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Stress and clinical psychosomatic problems

Stress (biological). the consequence of the failure to adapt to change. in medical terms, the consequence of the disruption of homeostasis through physical or psychological stimuli. the condition that results when person-environment interaction leads someone to perceive a painful discrepancy, re

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Stress and clinical psychosomatic problems

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    1. Stress and clinical psychosomatic problems Zhejiang University School of Medicine Ai-Min Bao M.D. Ph. D.

    2. Stress (biological) the consequence of the failure to adapt to change. in medical terms, the consequence of the disruption of homeostasis through physical or psychological stimuli. the condition that results when person-environment interaction leads someone to perceive a painful discrepancy, real or imagined, between the demands of a situation on the one hand and their social, biological, or psychological resources on the other. Stressful stimuli may be mental, physiological, anatomical or physical.

    3. Stress (biological) The term stress in this sense was first used by the endocrinologist Hans Selye in the 1930s specifically in relation to the physiological responses of laboratory animals. He later broadened and popularized the concept to include the perceptions and responses of ordinary people trying to adapt to the challenges of everyday life. Stress in certain circumstances may be seen as a positive phenomenon: an evolved adaptive response prompting activation of internal resources to meet such challenges and achieve realistic goals, etc.

    4. A model of stress: General Adaptation Syndrome Hans Selye found all animals exposed to unpleasant or harmful stimuli presented a very similar series of reactions, broken into three stages. The universal response to the stressors: the General Adaptation Syndrome, or GAS.

    5. A model of stress: General Adaptation Syndrome Alarm the 1st stage, when the threat or stressor is identified or realized, the body's stress response is a state of alarm: adrenalin will be produced in order to bring about the fight-or-flight response. There is also some activation of the HPA axis, producing cortisol. Resistance the 2nd stage, if the stressor persists, it becomes necessary to attempt some means of coping with it. Although the body begins to try to adapt to the strains or demands of the environment, the body cannot keep this up indefinitely, so its resources are gradually depleted. Exhaustion the 3rd and final stage in the GAS model, all the body's resources are eventually depleted and the body is unable to maintain normal function. At this point the initial autonomic nervous system symptoms may reappear (sweating, raised heart rate etc.). If this stage is extended, long term damage may result as the capacity of glands, especially the adrenal gland, and the immune system is exhausted and function is impaired resulting in decompensation. The result can manifest itself in obvious illnesses: ulcers, depression (physical or mental illnesses).

    6. A model of stress: General Adaptation Syndrome

    7. Signs and symptoms of poorly managed stress a variety of emotional, cognitive, behavioral and physical symptoms that vary enormously among different individuals. Common somatic (physical) symptoms: sleep disturbances, muscle tension, headache, gastrointestinal disturbances, and fatigue. Emotional, cognitive and behavioral symptoms: nervousness, anxiety, fear, depression, anger; distraction, ill-judge; changes in eating habits including making poor nutritional choices. none of these signs or symptoms means for certain that there is an elevated stress level since all of them can be caused by other medical and/or psychological conditions. people under stress have a greater tendency to engage in unhealthy behaviors, such as escape and avoidance, retrogress and dependant, hostile and aggression, helpless and self-pity, and substance abuse: alcohol, drugs, cigarette smoking. These unhealthy behaviors can further increase the severity of symptoms related to stress, often leading to a "vicious cycle" of symptoms and unhealthy behaviors. The experience of stress is highly individualized.

    8. Common sources of stress Both negative and positive stressors can lead to stress. Sensory: pain, bright light Life events: birth and deaths, marriage, and divorce Responsibilities: lack of money, unemployment Illness: depression, obsessive compulsive disorder Work/study: exams, project deadlines, and group projects Personal relationships: conflict, deception, Break up Lifestyle: heavy drinking, insufficient sleep Environmental: Lack of control over environmental circumstances, such as food, housing, health, freedom, or mobility Social: Struggles with conspecific individuals and social defeat can be potent sources of chronic stresses Adverse experiences during development (e.g. prenatal exposure to maternal stress, poor attachment histories, sexual abuse) are thought to contribute to deficits in the maturity of an individual's stress response systems.

    9. Model of psychological stress response in Medical Psychology

    10. Holmes and Rahe stress scale ---Life Events Stress Test In an attempt to measure life changes, Holmes and Rahe, developed the Life Events Scale (also known as the Holmes & Rahe Social Readjustment Rating Scale, SRRS). The life events are ranked in order from the most stressful (death of spouse) to the least stressful (minor violations of the law). Life events that you have experienced over the past 12 months.

    13. Adaptation to stress Richard Lazarus (1974): a model dividing stress into eustress and distress. When stress enhances function (physical or mental, such as through strength training or challenging work): eustress. When stress is persistent and not resolved through coping or adaptation: distress, may lead to anxiety or withdrawal (depression) behavior. The difference between experiences which result in eustress or distress is determined by the disparity between an experience (real or imagined), personal expectations, and resources to cope with the stress. cognitive processes of appraisal are central in determining whether a situation is potentially threatening or harmful. Robert B. Zajonc (1984): in opposition to the Lazarus model of stress, argued that emotional reactions occur before cognitive reactions, and in fact, may be at odds with cognitive responses. consonant with the previous James-Lange hypothesis. James-Lange hypothesis: the body's emotional reaction to stress occurred prior to and resulted in conscious responses. James-Lange hypothesis: the body's emotional reaction to stress occurred prior to and resulted in conscious responses.

    14. Adaptation to stress Responses to stress include adaptation, psychological coping such as stress management, anxiety, and depression. Over the long term, distress can lead to diminished health or illness. The psychological definition of coping:, the process of managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict. In coping with stress, people tend to use one of the three main coping strategies: appraisal focused, problem focused, or emotion focused coping. (Weiten, Lloyd, 2006)

    15. Adaptation to stress Appraisal-focused strategies occur when the person modifies the way they think, for example: employing denial, or distancing oneself from the problem. People may alter the way they think about a problem by altering their goals and values, such as by seeing the humour in a situation. Problem focused strategies try to deal with the cause of their problem. They do this by finding out information on the disease, learning new skills to manage their disease and rearranging their lives around the disease. Emotion focused strategies involve releasing pent-up emotions, distracting one-self, managing hostile feelings, meditating, using systematic relaxation procedures, etc. People may use a mixture of these different types of coping, and coping mechanisms will usually change over time. Men often prefer problem focused coping, whereas women can often tend towards an emotion focused response.

    16. Neurobiology In response to a stressor: CRH- and AVP-expressing neurons are activated in the PVN of the hypothalamus and secreted into the hypophyseal portal system. The locus ceruleus (LC) and other noradrenergic cell groups of the adrenal medulla and pons, collectively known as the LC/NE system, also become active and use brain epinephrine to execute autonomic and neuroendocrine responses, serving as a global alarm system. The ANS provides the rapid response to stress commonly known as the fight-or-flight response, engaging the SNS and withdrawing the PSNS, thereby enacting cardiovascular, respiratory, gastrointestinal, renal, and endocrine changes.

    17. Add the solution treating stressAdd the solution treating stress

    18. Here you see both nuclei PVN and SON in human tissue. Both nuclei contain about 50.000 neurons. But there is a difference. Almost all vasopressinergic SON neurons project to the posterior pitutary, thus influencing plasma levels. In the PVN there are 3 different types of vasopressin producing neurons. Some take part in the HPA-axis, some project to the neuropituitary, some to other brain areas. The general idea is that the SON produces more vasopressin than the PVN. Our results however will show a different situation. Now to the evidence that these neurons play a role in Major depressionHere you see both nuclei PVN and SON in human tissue. Both nuclei contain about 50.000 neurons. But there is a difference. Almost all vasopressinergic SON neurons project to the posterior pitutary, thus influencing plasma levels. In the PVN there are 3 different types of vasopressin producing neurons. Some take part in the HPA-axis, some project to the neuropituitary, some to other brain areas. The general idea is that the SON produces more vasopressin than the PVN. Our results however will show a different situation. Now to the evidence that these neurons play a role in Major depression

    22. Neurobiology: increased catecholamine For defence: increased catabolism of glycogen and lipids, increased energy supply increased function of cardiovascular system, increased BP and blood supply redistribution of blood to insure the needs of heart and brain expanded bronchium for increasing oxygen supply promote the secretion of other hormones for compensation Disbennifits: ischemia of organs hypertension increased blood viscosity, thrombosis over consumption of oxygen lipid over-oxidation

    23. Neurobiology: interaction Chronic secretion of stress hormones, glucocorticoids (GCs) and catecholamines may reduce the affect of neurotransmitters, including serotonin, norepinephrine and dopamine, or other receptors in the brain, thereby leading to the dysregulation of neurohormones. Under stimulation, norepinephrine is released from the sympathetic nerve terminals in organs, and the target immune cells express adrenoreceptors. Through stimulation of these receptors, locally released norepinephrine, or circulating catecholamines such as epinephrine, affect lymphocyte traffic, circulation, and proliferation, and modulate cytokine production and the functional activity of different lymphoid cells.

    24. Neurobiology: Psychoneuroimmunology Stress significantly affect immune systems. The Immune-Brain Loop: nervous systemimmune system interactions exists at several biological levels. The immune system and the brain talk to each other through signaling pathways, which is essential for maintaining homeostasis. Two major pathway systems are involved in this cross-talk: the Hypothalamic-pituitary-adrenal axis (HPA axis) and the sympathetic nervous system (SNS). HPA axis activity and cytokines are intrinsically intertwined: inflammatory cytokines stimulate adrenocorticotropic hormone (ACTH) and cortisol secretion, while, in turn, glucocorticoids suppress the synthesis of proinflammatory cytokines. The activation of SNS during an immune response might be aimed to localize the inflammatory response.

    25. Neurobiology: Psychoneuroimmunology Molecules called pro-inflammatory cytokines, which include interleukin-1 (IL-1), IL-2, IL-6, IL-10, IL-12, Interferon-gamma (IFN-Gamma) and tumor necrosis factor alpha (TNF-alpha) can affect the brain. Immune cells called macrophages, which are the first on the scene of any infection, create the molecules mentioned above and experiments showed that they can act directly inside the brain by creation of microglia and astrocytes. Cytokines are also locally produced in the brain, especially in the hypothalamus. Like the stress response, the inflammatory reaction is crucial for survival. Recent studies show pro-inflammatory cytokine processes take place during depression, mania and bipolar disease, in addition to autoimmune hypersensativity and chronic infections.

    26. Social Psychology: the application in the clinic we are all affected by the people we interact with, many of whom we don't even know personally. our social environments play a significant role in how we view ourselves, and conversely, how we see ourselves impacts our view of the world. the various aspects of social psychology, i.e. the interaction between our view of self and others, the role of power in social interactions, and the groups, or the people with whom we interact, affect our decision making process.

    27. Social Psychology Our View of Self and Others The way we look at ourselves plays an important role in how we see the world, and vice versa. attribution (how we interpret those around us) and attraction (what we seek in a friend or partner). Attribution Theory Attribution: An idea or belief about the etiology of a certain behavior. we tend to explain our own behavior and the behavior of others by assigning attributes to these behavior. There are basically two sources for our behavior; those influenced by Situational (external) factors and those influenced by Dispositional (internal) factors. Imagine walking into your boss's office and he immediately tells you, in an angry tone, not to bother him. your explanation of this behavior might be... Our view of the world, previous experience with a particular person or situation, and our knowledge of the behavior play an important role. There are two important errors or mistakes we tend to make

    28. Social Psychology Attribution Theory: two important errors or mistakes Fundamental Attribution Error: the tendency to over estimate the internal and underestimate the external factors when explaining the behaviors of others. This may be a result of our tendency to pay more attention to the situation rather than to the individual (Heider, 1958) and is especially true when we know little about the other person. For example, you were driving and got cut off, did you say to yourself "What an idiot" (or something similar), or did you say "She must be having a rough day.? Self-Serving Bias. We tend to equate successes to internal and failures to external attributes (Miller & Ross, 1975). For example, when getting a promotion most of us will feel that this success is due to hard work, intelligence, dedication, and similar internal factors. But if you are fired This bias is true for most people, but for those who are depressed, have low self-esteem, or view themselves negatively, the bias is typically opposite. For these people, a success may mean that a multitude of negatives have been overlooked or that luck was the primary reason. For failures Chances are that this behavior was assigned mostly internal attributes and you didn't give a second thought to what external factors are playing a role in her driving behavior. If you are fired, well obviously your boss wouldn't know a good thing if it were staring her in the face. For these people, a success may mean that a multitude of negatives have been overlooked or that luck was the primary reason. For failures, the depressed individual will likely see their own negative qualities, such as stupidity, as being the primary factor. Chances are that this behavior was assigned mostly internal attributes and you didn't give a second thought to what external factors are playing a role in her driving behavior. If you are fired, well obviously your boss wouldn't know a good thing if it were staring her in the face. For these people, a success may mean that a multitude of negatives have been overlooked or that luck was the primary reason. For failures, the depressed individual will likely see their own negative qualities, such as stupidity, as being the primary factor.

    29. Social Psychology Attraction: Why are we attracted to certain people and not others? Why do our friends tend to be very similar to each other? And what causes us to decide on a mate? Many of these questions relate to social psychology in that society's influence and our own beliefs and traits play an important role. Research has found five reasons why we choose our friends: Proximity - The vast majority of our friends live close to where we live, or at least where we lived during the time period the friendship developed (Nahemow & Lawton, 1975). Association - We tend to associate our opinions about other people with our current state. Similarity - The agreement or similarity in between would likely result in more attractiveness (Neimeyer & Mitchell, 1988). Reciprocal Liking - We tend to like those better who also like us back.When we feel good when we are around somebody, we tend to report a higher level of attraction toward that person (Forgas, 1992; Zajonc & McIntosh, 1992) Physical Attractiveness - Physical attraction plays a role in who we choose as friends, although not as much so as in who we choose as a mate.

    30. Introduction of Social Psychology Obedience and Power: Why do we obey some people and not others? Why are you able to influence your patients? What attributes cause a person to be more influential? These questions are paramount in understanding social order. Power is typically thought of has having a certain attribute which gives one person more influence over another. This attribute could be intelligence or experience, it could be job title, or perhaps money. According to most social psychologists, there are five types of power: coercive, reward, legitimate, expert, and referent. Coercive power: the power punish. For example, parents are said to have coercive power because they can place their child in time-out; boss Reward power: the power to reward. Parents and bosses have this type of power as well Legitimate power: the power granted by some authority. Expert power: results from experience or education. Those individuals with more knowledge tend to have more power in situations where that knowledge is important. For instance, the physician in a medical emergency, a plumber when the pipes explode... Referent power: admiration or respect. When we look up to people because of their accomplishments, their attitude, or any other personal attribute, we tend to give them more power over us.

    31. Introduction of Social Psychology Using Power to Influence Others the others (source) influence us (target), or a medical doctor influences his patient with power. The more types of power and the stronger each of them is, the more influential he/she will be. a person must be believable in order to influence the others, must be trustworthy, otherwise much more difficult to change the others minds. attractiveness plays a role in how influence the others. We tend to be influenced more by attractive people, including physical and social attractiveness, likeability, demeanor, and dress. the target or listener plays a role in how he will be influenced as well. Those with low self-esteem and/or high self-doubt tend to be more influenced than others. other factors such as age, IQ, gender, or social status do NOT appear to play a significant role in how we are influenced by others. the relationship between the source and the target plays important role: similarity,a moderate discrepancy in attitude---the difference must be great enough that a change is possible but small enough that the listener is open to the change.

    32. Introduction of Psychopathology Classifying Psychopathology Mental illness is classified today according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), published by the American Psychiatric Association (1994). The DSM uses a multiaxial or multidimensional approach to diagnosing because rarely do other factors in a person's life not impact their mental health. It assesses five dimensions as described below: Axis I: Clinical Syndromes: what we typically think of as the diagnosis (e.g., depression, schizophrenia, social phobia) Axis II: Developmental Disorders and Personality Disorders: Developmental disorders include autism and mental retardation, disorders which are typically first evident in childhood; Personality disorders are clinical syndromes which have a more long lasting symptoms and encompass the individual's way of interacting with the world. They include Paranoid, Antisocial, and Borderline Personality Disorders.

    33. Introduction of Psychopathology Axis III: Physical Conditions which play a role in the development, continuance, or exacerbation of Axis I and II Disorders Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here. Axis IV: Severity of Psychosocial Stressors: Events in a persons life, such as death of a loved one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in Axis I and II. These events are both listed and rated for this axis. Axis V: Highest Level of Functioning: the clinician rates the person's level of functioning both at the present time and the highest level within the previous year.

    34. Introduction of Psychopathology Psychiatric Disorders(the first two axes in more detail as these are what we typically think of when we think of mental illness or psychopathology). The DSM IV identifies 15 general areas of adult mental illness. 1. Delirium, Dementia, Amnestic, and Other Cognitive Disorders The primary symptoms of these disorders include significant negative changes in the way a person thinks and/or remembers. All of these disorders have either a medical or substance related cause. 2. Mental Disorders Due to a Medical Condition are directly related to a medical condition. 3. Substance Related Disorders two disorders listed: Substance Abuse and Substance Dependence. Both involve the ingestion of a substance (alcohol, drug, chemical) which alters either cognitions, emotions, or behavior. 4. Schizophrenia and other Psychotic Disorders The major symptom of these disorders is psychosis, or delusions and hallucinations. The major disorders include schizophrenia and schizoaffective disorder.

    35. 5. Mood Disorders The disorders in this category include those where the primary symptom is a disturbance in mood. The disorders include Major Depression, Dysthymic Disorder, Bipolar Disorder, and Cyclothymia. 6. Anxiety Disorders Anxiety Disorders categorize a large number of disorders where the primary feature is abnormal or inappropriate anxiety. The disorders in this category include Panic Disorder, Agoraphobia, Specific Phobias, Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, and Generalized Anxiety Disorder. 7. Somatoform Disorders Disorders in this category include those where the symptoms suggest a medical condition but where no medical condition can be found by a physician. Major disorders in this category include Somatization Disorder, Pain Disorder, Hypochondriasis. 8. Factitious Disorder Factitious Disorder is characterized by the intentionally produced or feigned symptoms in order to assume the 'sick role.' These people will often ingest medication and/or toxins to produce symptoms and there is often a great secondary gain in being placed in the sick role and being either supported, taken care of, or otherwise shown pity and given special rights.

    36. 5. Mood Disorders The disorders in this category include those where the primary symptom is a disturbance in mood. The disorders include Major Depression, Dysthymic Disorder, Bipolar Disorder, and Cyclothymia. 6. Anxiety Disorders Anxiety Disorders categorize a large number of disorders where the primary feature is abnormal or inappropriate anxiety. The disorders in this category include Panic Disorder, Agoraphobia, Specific Phobias, Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, and Generalized Anxiety Disorder. 7. Somatoform Disorders Disorders in this category include those where the symptoms suggest a medical condition but where no medical condition can be found by a physician. Major disorders in this category include Somatization Disorder, Pain Disorder, Hypochondriasis. 8. Factitious Disorder Factitious Disorder is characterized by the intentionally produced or feigned symptoms in order to assume the 'sick role.' These people will often ingest medication and/or toxins to produce symptoms and there is often a great secondary gain in being placed in the sick role and being either supported, taken care of, or otherwise shown pity and given special rights.

    37. 9. Dissociative Disorders The main symptom cluster for dissociative disorders include a disruption in consciousness, memory, identity, or perception. In other words, one of these areas is not working correctly causing significant distress within the individual. The major diagnoses in this category include Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, and Dissociative Identity Disorder. 10. Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders These disorders are all related to sexuality, either in terms of functioning (Sexual Dysfunctions), distressing and often irresistible sexual urges (Paraphilias), and gender confusion or identity (Gender Identity Disorder. It should be noted that for these, as well as many other categories, a medical reason should always be ruled out before making a psychological diagnosis. 11. Eating Disorders Eating disorders are characterized by disturbances in eating behavior. There are two types: Anorexia Nervosa and Bulimia Nervosa. 12. Sleep Disorders All sleep disorders involve abnormalities in sleep in one of two categories, dysomnias and parasomnias. 13. Impulse Control Disorders Disorders in this category include the failure or extreme difficulty in controlling impulses despite the negative consequences.

    38. 14. Adjustment Disorders This category consists of an inappropriate or inadequate adjustment to a life stressor. Adjustment disorders can include depressive symptoms, anxiety symptoms, and/or conduct or behavioral symptoms. 15. Personality Disorders Personality Disorders are characterized by an enduring pattern of thinking, feeling, and behaving which is significantly different from the person's culture and results in negative consequences. This pattern must be longstanding and inflexible for a diagnosis to be made. There are ten types of personality disorders, all of which result in significant distress and/or negative consequences within the individual: Paranoid (includes a pattern of distrust and suspiciousness, Schizoid (pattern of detachment from social norms and a restriction of emotions), Schizotypal (pattern of discomfort in close relationships and eccentric thoughts and behaviors), Antisocial (pattern of disregard for the rights of others, including violation of these rights and the failure to feel empathy), Borderline (pattern of instability in personal relationships, including frequent bouts of clinginess and affection and anger and resentment, often cycling between these two extremes rapidly), Histrionic (pattern of excessive emotional behavior and attention seeking), Narcissistic (pattern of grandiosity, exaggerated self-worth, and need for admiration), Avoidant (pattern of feelings of social inadequacies, low self-esteem, and hypersensitivity to criticism), Dependent (pattern of feeling as helpless and fearful), and Obsessive-Compulsive (pattern of obsessive cleanliness, perfection, and control).

    39. Psychosomatic disorders illness or disorder whose symptoms are caused by mental processes of the sufferer rather than immediate physiological causes. Some physical complaints may have a psychological cause: hysterical paralysis, somatization disorder, and tension myositis syndrome, etc., while some physical conditions can cause psychological symptoms: vitamin deficiency, brain injury, etc. Peptic ulcers were once thought to be the result of stress and are still considered to be psychosomatic, but also have been proven to have a connection to the H-Pylori bacteria. Often are attributed to a result from stress--- stress management plays an important role in the development, amelioration or avoidance of psychosomatic illness. Various types of psychotherapy and alternative therapies are used to treat psychosomatic disorders. In some cases, psychosomatic problems may improve or disappear following suggestion by a recognized authority.

    40. Evolution of Psychosomatic Diagnosis in DSM Recognition of the interaction of "psyche" and "soma" dates from antiquity, only in modern times have we developed the vocabulary and concepts . The first DSM developed between 1946 and 1951, just after World War II, with the new rubric: Psycho-physiological Autonomic and Visceral Disorders," with an explanation: "This term is used in preference to psychosomatic disorders since the latter refers to a point of view on the discipline of medicine as a whole rather than to certain specified conditions. The psychophysiological disorders were subcategorized into "reactions" of various organ systems: musculoskeletal, cardiovascular, gastrointestinal, genitourinary, endocrine, etc. DSM-II was published 16 years later. By then, psychoanalysis had become established in American psychiatry, with an emphasis on clinical observation and the idiographic approach. Psychosomatic conditions became "Psychophysiological Disorders," with "autonomic and visceral" dropped. Subsequently, questions about psychoanalysis continued to increase, accompanied by advances in the basic and applied neurosciences relevant to mental disorders. American Psychiatry became more scientific, with an emphasis on evidence-based diagnosis and treatment resting on data derived from appropriately designed research, and it became more neurobiological. Unfortunately, this new knowledge was applied within the tired old biomedical model rather than a "bio-psycho-social" model.

    41. Evolution of Psychosomatic Diagnosis in DSM In the vastly changed nature of DSM-III, "Psychophysiological Disorders" was removed. Instead, there was a new category designated as "Psychological Factors Affecting Physical Condition., the nature of which speaks for itself. A new feature of DSM-III: a "multiaxial" format, in which preexisting personality disorders or mental retardation, concomitant medical conditions, stressors, and functional capacity were included. With this incorporation of psychological, biological, and social factors into a dynamic framework, this system has the capacity to portray nonlinear psychosomatic causal adaptive processes. Fourteen years later, DSM-IV, with the same overall design as its predecessor, continued the same trends. "Psychological Factors Affecting Medical condition" was substituted for ".... Physical" condition, a further narrowing. More significant, this rubric no longer had the status of a category in itself, but became one of a series of subsections within the category "Other Conditions that May Be a Focus of Attention," grouped with medication-induced problems, relationship problems, abuse, etc: dilution of the concept of psychosomatic processes. As we look ahead toward the next DSM, we need to confront a fundamental and important question: Should there be a category for "Psychosomatic Disorders" at all? Psychological and biological factors are involved in all aspects of human function, healthy and disordered.

    47. Clinician-patient communication Factors involve patients seeing (a) doctor(s) Subjective feeling about a disease or symptom Quality and quantity of the symptoms Effects of psycho-social factors Psychological needs of patients: being accepted, being respected, being informed the diagnosis and the treatment, and being safe Factors involve adherence to medical recommendations (the extent to which a person's behavior coincides with medical or health advice, such as taking medication regularly, returning to a doctor's office for follow-up appointments, and observing preventive and healthful lifestyle changes) Subjective feeling of the disease and its severity Treatment regime and its convenience Patients obedience Strategies to encourage adherence intrapsychic factors: knowledge of the regimen, belief in benefits of treatment, subjective norms, and attitudes toward medication-taking behavior environmental and social factors: the interpersonal relationship between the provider and the patient and social support from family members and friends.

    48. when patients take more responsibility and initiative, put more effort into improving their health-related habits and self-management skills, things usually improve. many patients still expect medical interventions and interveners to fix them. A growing number of providers seek to alter patient preferences and expectations by explaining the advantages of a shift in roles, however gradual the shift may need to be in a particular situation,using concrete examples that relate to the patient.

    49. Clinician-patient communication: patient role adaptation The patient has to change his role of other social identity into a patient identity, but if his need/motivation in other social identity is larger than his motivation pursuing therapy for disease In the early stage of disease that diagnosed by clinician, the patient denies it or would not accept it The other social identities of the patient impact the patient and make him take actions that he should not Or the patient is content with the role of patient and wish to enjoy the benefit of being a patient Pessimistic, disappointed, bad mood; abnormal behavior e.g. aggressive, stubborn, depressive, suicide.

    51. Build clinician-patient relationships Patients self-Management Support aims for consistent care based on strong respectful relationships among patients, families, and health care providers, that can grow over time with the providers and patients making them stronger. Patients who report that their clinicians know them as people, who experience trust, empathy and respect, and who are provided with choices and options are more likely to participate actively in treatment and self-management and, as a result, experience improved outcomes. Physicians must be: Altruistic?compassionate, empathetic, trustworthy, truthful, professional, and aware of personal limits; Knowledgeable?biomedical knowledge related to diseases pathogenesis; Skillful?eliciting histories and performing physical examinations, technical procedures, critical care, communicating, relieving pain; Dutiful? includes knowledge of nonbiological determinants of poor health (social, psychological, and behavioral factors are relegated to this "nonbiological" category).

    52. Build Relationships The following specific communication skills can help clinicians and other team members build effective collaborative relationships with patients and families: Ask open-ended questions invite the patient to share their story, not just about immediate health problems. For example: What is most important to you now? Tell me about Use reflective listening seek to understand the meaning of the story. Express empathy seek to comprehend the patients perspective Respond to and reflect feelings, concerns, beliefs, values - You are quite frustrated and upset about... Normalize Many people experience Affirm You have been doing what you can Self-disclose (when appropriate).

    53. Psychological Aspects of Coping with Cancer A diagnosis of cancer often brings up one of peoples worst health fears. Most adults and children are actually psychologically resilient in coping with cancer. Resilience does not mean that one is forced into thinking positively all of the time. Most studies show that feigning a positive attitude may actually become an added stressor.It may be perfectly OK to be sad and angry. For many, a good coping strategy is to find out as much information as one can about the specific cancer. It is also a good idea to put together two support teams, the first a support and comfort team, and the other a medical and psychosocial team, the former may be family and close friends while the latter might consist of oncologists, surgeons, nurse practitioners, bedside nurses, a psychologist, a psychiatrist, a social worker and clergy. A close working relationships between the medical-psychosocial team members will be extremely important for purposes of coordinating treatments and for communicating and addressing an adults or a childs needs throughout treatment.

    54. Psychological Aspects of Coping with Cancer Shock - fear period Deny - doubt period Anger - depression period Acceptance - adaptation period

    55. Psychological Aspects of Coping with Cancer Several factors such as how well he/she developed his/her coping strategies and stress management skills contribute to how well one adjusts to anything in life, especially cancer Coping strategies and stress management skills can be learned. Psychologists working with cancer patients and their families try to assess how well people have faired in the past, not only weaknesses, but also strengths. They try to work with those strengths to come up with good, compatible coping strategies, help patients develop stress management skills. Problems concerning cancers can be acute or chronic, e.g., vomiting due to recent chemotherapy and/or with several courses followed; work security, insurance coverage, child care, financial pressures, problematic interpersonal relationships, etc. Children or adults with prior histories of emotional or mental health problems often face great challenges in coping with cancer and its treatments.. It is far better for them being open and honest with their health care team about their mental health history, which can help the team make an appropriate and timely referral to a psychologist or a psychiatrist. The team of physicians should be aware of any and all medications taken by the individual, including supplemental, alternative or complementary therapies in order for the team to be able to provide optimal care. It is far better for them being open and honest with their health care team about their mental health history, which can help the team make an appropriate and timely referral to a psychologist or a psychiatrist. The team of physicians should be aware of any and all medications taken by the individual, including supplemental, alternative or complementary therapies in order for the team to be able to provide optimal care.

    56. Psychological Aspects of Coping with Cancer The fear of death, especially true if someone from their family has died of cancer. While it will not necessarily impact outcome, feeling this way certainly does not help treatment. Stress and fear may also come from a recent personal loss: having someone very close die, a loss of functioning (i.e. being unable to walk straight after years of no treatment), loss of a role, or a loss of a breast or a limb. Sometimes, psychotherapy and/or medication are indicated, which is especially true when someone becomes so depressed and begin to contemplate suicide. Previous experiences often play an important role in determining ones adjustment to cancer: serious physical or emotional trauma such as a history of early childhood abuse, combat experiences, a history of rape, or even emotional abuse. Three other scenarios related: symptom tolerance, conditioned to being anxious when going to receive treatments (classically conditioned vomiting), and treatments associated with changes in mood or mental functioning (iatrogenic effects, a fancy way of saying treatment-related effects).

    57. Psychological Aspects of Coping with Cancer While it may raise the worst of fears in adults and children, thanks to modern treatments, a diagnosis of cancer is not always fatal. But, there is plenty that can be done psychologically to cope with the medical or psychological aspects of cancer with humanity, understanding, courage and dignity.

    58. Sleep and insomnia Sleep is a natural state of bodily rest observed throughout the animal kingdom. It is common to all mammals and birds, and is also seen in many reptiles, amphibians and fish. Regular sleep is essential for survival. However, its purposes are only partly clear and are the subject of intense research. In mammals and birds the measurement of eye movement during sleep is used to divide sleep into the two broad types of Rapid Eye Movement (REM) and Non-Rapid Eye Movement (NREM) sleep. Each type has a distinct set of associated physiological, neurological and psychological features.

    59. Sleep proceeds in cycles of REM and the four stages of NREM, the order normally being: stages 1 -> 2 -> 3 -> 4 -> 3 -> 2 -> REM. In humans this cycle is on average 90 to 110 minutes, with a greater amount of stages 3 and 4 early in the night and more REM later in the night. Each phase may have a distinct physiological function. Drugs such as sleeping pills and alcoholic beverages can suppress certain stages of sleep. This can result in a sleep that exhibits loss of consciousness but does not fulfill its physiological functions. Allan Rechtschaffen and Anthony Kales originally outlined the criteria for identifying the stages of sleep in 1968. The American Academy of Sleep Medicine (AASM) updated the staging rules in 2007.

    60. Stages of sleep Criteria for REM sleep include not only rapid eye movements but also a rapid low voltage EEG. In mammals, at least, low muscle tone is also seen. Most memorable dreaming occurs in this stage. NREM accounts for 7580% of total sleep time in normal human adults, relatively little dreaming, encompasses four stages: --- stages 1 and 2: 'light sleep', --- stages 3 and 4: 'deep sleep, or slow-wave sleep, SWS. --- they are differentiated solely using EEG --- there are often limb movements, and parasomnias such as sleepwalking occurs here. --- A cyclical alternating pattern (CAP, occurs in sleep, characterized as periodic episodes of aroused EEG activity (more Sleep spindles and K-complexes) followed by a period of more quiet sleep. Both these periodic activities, when combined, are considered the CAP period) may occur while does not occur in REM

    61. NREM consists of four stages according to the 2007 AASM standards: During Stage N1 the brain transitions from alpha waves (having a frequency of 8 to 13 Hz, common to people who are awake) to theta waves (frequency of 4 to 7 Hz). This stage is sometimes referred to as somnolence, or "drowsy sleep". Associated with the onset of sleep during N1 may be sudden twitches and hypnic jerks also known as positive myoclonus. During N1 the subject loses some muscle tone and conscious awareness of the external environment. Stage N2, is characterized by "sleep spindles" (12 to 16 Hz) and "K-complexes., muscular activity as measured by electromyography (EMG) lowers and conscious awareness of the external environment disappears. This stage occupies 45 to 55% of total sleep.

    62. In Stage N3, the delta waves (0.5 to 4 Hz), also called delta rhythms, make up less than 50% of the total wave-patterns. This is considered part of deep or slow-wave sleep (SWS) and appears to function primarily as a transition into stage N4. This is the stage in which night terrors, bedwetting, sleepwalking and sleep-talking occur. In Stage N4, delta-waves make up more than 50% of the wave-patterns. Stages N3 and N4 are the deepest forms of sleep; N4 is effectively a deeper version of N3, in which the deep-sleep characteristics, such as delta-waves, are more pronounced. In a recent ruling by the AASM, in order to make precision the scoring guidelines, stage four had been disbanded, and left is the stage of sleep N3 to describe the delta sleep attributed to it. Both REM sleep and NREM sleep stages 3 and 4 are homeostatically driven; that is, if a person or animal is selectively deprived of one of these, it rebounds once uninhibited sleep again is allowed. This suggests that both are essential to the functions of the sleep process.

    63. Sleep stages

    64. Sleep deprivation a general lack of the necessary amount of sleep, may occur as a result of sleep disorders, active choice or deliberate inducement. Some evidence of effects on the brain: prefrontal cortex displayed more activity in sleepier subjects. The temporal lobe involved in language processing was activated during verbal learning in rested subjects but not in sleep deprived subjects. The parietal lobe was more active when the subjects were deprived of sleep, associated with better memory. There are links to more serious diseases, such as heart disease and mental illnesses, such as psychosis and bipolar disorder. REM sleep deprivation was found to alleviate clinical depression: sleep deprivation mimics the effects of SSRI? However it was also indicated that REM sleep was essential for blocking neurotransmitters and allowing the neurotransmitter receptors to "rest" and regain sensitivity which in turn leads to improved regulation of mood and increased learning ability. Non REM sleep may allow enzymes to repair brain cell damage caused by free radicals. High metabolic activity while awake damages the enzymes themselves preventing efficient repair. Animal studies suggest that sleep deprivation increases stress hormones (such as cortisol and norepinephrine), which may reduce new cell production in adult brains.

    65. Sleep interpretation Starting around 300 BC, ancient Greece, the pilgrims flocked to asclepieia to be healed. They slept overnight and reported their dreams to a priest the following day. He prescribed a cure, often a visit to the baths or a gymnasium. In ancient Egypt, priests also acted as dream interpreters It was taken up as part of psychoanalysis at the end of the 19th century; the perceived, manifest content of a dream is analyzed to reveal its latent meaning to the psyche of the dreamer. One of the seminal works on the subject is The Interpretation of Dreams by Sigmund Freud. Freud argued that the foundation of all dream content is wish-fulfilment, and that the instigation of a dream is always to be found in the events of the day preceding the dream.

    66. Sleep interpretation Freud claimed, small children dream quite straightforwardly of the fulfilment of wishes that were aroused in them the previous day (the 'dream day'), while the dreams of adults have been subjected to distortion with the dream's so-called 'manifest content' being a heavily disguised derivative of the 'latent' dream-thoughts present in the unconscious. in the more refined terminology of Freud later years, discussion was in terms of the super-ego and 'the work of the ego's forces of defence'. In waking life, he asserted, these so-called 'resistances' altogether prevented the repressed wishes of the unconscious from entering consciousness; and though these wishes were to some extent able to emerge during the lowered state of sleep, the resistances were still strong enough to produce 'a veil of disguise' sufficient to hide their true nature. Freud's view was that dreams are compromises which ensure that sleep is not interrupted: as 'a disguised fulfilment of repressed wishes', they succeed in representing wishes as fulfilled which might otherwise disturb and waken the dreamer.

    67. Sleep disorders: Insomnia A symptom characterized by persistent difficulty falling asleep or staying asleep despite the opportunity. It is typically followed by functional impairment while awake. Occurs 1.4 times more commonly in women than in men (the US). About three types : Transient insomnia lasts from days to weeks, can be caused by another disorder, changes in the sleep environment, the timing of sleep, severe depression, or stress. Its consequences - sleepiness and impaired psychomotor performance - are similar to those of sleep deprivation. Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months. Chronic insomnia lasts for years at a time. It can be caused by another disorder, or it can be a primary disorder. Its effects can vary according to its causes, including sleepiness, muscular fatigue, hallucinations, and/or mental fatigue; but people with chronic insomnia often show increased alertness.

    68. Sleep disorders: Insomnia Pattern of insomnia (often is related to the etiology ) : Onset insomnia - difficulty falling asleep at the beginning of the night, often associated with anxiety disorders. Middle-of-the-Night Insomnia - characterized by difficulty returning to sleep after awakening in the middle of the night or waking too early in the morning. Also referred to as nocturnal awakenings. Encompasses middle and terminal insomnia. Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with pain disorders or medical illness. Terminal (or late) insomnia - early morning waking. Characteristic of clinical depression.

    69. Treatment of Insomnia Cognitive behavior therapy more effective than hypnotic medications, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Hypnotic medications are equally effective in the short term treatment of insomnia but their effects wear off over time due to tolerance. The effects of cognitive behavioral therapy have sustained and lasting effects on treating insomnia long after therapy has been discontinued. Biofeedback: used in conjunction with relaxation training and other behavioral approaches to controlling anxiety such as cognitive restructuring (which helps people rethink just how threatening the very real stresses they need to deal with really are) helps people recognize when they are having exaggerated physical stress responses and what they are responding to. Medications Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down Placebo for highly suggestibility mild insomnia

    70. Treatment of Insomnia Benzodiazepines The most commonly used class of hypnotics prescribed for insomnia bind unselectively to the GABAA receptor such as temazepam, flunitrazepam, triazolam, flurazepam, nitrazepam and midazolam. can develop tolerance and dependence, especially after consistent usage over long periods of time Non-benzodiazepines such as Ambien (zolpidem), Sonata (zopiclone) and Lunesta (eszopiclone), more selective for the GABAA receptor and may have a cleaner side effect profile than the older benzodiazepines controversies over whether they are superior to benzodiazepines. cause both psychological dependence and physical dependence though less than traditional benzodiazepines; can also cause the same memory and cognitive disturbances along with morning sedation. belong to the new category of medications called sedative-hypnotics Antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone may have a sedative effect The major drawback is that their antihistaminergic, anticholinergic and antiadrenergic properties can also lead to physical dependence; withdrawal may induce rebound insomnia and actually further complicate matters in the long-term.

    71. Treatment of Insomnia Melatonin effective for some insomniacs in regulating the sleep/waking cycle, but there is little definitive data regarding its efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. A relatively mild side effect profile and lower likelihood of causing morning sedation. Natural substances such as 5-HTP and L-Tryptophan have been said to fortify the serotonin-melatonin pathway and aid people with various sleep disorders including insomnia Antihistamines The antihistamine Benadryl (diphenhydramine) is widely used in nonprescription sleep aids such as Tylenol PM, with a 50 mg recommended dose mandated by the FDA. the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs. Atypical Antipsychotics Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia. Over time, Seroquel may lose its ability to produce sedation.

    72. Treatment of Insomnia Other Substances herbs such as valerian, chamomile, lavender, hops, passion-flower, and even Cannabis, have been suggested as effective treatment; relaxing essential oils help induce states of restfulness Complementary and alternative medicine Some traditional and anecdotal remedies: sleep hygiene Relaxation techniques: meditation Traditional Chinese medicine: acupuncture, dietary and lifestyle analysis, herbology and other techniques Buddhist tradition: meditate on "loving-kindness", or metta, generating a feeling of love and goodwill to have a soothing and calming effect Hypnotherapy: self hypnosis and guided imagery can be effective in not only falling and staying asleep, but also in develop good sleeping habits over time.

    73. The Psychology of Pain in the sense of physical pain, is a typical sensory experience the unpleasant awareness of a noxious stimulus or bodily harm experience by various daily hurts and aches, occasionally through more serious injuries or illnesses, the response involving sensory, behavioral (motor), emotional, and cultural components For scientific and clinical purposes, pain is defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage highly subjective to the individual experiencing it, a major symptom in many medical conditions--- Chronic pain may be more debilitating than the trauma itself, a leading cause of suicide. part of the body's defense system Pain triggers a reflex reaction to retract from a painful stimulus, and helps adjust behavior to increase avoidance of that particular harmful situation in the future. Pain triggers a reflex reaction to retract from a painful stimulus, and helps adjust behavior to increase avoidance of that particular harmful situation in the future.

    74. Components of Pain

    75. The Cost of Pain Pain inflicts significant costs on individuals, their families, the health services and society in general. The economic costs are very high due to extended hospital stays, lost working days and increased take-up of benefits. The cost of pain in terms of human suffering is also high. It is often the most distressing and debilitating aspect of chronic illness. Its effects on quality of life can be devastating to the individual and their significant others. The emotional toll of severe chronic pain should not be underestimated It is estimated that around 50% of severe chronic pain patients consider suicide.

    76. THEORIES OF PAIN Specificity Theory Pattern Theory Gate Control Theory

    77. Specificity Theory (Von Frey, 1894) describes a direct causal relationship between pain stimulus and pain experience.

    78. Pattern Theory Proposed stimulation of nociceptors produces a pattern of impulses that are summated in the dorsal horn of the spinal cord. Only if the level of the summated output exceeds a certain threshold is pain information transmitted onwards to the cortex: pain perception. Evidence of deferred pain perception raised questions: Soldiers not perceiving pain until the battle is over Phantom limb Injury without pain perception Growing evidence for a mediating role for psychosocial factors in the experience of pain, including cross-cultural differences in pain perception and expression.

    80. Gate Control Theory the perception of physical pain is not a direct result of activation of nociceptors, but is modulated by interaction between different neurons, both pain-transmitting and non-pain-transmitting. activation of nerves that do not transmit pain signals can interfere with signals from pain fibers and inhibit an individual's perception of pain. Afferent pain-receptive nerves, those that bring signals to the brain, comprise at least two kinds of fibers - a fast, relatively thick, myelinated "Ad" fiber that carries messages quickly with intense pain, and a small, unmyelinated, slow "C" fiber that carries the longer-term throbbing and chronic pain. Large-diameter A fibers are nonnociceptive (do not transmit pain stimuli) and inhibit the effects of firing by Ad and C fibers.

    81. Gate Control Theory It explains how stimulus that activates only nonnociceptive nerves can inhibit pain. One area of the brain involved in reduction of pain sensation is the periaqueductal gray matter that surrounds the third ventricle and the cerebral aqueduct of the ventricular system. Stimulation of this area produces analgesia (but not total numbing) by activating descending pathways that directly and indirectly inhibit nociceptors in the laminae of the spinal cord. It also activates opioid receptor-containing parts of the spinal cord. Afferent pathways interfere with each other constructively, so that the brain can control the degree of pain that is perceived, based on which pain stimuli are to be ignored to pursue potential gains. The brain determines which stimuli are profitable to ignore over time. Thus, the brain controls the perception of pain quite directly, and can be "trained" to turn off forms of pain that are not "useful". This understanding led Melzack to assert that pain is in the brain.

    82. PSYCHOLOGICAL ASPECTS OF PAIN Many psychosocial factors have been investigated in relation to pain and these appear to exert independent effects on the experience of pain. eight of these factors: Cognitions Self-efficacy Perceived control Prior experience and conditioning Secondary gains Personality Mood Stress

    83. Cognitions influence the experience of pain, particularly the appraisal of situations for their significance and meaning. Aspects of cognition that have received attention related to pain are: Attention: Increased attention to pain has been associated with increased pain perception. This may explain why distraction techniques are useful in combating pain. Dysfunctional thinking: Dysfunctional thoughts, attitudes and beliefs about pain are automatic patterns of thinking that block the attainment of an individuals goals. Coping styles: strategies used to attempt to deal with the pain. In general, active coping styles (e.g. keeping oneself busy) have been found to be associated with improved coping, reduced pain intensity and improved recovery rates.

    84. Perceived control Bowers (1968) showed that individuals endure more pain when they control the pain-stimulus on/off switch than when it is controlled by someone else. This concept relates to the development of patient controlled analgesia (PCA), in the management of post-operative pain and in palliative care. PCA resulted in patients administering less analgesic morphine than when it was controlled and administered by nurses or through continuous infusion. PCA appears to result in better pain management, less opiate use and earlier discharge from hospital than intramuscular therapy (Royal College of Surgeons & Anaesthetists, 1990).

    85. Previous Experience and Conditioning Both classical and operant conditioning have been implicated in the aetiology of chronic pain via the association of behaviour and pain. In classical conditioning theory a particular situation or environment may become associated with pain and therefore provoke increased anxiety and pain perception. In operant conditioning theory, pain behaviours become conditioned responses through positive (e.g. attention, medication, time off work) and negative (e.g. disapproval of others, loss of earnings) reinforcements.

    86. Secondary Gains relates to social rewards accruing from the demonstration of pain behaviours. to reinforce pain behaviours and thus maintain the condition. However, this may actually reflect that those in receipt of compensation can allow themselves appropriate time to recover and says nothing about the quality of life of those who returned to work earlier. For many individuals, pain results in the loss of jobs, social contact, leisure activities, valued identities, reduced incomes and concomitant reduced standard of living. Such losses are very real and distressing and are often associated with substantial hardships, lowered mood and loss of self-esteem, unlikely to be outweighed by incidental benefits.

    87. Personality It has been suggested that there is a pain-prone personality (Engel, 1959): Features of the pain prone personality include continual episodes of varying chronic pain, high neurotic symptoms (guilt feelings, anxiety, depression and hypochondria) Generally, empirical support for the pain-prone personality has not been forthcoming and it has been suggested that the higher scores for particular personality factors (i.e. neurotic triad) may be a consequence rather than a cause of long-term pain.

    88. Mood There is a relationship between pain and anxiety Acute pain increases anxiety. But once pain is decreased through treatment, the anxiety also decreases, which can cause further decreases in the pain, a cycle of pain reduction. Chronic pain remains unalleviated by treatment and therefore anxiety increases which can further increase the pain, creating a cycle of pain increase. Depression is also commonly associated with pain. People who experience severe and persistent pain often have feelings of hopelessness, helplessness and despair. While correlations between mood states and pain have been found, the causal direction and the nature of the relationships remains unclear.

    89. Stress Chronic pain both exacerbates and is exacerbated by stress. Experiencing persistent high levels of pain can itself can be a substantial stressor, possibly even the most significant stressor in the lives of many individuals. It is also often the source of additional life stresses, like loss of employment, relationship difficulties and financial hardship. Individual, stereotypical physiological responses to stress (e.g. clenching jaws, migraine headaches) can be a direct source of pain and the physiological arousal associated with stress may lead to increased pain and inhibit effective adaptation. Stress is such a frequent concomitant of pain that stress management techniques are routinely included as an integral part of pain management programmes.

    90. SOCIOCULTURAL INFLUENCES ON PAIN Several sociocultural factors have also been implicated in the experience of pain. the role of: Culture Gender Age Significant others and the family

    91. Culture Pain experience is expressed differently across cultural groups. Social learning influences pain tolerance levels, communication about pain, pain behaviours and the meaning of pain. Cultural influences may encourage avoidance or acceptance of pain, demonstrable pain behaviours or stoic concealment. It may also affect the treatment received within healthcare systems in terms of cultural expectations and communication traditions. Further research is needed on the influence of social factors and discrimination on the experience of pain treatment for minority groups.

    92. Gender There is much evidence to suggests that women are better at dealing with pain than men. Biology, sex hormones, culture, socialization and role expectations, psychology, and past experience have been offered as explanatory variables. However, the relationship between pain and gender is complex. The particular type of pain, when it occurs, and the researchers gender are all implicated in pain reporting. Skevington (1995) argues gender differences may have been overemphasized and significant similarities exist between the sexes regarding pain experiences and actual differences may relate to treatment behavior and pain severity. Further research is needed to unpack the relationship between gender and pain.

    93. Age The experience of pain has been found to vary across the lifespan. Less is known about pain in children than in adults. Chronic pain in children appears to be under represented in the pain literature, despite the reporting of both persistent and recurring chronic pain by children. For older adults, pain may be a pervasive aspect of their lives differing qualitatively from that experienced by younger age groups. The elderly are also consistently under-represented in the pain literature and pain in this group is substantially under-diagnosed and under-treated. Health psychologists should work to improve diagnostic techniques and understanding of the pain across the lifespan, especially among children, older adults and the way it interacts with other aspects of their lives.

    94. Significant others and the family A common concept in chronic pain research is that subjective pain and pain related behaviour may be affected by significant others who are perhaps one of the major reinforcers for pain-related behaviours and chronicity. Spousal solicitousness may inadvertently maintain or increase the experience of pain and disability. Parents are the most significant influence on a childs pain perception, modeling behaviours as well as reinforcing them. Pain within the family is likely to affect all family members and the family will affect how they all cope. Further research is required with measurement instruments specifically developed to assess the relevant variables in pain populations need to be extended to include families and significant others.

    95. ASSESSMENT Assessment of pain is difficult and various techniques are used singly or in combination. These can be grouped under one of four categories: Physiological measures e.g. medical examination, EMG, heart rate, galvanic skin response, etc. Pain questionnaires e.g. McGill Pain questionnaire Mood assessment questionnaires e.g. Becks depression inventory, HADS, etc. Observations Direct observation Self-observation

    96. Issues in assessment Many assessment instruments are insensitive to age, disability and culture. For example, for groups who have communication difficulties, assessment may rely on the reports of significant others (e.g. carer, interpreter) rather than the individual. Research that focuses on pain assessment among under represented groups is needed. Similarly, more work is required to address issues around the impact of situational context and assessor characteristics on the assessment process. Further investigation is needed of the influence of assessment, including the impact of compensation claim assessments and of the need to prove the existence of pain and how it restricts the sufferers daily activities.

    97. MANAGEMENT OF PAIN several strategies: Behavioural strategies Cognitive strategies Cognitive Behavioural Therapy (CBT) Pharmacological strategies Physical strategies Other strategies and approaches Palliative care Multidisciplinary Pain Management Centres/Programmes

    98. Behavioural strategies Most are based upon operant learning processes. Conditioning was integral to contingency management. This was a 2-6 week inpatient program during which nursing staff would ignore medication requests, reinforce targeted well behaviours, introduce increasing exercise quotas, and employ a fixed-schedule pain cocktail. The pain cocktail delivered medication within a strong tasting masking fluid that allowed medication dosages to be reduced without the patient noticing. While such programs have had good (even dramatic) short-term results, they have been less successful in maintaining such gains, possibly due to non-generalisation outside the hospital environment. It is rare for programmes today to focus solely on conditioning methods.

    99. Behavioural Strategies Other behavioural strategies: Graded exercise strategies involve setting a starting level of activity that the person can manage and then developing a schedule to gradually increase the length of time and intensity of the exercise. Biofeedback and autogenic training teach the individual to control aspects of their physiology. The individual receives continuous feedback through visual and audio signals from a machine that monitors their physiology, through which they learn to control their response. Relaxation probably affects pain perception both directly and indirectly, through its positive effects on stress and anxiety. This may involve progressive muscle relaxation or more simply deep rhythmic breathing. This is often used in conjunction with meditation or imagery techniques.

    100. Cognitive strategies aim to help identify and understand the cognitions and the connection with experience of pain and then change negative cognitions, or to improve it. teaching individuals to identify and challenge distorted thinking Cognitive restructuring: an active coping technique that promotes the internal attribution of positive changes.

    101. Cognitive behavioural therapy (CBT) utilises the full range of cognitive and behavioural techniques already described in individualised programmes that emphasise relapse prevention strategies. Stress management training is often included due to the significant levels of stress implicated in the generation and exacerbation of pain. The literature on CBT and pain suggests it shows considerable promise as an effective treatment for pain in adults (Eccleston, et al., 2002).

    102. Pharmacological strategies Various analgesics and anaesthetics are prescribed for the treatment of pain. Anaesthetics are used to numb the sensation of pain. However, the associated perceived high risk of addiction has resulted in their use being restricted. Non-opioid analgesics, non-steroidal anti-inflamatory drugs (NSAIDs) and drugs that control pain indirectly (e.g. antidepressants, sedatives) are also commonly used. Another aspect relating to drugs is the placebo effect. In addition, many individuals self-medicate with recreational drugs like alcohol and cannabis to alleviate their pain. However, the informal use of cannabis for pain control and its interaction with other pain control strategies needs further investigation.

    103. Physical strategies Surgical control of pain mainly involved cutting the pain fibres to stop pain signal transmission. However, it provided only short-term results and the risks associated with surgery mean it is no longer viewed as a viable treatment option (Melzack & Wall, 1982). Physiotherapy may be used to increase mobility and correct maladjusted posture, encourage exercise and movement and education. Other physical strategies include the stimulation of nerves under the skin (i.e. transcutaneous electrical nerve stimulation/ TENS treatment), massage, spinal cord stimulation, etc.

    104. Other strategies and approaches Acupuncture has been around for centuries and while the mechanisms by which it produces beneficial effects are not well understood it does appear to exert substantial analgesic effects (WHO, 2003). There is substantial, reliable evidence that hypnosis has beneficial effects for the treatment of acute (e.g. childbirth) and chronic pain (e.g. cancer-related) conditions. Individuals frequently use complementary or alternative therapies (e.g. aromatherapy, Chinese medicine) to combat pain and there is growing support that they help chronic pain control (e.g. NIH, 1997). The widespread use of alternative strategies may reflect dissatisfaction with mainstream approaches. It is important that such strategies are evaluated independently and in conjunction with traditional approaches

    105. Palliative care the alleviation of symptoms of illness when there is no cure available, particularly concerning terminal illness. Aims: to reduce suffering, fear and distress, normalise the dying process, maintain active participation in life, increase quality of life and maintain dignity until death for the patient. Terminally ill patients are often asked to take part in drug trials, even without any expectation of the drugs helping them. Despite this, effective pain management underpins palliative care, including medication, CBT and alternative therapies.

    106. Multidisciplinary Pain Management Centres Pain management programmes today tend to be run on an outpatient basis in specialist pain management centres. Multidisciplinary teams may include doctors, nurses, physiotherapists, psychologists, psychiatrists, occupational therapists and counsellors. Individual programmes are developed that aim to improve the individuals quality of life by reducing pain, increasing activity and coping, restoring function, promoting self-efficacy and self-management. The patient receives a full assessment, education, skills training, exercise schedules, relapse prevention and family work. Multidisciplinary rehabilitation programmes represent the most comprehensive approach to date, by targeting the individuals specific pain experience and tailoring appropriate treatment combinations.

    107. Treatment issues Pain management can be a particularly controversial issue. Evidence suggests that in many circumstances pain is under-treated due to (Greenwald et al., 1999): Inadequate assessment Focus on underlying pathologies Negative stereotypes and erroneous assumptions about certain population groups Addiction fears The inappropriateness of non-pharmacological treatments Patients inability to verbalise pain information or requests for medication many prejudices and misconceptions operate in the treatment of pain patients, with various populations being under treated for pain (Todd et al., 2000): Children, people with communication difficulties and the elderly

    108. Treatment issues Pain is sometimes deemed to be psychogenic, resulting from emotional, motivational or personality problems. However, the distinction between organic and psychogenic pain may have little practical value. While psychogenic pain may represent a convenient label for cases where underlying pathology has not been found, it has a tendency to inherently ascribe the problem to the patient and thus promote prejudice and injustice. Health psychologists must endeavour to promote the sensitive and respectful treatment of individuals reporting pain, both within the discipline and externally, in terms of research, intervention development, and treatment.

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