Why do we have pain?Pain is a phenomenon which occurs in a wide variety of medical conditions, but it also occurs in the absence of any physical problems. Pain warns us that something is wrong with our bodies and therefore we can act in certain ways to prevent injuries from getting worse. Of all psychical symptoms presented in practice, 50% of the symptoms are pain, 20-30% are respiratory related symptoms and 20-25% of the symptoms are non-pain and non-respiratory in nature, for example fatigue and dizziness. Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain has a sensory and emotional component (fear and anxiety of developing pain and actual physical pain). Tissue damage is not necessary to experience pain: pain may occur in the absence of any physical problem. The two most frequently reported reasons for consulting a primary care physician are common colds, low back pains (in 85% of patients consulting for low back pains, only minor pathology is present) and headaches (usually no clear physical can be determined). How can pain be classified?Pain can be classified either according to cause or according to duration. According to cause there are four types of pain. Nociceptive pain is (musculoskeletal) pain due to tissue damage and causes pain in muscles, bones, joints and/or skin. For example a fracture, burn wounds or RA cause pain receptors to be activated and therefore cause the feeling of pain. Neuropathic pain is a consequence of damage to (or pathology of) the central/peripheral nervous system. It causes changes at the level of the nervous system to become permanent in nature over time and it therefore is difficult to treat. Many compare it to a sensation of needle pricks, electrical shocks, burning or freezing sensation or the sensation as if ants are crawling up and under their skin. Allodynia is when pain is...


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      Lectures Health & Medical Psychology 2018/2019

      Lecture 1: Health Psychology: Being and staying healthy

      Lecture 1: Health Psychology: Being and staying healthy

      What is health psychology?

      Health psychology is the study of behaviour when it comes to health, illness and healthcare. Health psychology focuses on individual strengths and puts emphasis on prevention and adaption during all phases from health to illness. Questions like How to remain healthy for as long as possible? and How to adapt in the most healthy way? are related to this.

      Health psychologists work in health care (private practice, medical psychology department in the hospital, rehabilitation centres, medical centres), research, policy (local or federal government, developmental aid organisations) and primary prevention and training centres (Hersenstichting, KWF, Voorlichtingsbureau Voeding).

       

      How can we prevent unhealthy behaviour?

      There are three forms of prevention. Primary prevention is a method to keep people healthy for as long as possible. The target group of this form of prevention is healthy people. Secondary prevention focuses on finding early signs of an illness. This is done by screening and early treatment. The symptoms that may occur are still reversible at this stage. The target group for secondary prevention is (healthy) people with an increased risk of developing a certain condition. Tertiary prevention is based on the prevention of symptoms growing worse and rehabilitation. The people who this type of prevention is aimed at have already developed a certain condition.

       

      What is ‘health’?

      There are different opinions on the exact meaning of health. Some people see health as being not ill, which means showing no symptoms and not having to visit a doctor. Others see health as a reserve/resource (quick recover, strong family), behaviour (looking after yourself), physical fitness and vitality, psychological well-being (being in balance, enjoyment, harmony) or as a function (being able to do what you have to do or what you want to do).

      According to the WHO, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

       

      Why do we become ill?

      According to the biopsychological model there are multiple factors which influence the development of illness. These factors are biology, psychology and social context. These three factors are work together and is shown in an overview on slide 13. Health behaviour (sleep, nutrition, smoking, drinking, gender, disability), stress/emotions (past trauma, behaviour, personality, attitudes/beliefs), social relations (support, conflict, education) are related to these three main factors. These three main factors influence each other continuously. Within health and health psychology there is an body-mind interaction which determines health and illness.

      The Alameda Seven Study is a research projected that investigated the seven main health factors for longevity. These factors are:

      • Sleep 7 to 8 hours
      • No eating between meals
      • Eat breakfast regularly
      • Maintain proper weight
      • Regular exercise
      • Moderate or no use of alcohol
      • No smoking

      According to the biomedical model exposure to contagious agents, like viruses and bacteria, together

      .....read more
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      Lecture 2: Changing health behaviour

      Lecture 2: Changing health behaviour

      The main questions during this lecture are Can everyone become motivated to change?, How can motivations be influenced? and When are you motivated to perform behaviour X?

      Two answer these questions, theories have been placed into four categories:

      • Early theories: “It could happen to you”
      • Later theories: “You can do it”
      • Newer theories: “If only you want to”
      • Newest theories: “Stick to your plans”

       

      Early theories: It could happen to you

      The Health Belief Model is an example of an early theory. According to this model, chances of someone changing their behaviour is determined by demographic variables like age, culture and SES. View the previous lecture for a more detailed description of this model.

      According to the Parallel Process Model fear can have two consequences. When fear arises, someone can have the urge to control the fear or to control the danger. Fear control is about the need to reduce the emotion of fear and can be done by denial, avoidance or distraction. Danger control is about the need to reduce the negative consequences of the danger.

       

      High efficacy
      Beliefs that one is able to effectively avert a threat

      Low efficacy
      Beliefs that one cannot avert a threat and even if he/she could, it wouldn’t work anyway

      High threat
      Beliefs that one is at-risk for a significantly harmful threat

      Danger control
      People taking protective action against health threat

      Fear control
      People in denial about health threat, reacting against it

      Low threat
      Beliefs that a threat is irrelevant and/or trivial

      Lesser amount of danger control
      People taking some protective action, but not really motivated to do much

      No response
      People not considering the threat to be real or relevant to them, often not even aware of threat

       

      However, fear only works in combination with response-efficacy and self-efficacy. Response-efficacy is the possibility of reducing the threat and self-efficacy is the ability to control your behaviour and to perform certain behaviour.

       

      Later theories: I can do it

      Bandura’s Social Learning Theory describes how performance accomplishments, vicarious experience, social persuasion and physiological and emotional states can influence self-efficacy judgements (believing you can do it), which ultimately influences behaviour/performance. Self-efficacy can be increased by performance accomplishments & social coaching/training (step-by-step mastery, instructions, they have

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      Lecture 3: Health promotion at the work-site

      Lecture 3: Health promotion at the work-site

      What is health promotion?

      When talking about health promotion at the worksite, many things may pop up in your mind, like dealing with the (un)healthy food offered in the canteen, dealing with those who are smoking, bad sitting positions and offering fitness at the workplace.

      There have been multiple generations of WHP programmes. The first programmes mainly focused on safety and quality of the products. For example, they wanted to make sure that the remains of cigarettes would not end up in the food, since some would smoke while producing food.

      In the 60s/70s the focus of WHP programmes shifted to the top management. It became clear that top management experienced a lot of stress and that there was a higher prevalence of heart attacks and such among top management. Those WHP programmes focused on improving their health behaviour, by motivating them to quit smoking, exercise and eat healthy food.

      The third generation of WHP programmes focused on improving medical risk factors. Now it was easier to assess things like glucose and blood pressure. Therefore, questions like Can we reduce high blood pressure/glucose/cholesterol? were asked, since risk factors like these were associated with things like strokes.

      In the 80s, the fourth generation of WHP programmes shifted their focus to health improvement and health behaviour, by promoting healthy nutrition and exercising.

      Nowadays, WHP programmes focus on health wellness and psychological well-being. This generation of WHP programmes will be discussed later on.

       

      Why health promotion at the worksite?

      It is important to promote health behaviour at the worksite, since life styles are connected with mortality and morbidity, but to other things as well, like absenteeism, health care costs (which are higher for those who show unhealthy behaviour) and productivity. In the USA the health insurance is based on the employer paying health care costs of employees. Therefore it is important for those employers to promote health behaviour for their employees. The more lifestyle risks/unhealthy behaviour, the lower the productivity. Each additional risk factor has been associated with a 2.4% excess productivity reduction, in medium risk employees 6.2% and in high risk employees are even 12.2% less productive.

      Those with higher risks have higher rates of absenteeism. A graphic is shown on slide 11.

      Smokers have a higher absence frequency (1.5x) and a higher number of absenteeism (14 days) than non-smokers). The estimated costs for a smoking employee are about 105 more euros than those for non-smokers. A risk of work disability is higher in those who are overweight and those have a higher absenteeism rate than employees with a healthy weight, about 14 more days. Employees who exercise are less often absent, but especially their absence spells are shorter.

      Return investment means that when an employer invests in healthy nutrition, exercise in workplace and promoting employees to quit smoking gets less absenteeism and less additional costs in return.

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      Lecture 4: Mechanisms and diagnosis of stress-related symptoms

      Lecture 4: Mechanisms and diagnosis of stress-related symptoms

      What are research topics in Health & Medical Psychology?

      In the area of Health and Medical Psychology much research is done in the fields of health promotion and prevention, stress (for example, how stress works in relation to work or chronic diseases), psychological factors in somatic conditions (like chronic fatigue, chronic pain and itches), placebo/nocebo, expectancy learning, conditioning and interventions on health behaviour (for example, e-health).

      Health and Medical Psychology is a relatively novel area in the field of psychology. It often requires knowledge of more than psychology alone to better understand the complex problems, therefore health/medical psychologists often work very tightly with doctors. Interaction with medical care professionals to consult and receive advise both ways is extremely important.

       

      What is stress?

      We all know what stress is, yet it is hard to define. Stress depends on the threat value and the resources an individual has to cope with a stressful situation. Stress is associated with development and the maintenance of a variety of illnesses, like heart diseases and strokes. The more stressed you are, the more likely you are to get a chronic disease. If you are able to destress, you are more likely to be free of any symptoms. Besides, stress is not necessarily bad, as many people think. Stress can be very functional, for example when you have to fight or flight. According to the Yerkes-Dodson law there is an empirical relationship between arousal and performance. The law says that performance increases with physiological or mental arousal, but only up to a certain point. Too much arousal can cause impaired performance because of strong anxiety.

      Stress can be unhealthy when we chronically active stress systems which were developed for acute fight-flight situations. Stress is good, but it must not be chronic. Acute cataclysmic events may have long term consequences. Those reporting both a high amount of stress and the perception that stress affects their health are at a greater risk of premature mortality. Being convinced that ‘stress is bad for you’ was prospectively associated with somatic symptoms during a stressful period.

      Stress response has a biological cost. The duration of the physiological response is important. Repeated or prolonged stress can cause an overload of physiological system due to ‘wear and tear’. There is an excessive energy consumption during high stress, therefore reinstatement to normal body functions can fail and the system will wear out. An allostatic load occurs when body systems achieve a kind of balance, but everything is working too hard and we then slowly begin to break down. When there’s a balance between stress and adaption, it is called allostasis.

       

      How does the physiological stress response work?

      There are two important stress systems, because we need fast and slow systems to respond to stimuli/stress.

      The sympathetic nervous system (SNS) is the faster system. Transmission goes through neurotransmitters, therefore the SNS is the faster system.

      .....read more
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      Lecture 5: Symptom perception and illness

      Lecture 5: Symptom perception and illness

       

      There are many factors which influence symptoms and symptom perception. An experiment is done to show this. Factors like temperature, background information and cognition, colours of the objects and environment are examples. The experiment consists of two parts. During the first part of the experiment, the scientist said touching the ice water with chemical substances in the tank would increase pain and during the second part of the experiment, the scientist said the water tank was filled with pain reducing substance. This kind of information and the different appearances of the substances in the tanks can influence one’s perception of their symptoms and stated level of pain.

       

      Complaints

      About two third of the general practitioner’s come across patients’ complaints which they have no explanation for. Somatically unexplained physicial symptoms are quite common in general practice. About 20-50% of the complaints are somatic. This means that no objective physical distortions or disrupted bodily processes can explain the complaints. These complaints often disappear spontaneously, usually after reassurance by the general practitioner.

      The Symptom Perception Model describes how psychological factors influence symptom perception. One of these factors is negative affectivity. Negative affectivity is the tendency to experience negative mood, feel distressed and feel critical about oneself, and to view the self and the world in generally negative terms. It is related to neuroticism. Symptom perception can lead to long-term activation and reactivation of symptom related cognitive networks, like paying attention to and earlier detection of somatosensory signals, interpretation of ambiguous internal and external information in terms of somatosensory symptoms and attribution of signals as somatosensory symptoms. There is a bidirectional relationship between the attention paid to the symptoms and the perception of those symptoms. An overview of this model is shown on slide 12.

      Mood also influences symptoms and symptom perception. Negative mood results in more pain and itch reports in healthy subjects. Anger and sadness enhance pain in response to experimental pain exposure in healthy controls and chronic pain in patients with fibromyalgia.

      Pennebaker once did an experiment in which he investigated the role of somatic attribution in symptom perception. According to this research, misattribution of physical arousal may occur due to certain information, e.g. information about catching a common cold or not. Subjects who received information about common cold reported more symptoms of a common cold.

      Placebo and nocebo effects also play a role in symptom perception. Placebo and nocebo effects are (un)favourable treatment effects not due to treatment mechanisms itself. The effects are induced by expectations of improvement or worsening symptoms. An example is decreasing pain when only seeing a pain killer. Once an experiment was done in which they concluded that pain killers may not work if the person doesn’t know he or she is receiving the pain killer. Other examples of placebo and nocebo effects are a decrease of willingness to take medication after reading an information leaflet, an increase in their occurrence

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      Lecture 6: Psychological consequences of chronic disease

      Lecture 6: Psychological consequences of chronic disease

      This lecture is mainly based on tertiary prevention. Tertiary prevention is prevention aimed at those who have already gotten a diagnosis of a disease.

      The lecture starts with two case studies. The first case study is about David. He’s 52 years old and had a sudden/unexpected myocardial infarction 6 months ago. His lifestyle is reasonable, he works as an accountant and makes long hours, causing him to feel stressed often. Ever since his first, he has been anxious about getting a second myocardial infarction. Therefore he is afraid to do sports and his stress-management is poor.

      The second case study is about Anna. He’s a 19-year-old girl who has had type 1 Diabetes since the age of 4. Her self-management used to be good and she has a high blood glucose. She studies Biology and has a dynamic social life. She is afraid to tell others about her diabetes because she’s afraid of being seen as different. Her self-management has worsened, mainly because of her avoidance.

      For both patients it is important to gain (more) information about their backgrounds, network, friends, family, stressors and their history, to know whether these factors play roles in their self-management and coping.

       

      What is the difference between chronic disease and chronic illness?

      A chronic disease is long in duration, often with a long latency period and protracted clinical course. The diagnoses of chronic diseases are categorised in the biomedical system. Examples of chronic diseases are diabetes, HIV and cancer.

      A chronic illness is an experience of long-term bodily or health disturbance. Examples of chronic illnesses are chronic headaches and chronic pains.

      25% of the people get at least one diagnosis once in their lives. When people grow older, more diagnoses are likely to occur. 25% of the people with a chronic disease have some type of activity restriction, for example in mobility, personal care, work or schooling.

      Having a chronic disease of chronic illness is a challenge for many: for individuals, for caretakers, for partners, relatives and friends and for society. These challenges occur on different levels. Challenges related to psychological status are mailaise, fatigue, pain, weakness, loss of appetite, loss of libido and dizziness. Challenges related to cognitive functioning are the inability to concentrate, forgetfulness, difficulty with higher reasoning tasks, word-finding difficulty and cognitive overload, which occurs due to the body which keeps telling the brain to be aware, because the body is in pain. Your brain has to ignore these messages because it cannot do anything about it. Challenges related to psychological functioning are emotional distress, depressive feelings, worry, ruminantion and anxiety, panic, distortions of self-identity, self-image and self-esteem, hopelessness, frustration, irritability and loneliness and detachment. Challenges related to social context are behavioural inactivity, unpredictable nature of diseases, social interactions, resistance to socialising, isolation and lack of understanding from friends and family.

      A video of a woman named Teresa is shown. Teresa was

      .....read more
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      Lecture 7: Pain and pain management

      Lecture 7: Pain and pain management

      Why do we have pain?

      Pain is a phenomenon which occurs in a wide variety of medical conditions, but it also occurs in the absence of any physical problems. Pain warns us that something is wrong with our bodies and therefore we can act in certain ways to prevent injuries from getting worse. Of all psychical symptoms presented in practice, 50% of the symptoms are pain, 20-30% are respiratory related symptoms and 20-25% of the symptoms are non-pain and non-respiratory in nature, for example fatigue and dizziness.

      Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain has a sensory and emotional component (fear and anxiety of developing pain and actual physical pain). Tissue damage is not necessary to experience pain: pain may occur in the absence of any physical problem.

      The two most frequently reported reasons for consulting a primary care physician are common colds, low back pains (in 85% of patients consulting for low back pains, only minor pathology is present) and headaches (usually no clear physical can be determined).

       

      How can pain be classified?

      Pain can be classified either according to cause or according to duration.

      According to cause there are four types of pain. Nociceptive pain is (musculoskeletal) pain due to tissue damage and causes pain in muscles, bones, joints and/or skin. For example a fracture, burn wounds or RA cause pain receptors to be activated and therefore cause the feeling of pain.

      Neuropathic pain is a consequence of damage to (or pathology of) the central/peripheral nervous system. It causes changes at the level of the nervous system to become permanent in nature over time and it therefore is difficult to treat. Many compare it to a sensation of needle pricks, electrical shocks, burning or freezing sensation or the sensation as if ants are crawling up and under their skin. Allodynia is when pain is experienced as a consequence of a stimulus that does not normally cause pain, for example rubbing a cotton swab on your skin causing excruciating pain. It is a painful response to an innocuous stimulus. Hyperalgesia is when pain is experienced as disproportional to the pain stimulus. The pain stimulus is painful to begin with, but it is experienced way worse in hyperalgesia. For neuropathic pain, the pain threshold often becomes very low for any kind of pain.

      Mixed pain is a mixture of neuropathic and nociceptive pain. An example is when a buffer disci in the spinal cord has been damaged (herniated disc, nociceptive element), causing fluid to drip in the spinal canal, causing inflammation of the nerves and then eventually causing dull pain in the lower back (neuropathic element) which can lead to paralysis.

      Idiopathic pain is pain for which no clear organic cause can be found. There is no diagnosis referring to a

      .....read more
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      Lecture 8: Psychological interventions to chronic disease

      Lecture 8: Psychological interventions to chronic disease

      How to classify psychosocial interventions in chronic disease?

      Maes has designed a cubical model to structure the variety of interventions which are offered to patients with chronic diseases. This model distinguished between three different dimensions along which an intervention can be located:

      • Intervention aims
        Quality of Life interventions and self-management interventions
      • Intervention level
        The individual patient, a group of patients or the social and physical environment of the patient
      • Interventional channel
        This is can be either in a way of direct face-to-face contact between the psychologist and the patient, or in a way of indirect interventions. For example with self-help, lay people or other health care professionals.

       

      Intervention aims: Quality of Life interventions

      Quality of Life intervention focus on restoring and improving the physical, psychological and social well-being of the patient and his/her immediate environment. This is done by stimulating a process of adaption to and/or acceptance of the disease. QoL interventions focus on reducing stress, reducing pain, or reducing problems related to performance of everyday activities which cause physical, emotional or social limitations.

      Physical training programs are in most cases part of larger (multicomponent) rehabilitation programs, for example for patients with CHD, cancer or diabetes. These programs have beneficial effects on morbidity and mortality and it has effect on quality of life and well-being of patients (with anxiety and/or depression) as long as patient engage in physical activity.

      Stress management programs have positive effects on quality of life, but also on disease progression and mortality in patients with e.g. cancer, CHD, diabetes and HIV. Cognitive restructuring is a stress management program which focuses on changing cognitions which can influence your behaviour and emotions.
      The Hook is a cognitive restructuring program. Its aim is to help post myocardial infarction patients gain control over their emotional reactivity to daily stressors. At the start of the group session, participants are asked to describe an incident in which they became angered, irritated or impatient. This introduction is followed by a group discussion around three questions. The first question is What is behaviour modification?. By asking this question, the therapist introduces a general idea of cognitive change (“You can gain control over your emotional reactivity by changing your way of thinking”). When confronted with a stressful situation, you have a choice between changing the situation/people involved in the situation, or changing the way you think about the situation. The second question asked is What is impatience/irritation?. This questions is asked to make patients more aware of the type of stressor that leads to frustration, irritation and anger. The metaphor of the hook is introduced to describe this type of response (you are hooked). The third question is What can we do about it?. By asking this question the therapist introduces to a cognitive strategy to get to grips with one’s emotional activity and to label the stressor as  a ‘hook ‘instead of an

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