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Define Health Behaviours
'Behaviours that are related to the health status of the individual' (Ogden, 2007)
How can health behaviours be broken down and give some examples?
- Good health behaviours: Sleeping (7-8 hours), regular exercise, healthy eating, eating breakfast every day
- Health protective behaviours: Wearing a seatbelt, attending regular check-ups, health screening
- Health impaling habits: Smoking, eating a high fat diet, alcohol abuse
Give examples for the bio-psycho-social model
- Bio: Viruses, Genetics, Bacteria
- Psycho: Behaviour, emotions, beliefs, coping, stress
- Social: Class, employment, ethnicity
Name some areas of Individual differences and health
- Emotional dispositions (present - psychological processes involved in both the experience and expression)
- Generalised expectancies (future - psychological processes involved in formulating expectations in relation to future outcomes )
- Explanatory styles (past - psychological processes involved in explaining the causes of negative events)
What personality traits analysis can be used when analysing emotional disposition?
- O - Openness to new experiences - Intellect and interest in culture
- C - Conscientiousness - The will to achieve
- E - Extroversion - Outgoing
- A - Agreeableness - Loving, friendly and complaint
- N - Neuroticism - Experience more negative emotions
Describe the aspects of generalised expectancies.
- Locus of Control - Expectations that future outcomes will be demonstrated by factors that are either internal (self - responsible for own health, illness can be avoided etc.) or external (powerful others, and chance)
- Self-Efficacy - Belief in one's own ability to organise and execute a course of action, and the expectation that the action will result in, or lead to, a desired outcome
Draw out the Health-Belief Model.
- Perceived Susceptibility + Perceived Severity = Perceived Threat
- Percevied Benefits + Perceived Barriers = Perceived Efficacy
- Perceived Threat + Perceived Efficacy = Health Behaviour
Draw out the Theory of Planned Behaviour.
- Behavioural Beliefs + Outcome Evaluation = Behavioural Attitude
- Normative Belief + Motivation to Comply = Subjective Norm
- Control Beliefs + Self-efficacy = Perceived Behavioural Control
- Behavioural Attutude + Subjective Norm + Perceived Behavioural Control = Behavioural Intentions = Behaviour
Name the 5 stages of the transtheoretical model (aka stages of change)
- (Relapse can occur at any time)
What intervention techniques can be used to prevent relapse?
- Behaviour analysis
- Coping skills training - cues, negative affect, peers
- Cognitive restructuring - understanding relapse as both a process and as an event
- Integration into social supportive networks
What factors prevent relapse?
- Identifying high risk situations
- Develop coping strategies
- Preventing lapse from slipping into relapse
- How people respond to a lapse
What factors will change during progression through the transtheoretical model?
- Self - Efficacy ?
- Temptations ?
Name the 4 determinants of health behaviours
- Background factors
- Stable factors
- Social factors
- Situational factors
Give some examples of background factors
- Context in which individuals live:
- Cultural norms; Social-Economic Status; Gender; Ethnicity; Genes; Chronic Health Status
Give some examples of stable factors
- Relatively enduring and resistant to change:
- Emotional disposition (Present); Generalised expectancies (Future); Explanatory styles (Past)
Give some examples of social factors
- Resources available through social relations:
- Perceived support (family, friends, peers, etc); Subjective norm; Helping relationships
Give some examples of situational factors
- Give meaning to salient events and respod to demands e.g. appraisal & coping:
- Situation-specific self-efficacy; Perceived risk; Emotional response; Intention (motivation); Outcome evaluation
Name 3 social cognition theories
- Health Belief Model
- Theory of Planned Behaviour
- Transtheoretical Model
- Protection Motivation Theory
- Theory of Reasoned Action
Define Illness Behaviour
- Behaviours that patients engage in once they believe that they are ill. The belief can be objective or subjective; confirmed or suspected, self or other notified.
- Active process not passive e.g. help seeking, treatment adherence, behaviour change
Define Illness Beliefs
A patient's implicit understanding of their health status based on common-sense beliefs about their illness e.g. beliefs about the cause, course and consequences of the illness
Define Illness Representations
Clustering of related beliefs which provide a framework for an understanding, or picture, of illness that serves to direct coping responses and illness behaviour
What are the 5 belief dimensions of illness representation.
- Identity: What is it? (diagnostic)Label patients give to their illness, labels bias the interpretation and assimilation of illness related information
- Cause: What caused it? Patients develop ideas about the cause of their illness, causal beliefs influence treatment expectations, causal beliefs influence emotional response to illness
- Time: How long will it last? 3 main timelines for illness (Acute, chronis & cyclical), Mismatch in perceived time and natural illness course is not uncommon (Hypertension commonly believed to be cyclical, therefore patients negate the need to take meds)
- Consequence: How will it impact my life? Perceived effect of illness on the patient's life, perceived severity of consequence is prognostic (MI who thought more severe condition on admission spent longer in hospital, greater disability & increased risk cardio related morbidity)
- Control-cure: Can it be treated, controlled, managed etc. Beliefs about how an illness can be treated and the effectiveness of treatment, patients who believe its possible to control illness are more likely to adhere to treatment
How can background influences affect symptom perception and reporting?
Beliefs about illness can affect health status as people with chronic conditions both over-report of symptoms that relate to the condition and under-report of symptoms that, they believe, are unrelated to condition.
How can stable influences affect symptom perception and reporting?
- Emotional disposition:
- - Ps with negative affect are more likely to notice symptoms, report more symptoms and do so more quickly, i.e. high false-positive
- - Ps with low expression block emotionally arousing stimuli and tend to report fewer symptoms, i.e. high false-negative
- Generalised expectancies
- - Ps with favourable outcome expectancies (I-LoC; high Self-efficacy) report fewer symptoms ... But there might be a cost
- - Lack of vigilance + control beliefs = delay & disease progression
- Explanatory style: Pessimistic styles perceive more symptoms and symptoms of greater severity, but delay help seeking
How can social influences affect symptom perception and reporting?
- Illness information often from social cues
- - 'You look a bit pale' cues a search for confirmatory evidence
- - Lay referral network for advice, diagnosis and treatment
- Being a medical student
- - 'Medical Student Syndrome' - Symptom information leads to symptom searching; easier to confirm presence rather than confirm absence;
- Perceived social support
- - High: rate oneself as more healthy, recall fewer illness-related memories, and report fewer symptoms
- - Low: higher perceived vulnerability to illness, pessimistic about symptom relief, and report more symptoms
How can situational influences affect symptom perception and reporting?
- Competition for cues (attention)
- - Attention for internal (bodily changes) vs. external (environmental) cues
- - If internal cue is strong (e.g. pain) we notice symptom, however if external distractions are stronger we may not notice symptoms e.g. running
- Stress (acute)
- - Often aggravate perception and reporting of physical symptoms
- - Increases perceived vulnerability to illness, and/or mis-attribution of physiological reactivity as symptoms of illness
- Symptom characteristics
- - Onset speed; Public visibility; Chronic illness-related complication
Describe Self-Regulatory Model
- See diagram but involves:-
- Representation of Illness
- Emotional response to illness
How can a SRM be applied clinically?
- - Illness perception questionnaire
- - Develop appropriate management plan with patient
Define primary prevention.
Health care initiatives aimed at maintaining or improving health among people who are currently free of symptoms. This includes the modification of risk factors (e.g. smoking, diet, alcohol intake) to avoid development of disease e.g. health promotion campaigns
Define secondary prevention.
Interventions aimed to detect disease early to delay or halt disease progression and developing symptoms e.g. screening
Define tertiary prevention.
Rehabilitation or treatment interventions of already established disease/illness.
What are the 3 types or screening and their definitions?
- Population Screening
- Services aimed at identifying specific health problems e.g. mammography and PAP smear
- Behaviours aimed at identifying health problems e.g. breast & testicular self-examination and H1N1 Flu
- Opportunistic Screening
- Adjunctive identification of (other) health problems e.g. hepB in pregnancy and depression in primary care
How does variation in the uptake of screening services vary?
- Disease � Mammography 75%, HIV testing 6%
- Country � Mammography 78% England, 68% Wales, 38% Ireland
- Geographical region - Mammography 81% South-East, 62% North-East
- Sub-groups � Mammography <50% in low SES and minority groups
What factors influence the uptake of screening services?
- Patient factors � Demographics, stable individual factors, social network
- Provider factors � Provider beliefs and behaviour
- Organisational factors � Invitation delivery & screening location
What are the psychological and behavioural effects of screening?
- True +ve Anxiety, fear, stress, guilt etc
- False +ve Unnecessary testing etc
- True -ve Maintain health damaging behaviours & ignore subsequent symptoms
- False -ve Untreated progression of disease
- Amended Loss of trust in service and provider, therefore less and delayed use of health care
What questions would you use to screen for depression?
- - During the past month have you often been bothered by feeling down, depressed or hopeless?
- - During the past month have you been bothered by having less interest or pleasure in doing things?
What are the 3 categories excessive alcohol consumption can be classified?
Alcohol dependence, Harmful Use, Hazardous Use
What questions can be used in alcohol screening?
- - Have you ever felt the need to Cut down your drinking?
- - Have you ever felt Annoyed by criticism of your drinking?
- - Have you ever felt Guilty feelings about your drinking?
- - Did you ever need a morning Eye-opener?
What should you ask every patient at every consultation?
- The 5 A's
- Ask the patient if they use tobacco
- Advise them to quit
- Assess willingness to make a quit attempt
- Assist them in making a quit attempt
- Arrange for follow-up to prevent relapse
What should you consider for smokers who are unwilling to make a quit attempt?
- The 5 R's
- Relevance - Tailor advice & discussion to each patient
- Risks - Outline the risks of continuing smoking
- Rewards - Outline the benefits of quitting
- Roadblocks - Identify barriers to quitting
- Repetition - Repeat message at every visit
How would you assess a motivation in stopping smoking?
- - Do you want to stop smoking?
- - Are you interested in making a serious attempt to stop in the near future?
- - Are you interested in receiving help with your quit attempt?
- *Yes to all suggests high motivation to quit
How would you assess nicotine dependence?
- - How many cigarettes do you smoke a day? - 15+ = high dependence
- - How soon after you wake up do you smoke your first cigarette? - Within 30 min reflects high dependence
How can nicotine dependence information be used?
Guides choice of nicotine-based pharmacotherapy
- Depression is a disorder of emotion, can be subdivided into two types.
- Unipolar: depressive state
- Bipolar: involves (rapid) transition between depressive and manic phases ~25% of all depression cases
What are the symptoms of depression? ABC
- Affect e.g. persistently lowered mood, dimished interest or pleasure in activities
- Behaviour e.g. not eating (appetite loss), sleep disturbance, lowered libido, social withdrawal
- Cognition e.g. depressive ideation (guilt), suicidal thoughts, fatalistic (hopelessness)
Describe the stepped care model for depression.
- Step 1 - Recognition in primary care and general hospital settings
- Step 2 - Treatment of mild depression in primary care
- Step 3 - Treatment of moderate to severe depression in primary care
- Step 4 - Treatment of depression by mental health specialists
- Step 5 - Inpatient treatment for depression
Name 3 key approaches in psychological medicine.
- Egan's 3 stage model
- Cognitive Behavioural Therapy
- Psychodynamic Therapy
- Humanistic Approach
- Systemic Approach
- Transactional Analysis
- Integrative Approach
Describe Egan�s 3 stage model.
- 1. Explore - What is the problem?
- 2. Understand - How has the problem arisen?
- 3. Action - How might change be achieved? What strengths and resources does the patient?
- Review and evaluate the outcomes of the strategies.
Describe Cognitive Behavioural Therapy (CBT).
- Identify and change/correct negative thought patterns, beliefs and behaviours by combining:
- Behavioural techniques:
- Change unwanted behaviours e.g. activity scheduling, rewards, desensitisation, relaxation techniques, challenging irrational beliefs.
- Cognitive techniques:
- Change negative automatic thoughts e.g. overgeneralisation & personalisation, thought stopping, replacing irrational beliefs with rational thoughts
What disorders can CBT help with?
Depression, anxiety, addictions, OCD, eating disorders, phobias, Chronic fatigue syndrome
What are the aims for psychodynamic therapy?
Aims are to help individuals to better understand themselves and modify internal perceptions of self and others.
What techniques are used in psychodynamic therapy?
Clarification of facts and exploration and reflection on significant issues can be used with those that suffer from depression, anxiety, panic disorders, PTSD, phobias, eating disorders, schizophrenia and addictive behaviour
What are the aims of humanistic therapy?
Aim is to help the individual approach a stronger and more healthy sense of self
What techniques are used in humanistic therapy?
Explorations of self-evaluation of life experience can be used to help those with depression, anxiety and substance abuse
What is the aim of systemic therapy approach?
Aim is to address people not on an individual level, but as people in a relationship
What techniques are used in systemic therapy?
This is done by exploration of individual identity and sense of purpose which can be used to help those with depression.
What can be the effects of poor communication during a consultation?
- Less likely to adhere to medical regimes
- Less likely to use health care services/seek professional medical help in future
- Less likely to attend check-ups, screening or other forms of preventative health care
- More likely to experience negative health outcomes
- Quality of communication in consultation can, and should, be considered a risk factor for patient health
What is the purpose of medical communication?
- Create a good interpersonal relationship �
- Social relationship (friendliness, conveying interest, making personal remarks), Therapeutic relationship (empathy, respect, genuineness and warmth), patient-centred communication (patient can express all their reasons, feelings, symptoms)
- Exchange information -
- Balance of information giving and information seeking
- Make treatment related decisions -
- Shared Decision Making (SDM), important for long term conditions
What can be done to improve communication?
- Understand the problem:
- Dr�s perspective � Fear of increasing patient distress, limited time, unaware patients fail to disclose important information
- Patients perspective � Worry fears will be confirmed, belief that nothing can be done, desire not to seem ungrateful or critical, concern that it is not appropriate to disclose some problems
- Intervene in the process
- Evaluate the effects
Which groups are susceptible to communication inequality?
- Ethnic minorties
- Low SES groups
- Chronic illness
- Psychological symptoms
- NB Could be a result of stereotypic knowledge
What are the different components of addiction?
- Biological - Life sustaining activities are rewarded with dopamine, drugs and alcohol can release 2-10 times the amount of dopamine as a reward, brain interprets these drugs as essential for survival
- Social - Peer Pressure
- Psychological - Pleasure seeking, self-medication
What are the four classes of effects of stress?
- Affective - Shock, anxiety, fear, depression, anger, frustration, lowered self-esteem, guilt
- Behavioural - Smoking, alcohol, help seeking delay, poor adherence, relapse, social withdrawal, illicit drugs, sexual function
- Cognitive - Poor attention, errors in decision-making, hyper vigilance for threats, bias to interpret ambiguous events as threatening, memory loss and learning difficulties
- Physiological - Activation of nervous system, hormone production, metabolic function (fewer calories are burned), fatigue, disease and illness
What effect can stress have on the immune system?
Stress can cause a down-regulated immune response. This can be reversed with a psychological intervention which can enhance immunocompetence.
How can stress affect patient health?
- On the ward:
- Slower wound healing, more post-surgery complications, longer in-patient stay, more staff time per day, more analgesia use, less satisfaction with treatment associated with poor adherence
- After discharge:
- Longer recovery e.g. return to work, more service use e.g. related symptoms, less use of rehab services, increased risk of co-morbidity and early mortality
How can impact of stressors on patients be removed or reduced?
Problem-focused coping vs emotion-focused coping
What are the main perspectives on stress?
- Stimulus - Focus on cause (stressor)
- Response - Focus on effect (outcome)
- Process - Focus on the person-environment interaction (transaction)
Name the 3 types of stressor
- Chronicity - Discrete sudden trauma to continuous chronic stressors, e.g. car accident and diabetes
- Magnitude - Life changing events to daily hassle e.g. getting married/divorced and car parking at WMS
- Inclusiveness - Individuals to societies e.g. driving test and September 11th
Describe stress in the medical profession.
- Personal Factors
- Work-life Balance
Name 5 somatoform disorders.
- Somatisation disorder (Briguet's syndrome)
- Conversion disorder (Conversion hysteria)
- Hypochondriacal disorder (hypochondriasis)
- Somatoform pain disorder (Psychogenic pain)
- Body dysmorphic disorder (dysmorphophobia)
What techniques can be used to deal with stress management?
- Progressive muscle relaxation
- Passive muscle relaxation
- Autogenic 'self-hypnosis'
Describe some somatoform symptoms.
- Pain - Different sites, specific bodily functions
- GI - Nausea/vomiting, bloating, food intolerances, diarrhoea
- Sexual - Erectile dysfunction, irregular menses
- Pseudoneurological - Voice loss, impaired vision, hallucination amnesia
How are somatoform disorders characterised?
- -Presence of physical symptoms not fully explained by presence of medical condition
- - Symptoms cause clinically significant distress and impairment
- - Psychological factors judged important in symptom onset and severity
- - Symptoms are chronic and not normally intentionally produced
What are the principles of assessment of somatoform disorders?
- C � Context � Review recent history of current symptoms in context of life events
- R � Reaction � Ask questions about patients reactions and coping to symptoms
- I � Iatrogenic Harm � Be vigilant to IH
- S � Screen � Use screening questions for psychiatric morbidity
- P � Perceptions � Identify patients� concerns & beliefs
What are the principles of treatment of somatoform disorders?
- P � Provide � Provide a framework
- A � Agree � Agree on a treatment plan tha includes a follow up and review
- R � Reassure � Reassure the patient
- A � Advise � Advise on how to cope with symptoms
- D � Discuss � Discuss patient concerns at the earliest opportunity
- E � Encourage � Encourage to return to normal activity as soon as possible
- S � Set Homework � Set Homework for next meeting
What are the principles of management of somatoform disorders?
- C � Consistency � Consistency of care
- R � Relative � Co-opt a relative
- E � Expand � Expand agenda
- E � Expectation � Expectation management
- P � Proactive � Proactive not reactive
What questions would you ask in order to distinguish between normal and abnormal somatisation?
- ICE B/S
- I � Internalised � Has the �sick role� been internalised?
- C � Coping � Symptoms significantly affect ability to cope?
- E � Excessive � Excessive but unsatisfactory service use?
- B � Belief � Is there resistance to explanation & reassurance?
- S � Symptoms � Are symptoms beyond the norm?