespread use of alternative strategies may reflect
dissatisfaction with mainstream approaches.
• It is important that such strategies are evaluated
independently and in conjunction with traditional
approaches
Palliative care
• the alleviation of symptoms of illness when there is no cure
available, particularly concerning terminal illness.
• Aims: to reduce suffering, fear and distress, normalise the dying
process, maintain active participation in life, increase quality of life
and maintain dignity until death for the patient.
• Terminally ill patients are often asked to take part in drug trials, even
without any expectation of the drugs helping them.
• Despite this, effective pain management underpins palliative care,
including medication, CBT and alternative therapies.
Multidisciplinary Pain Management Centres
• Pain management programmes today tend to be run on an outpatient
basis in specialist pain management centres.
• Multidisciplinary teams may include doctors, nurses,
physiotherapists, psychologists, psychiatrists, occupational therapists
and counsellors.
Individual programmes are developed that aim to improve the
individual’s quality of life by reducing pain, increasing activity and
coping, restoring function, promoting self-efficacy and selfmanagement.
• The patient receives a full assessment, education, skills training,
exercise schedules, relapse prevention and family work.
Multidisciplinary rehabilitation programmes represent the most
comprehensive approach to date, by targeting the individual’s specific
pain experience and tailoring appropriate treatment combinations.
Treatment issues
• Pain management can be a particularly controversial issue.
• Evidence suggests that in many circumstances pain is under-treated
due to (Greenwald et al., 1999):
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Inadequate assessment
Focus on underlying pathologies
Negative stereotypes and erroneous assumptions about certain population groups
Addiction fears
The inappropriateness of non-pharmacological treatments
Patients inability to verbalise pain information or requests for medication
• many prejudices and misconceptions operate in the treatment of pain
patients, with various populations being under treated for pain (Todd et
al., 2000):
Children, people with communication difficulties and the elderly
Treatment issues
• Pain is sometimes deemed to be psychogenic, resulting from emotional,
motivational or personality problems.
• However, the distinction between organic and psychogenic pain may
have little practical value.
• While psychogenic pain may represent a convenient label for cases
where underlying pathology has not been found, it has a tendency to
inherently ascribe the problem to the patient and thus promote prejudice
and injustice.
• Health psychologists must endeavour to promote the sensitive and
respectful treatment of individuals reporting pain, both within the
discipline and externally, in terms of research, intervention development,
and treatment.