Do wounds have emotions? -Psychological influences on wound Healing. Who fares better?

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Do wounds have emotions? -Psychological
influences on wound Healing. Who fares better?

• Frank McDonald Consultation-Liaison
  Psychologist
• The Townsville Hospital July 2007
  www.fmcdonald.com

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Overview

• Do psychological factors like stress, negative
  emotions e.g. worry depression influence wound
  healing? (Short answer Yes evidence )
• Who does who doesnt cope with demands of wound
  healing?
• Your professional personal input

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Influences on wound-healing

• Clinical experience tells you pts under roughly
  comparable medical conditions care vary
  considerably in their rate of wound recovery
• Differences, in part, can be explained by
  psychophysiological responses
• Notably, psychological states profiles that
  impact upon inflammatory immunity causal
  pathways

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Influences on wound-healing

• Broad classes of psychological factors studied to
  date those that travel via
• 1. biological paths e.g. stress/hyperarousal,
  depressed mood, anxiety, response to pain
• 2. behavioural paths health-risk behaviours
  that ? w. distress, despair, demoralisation
• Smoking (vasoconstriction)
• Alcohol drug abuse
• ? Nutrition (need for protein etc)
• Reduced compliance/self-care behaviours
• Sleep disturbances (compromises immunity)

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Influences on wound-healing

• Understanding being alert to relevant factors
  guides your interventions
• One key issue stress
• This can be large enough to be health risk
  (Rozlog et al. 1999). Impacts on speed of wound
  healing (Kiecolt- Glaser et al., 1995) recovery
  from surgery (Broadbent et al., 2003) as measured
  by in-hospital time, re-admission rates,
  complications, pt discomfort delay in return to
  activity

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Influences on wound-healing

• High or chronic stress impairs inflammatory stage
  of wound repair
• Excess stress activates HPA axis producing
  hypersecretion of cortisol (Selye, 1976)
  pro-inflammatory cytokine production (Glaser et
  al., 1999) at wound site
• Even mild stress (like students doing exams who
  are used to them) can slow healing of puncture
  wounds by 40 (Marucha et al., 1998)
• Similar age for couples experiencing hostile
  marital interactions (Kiecolt-Glaser, 2005)

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Influences on wound-healing

• So, no surprise that surgery (for most a major
  stressor due to its higher stakes), is
  well-proven cause of psychological physical
  stress, ? even more potent release of cortisol
  (Kiecolt-Glaser et al., 1998)
• Further indirect proof of stress on wound repair
  burns units have poorer outcomes when co-morbid
  psych conditions not addressed (Tarrier, et al.
  2003)

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Influences on wound-healing

• Negative emotions such as depression anxiety
  also have well-studied influences on wound
  healing
• These can disrupt activity of macrophages
  lymphocytes in healing process (Cole-King et al.,
  2001)
• Depression associated with widespread impairment
  of both cellular humoral immunity (Herbert
  Cohen, 1993)
• In turn, pt susceptible to more infection

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Influences on wound-healing

• Other negative, distressing influences
• social isolation (DeVries, 2007)
• Greater acute pain on days 1 and 2 post-surgery
  pain greater persistent post-surgical pain
  averaged over 4 weekly pain ratings (McGuire et
  al., 2006)
• pain associated with procedures (Krasner, 2005)
• chronic wound pain (Price, 2005)
• Pain may act on both stress / inflammation
  pathway immune pathway

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Who doesnt cope?

• Vulnerabilities identified by research to date
• Acute stress (this worthy of attention because
  success in later stages of wound repair highly
  dependent on initial events. Often the largest
  differences between better worse outcomes in
  stress and wound studies apparent early in
  process) e.g. in days after surgery or procedure
• Chronic stress/hyperarousal (anti-inflammatory
  agents which are meant only for brief release
  e.g. to ease pain, weaken immune system over
  time)
• Depression
• Anxiety

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Who doesnt cope?

• Poor social connectedness or disrupted social
  bonds (e.g. bereaved, divorced) dysregulates
  immune function (Bartrop et al., 1977
  Kiecolt-Glaser,1987)
• Lifestyle /behavioural issues e.g.
• Reductions in deep sleep (depletes growth hormone
  needed for wound repair)
• Poor diet (? vitamins, trace elements)

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Who copes?

• Pts administered psychological interventions pre-
  post-operatively that target 3 things
  emotional support, positive expectancy coping
  strategies (Mumford et al.,1982)
• Strategies that mentally prepare patients for
  upcoming events like ostomies, surgery,
  amputations with information about what to expect
  re the procedure wound healing. May cause
  emotional reaction but stimulates person to
  mobilise resources not rely too long on denial
  (Janis, 1958)

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Who copes?

• Pts taught a quietening response to counter to
  arousal pre- immediately post-operatively e.g.
  via recordings, as in Holden-Lunds (1988)
  broadly efficacious protocol using 4 x 20 min.
  recordings Tape 1. Afternoon prior surgery
  introd concept of relaxation and notion of
  surgical recovery and wound healing in general
  10 minute progressive relaxation exercise. Other
  tapes had 5 minute relaxation mental journey
  thru body to healing area to picture normal
  phases of successful wound healing as guided by
  suggested images

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Who copes?

• Tape 2. Inflammatory phase
• Tape 3. Proliferative phase
• Tape 4. Maturation phase
• Interventions like these highlight timing issue -
  when tissue demands greatest, when arousal
  greatest. Early is better
• Research beginning to suggest arousal may be more
  important than negative emotions e.g. Segerstrom
  Miller (2006). So stress immune system links
  more relevant to w.h. may turn out to be mental
  states (like cognitive appraisal motivation)
  that reduce arousal

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Your professional personal input

• So problem is not just disease management
  (biomedical aspects) but pressure on pt to
  cope
• Everyone with chronic conditions suffers
  psychologically socially degree depends on
  number intensity of challenges faced

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Your professional personal input

• How can we help patients meet psychosocial needs?
• 3 levels
• your professional personal input
• encouraging supporting self-management
• specific psychological strategies shown to
  alleviate condition associated problems

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Your professional personal input

• Professional contributions can significantly
  improve patients psychological state
• Patients sense of control esteem can be
  heightened by progress improvements with
  physical therapy, exercise, speech therapy,
  occupational therapy medications

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Your professional personal input

• Patients benefit from attentions of concerted
  professional team approach e.g. primary care
  physicians nurse educators
• Appreciate being able to discuss manage their
  various concerns with appropriate range of
  specialists

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Your professional personal input

• First thing pt family need to adapt is correct
  information about their condition, its prognosis
  treatment. Can prevent or reduce significant
  anxiety, give direction hope
• Assistance with goal-setting e.g. graphical or
  verbal feedback about progress towards goals
  because pts often dont notice
• (e.g. photos of wounds progress)

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Your professional personal input

• Personal contributions also can significantly
  improve patients psychological state
• Patients do better with professionals whom they
  say
• generally are able to empathise
  communicate a sense of how difficult things must
  be
• are willing to listen my answer questions
  without judging me allowing me to be more
  informed knowledgeable about my illness

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Your professional personal input

• see the whole person - not the hole in the
  person. They see me not just from the perspective
  of their profession
• enquire about common problem areas associated
  with my illness so might ask This illness may
  affect the things you feel you are capable of
  doing in turn your self-esteem. How are going
  in that area?

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Your professional personal input

• are willing to bring up issues I may be
  reluctant to like sexuality or the anger /
  why me? stuff I was half-denying
• give a sense of hope to recently diagnosed pts
  about the promise of new therapies treatments.
  They understand the importance of conveying a
  positive attitude

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Your professional personal input

• enquire about degree of support understanding
  from partner, family, friends or boss
• refer to other professionals, like psychiatrists
  or psychologists, when they do not have the time
  or skills to get into things - without implying
  youre not coping with this as well as you
  should

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Specific psychological strategies

• Studies point to importance of positive,
  supportive interactions with family or friends
  during healing e.g. Detillion (2004). So thinking
  of ways to reduce isolation often related to
  institutional settings may help
• Restoring the person to a supportive family
  situation, if possible, seems especially
  important in wound care. Alternatives if home is
  hostile, demanding or restraining

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Specific psychological strategies

• Anxiety management (e.g. coping with worry
  strategies catastrophe scale, stimulus control
  techniques, problem-solving / decatastrophising
  etc.)
• Coping strategies for symptoms of disease e.g.
  via sleep-wake cycle therapy (See Victoria Health
  website for fact sheet on sleep hygiene)
• Increasing either mastery or pleasure activities
  to at least one per day to counter self-esteem
  non-severe mood problems (See Activity
  Scheduling/Pleasant Events handout
  www.fmcdonald.com)

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Specific psychological strategies

• Pt self-monitoring of self-care activity
  rewards e.g. diabetes adherence
• Stress Management (often within support group
  framework)
• Social Support sessions with family friends
  active listening by leaders

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Specific psychological strategies

• Pain-coping skills
• Progressive Muscle Relaxation. Isometric
  Relaxation
• EMG Thermal Biofeedback Autogenic training
• Hypnosedation (e.g. in burns rx)
• Guided imagery e.g. for symptom control
• Attention re-focussing (stimuli outside body, on
  to activity)

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Specific psychological strategies

• Dissociation (self-hypnosis/meditation.
  Meditation especially helpful with refractory
  depression)
• Self-encouragement via self-reward contingencies
• Communication skills training/assertiveness
  training to improve communication with health
  care professionals, carers, workmates

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Final word Science and Art of Wound Care

• Ultimately wound care professionals can help pts
  by applying care based on the best available
  evidence enhanced by a healthy dose of positive
  psychosocial support