Understanding the psychological needs of individuals with

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Understanding the psychological needs of
individuals with long-term physical health
problems Bridging the Gap

• Denise Fisher

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• Overview
• Rationale
• Evidence
• Health beliefs
• Risk assessment the impact of pain
• Living with pain

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Overview rationale evidence
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Physical Psychological Illness the missing
link

• Severe/chronic illness powerful stressor
• Restrictive capacity to work
• Overwhelmed emotionally - Denial
• Reactions
• Anger
• Fear
• Anxiety
• Relationship/family issues

Physical health not the sole target
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Major Depression Physical Illness
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Cancer

• Depression least noticed symptom
• Co-morbidity may be as high as 58
• At early diagnosis
• After treatment
• Prognosis good 8 out of 10

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Coronary Heart Disease

• Depression risk factor in ischaemic heart disease
  in men
• Risk of CHD exists on continuum according to
  severity of depressive symptoms
• CHD - more likely to suffer depression
• People with depression more at risk CHD
• If depressed greater risk of death from MI
• Symptoms hopelessness doubles risk of CHD

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Diabetes

• 2-3 times more likely to be depressed than
  general population
• Co-morbid depression increased health costs
• Diabetes Depression increased perceived
  symptom load
• depression symptoms poor hyperglycaemic
  control

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Stroke

• Prevalence post-stroke depression 61
• Untreated negative impact on functioning
  outcome QoL ADL
• Effective treatment D enhanced QoL,
  physical/social/emotional functioning
• Strong association D fatal strokes in
  middle-aged men. 14yr Caerphilly study risk
  trebled
• Post-stroke depression associated with later life
  mortality

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Health Beliefs
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Defining health

• State of complete physical, mental social well
  being (WHO)
• socially economically productive life.
• Optimum capacityeffective performance
  roles/tasks (Talcot Parsons)
• Effectively respond to challenges (stressors)
  effectively restore/sustain state of balance
• Need to consider QoL as primary aim with LTC
  (Fallowfield 1990)

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Lay people distinguish between health illness
more sharply than the health professional
(Herzlich 1973) Lay people view health in terms
of will power, self-control, self-discipline a
duty to be well Hence illness failure (Blaxter
1993)
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Blaxter (1995)

• Not being ill
• A reserve
• Behaviour
• Physical fitness
• Energy/vitality
• Social relationships
• Psycho-social well-being

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Psychological factors Anxiety stress fear
tension
Social factors Previous learning Cultural
factors Patient role whats expected of
us/asked of us Modelling
Familial factors Observed experience of illness
as child ways parental models sought help when
ill
Genetic factors Predisposed to ways of
responding to/coping with stress
Health beliefs Extent feels in
control/controlled by events Personal coping
style Beliefs, expectations communicated by
professional
Harrison Hart (2006)
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From Harrison A. Hart C (2006)
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Coping/adapting to illness

• Thinking about illness, diagnosis
• Identifying ways in which to cope with, respond
  to, deal with problem(s)
• Planning implementing particular strategies,
  responses

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Gask Underwood (2003) 3 essential components
of good psychological care
Providing information Right amount _at_ the right
time on the right issues Negotiating a care
Plan Dynamic process partnership between
worker patient, develop individualised care
plan Appropriate use of reassurance Only useful
if you know what individual is anxious/worried
about
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Cultural Views/Beliefs
Views/beliefs of health illness - reflected in
different cultures lack of knowledge/understandi
ng can lead to frustration people ignoring
health system(s) All of us whether we are
professional health workers or lay people,
create and re-create meanings of health illness
through our lived experience (Jones
1994) Perceptions may change over life-span
young - fitness/energy older
functioning/coping Beliefs dictated by world we
live in, where we live dominant social/economic
environment
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Risk assessment the impact of pain
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Pain signs, symptoms prevalence

• Depression back pain 2 most common problems
  encountered by healthcare professionals
• Strong link major depression back pain
• 60 pts with depression c/o back pain at time of
  diagnosis
• gt older person neck, back, hip pain
• Pain programmes 50-62 pts major depression
• Decreased mobility increased depressive
  symptoms
• Increasing statistics depression 1st degree
  relatives
• Not simply co-morbid condition interacts chronic
  pain

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Physical illness a risk factor

• 3 most common life problems associated with
  suicide
• Physical illness
• Bereavement
• Interpersonal problems
• Physical health problems present 82 cases
• Considered contributory to death 62 cases
• Pain, breathlessness, functional limitation
  most frequent symptoms

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Psychological theory

• Focus on control
• Pain inability to work, less recreational
  activity, less interaction negative spiral
  loss of control
• Totally controlled by pain major depression
• USA veterans
• 42 depression prior to pain
• 58 pain followed by depression
• Patients often fail to recognise Depression
  Doctors fail to look for it
• Combined treatment improved outcomes

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Living with Pain
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Chronic pain

• Pain natural survival mechanism
• Messages brain parts of body bottleneck
  at peak times feels more acute at night
• Acupuncture sends alternate messages
• Its not all in your mind
• Psychogenic pain
• Chronic pain induces psychological factors

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What chronic pain does

• Loss of mobility - assoc. suicidal ideation
• Depression heightened perception pain
  reluctance to exercise increased pain
  irritability, marital issues, anger, fear,
  hopelessness.
• Misperceptions shrink from treatment (some
  pain) injure by doing too much
• Medication side effects
• Anxiety - gtmuscle tension, spasms, flashbacks
• Caregiver- ill member overly involved others
  needs fear, rejection, resentment, not
  contributing

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What patients want from professionals

• Understanding of chronic pain
• Genuine wish to help
• Listens well
• Sets _at_ ease
• Encourages questions
• Allows disagreement
• Willing to talk to family/others
• Has a positive attitude

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Working with the patient

• Medication
• Relaxation
• Goal setting
• Challenging harmful/negative patterns
• Exercise
• Hypnosis
• Acupuncture
• Referral on as necessary stepped care

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Dee a case study

• Accident aged 6 lost toes, ball of foot
• 5 ops , skin graft, physiotherapy
• Aged 8 horse riding- wrecked havoc
• Aged 13 constant pain advised stop riding
• Personal choice observer active participant
• Aged 22 neuroma injections temp. respite-
  pain 6-8
• Neurolytic injection pain constant 10-
  permanent

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Dee continued

• Multi-faceted pain management 3 weeks
• Lifestyle nutrition, sleep, physical activity
• Stress management
• Physical therapy
• Chemical education Rxs, illicit drugs, alcohol,
  nicotine chronic pain
• Biofeedback Relaxation
• Individual counselling situations/behaviours

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Medication

• Anti-depressants as analgesics
• Tricyclics most effective (unless
  contra-indicated)
• Superior to placebo 80
• Evidenced ltpain intensity scores
• Studies on SSRIs variable inconsistent
• As prescribed

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Relaxation

• not part of denial process
• from pressured sense must return to normal
• escapism - gtanxiety
• ?how/type

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Goal setting

• Reasonable
• Easily attainable
• Break harmful patterns
• Each goal achieved gtpower over pain
• Medication management goal
• Perception harsh realities of situation
  opportunities to gtcommitment to life

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Challenging harmful patterns

• Be informed not obsessed
• Replace focussing on whats wrong
• Build on whats still right
• Patterns
• Avoiding normal activity
• Irregular sleep pattern/napping
• Unhealthy foods
• Ignoring psychological symptoms
• Using pain med. stress, irritability,
  frustration
• Focussing on blame
• Smoking, alcohol, drug use

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Hypnosis

• Self-hypnosis relaxation, sleep
• Exercise 1
• Externally oriented eyes open outward focus
  pleasant trance
• Exercise 2
• Associational cue

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CP Management Services in Primary Care

• CP one most significant common causes suffering
  in UK
• Back pain 12.3b lost working days
• 22 UK healthcare expenditure but pain relief not
  priority
• Study LTC Alliance Patients Association
• 55 response rate across UK

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157 PCOs did not respond to survey
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PCOs Continued

• 96 no register
• 92 no budget for training staff in P.Care
• 69 - no guidelines management non-cancer pain
• 64 PCOs no specific funding allocated to P.Care
• 57 - no guidelines Rx non-cancer pain
• NSF Older People- systematic care
• 14 specific pain man. Services 65
• 10 specific pain man. Services 65 in
  residential care

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Thank you