Psychosocial Aspect

Incidence of Underlying Trauma

• Nearly 900,000 children have been identified as victims of abuse or neglect in the United States. More than 500,000 adults over 60 years of age suffer abuse or neglect annually.

• About 1.5 million women and close to 835,000 men are raped or physically assaulted by someone close to them each year. Approximately 2 out of every 3 women reporting rape, assault, and stalking are victims of repeated abuses.

• Conservatively, 2 million episodes of domestic violence occur in the United States annually. Each year, more than 1000 women (about 4 per day) are killed.

Psychological Considerations in Health Care

• The cognitive, physical, emotional, and spiritual systems of human beings are intricately intertwined and interdependent.

• The more vague and multifaceted the diagnosis and symptoms, the more the clinician must remember that emotional, mental, physical, and spiritual components are intricately interconnected and cannot be separated.

• Physical pain and symptoms that have nonphysical roots will not resolve unless the underlying causes of the problems are addressed.

Biopsychosocial Model

• Philosophy of care

  • How suffering, disease, illness are affected by multiple levels of organization

• Practical clinical guide

  • A way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, outcomes and humane care

• Clinicians must attend to the biological, psychological, and social dimensions of health and illness simultaneously

Philosophy of care

How suffering, disease, illness are affected by multiple levels of organization

Practical clinical guide

A way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, outcomes and humane care

George Engel

• Formulated biopsychosocial model in response to biomedical model which he viewed as overly-analytic and reductionist (problems reduced to smaller parts); strict separation between mind and body

  • Dehumanizing and disempowering

• Holistic, contextual and cross-disciplinary

  • Complexity model – each dimension interacts

  • Empathy and compassion

Pillars of the BPSM

• The patient’s subjective data should be considered along with objective biomedical data.

• Causes of illness are more comprehensive and naturalistic than what the simple linear biomedical model suggests.

• The patient-clinician relationship should give more power to the patient in the clinical process.

Complexity and Causality

• Multiple interacting causes and contributing factors

• Obesity → DM and OA → reduced exercise capacity → HTN → stroke and CAD

  • Some of the secondary effects than become causal

  • Depression after MI → another MI

• Feedback loops sustain a specific pattern of behavior over time

• The science is to understand these “systems” and find ways to intervene on the interrelated causes

  • Depression screening and lipid lowering drugs

Relationship-Centered Model

• Arriving at a Diagnosis is only part of a clinician’s task

• Interpreting illness and health from the patient’s perspective

  • Hearing their concerns

  • Learning their expectations

• Egalitarian relationship

• Dialogic relationship

  • Reality is not to be interpreted by the clinician; the truth is come to by dialogue with the patient (i.e. between the patient and the clinician)

Emotions of Clinical Practice

The clinician must be reflective of their own tendencies that may choke off a relationship with the patient

Psychosocial Domains

• negative emotional stress

• chronic stressors and acute live stress

• social factors - social ties and support

Negative Emotional State and CVD

• Depressed affect was significantly associated with 50-60% excess risk of fatal and nonfatal IHD after adjusting for traditional RFs

• Hopelessness is one symptom of depression that appears to have a particular adverse effect on health.

• Type A men were 2x as likely as Type B men to develop CAD in 8 years of follow up

Psychosocial Stressors and CVD

• Chronic Stress usually studied as occupational stress

  • High job demand-low job control

  • Effort-Reward balance

  • Positive association between overall job strain and CVD morality

    • Low control most strongly associated with risk

• Non-occupational chronic stress is most often studied as caregiving stress

  • Also associated with greater rates of CVD

• Acute stress related to traumatic events

  • Incidence of SCD the week before:after earthquake …4.6:24

social factors

ties, conflict, support

Social Determinants of Health and Health Equity

• SDOH: nonmedical factors influencing health, including health-related knowledge, attitudes, beliefs, or behaviors.

• Health Equity: encompasses the spectrum of causes of racial/ethnic and other social disparities in health that raise concerns about justice.

• The dramatic health problems we face cannot be successfully addressed by medical care alone.

SDOH - social determinants of health

nonmedical factors influencing health, including health-related knowledge, attitudes, beliefs, or behaviors.

Health Equity:

encompasses the spectrum of causes of racial/ethnic and other social disparities in health that raise concerns about justice.

Upstream vs Downstream

SDOH represent the downstream events in the causal pathway – the result from other upstream cause

Mediators and Moderators

Low-SES individuals also clearly live under worse physical conditions, with greater exposure to toxicants, pollutants, and other hazards, both in their homes and neighborhoods (Evans 2004). Although these exposures partly account for the SES gradient, they do not explain it entirely. Similarly, low-SES individuals are known to disproportionately engage in health-compromising behaviors such as smoking and inactivity. However, health behaviors account for only a small percentage of the variance in the SES and mortality relationship (Lantz et al. 1998).

Ecological Approach

acknowledges that SES creates differences at the individual, family, and neighborhood levels that affect how individuals experience their lives. At the same time, it embraces the view that individuals are nested within larger ecological systems— e.g., family environments, broader social structures—that both shape the individual and are shaped by the individual (Bronfenbrenner 1979).

Moderators

• Resilience – psychological/mental health

• Social Support, esp maternal warmth

  • Improved health with more maternal care/warmth

    • Biological mechanism related to cortisol showing “buffering” of the effects of low SES

    • Short and long term effects

Shifting

Primary vs. Secondary control coping

Physiologically, shift strategies such as reappraisal and emotion regulation appear to mitigate pathogenic processes that are implicated in physical health problems

Persisting

Enduring adversity with strength by finding meaning in difficult situations and maintaining optimism about the future.

Physiologically, persistence in terms of optimism, hopefulness, and the maintenance of goal pursuits has been associated with longer-term pathogenic processes relevant to health.