PSY 440: Final Exam

Inpatient

Require medical attention on a continuous schedule or specialized equipment

Hospitals

Complex medical facilities that provide a wide range of services

Nursing homes

Care for individuals who need relatively long term medical and personal care

Outpatient Treatment

• Outpatients: typically require less intensive care

  • May have home health care services instead

• A move away from inpatient care has been caused by

  • Costs

  • Technology

American Healthcare system

• Health insurance pay for costs

• Employers provide insurance for most working people

Medicare

Covers elderly people (typically 65+)

Medicaid

Covers low-income people

Medicaid Expansion

• State-level Medicaid expansions caused by the ACA caused significant reductions in poverty rates

• How?

  • “By shielding beneficiaries from growing out-of-pocket spending.”

Systems in other countries

* Universal health care systems- medical care coverage is provided for virtually all citizens, and is usually funded by taxes and payroll deductions
* Australia, Canada, Germany, Italy, Sweden, UK
* Less complicated than U.S

Symptom perception affected by:

• Individual differences

• Competing environmental stimuli

• Psychosocial influences

• Gender and sociocultural differences

Symptom interpretation and response affected by:

• Illness identity

• Causes and underlying pathology

• Timeline (prognosis ideas)

• Consequence

Lay referral network

Advice from nonpractitioners (family, friends) about their own interpretations about a person’s symptoms

• Not always good advice

• Can make conditions worse

• Use and misuse of health services

Illness Identity

* The name of the disease or illness and its symptoms
* Name, strep throat; symptoms: sore throat

Causes and underlying pathology

* Your idea of how you got the illness
* Ex. you had a roommate with strep throat

Timeline (prognosis ideas-

* How long the disease takes to appear and how long it lasts
* Ex. You didn’t notice the strep throat in particular until you had had it for three days already; it lasts a week

Consequence

How serious the disease is, what its outcomes and affects are

Age and Gender

• Babies go to the doctor a lot

• Middle-aged people don’t go as often

• Elderly go to the doctor a lot

• Women go to the doctor more frequently than men (could be because women don’t care about proving themselves in the same way, maybe they have more symptoms, etc.)

Sociocultural factors

• A person with a higher SES=more likely to go to the doctor

• Person with lower SES/rural areas=less likely to go to the doctor

Iatrogenic conditions

* Developing a medical condition as a result of medical treatment (errors, normal side effects of risk of treatment)
* Ex. lots of fungal infections in hospitals..
* Medical errors cause about 250,000 deaths/year

Ideas and beliefs

• People don’t go to the doctor when they don’t trust their doctor

• Occurs among LGBTQ+ population if they’re worried about what people think of htem

Health belief model

If you don’t think that the flu is a big deal because you’re young and healthy, then you probably won’t go to the doctor as often

Social and emotional factors and seeking medical care

• Sanctioning: someone asks or insists that an ill person can be treated; someone close to you “makes” you go

• People who are depressed are less likely to go to the doctor

• People who are afraid can go either way (fear can also motivate)

Stages in delaying medical care

• Starts with noticing symptoms

• Treatment delay

  • Appraisal delay

  • Illness delay

  • Utilization delay

Treatment delay

The time that elapses between when a person first notices symptoms and when they enter medical care

Appraisal delay

The time it takes for a person to interpret a symptom as an association with illness (Ex. you feel like you have a scratchy throat but assume it’s because you talked most of the day)

Illness delay

Time between recognizing one is ill and deciding to seek medical attention (you notice white spots in your throat, know you’re sick, and contemplate making the appointment for the doctor)

Utilization delay

the time after deciding to seek medical care and actually going in to use that services (you called the doctor, have to wait two days to go)

Complementary and alternative medicine (CAM)

• Manipulative and body-based methods, natural products, mind-body interventions, energy fields, homeopathy, traditional Chinese medicine

• Little or no scientific evidence of their safety and effectiveness; those with evidence are adopted

Doctor-centered style:

Very brief conversations, “yes/no” questions (do you have a fever?, do you have a sore throat?)

Patient-centered style:

More open-ended questions to start conversations with patients, less medical jargon (tell me more about the pain you’re having)

Important factors for patient satisfaction

• Sensitivity

• Warmth

• Concern

  • Agreeableness

Adherence and compliance:

The degree to which patients carry out behaviors and treatments their practitioners recommend

Adherence

Implies collaboration; the likelihood that patients do what their doctor recommends

Compliance

Implies giving into a demand; more old school (you’re going to take this drug this many times per day)

Adherence depends on

• Medical regimen characteristics

• Age, gender, and sociocultural factors

• Psychosocial aspects

• Patient-practitioner interactions

Medical regimen characteristics

Could be complicated/a lengthy process for some people… makes them not want to continue

Age, gender, and sociocultural factors

• If you just look at one thing (gender, age) there are NO real differences

• When they’re combined is when the differences come up

Psychosocial aspects

Ration nonadherence: patients who act rationally when they fail to take medication (side effects are very unpleasant, are confused about when to take it, don’t have money to buy refill)

* Some people don’t do what they’re supposed to be doing… for vary valid reasons (can’t afford it)

Patient practitioner interactions

• Communication skills

• Changes in discussions can influence the likelihood that the patient takes your advice and adheres to a health plan

Hospital topics/Hospital hazards

• Nosocomial infections

• Biological

• Physical

• Chemical

Nosocomial infections

an infection a person contracts while in the hospital setting

* Safety checklists

Biological

Exposure to disease-causing microorganisms (MRSA, HIV)

Physical

Patient handling, violence and defibrillators

Chemical

Latex, cyclophosphamide

What is burnout?

A state of psychological and physical exhaustion that results from chronic exposure to high levels of stress and little personal control

Emotional exhaustion

Feeling drained of emotional resources and unable to help others on a psychological level

Depersonalization

A lack of personal regard for others; treating people as objects, having little sensitivity

Low personal accomplishment

Feeling low in self-efficacy and falling short of personal expectations

What is compassion fatigue?

The profound emotional and physical exhaustion that helping professionals and caregivers can develop over the course of their career as helpers

What is vicarious trauma?

* The profound shift that workers experience in their world view when they work with clients who have experienced trauma

Primary trauma

Caused by a traumatic event that happens to you (from your personal life or from a work-related exposure)

Secondary trauma

Caused by secondary exposure to trauma through stories, descriptions, audio or video recordings

Adjustment to Hospitalization

• Psychosocial preparation for surgery

• Behavioral control

• Cognitive control

• Informational control

Coping styles and preparation

• Avoidance strategies: people are trying to minimize the effects of the problem

• Attention strategies: people seek out detailed information about the problem

• TL; DR: the benefits of preparation depend on patients’ coping styles:

  • Avoidance copers have less anxiety with less information

  • Attention copers have less anxiety when they get information

Helping children cope:

• Parents should accompany children

• Tours describing the hospital

• Use puppets to demonstrate procedures

• Video about the hospital experience

Factors that lead to “problem behaviors”

• ‘Active’ patients (those who argue, and complain)

• Serious illness, severe complications, poor prognosis

• Loss of control and freedom

• Reactance

What is pain?

• Pain: the sensory and emotional experience of discomfort (usually associated with actual or threatened tissue damage or irritation)

• Accounts for 80% of all visits to physicians

Dimensions of pain

• Some pains are sharp, others are dull

• Burning sensation

• Cramping, itching, or aching feel

• Some are throbbing, constant, or shooting

• Pervasive or localized

Organic pain

Pain linked to tissue pressure or damage (e.g., burn or sprain)

Psychogenic pain

Pain linked to psychological processes (e.g., social rejection)

Acute pain

Temporary painful conditions that last less than 3 months

Chronic pain

A painful condition lasting longer than 3 months

Three major components of pain

• Cognitive

• Physical

• Emotional

Cognitive

Attention, memory, expectations and beliefs about pain

Physical

a signal from the limbic system responding to a noxious stimulus E

Emotional

A signal from the anterior cingulate gyrus (also, serotonin, and norepinephrine)

Sleep and pain

• A day with high levels of pain is followed by poor sleep, and poor sleep tends to be followed by higher amounts of pain the next day

• Not just pain, but depression, intrusive thoughts, and worry impair sleep

Chronic-recurrent pain

Stems from benign causes; repeated and intense episodes of pain separated by periods without pain

Chronic-intractable-benign pain

Discomfort that is typically present all the time; varying levels of intensity, not related to malignant condition

Chronic progressive pain

Continuous discomfort; associated with the malignant condition and becomes increasingly intense as condition worsens

Perceiving pain

• The body has no specific receptor cell that transmits information only about pain

• The body senses pain in response to many stimuli (physical pressure, lacerations, intense heat or cold)

• Pain perception almost always includes a strong emotional component

The physiology of pain

• Noxious stimulation triggers chemical activity (serotonin, histamine)

• Inflammation at injured site

• Activation of nerve fibers signaling injury

• Nerve endings (nociceptors) in the PNS carry injury signal to spinal cord

• Spinal cord carries signal to the brain

Nociceptors

a nerve ending that responds to pain signal that sends pain signals 

A-delta fibers

• Motor and sensory areas of the brain

• Move at 40 mph

• Sharp, quick pain

C fibers

• Affect our mood, emotional, motivational states

• Move at 3 mph

• Dull, aching pain

• Not covered in myelin

Referred pain

* the experience of discomfort as coming from an area of the body other than where the injury exists  
* Example: heart attack is often felt as pain in the shoulders, pectoral area of the chest, and arms  

Neuropathic pain

No noxious stimulus is present as a cause for the pain; results from current or past disease or damage in peripheral nerves  

Neuralgia

Recurrent episodes of intense shooting or stabbing pain across the course of a nerve  

Causalgia

Recurrent episodes of burning pain  

Phantom Limb pain

Pain in a limb that is no longer there or no longer has functioning nerves   

Gate control theory

• A neural “gate” that can be opened or closed in varying degrees, thereby modulating incoming pain signals before they reach the brain

• Three factors involved in theory

  • The amount of activity in pain fibers

  • Amount of activity in other peripheral fibers

  • Messages that descend from the brain

Clinical Pain

• Any pain that receives or requires professional care

• The transition from acute to chronic pain is critical-many people become disabled, avoid activities, develop feelings of helplessness

Neuroablation

surgery removes/disconnects part of the PNS or spinal cord

Synovectomy

surgery removes membranes that become inflamed in arthritic joints

Spinal fusion

procedure that joins two or more adjacent vertebrae to treat severe back pain

Laminectomy

removing part of a vertebra to reduce pressure on spinal nerves  

Chemical methods for treating pain

• Pharmaceuticals are effective at relieving acute pain (e.g., after surgery)

• Many patients are undermedicated (receive too little pain relief)

  • Children

  • Minorities

• PRN (pro re nata) or “as needed”

• Epidural block: narcotics injected near the membrane that surrounds the spinal cord

• Patient-controlled analgesia allows patients to determine how much painkiller he or she needs

• Is patient-controlled analgesia just an opportunity to abuse narcotics?

  • Pain relief is somewhat greater in women than men

  • In the days after surgery, patients use more medication but get better pain relief than conventional methods

• Chronic pain occurs most commonly for disorders that are not life-threatening (e.g., arthritis)

• Chronic back pain and opioid use is associated with substance abuse, no reduction in pain

• Cautions on physician use of narcotics:

  • Some patients become addicted to narcotics

  • Studies need to determine how daily doses of narcotics alter patients’ lives and functioning

  • Why are tolerance and addiction to narcotics less likely when taken to relieve pain? Is It because doses are small, or practitioners can monitor and set limits?

• Chemical methods alone are not sufficient for controlling pain

• Medical treatments of pain focus mainly on using chemical approaches to reduce discomfort, but these approaches can be enhanced when combined with other methods (e.g., therapy)

Behavioral and cognitive methods

• Operant approach

  • Give medication every 4 hours (no association between request for drug and relief; reduce the amount over time; encourage “well” behaviors)

• Fear reduction, relaxation, biofeedback

  • Weekly sessions over 2–3-month period

  • Reduce stress and the physiological processes that lead to headache and other pain conditions

• Do improvements last? How long?

  • Headache pain decreased after intervention and stayed that way for 5 years

  • Helpful in reducing discomfort, but do not provide all the pain relief patients need.

• Negative thoughts can make pain worse

• Passive coping: taking to bed, avoiding social activities, which leads to feelings of hopelessness

• Active coping: try to keep functioning by ignoring pain, keeping busy

  • Distraction

  • Focusing on a nonpainful stimulus in the immediate environment to divert one’s attention from discomfort

  • Effectiveness depends on 3 factors:

    • Amount of attention task requires

    • If task is interesting

    • The credibility of the task

• Imagery

  • (i.e., guided imagery) conjuring up a mental state that is pleasant (e.g., being at the beach)

  • Limitation: not everyone is good at imagining scenes!

• Redefinition

  • Pain redefinition: substituting constructive or realistic thoughts about the pain experience for those that arouse feelings of threat or harm

  • Coping statements: (“Be brave, you can do it!”)

  • Reinterpretive statements: “It’s not the worst thing that could happen.”

• Active coping strategies effectively reduce acute pain

• Distraction and imagery useful for mild or moderate pain

• Redefinition more effective than a distraction for chronic pain

• Hypnosis

  • How it works:

    • Physiological changes occur in the brain and spinal cord

    • May involve deep relaxation

    • Expectancies for pain relief

  • Can reduce intensity of acute pain, but is not highly effective for everyone

Counter irritation

reducing one pain by creating another (e.g., cupping)  

Transcutaneous electrical nerve stimulation (TENS) 

Placing electrodes on the skin near where the patient feels pain and applying a mild electrical current  

Acupuncture

Fine metal needles are inserted under the skin at special locations and then twirled or electrically charged to create stimulation  

Physical therapy

• Patients perform exercises to enhance muscular strength and tissue flexibility

• Used widely for arthritis and low back pain (e.g., strengthening exercises for back pain)

Pain clinic

Institution or organization developed specifically for treating pain conditions  

Unconscious bias in healthcare and how it affects patients

A cognitive error in the thinking process that leads to serious outcomes (e.g., diagnostic errors)  

System 1 (Fast) thinking

• Intuitive

• Unconscious

• Requires little energy

• Good for daily decisions

• Prone to bias

System 2 (slow)  thinking

• Analytical

• Controlled

• Requires energy

• Good for complex decisions

• Can filter out bias

Avoiding bias with cognitive forcing strategies 

• Seek alternative explanations

• Explore the consequences of alternative diagnoses

• Be open to tests that would differentiate diagnoses

• Accept uncertainty

• Consider gut reactions/ intuition as an indicator of bias

• Learn from your errors

• Reflect on your thinking process

• Maintain cultural competence

How to maintain cultural biases

• Reflect on your own cultural biases

• Individualize patients

• Note their cultural identity (e.g., language)

• Recognize that cultures have different idioms to express distress (e.g., “nerves”, somatic complaints)

• Communicate with patient

Crisis theory

Factors that influence how people adjust

Illness related factors

The greater the threat patients perceive, the more difficulty they are likely to have coping with the condition