Summary of Introduction to Health Psychology by Morrison and Bennett - 5th edition

What do health differentiations entail?

The environment in which we live has just as much effect on our health as the way we live. It matters a lot whether you belong to a majority (high social economic status) or to a minority (low social economic status) in a country. People who are poor live, on average, five years shorter than the richer ones in the society. On average, women live longer than men. This chapter describes how different groups experience different levels of health.

Clear health differentiations (differences in health status and life expectancy among different groups) can both be found within and between countries. The World Health Organization developed a method to calculate the expected lifespan of people, which is called healthy life expectancy. This calculation is based on the number of years that a person can live in full health, taking the number of years that the person lived in poor health due to illness into account or taking an accident into account. 

Poverty probably has the most important social and economic impact on health. In a developing country, one third of the population dies at the age of 5 years. The most common causes of death are diarrhea, dysentery, and lower respiratory tract infections. Another third dies before the age of 65 and finally, another third dies at the age of 65 or older. In developed countries, only a third dies before the age of 65. This is explained by differences in the availability of clean water, sanitation, food and access to health care institutions. The causes of death of young children in particular are often very easy to prevent or remedy in Western countries.

Explanations of socio-economic health inequalities

It is clear that there is a connection between health and SES, but the question is still in which direction the conclusions can be drawn. Is it the case that a low SES is the cause of poor health (social causation model)? Or does poor health prevent you from holding a job or have a lower education (social drifting model)?

Most studies show that the SES has a significant impact on health. When people change jobs often because of reorganisations for example, it appears that these people experience emotional and physical problems.

Different health behaviors

Premature mortality means that someone dies at an age when they are not normally expected to die. This is usually set at deaths under the age of 65. Premature mortality is found more often among people with a low SES than among people with a high SES. There are a number of explanations for this. It appears that people with a low SES exhibit more health-deteriorating behavior and less health-promoting behavior. These people smoke and drink more, eat less healthy, and exercise less than people with a high SES.

It appears that there is no shortage of knowledge, but a voluntary choice based on a comparison between the costs and benefits of such behaviors. 

Access to healthcare

Access to health care appears to differ between both personality characteristics and the health systems to which the individual has access. It appears that people with a low SES have poorer access to healthcare. Poorer access to health care appears to be associated with a poorer quality of life, more hospital admissions and a higher prevalence of angina. A study in Scotland showed that there were differences in the number of medical and surgical procedures in poorer and richer areas in Scotland. For example, the number of hip replacements per head was higher among the better-off than those living in economically deprived areas. Several studies have confirmed this inequality in health care.

Environmental factors

People with a low SES work in a dangerous environment more often. They also live in poor housing. The overcrowding associated with poor housing may also have a more subte and long-term impact, and is associated with high levels of stress. High levels of stress can cause coronary heart disease (CHD). 

The stress hypothesis

People with low SES experience more stress than people with high SES. The effects of stress are poor health. For each age category there are a number of examples of the type of stress that these people can experience:

• Childhood: family instability, unhealthy food, less educational opportunities.
• Adolescence: family aspiration, smoking, exposure to other people's smoking, leaving school with poor qualifications, experiencing unemployment or low-paid and insecure jobs. 
• Maturity: working in hazardous conditions, financial insecurity, periods of unemployment, low levels of control over work or personal life, negative social interactions.
• The elderly: no or small occupational pension, inadequate heating and food.

The greater the income inequality within a country, the worse the health within that country. The greater the inequality in wealth within a society, the lower the levels of social cohesion and social capital (the feelings of social cohesion, solidarity and trust in one's neighbors). A low social capital is associated with feelings of dissatisfaction and distrust. This is stressful and is confirmed by several studies. There is a relationship between social capital and social support. A large number of positive social relationships and few conflictual ones may buffer individuals against the adverse effects of the stress associated with low economic resources. A poor social support system may increase risk for disease. 

Work status and stress

Despite all the laws of today, it is inevitable that some jobs involve more risk of accidents or illness than others.

Some types of work have a character that causes more stress for employees.

On average, work factors associated with more alcohol consumption are job alienation, job stress, inconsistent social controls and a work culture of drinking. Furthermore, long work hours, lack of control and poor social support have been associated with higher tabacco consumption.

The Strain Model, developed by Karasek and Theorell, describes how different factors of the work environment contributes to stress and illness. 

The following three factors are included in the model:

1. The demands of the job.
2. The degree of freedom to make descisions about how best to cope with these demands (job autonomy).
3. The degree of available social support. 

These factors together determine the degree of work stress that the employee experiences. Stress-related diseases can be predicted as well.

Research shows that experiencing high demands and little autonomy, little social support has a negative impact on the health of the employee. The employee feels stressed and is at risk of illness. If an employee has high demands, but a lot of autonomy, this results in less stress.

Siegrist and colleagues (1990) have devised a different theory about work stress, but this is less known. If a high effort is rewarded with a high reward, this is acceptable. If a high effort is rewarded with a low reward, this leads to emotional stress and negative health effects. This theory has received some support.

An example of a combined risk is the work-home spillover phenomenon. This means that after work the responsibilities also continue at home. For men, the amount of (work) stress experienced is often a direct function of their working environment. The so-called work-home spillover theory often occurs in women. For women, it often applies that when they come home from work, a household job is still waiting for them at home. As a result, they often do not experience the self-confidence at work that men do get from their work.

Unemployment

Being unemployed has negative health effects, such as greater risk of heart attacks and strokes. The impact is especially large for people with little financial security.

What is the link between minority status and health?

People from an ethnic minority group often have relatively poor health. The most important issue when explaining this is that a disproportionate number of them also occupy low socio-economic groups. Before suggesting that being in an ethnic minority alone influences health, the effects of these socio-economic factors need to be excluded. For valid research results you have to compare disease rates between people in ethnic minorities and people from the majority population matched for income or other markers of SES. 

Differential health behaviours

The differences can also be explained by differences in behavior. In Britain for example, men of African and Asian descent sometimes consume more alcohol than other men with similar SES and age. As a result, these men are more likely to develop an alcohol related illness.

Stress

A second explanation for the negative health of people belonging to a minority group focuses on the psychosocial aspect. People belonging to an ethnic minority group experience more stressors than majority populations, due to specific stressors such as discrimination, racial intimidation and adaptation to a new culture.

Accessing health care

Research shows that black residents of the United States are less likely to be examined, operated, or treated than white residents. The number of people who die per disease is also higher for black people than for white people. In Britain this difference is also there, but not for ethnic background, but for SES. Unfortunately, it is often the minorities that are at most risk for illness or mental health problems.

In areas in the UK, where many ethnic minorities are of Asian descent, there are usually few women who work. Traditionally, it is not very common for Asian women to have such a function. This prevents many women in those areas from seeking help.

What is the link between gender and health?

In general, men have a shorter life expectancy than women. Despite this, men judge their own health higher than women and are less likely to seek help. 

If you look at what kind of diseases men and women get, men are less likely to suffer from acute diseases. Women suffer more often from a number of symptoms and also suffer longer from the symptoms than men, but in the end they are less likely to have a real chronic disease than men. In countries where industry is emerging, these differences are often smaller or even vice versa.

Biological differences

Women are more resistant to infectious diseases. Estrogen inhibits the development of CHD because it prevents blood clotting and it reduces cholesterol. The role of testosterone in men has changed over the years. High levels of testosterone are associated with low levels of HDL cholesterol (the so-called 'good cholesterol').

For men, the response to stress situations is greater, or at least different, than in women. This results in an increased risk of CHD. The question is whether this greater stress response can be attributed to biological or social and contextual aspects. Perhaps it is because men are more likely to end up in situations that would also cause such a major stress response in women. In controlled research situations, where men and women are exposed to the same stressors, there are usually hardly any differences to be found.

Behavioral differences

When they have a choice, women eat healthier than men. They are more inclined to eat the recommended daily amount of fruit and vegetables and pay more attention to what kind of food contains a lot of fat. More men than women engage in health-threatening behaviors such as smoking, drinking a lot of alcohol, not wearing seatbelts in the car, driving while they have drunk alcohol and not going to the doctor for a check-up.

However, there is an area where men are much healthier than women: men get much more exercise. Often this has to do with 'masculinity'.
Inequalities in power between the sexes can also have a negative impact on women's health, for example having unwanted sex is associated with inconsistent condom use.

Economic and social factors

In the UK, 30% of women are unemployed and the women who do have a job, on average, have jobs with less prestige and status and a lower salary.

Men drive more cars, certainly because women with a low SES have relatively less driver's license or a car. As a result, more women live in social isolation than men. As women get older, they live more often alone (as a widow) than men. This last point is probably related to the longer life expectancy of women. Women are also more vulnerable to a bad or broken social network than men.

What is meant by adherence behavior?

As previously discussed, our behavior influences our health. However, not all behavior is harmful. There is enough you can do to improve health.

Definition and measurement

Depending on which literature you read (medical, psychological or pharmacological), terms such as adherence' compliance and concordance are used interchangeably with different meanings. Roughly speaking, it's about the relationship between a patient and a healthcare professional. The term adherence is used here to indicate that the patient is following the advice of the expert. The meaning of non-adherence also differs between studies and books. This makes it difficult to compare studies. If 70% of a medical product has to be taken to be effective and less than this amount is taken, this is considered as non-compliance. Compliance means patient medicine taking behavior which conforms with doctor's orders. Concordance can be defined by a jointly determined agreement between physician and patient as to what is the appropriate treatment, following the patient having been fully informed of the costs and the benefits of adhering to their particular treatment. 

Do people adhere to this behavior?

About half of all prescription medication for longer-term use is not taken as directed. The numbers differ per type of condition and depend on many factors. A few examples of possible factors:

• Patient-related factors: personality, knowledge, culture, age, beliefs with regard to medication.
• Condition-related factors: the observed severity, presence or absence of pain, prognosis, symptoms, etc.
• Treatment-related factors: frequency and duration of the medication dose, presence and extent of possible side effects, type of treatment, number of treatments.
• Socio-economic factors: treatment costs, social isolation, low educational level.
• System-related factors: communications with healthcare providers regarding medicines, necessity or function, presence of traditional healing beliefs and systems.

What does a healthy diet entail?

Fruit and vegetables

Fruits and vegetables contain vitamins, fibers and antioxidants (chemicals that inhibit the oxidation process), all three of which are essential for good health. They can also protect the body against some forms of cancer, heart disease and strokes. Vegetarianism can reduce the risk of ischemic heart problems . This is a heart disease caused by the restriction of blood flow to the heart. However, some studies show that these results might be because participants smoked less and consumed less alcohol than non-vegetarians.

The daily recommended amount of fruit and vegetables is five or more servings per day (1 serving is approximately 80 grams). Less than 20% of young people adhere to this recommendation. A large proportion of adults do not adhere to these recommended amounts either. The reason for this is that people like other things better. Much more than in the past, it is common for young people to buy food themselves during the school lunch break and in most school canteens the supply is well adapted to demand.

Parents play a major role in the development of eating patterns, food choice and physical activity of their children. Children take over cooking habits from their parents. What food they eat in their youth, largely determines their later taste preference, which in turn partly determines the choice of product. Children can adopt the following preferences from their parents (through a socialization process):

• Cooking methods: warm up meals or freshly cooked meals.
• Products: for example, products that are high in fat or not.
• Flavors: mild or spicy.
• Food components: red or white meat, vegetables and fruits for example.

Various interventions have targeted the fruit and vegetable intake of young people. An effective program builds on the learning theory of increased exposure to taste of fruit and vegetables, modeling of healthy behavior through childhood cartoons and empowerment through child-friendly rewards (such as stickers) for eating fruits and vegetables. This appears to be effective for children.

What are the benefits of exercise?

What are the physical health benefits of exercise?

It is well known that exercise reduces the risk of cardiovascular disease, type II diabetes, osteoporosis and being overweight. It appears that regular performance of exercise:

• Strengthens the heart muscles.
• Increases heart and respiratory efficiency.
• Tends to reduce blood pressure.
• Reduces the tendency to accumulate body fat.

Exercise has benefits for those already with disease: for example, increasing muscular strength, function and quality of life, reducing fatigue and the side effects of cancer treatments and reducing fatigue in those with Chronic Fatigue Syndrome. Extreme exercise is sometimes associated with poor body image and with other compulsive disorders including eating disorders. Moreover, there is also a risk of injury and damage to the muscles.

Psychological benefits of exercise

Exercise has been associated with psychological benefits in terms of elevated mood among clinical populations. Research has shown that participating in aerobic training on a limited frequency is associated with reduced anxiety, more self-confidence and prosocial behavior (positive social behavior). This is because natural opiates are released during training, which act as a painkiller. Also stimulation of the release of the catecholamines (noradrenaline and adrenaline) is encouraged, they counter any stress response and enhance mood. Catecholamines are neurotransmitters in the brain. However, the relationship between exercise and a positive mood is not as simple as suggested here. For example, research has shown that when the intensity of the training increases, a negative mood arises. There are many more factors involved in this relationship, such as the area where people exercise, the help available and encouragement during exercise, and so on. Exercise can also be positive for people who experience cognitive deficits due to aging or dementia. It slows neuronal dysfunction and degeneration in Alzheimer's and it improves some aspects of cognitive functioning.

The negative consequences of exercise

For some people, the desire to excersize becomes compulsive, interfering with other aspects of life and leading to dependence. Excersizing does not solve health risks anymore and can even lead to problems. Regular exercise is better than extreme exercise. Just as with eating disorders, it may be that exercise is an element of control to those who feel aspects of their lives are uncontrollable. This can cause dependancy on sports.

Why do people exercise?

People who choose to exercise cite a variety of reasons:

• Desire to be physically fit.
• Improve body weight or body shape.
• Maintain health.
• Reduce stress.
• They see sports as a social activity.
• Improve self-image and state of mind.

Why do people not exercise? 

• Lack of time.
• Costs.
• Lack of access to good facilities.
• Shame.
• Do not believe in themselves ('it doesn't help me' or 'I can't keep that up').
• The lack of someone who wants to go with them.

People who exercise are often more aware of the positive consequences of this than people who do not exercise. They are also more convinced that they have the result in their own hands and that they will keep it up.

What is meant by health-screening behavior?

There are roughly two types of health research:

1. Research to detect early symptoms of disease in order to treat.
2. Identification of risk factors so that behavior can be changed on time.

An example of the first type is that pregnant women over 30 can be examined. For example, testing certain values ​​in the amniotic fluid whether the future baby will have Down syndrome. There is no treatment, but one may consider terminating the pregnancy early.

Examples of research in which risk factors can be easily detected are the measurement of cholesterol and blood pressure because of heart problems, eye tests for the risk of diabetes and genetic tests for Huntington's disease.

Screening for risk factors

A second goal of screening is to screen risk factors in individuals who are thought to be healthy. The goal is to detect someone's personal risk for a certain future disease, so that this person can be sufficiently informed about minimizing future health risks or planning further investigation and treatment. Examples of such primary prevention include:

• Screening for the risk of a cardiovascular disease (measuring cholesterol and blood pressure).
• Genetic testing for carrier status of the cystic fibrosis, or Huntington's disease gene or for breast, ovarian or colon cancer, in those with family history.
• Prenatal genetic testing.

Screening for disease detection

Screening with the aim of detecting certain diseases is based on a biomedical model. According to this model,  treatments can be implemented prior to the onset or advancement of disease symptoms by identifying abnormalities in cell or organ functions as early as possible. The best known examples of such a screening are:

• Screening for breast cancer (mammography).
• Screening for cervical cancer.
• PSA (prostate specific antigen) screening for prostate cancer. 
• Antenatal screening, for example for Down's Syndrome.
• Bone density screening.

Criteria for establishing screening programmes

The general criteria are that:

• The condition should be an important health problem.
• There must be a recognizable early stage to the condition or clear benefit to identifying changeable risks.
• Treatment at an early stage of a detected disease should have clear benefits to the individual compared with treatment at a later stage.
• A suitable test with good sensitivity and specificity should be available.
• The test should be acceptable to the general population.
• Adequate facilities for diagnostic assessment and treatment should exist.
• Screening frequency and follow-up should be agreed.
• Costs should be considered in the relation to the individual and public health benefits.
• Evidence-based information should be available to potential participants.

Costs and benefits of screening

According to Marteau and Kinmouth (2002), the effects of screening on the individual are not yet sufficiently known. There are also questions about the usefulness of screening and about the variation in availability and effectiveness between countries. The process can also cause stress if it appears that someone carries a gene for breast cancer, for example. Research shows that models about making decisions need to look further than simply the pros and cons of behavior. Many people nowadays also use the internet for health purposes (for example searching information), and this information is often biased: the judgments of screening are overestimated on the internet.

Self-screening behavior

It is already very common for women to check themselves regularly for lumps in their breasts. These bumps can be breast cancer, so it is important to go to the doctor when you feel something unusual. Testicles and skin are increasingly being examined by people themselves. These forms of preventive investigations are extremely useful when you consider that it costs someone nothing and is accessible to everyone. It is of course important that someone knows exactly how to examine themselves. It is really effective, because research shows that around 90% of breast cancer cases are detected by women themselves. As with many other health behaviors, a lack of self-examination is associated with a number of (social) factors: lower levels of income and education, age (young people do it less), lack of knowledge about the subject, shame about the possible following procedures, fear of something being discovered, fear of pain and a lack of confidence in the effect of self-examination. Men also do less self-screening than women. An intervention aimed at making an individual plan for action, also called 'implementation plan' with regard to self-screening, proved to be effective.

Immunisation behavior

Vaccination is the oldest form of immunization. Someone who is vaccinated receives a small amount of an antigen in his body. This can be done in three way:  orally, in the muscles or in the skin. The antigen causes the body to make antibodies against the specific antigen. This means that the body is always able to attack immediately if the disease enters the body. This form of prevention ensures that diseases, such as polio and diphtheria, no longer occur on a large scale, which means that almost no people die anymore due to these diseases. A new vaccine is available which targets human papilllomavirus (HPV), which is present in 70-95% of cercival cancers. It is effective in 90% of the alduts and children who have not already acquired infection. Emotional and cognitive predictors are present for taking a vaccination, for example fear of the risks of the vaccination or lack of knowledge about the benefits of a vaccination.

In the previous sections, the importance of encouraging people to show healthy behavior and to refrain from unhealthy behavior has been discussed. It is also important to examine people preventively for risks and possible illnesses.

What does the development of interventions entail?

General health interventions are designed to change health behaviors in an entire population. The best-known model for this is the PRECEDE-PROCEED model. The PRECEDE element identifies various psychosocial variables that may be the goal of intervention:

• Predisposing factors: knowledge, attitudes, beliefs, personal preferences and existing skills and self-efficacy in relation to desired behavioral change
• Enabling factors: characteristics of the environment that can facilitate behavioral changes and the skills or resources needed to achieve change.
• Reinforcing factors: factors that reward desired behavioral change, for example social support.

The PRECEDE model:

1. Phase 1, social diagnosis: planners get an impression of the health problems that affect the quality of life in a community and what the strengths and weaknesses are.
2. Phase 2, epidemiological, behavioral and environmental diagnosis: the identification and assessment of health issues specific to the community and the related behavioral and environmental influences.
3. Phase 3, educational and ecological diagnosis: setting priorities and determining how behavior from phase 2 can be changed. Identification of predispositions, enabling and reinforcing factors.
4. Phase 4, administrative and policy diagnosis: the aim is to ensure that the program is consistent with the policy of the organization.

The PROCEED model: implementation of the program; the implementation of the planned intervention with three elements of evaluation:

1. Process: did the program do what it intended?
2. Impact: what impact does the intervention have on the outcome?
3. Outcome: what are the long-term effects on health?

What are the approaches to behavioral change?

How do we change behavior? The UK Government Cabinet Office identified several factors (MINDSPACE) that influence behavior and form targets for intervention. 

• The messenger: we are influenced by who spreads the information. 
• Incentives: we tend to strive for short term gains and to avoid losses. 
• Norms: we are influenced by what others do. 
• Salience: our attention is drawn to what is novel and salient from the environment. 
• Priming: our behavior is influenced by subconscious cues. 
• Affect: our emotions influence our behavior. 
• Commitments: we seek to be consistent with our beliefs and values. 
• Ego: we act in ways that make us feel better about ourselves. 

These principles can be applied in practice through what the UK Government cabinet termed the 4Es policy framework.

• Enable: through interventions in the environment, like the design of buildings.
• Encourage: through different approaches such as legislation, regulation, inventives to change, and information.
• Engage: through working with individuals and communities.
• Exemplify: through leading by example, policy consistency and organisational learning.

There are more psychological frameworks that can be used to guide the development of interventions. The best-known model in the UK is by Mitchie and colleagues (Mitchie et al. 2012). The core of their approach is a behaviour system incorporating the following three elements.

• Capability: the individuals psychological and physical capacity to engage in and activity.
• Opportunity: all factors that lie outside the individual that enable, prompt, or inhibit change.
• Motivation: involves the individual being able to make active choices related to engaging in new behaviour and having the energy to engage in them.

Strategies of change

We have seen before that behavioral change doesn't happen overnight, but gradually. The behavior can often be best described on the basis of phases. A phase model from Prochaska and di Clemente is one that is very similar to the phase models discussed earlier in this text and looks like this:

1. Pre-contemplation.
2. Contemplation.
3. Preparation.
4. Change.
5. Maintenance or relapse.

The model appears to be reasonably accurate with regard to predicting behavior. There is of course criticism of this model. The focus is on what is the best type of intervention to conduct within each state of change. For example, it makes no sense to show people how they can change while they are still in the pre-contemplation phase. An individual in the preparation or action phase will appreciate this more.

Motivating change

Providing information is an easy way to increase motivation. If individuals are not aware of the benefits of change, they are not motivated. Yet this is often not enough. The NICE guidelines for behavioral change have a number of guidelines. Key messages for behavioral change should influence:

• Outcome expectancies.
• Personal relevance.
• Positive attitude.
• Self-efficacy.
• Descriptive norms.
• Subjective norms.
• Personal and moral norms.

The Elaboration Likelihood Model (ELM) suggests that attempts to motivate people who are not interested will not succeed if you use rational arguments. Only individuals who are already interested beforehand pay attention to the information and may act accordingly. Individuals will centrally process messages sooner if they are motivated to receive an argument when:

• It is congruent with their pre-existing beliefs.
• It is personally relevant to them.
• Recipients have the intellectual capacity to understand the message.

According to the ELM, peripheral processing takes place when individuals are not motivated for a particular argument, are not really involved and have incongruent beliefs. Peripheral processing is about maximizing the credibility and attractiveness of the source of the message through the use of indirect cues and information.

Another approach to increase the influence of mass media and interpersonal communication is the use of fear messages. The protection motivation theory of Rogers (1993) says that someone behaves adaptively in response to a fear message if they have evidence that such behavior reduces a threat and if they believe they are capable of doing so. In conclusion, the most convincing messages are messages that:

• Arouse some degree of fear.
• Invoke a sense of severity if no change is made.
• Emphasis the ability of the individual to prevent the feared outcome (efficacy).

Both positive and negative framing of messages is sometimes effective.

Motivational interviewing

Another technique to motivate people is the so-called motivational interviewing. It's goal is to increase an individual's motivation to consider change, not to show how to change. During the interview, the interviewee (if all goes well) will be in a state of cognitive dissonance.

Cognitive dissonance means that someone does things that he actually disagrees with. An individual has conflicting thoughts. To get rid of the dissonance, he / she must reject a certain set of thoughts. During the interview, a smoker may realize that quitting smoking would actually be better because he has become aware of the adverse effects. Only when someone has decided to change their behavior, the interview will be focused on that.

The questions in the interview are not intended to put pressure on people. A question that could be asked is "what are the negative things about your current behavior?" Additional strategies for changing behavior are:

• Consideration of the disadvantages of the status quo.
• Consideration of the benefits of change.
• Evoking the intention to change.
• Evoking optimism about change.

Problem-solving approaches

These strategies focus primarily on how behavior can be changed and not so much why behavior should be changed. A good example is the approach of Egan (2001) and is a problem-oriented counseling approach. Counseling emphasizes the importance of a proper analysis of the problem and consists of three phases:

1. Problem exploration and clarification.
2. Goal setting.
3. Facilitating action.

An important element of his strategy is a thorough analysis of the problem. This is done by asking direct questions, descriptive questions and by giving empathic feedback. Then a suitable solution can be found.

Quit smoking

That people keep smoking is caused by two factors:

1. A conditioned response to a variety of cues in the environment (such as drinking coffee: many people smoke a cigarette with their cup of coffee).
2. A physiological need for nicotine: smoking to increase the nicotine level or to prevent the onset of withdrawal symptoms.

When someone has quit smoking, he may have trouble paying attention and concentration and become very restless. A good anti-smoking program takes this into account, as well as the difficulty that someone may have with the environmental cues and the biological withdrawal symptoms. The withdrawal symptoms are the worst for the first two to three days, and after two weeks they have virtually disappeared. However, the risk of relapse is not over yet.

One way to get rid of the behavior without any withdrawal symptoms, is to use nicotine gum or patches. This is called nicotine replacement therapy (NRT). This method often works well as long as the patches or chewing gum is used, but as soon as it is stopped, someone often falls back. The best approach is therefore a combination program: nicotine replacements and problem-oriented intervention.

Implementing plans and intentions

Planning change can be effective. These are called implementation intentions and include an if-then approach. The action must be specified in terms of when, where and how.

Following Bandura's theory of observational learning ( social learning theory ), programs have been developed that want to provoke behavioral change by showing the good example on video. Modeling can be effective, as well as practicing new behaviors.

Cognitive interventions

Cognitive theories assume that our thoughts have a major influence on the behavior that we display. If we take drug use as an example, we clearly see that the cognitions at the start of use are very different from when someone has been using drugs for a long time. In the beginning, someone is mainly focused on the positive effects. Curiosity will be satisfied and the use itself is fun. When someone becomes dependent on the substance, his cognitions will be dominated by thoughts such as "I need a shot now to feel better".

Cognitive intervention tries to make people aware that their cognitions are hypothetical. Alternative thoughts and alternative outcomes are possible, such as 'it has already been possible to have fun without the drug, so maybe it will work again'.

Beck (1976) introduced the Socratic dialogue. This is a structured conversation in which the therapist asks questions about the views on, for example, drug use. The intention is that the individual starts to wonder if he has the right cognitions about the subject. When you ask someone about why he is using something and ultimately summarize it, the reason for use is not seldom illogical, even in the patient's ears.

Changing the environment

The health belief model suggests that an environment that encourages healthy behavior should:

• Provide cues to engage in healthy behaviors or remove cues to unhealthy behavior.
• Minimize the costs and barriers associated with engaging in healthy behavior.
• Maximize the costs of engaging in health-damaging behavior.

Environmental strategies are central to the PRECEDE model.

Spreading the word

To spread new behavior in the population, individuals or groups are used to promote change. Rogers divided the population into these groups:

• Innovators: a small group of individuals with usually high status. They test new ideas.
• Early adopters: a larger group that has a wider sphere of influence than innovators. They are also described as opinion leaders.
• Early majority: this group adopts ideas reasonably early, but does not have the power to influence the rest of the population
• Late majority: the people who adopt the innovation only after adopting by the early majority. It is a careful group.
• Laggards: adopt the change as last, or not at all.

Problem-oriented strategies include:

• Goal setting.
• Action planning.
• Barrier planning / problem solving.
• Set graded tasks.
• Prompt review of behavioral goals.
• Prompt review of outcome goals.
• Prompt rewards contingent on effort or progress towards behavior.
• Prompt rewards contingent on successful behavior.

What does the anatomy of the brain entail?

The brain is divided into four anatomical areas: hindbrain, midbrain, forebrain and cerebrum.

Hindbrain

The hindbrain contains the parts of the brain that are necessary for life. The medulla that controls blood pressure, heart rate and respiration, the reticular formation, which controls alertness and wakefulness and the punch and cerebellum, which integrate muscular and positional information. 

Midbrain

Contains parts of the reticular system and both sensory and motor correlation centers, which integrate reflex and automatic responses involving the visual and auditory systems and are involved in the integration of muscle movements. 

Forebrain

Contains key elements that influence mood and behavior:

• Thalamus: connects the basic functions of the hindbrain and midbrain with the cerebral cortex.
• Hypothalamus: regulates appetite, sexual arousal and thirst. It also has some control over emotions.
• Limbic system: a series of structures including the Circuit of Papez. 

Cerebrum

The most recently developed part of the brain with the following parts:

• Basal ganglia: responsible for complex motor coordination.
• Cortex: the outer layer of gray matter that contains the cell bodies and their synaptic connections. It consists of four lobes: the frontal, temporal, parital, and occipital lobe. The frontal lobe has an executive function. It is involved in complex processes such as speech, planning and motor coordination. 

During rewarding behavior, the connections between the frontal lobe and the limbic system are activated. Multiple functions can be found in the temporal lobes. They are involved in scent, hearing, memory and language. The language is generally in the left hemisphere and the visual-spatial part in the right hemisphere. The integration of sensory information is in particular the function of the occipital and parietal lobes.

Problems of neurological functioning

The most common neurological problem is known as a cerebrovascular accident. The cause of this is a disruption of blood flow to parts of the brain, causing death of these neurons. This can have two causes, a clot of blood (thrombosis) that disrupts blood flow or the rupture of a blood vessel wall. A temporary disruption of the blood supply can also lead to experiences of symptoms similar to a stroke, but these can be reversed. This is called a TIA. Symptoms of the onset of a stroke are:

• Sudden weakness in the face, arm or leg, especially on one side of the body.
• Sudden confusion, difficulty speaking or understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden difficulty in walking, dizziness, loss of balance or lack of coordination.
• Sudden severe headache without cause.

If the cause is a thrombosis, thrombolytic drugs can be given to resolve the blood clot. CVAs in the left hemisphere cause problems in language and communication, in the right hemisphere it causes problems with muscle weakness or paralysis in limbs. Long-term effects may include hemiplegia, hemiparesis, dysphasia, dysarthria, aphasia and apraxia, visual field loss and hemianopia. Problems can also arise in learning, concentration, and short- and long-term memory and emotional responses.

What does the autonomic nervous system entail?

The autonomic nervous system is responsible for controlling activity levels of important organs in the human body. This activity is controlled by multiple areas of the brain, the most important is the hypothalamus. This receives information about requests made by the body from various sources:

• Information about the temperature of the skin (reticular formation).
• Information about light and darkness of the optic nerves.
• Receptors in the hypothalamus itself provide information about the balance of the ions and the temperature of the blood.

The hypothalamus responds to physical and psychological demands of the body.

The autonomic nervous system consists of two parts:

1. Sympathetic nervous system: involved in activation and arousal - the fight-flight response.
2. Parasympathetic nervous system: involved in relaxation - the rest-recover response.

If more activity takes place in the sympathetic nervous system, the body is activated. When more activity takes place in the parasympathetic nervous system, the body is at rest, making basic functions such as digestion and urine production easier. The sympathetic nervous system uses acetylcholine, noradrenaline and adrenaline as neurotransmitters. The parasympathetic nervous system only uses acetylcholine as a neurotransmitter.

Endocrine processes

The activity of the sympathetic nervous system is only of short duration. A second system is therefore used to provide the body with longer-term arousal. This system uses endocrine glands (endocrine glands), which communicate with their target organs through the release of certain hormones into the bloodstream. The endocrine glands that are responsible for the activity of the sympathetic nervous system are the adrenal glands, which are located above the kidneys. These are activated in two ways:

1. The center of the adrenal medulla.
2. The surrounding tissues, known as the adrenal cortex.

Cortisol increases the availability of stored energy and fats, which results in periods of increased physiological activity. It also inhibits the repair of damaged tissue. A second system that can provide the body with longer-term arousal is the pituitary gland, which is also controlled by the hypothalamus. When the hypothalamus activates the pituitary gland, it releases a number of hormones into the bloodstream that are known as adrenocorticotropic hormone (ACTH). As soon as ACTH reaches the adrenal glands, corticosteroids (including cortisol) are released.

What does the immune system entail?

The immune system provides a variety of protective mechanisms that respond to attacks from bacteria. It produces certain cells that fight organisms from outside the body and foreign cells. These threats are called antigens or pathogens. A number of organs and chemicals form the front line of the system:

• Physical barriers: such as the skin.
• Mechanical barriers: cilia (small hairs on the lungs) ensure that pathogens are expelled from the lungs and airways. Tears, saliva and urine also ensure that antigens are expelled from the body.
• Chemical barriers: acid from the stomach drives away antigens. Saliva and the walls of the respiratory tract contain antibodies (immunoglobulins).
• Harmless pathogens: there are a number of bacteria in the body that do not have a harmful effect on us. They protect their territory and can attack other bacteria that are trying to invade.
• Lymph nodes: these are secondary organs at or near possible places where antigens can enter. The almonds are an example of this. They contain a high level of lymphocytes (white blood cells) that can attack antigens.

Immune cells are white blood cells (lymphocytes and phagocytes). Phagocytes are attracted to infections. When they are at their place of destination, they destroy all foreign cells or antigens by enclosing or absorbing them. Lymphocytes are activated by phagocytes (by macrophages to be precise). Lymphocytes consist of different types of T cells , B cells and killer cells. B cells mark a foreign cell, so that it can be destroyed, and so that the body later knows that these cells are harmful. The plasma of the B cells remains in the blood and continues to produce antibodies until the hostile bacterium or disease is completely gone.

The natural killer (NK) cells ensure that the growth of the hostile cell or bacterium is delayed. The task of natural killer cells and phagocytes is seen as a non-specific form of immunity because they are the first line to attack a number of bacteria and cells. B and T cells provide specific immunity. All types of immune cells help each other fight against foreign cells and bacteria. The stress hormone cortisol appears to destroy T and B cells and thus increases the risk of infection if someone is stressed.

Immunity dysfunction - HIV

The human immunodeficiency virus (HIV) is the cause of a potentially fatal condition, known as Acquired Immuno Deficiency Syndrome (AIDS). The virus belongs to a group of viruses known as the "slow viruses'' since there is a long period between the initial infection and the onset of serious symptoms. The virus damages the T helper cells (CD4 + cells). Ultimately, the immune system of a body infected with HIV attacks its own T helper cells, destroying half of the immune system. This makes the body very susceptible to minor infections such as the common cold.

The treatment for HIV consists of three classes of medication:

1. Reverse transcriptase inhibitors: HIV uses reverse transcriptase to copy its genetic material and thereby generate new viruses. Reverse transcriptase inhibitors disrupt this process and thereby suppress the growth of the virus.
2. Protease inhibitors: these interfere with the enzyme that HIV uses to produce viral infections.
3. Fusion inhibitors: these interfere with the ability of the virus to fuse with the cell membrane or other T helper cells.

These drugs do not cure HIV or AIDS. They can only suppress the virus, but are unable to completely remove the virus from the body. Infected individuals must still take antiretroviral drugs. Certain HIV viruses are resistant to the antiretroviral drugs. These people must take a combination of two types of antiretroviral drugs. If these medicines are used in the right way, it has a good effect. These medicines have a strict regime with regard to taking the medicines and can cause side effects.

Autoimmune conditions

Autoimmune diseases are a group of diseases where the immune system functions abnormally. The immune system then produces antibodies against its own tissues.

Diabetes

There are two types of diabetes:

1. Type 1 diabetes: this diabetes is caused by producing too little insulin in the pancreas ( pancreatic ). The treatment is therefore the injection of insulin, and the planning of meals and sufficient exercise. This type of diabetes can lead to a life-threatening coma (diabetic ketoacidosis). Less serious symptoms are poor vision, constant hunger and thirst, weight loss and extreme tiredness.
2. Type 2 diabetes: diabetes is caused by a resistance to insulin. So the body produces enough insulin, but the cells get a resistance to the substance. Type 2 diabetes often develops later in life and is associated with being overweight. The treatment consists mainly of weight loss and exercise.

Rheumatoid arthritis

Rheumatoid arthritis (RA ) can be triggered for viruses in individuals with a genetic predisposition to the disease. It is a systemic disease that has an effect on the entire body and is characterized by inflammation of the membranes lining the joints. Every joint can be affected, but the hands, feet and wrists are the most frequently involved. Unfortunately, no cure is known for RA. The purpose of the treatment is to reduce pain and inflammation and to maximize the function of the joints. Medications are also used to reduce pain.

Multiple sclerosis

Multiple sclerosis ( MS ) is a neurological condition with repeated episodes of inflammation of the central nervous system. This results in delay or blocking of the transmission of nerve impulses. The inflammation is caused by damage to the myelin sheath.

What does the digestive system entail?

Various organs are involved:

• The mouth: here the food is crushed by chewing, thereby releasing enzymes that begin the process of digestion.
• The oesophagus: it transports food from the mouth to the stomach.
• The stomach: here the food is mixed with stomach acid and chemically decomposed.
• The small intestine: this is responsible for mixing bowing contents with chemical substances to break it into smaller parts and then absorbing them into the bloodstream for transportation to other organs. One of the chemicals involved in this is bile that is made in the liver and stored in the gallbladder.
• The colon: this is responsible for the reabsorption of water.

Controlling digestion

Each of the above digestive processes is controlled by both hormones and nerve regulators. Examples of this are gastrin, secretin and cholecystokinin. The parasympathetic nervous system activates digestion.

Disorders of the digestive system

Various disorders of the digestive system are discussed here.

Stomach ulcers

Hereby there is an ulceration in the stomach ( mucosa ) that can result in various symptoms, such as pain. It comes and goes for several days or weeks and it happens two to three hours after eating. The pain is often the worst at night - when the stomach is empty after a meal. Other symptoms include loss of appetite, nausea and vomiting. If the disease is not treated, this could be a potentially fatal outcome of the stomach lining. The cause of the stomach ulcer is determined by 70% by the Helicobacter pylori : an infection that weakens the protective mucous coating of the stomach and duodenum. It may also increase the amount of stomach acid secreted.

The treatment consists of suppressing the release of stomach acid and if possible, eradicating the virus. Different types of medication are used for this. In a rare case, the ulcer is surgically removed.

Inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of infection conditions of the large - and sometimes - small intestine. The main forms of IBD are: Crohn's disease and ulcerative colitis.

Crohn's disease may be involved in any part of the gastrointestinal tract. It is an inflammatory condition characterized by episodes of severe symptoms. The main symptoms are chronic and occasionally severe diarrhea and disturbed digestion. The inflammatory process can result in a thickening of the intestinal wall, so that the diameter of the intestine is reduced so that food can no longer pass through it. Often the disease can only be remedied with a surgical procedure. The symptoms are:

• Stomach ache.
• Changes in bowel movements.
• Loss of appetite.
• Unexplained weight loss.
• Blood ulcers and fistulas (the formation of small passages).
• General malaise.

Ulcerative colitis is similar to Crohn's disease, except that the disease damages the terminal part of the large intestine and rectum. It can develop into cancer after a number of years. There are different levels of this disease:

• Mild: fewer than four stools daily, with or without blood, mild abdominal pain;
• Moderate: more than four stools daily, moderate abdominal pain and fever;
• Severe: more than six bloody stools a day and evidence of systemic diseases such as fever and tachycardia (high heart rate);
• Fulminant: ten bowel movements daily, continuous bleeding and severe abdominal pain.

Irritable bowel syndrome 

Irritable bowel syndrome (IBS) is a bowel condition with the following characteristics:

• Pain.
• Pain associated with a change in the frequency of bowel movements.
• Change in the form of stool.

A central point in the diagnosis of IBS is that these symptoms arise in the absence of an organic pathology.

Colorectal cancer

This type of cancer is the third most common type of cancer in men and women. Symptoms are often not noticed, because they are relatively mild: bleeding, constipation or diarrhea and unformed stools. An early symptom can be general fatigue and reduced breathing. As with other types of cancer, this type of cancer can also be described in terms of different phases:

1. The cancer is limited to the inside of the bowel.
2. The cancer penetrates through the wall of the bowel to the outside layers.
3. The cancer penetrates the lymph glands in the abdomen.
4. The cancer has metastasised to other organs.

What does the cardiovascular system entail?

The most important function of the cardiovascular system is to transport nutrients, immune cells and oxygen through the organs and to remove waste products of them. The most important transport medium is blood. The pumping system that pumps blood through the body consists of the heart and various types of blood vessels:

• Arteries: transport blood away from the heart.
• Arterioles: these are the small arteries that connect the large arteries with the organs.
• Veins (arteries): they transport blood back to the heart. They are thinner than the arteries and have a lower pressure.

The heart

The heart consists of a right half and a left half. The right half is involved in the transport of blood to the lungs; the left half pumps blood to the rest of the body. Each half has two rooms, known as the atria and the ventricles. The right atrium takes deoxygenated blood from the veins and pumps it to the right ventricle. Blood is then pumped into the pulmonary artery to the lungs, where oxygen is absorbed. The blood with oxygen goes back to the heart where it enters via the left atrium. It is then pumped further to the left ventricle and then to the main artery, the aorta , which pumps the blood further to the rest of the body.

The rhythm of the heart is controlled by an electrical system. This can be measured with an EEG. Different phases can be distinguished:

• The P wave indicates the electrical activity of firing the atria.
• The QRS complex represents the activity of the ventricles.
• The T wave represents the repolarization of the ventricles.

If the heart is irregular or no longer beating, a defibrillator can be used. The electrical current stops irregular or dangerous activity of the muscles of the heart.

The blood

The body has approximately 5 liters of blood. Its content consists of a liquid called plasma and different types of cells. As well as the various exogenous (things outside the body) cells such as nutrients and oxygen, it produces its own cells. These are manufactured by stem cells in the bone marrow. There are three different types of cells:

1. Erythrocytes (red blood cells): transport oxygen around the body.
2. Phagocytes and lymphocytes (white blood cells): contain the B cells and the T cells.
3. Platelets (platelets): cells that respond to damage to the circulatory system.

Blood pressure contains two components: the lower and upper pressure. Blood pressure is highest when the heart squeezes together (upper pressure , diastolic blood pressure, DBP) and lowest when the heart relaxes (suppression, systolic blood pressure, SBP). Physiological processes are involved in the monitoring of blood pressure. Pressure sensitive nerve endings (baroreceptors) in the aorta and carotid arteries send information to the brainstem. The vasomotor center in the brain stem sends the information back to the hypothalamus.

Diseases of the cardiovascular system

There are various diseases of the cardiovascular system.

Hypertension is a condition where the resting blood pressure is significantly above average. There are two general causes of hypertension:

1. Secondary hypertension: here hypertension is the result of a disease process that often involves the kidneys, adrenal glands or the aorta. About 5% of hypertension cases can be explained by this cause.
2. Essential (primary) hypertension: in the majority of cases there is no known disease process that causes the problem. It appears that hypertension is caused by a number of risk factors such as being overweight, lack of exercise or excessive salt intake. It is a progressive condition and people with this disease experience a gradual increase in blood pressure over a period of several years with no obvious symptoms.

Psychological stress can also contribute to the development of essential hypertension. In times of stress, the activity of the sympathetic nervous system increases and with it the strength of the contractions of the heart also. This in turn can cause high blood pressure.

High blood pressure can considerably increase the risk of a heart attack or heart failure (with which the heart muscle is damaged or weakened). It also contributes to the development of atheroma (when there is a greasy deposit in an artery). Hypertension is often treated with various antihypertensive drugs, such as ACE inhibitors, diuretics and beta-blockers.

Coronary Heart Disease (CHD) develops gradually, just like hypertension, so that people with the disease may not be aware of their symptoms for a long time.

Atherosclerosis is a disease in which atheroma is built up in the arteries. The most important component of atheroma is cholesterol. This substance ensures the integrity of the blood walls. However, too much cholesterol can be very harmful. To repair the cell walls, cholesterol must be transported through the blood. However, it is not soluble in blood. To make transportation possible, there are two groups of proteins called lipoproteins. One group consists of the low-density lipoproteins (LDLs). This group transports cholesterol into the inner surfaces of the blood vessels. High-density lipoproteins (HDLs) transport too much cholesterol from the tissues back to the liver where it is broken down. LDLs is therefore seen as harmful cholesterol. The development of atherosclerosis involves a number of phases:

• Early processes: atheroma usually occurs in places where blood flow is disturbed. It is part of the recovery process. Monocytes absorb the LDL cholesterol and change into foam cells . It then forms a protective layer over the wall of the damaged artery. When foam cells die, they release the LDL cholesterol which then roams the artery. The artery is filled with foam cells, LDLs and eventually the diameter of the artery decreases.
• Acute events: lumps of foam cells and cholesterol become detached from the walls of the artery, transported, trapped in another artery and possibly block an important organ. If this happens around the heart, this results in a myocardial infarction (myocardial infarction).

Myocardial infarction (MI) is the death of the heart muscle due to a blockage of the blood supply. The disease is better known as a heart attack. The classic symptoms are often described as a pain in the chest. Other symptoms include reduced breathing, dizziness, pain in the left forearm, nausea, or vomiting. About 45% of people who have had a heart attack unfortunately do not survive the MI. Fortunately, the majority survive and these people can make a good recovery.

Angina is a severe pain in the chest associated with a temporary insufficient blood supply to the heart. The main symptom, like MI, is a central chest pain that can extend to the left shoulder and arm. However, unlike MI, angina is a temporary condition that happens when the heart muscle needs more oxygen than it is supplied by the veins. Angina is often the result of stress and can also be caused by:

1. Lesions on the coronary veins, reducing the diameter of these veins and limiting the blood flow through these veins.
2. Vasospasm of the coronary veins (a situation where the muscles of the artery walls in the heart contract and relax quickly, resulting in a reduction in blood flow through the arteries).
3. A combination of the two.

Angina is often treated with a bypass operation, in which veins or arteries from another part of the body are moved from the aorta to the coronary veins.

What does the respiratory system entail?

The respiratory system supplies oxygen and removes carbon dioxide from the blood. The exchange of oxygen and carbon dioxide takes place in the lungs. This system contains:

• The upper respiratory tract: the nose, mouth, larynx and windpipe.
• The lower respiratory tract: the lungs, bronchi, bronchioles and alveoli.

Breathing is done by breathing in oxygen and then breathing out carbon dioxide. There are two muscles involved in the inhalation, the most important being the diaphragm (diaphragm) that separates the abdomen into two parts and is located directly under the lungs. Upon inhalation, this muscle contracts. The second set of muscles consists of the intercostal muscles that can be found between the ribs. Exhalation occurs through relaxation of the diaphragm and intercostal muscles, which allows the lungs to contract. This reduces the volume of the lungs so that air is blown out of them.

The degree of breathing is controlled by the breathing centers in the brain stem. These respond to:

• The concentration of carbon dioxide in the blood (a higher level ensures deeper, faster breathing).
• The air pressure in the lung tissue.

Diseases of the respiratory system

Two types are discussed: chronic obstructive airways disease and lung cancer .

Chronic obstructive airways disease (COPD)

COPD consists of a group of lung diseases that are characterized by a limited air flow through the airways as the result of damage to the alveoli.

Emphysema results from damage to the alveoli, resulting in a reduced lung elasticity and reduction in the airways where the exchange of oxygen and carbon dioxide takes place. People with this disease experience reduced breathing, a strange cough (which does not produce mucus) and a remarkable reduction in the capacity to exercise. The condition is caused by exposure of the alveoli to irritating substances (such as active and passive smoking and polluted environment). About 15% of smokers will develop COPD. Various treatments are possible: medicines such as bronchodilators, oxygen therapy and antibiotics.

Chronic bronchitis results from infection and narrowing of the airways. Bronchitis is considered chronic if it lasts more than two years. People with this condition experience reduced breathing and an extreme degree of mucus in the bronchi and a 'wet' cough. Just like emphysema, it is mainly caused by smoking and passive smoking. Allergies can deteriorate the condition. Oxygen therapy and bronchodilators are the possible treatments.

Lung cancer

Lung cancer is the second most well-known type of cancer in both men and women. The symptoms are a dry cough, reduced breathing, a pain in breathing, decreased appetite, fatigue and a decrease in weight. The main cause of lung cancer is smoking. Other risks include exposure to carcinogens and (scarring of) tuberculosis. There is also a genetic risk. There are two different types of lung cancer:

1. Small cell cancer. The main treatment is radiotherapy or chemotherapy. The chance of survival depends on the phase the disease is in. Approximately 25% of people can be fully cured in the first phase of the disease, while only 5% in the final phase are completely cured.
2. Non-small cell cancer (approximately 70% to 80% of cases). The main treatment is the removal of the cancer through surgery. If the tumor is small and has not spread, about 50% of people survive the operation. The prognosis depends on the size of the tumor. If the tumor has spread and the lymph nodes are involved, the disease can often not be cured. Then the goals of therapy are to extend life and improve the quality of life.

What does the medical consultation entail?

When someone has decided to seek help, he goes to a care provider who is keen to collect as much information as possible about the patient to inform their diagnosis and treatment decisions. This is necessary to properly monitor the course of the disease and to interfere where necessary. This consists of five phases:

1. Establishing a good relationship between the care provider and the patient.
2. Finding out the reason for the patient's attendance.
3. Doing a verbal or physical examination or both.
4. The doctor, or the doctor and the patient, or the patient, considers the condition.
5. The doctor considers further treatment or further investigation.

When someone makes a decision together with the specialist, it is important that the specialist pays attention to a number of elements to make the conversation as pleasant and effective as possible:

• Have a good knowledge of research or medical information and be able to communicate this to the patient.
• A good relationship with the patient.
• Find out the nature of the patient's problem.
• Get an understanding of the patient's understanding of his problem.
• Involve the patient in decision-making processes.
• Managing time so that the consultation does not appear rushed.

Who has the power?

In a conversation between patient and caregiver it may be that the patient is central or that the caregiver is central. In the first case, the patient and the caregiver make the decisions together, the specialist listens quietly to the patient, the patient actively participates in the conversation, both the caregiver and the patient provide as much relevant information as possible and both agree afterwards with the decisions taken.

When the counselor is at the center of a conversation, he or she has control of the conversation, introduces the topics and closes them when he knows enough, the specialist asks questions with the main objective of obtaining information that is relevant to the decisions that has to be made, the caregiver makes the decision and the patient accepts it passively. In the past decade there has been a gradual shift from professional-centered to patient-centered.

Most people prefer to make decisions together with their specialist. Unless they value their situation so much that they don't know what to do, don't know enough about the subject or don't want to think about it because it is too frightening. When an operation has cosmetic consequences, such as an operation against breast cancer, people are happy to decide together with the specialist or alone. Older people, women, those with a serious problem, educated people and people with an active coping style want to be involved in decision making. Patients are more satisfied, have more confidence in health care, and have improvements in their well-being if they are involved in the decision-making process. The process of shared decision making consists of three steps:

• Choice: refers to the step of making sure that patients know that there are reasonable treatment options.
• Option: refers to providing more detailed information about options.
• Decision: refers to supporting the work of considering preferences and deciding what is best.

Which factors influence the process of consultation?

• Type of care provider: the type of interaction between patient and care provider depends on the type of care provider. Nurses are known for the fact that you can easily talk to them and listen well. On the other hand, doctors would find it difficult to empathize emotionally with a patient.
• Gender: research shows that patients themselves tell more if they have a female social worker facing them. Women also seem to convey more empathy and appear more caring, which increases patient satisfaction with the interview. Men and women who had been treated more often with disrespect by a doctor indicated that this was due to the opposite sex.
• Culture and language: the best consultation takes place when patients see themselves as being equal to the health professional in terms of values ​​and spiritual beliefs. So ethnic equality also helps.
• Type of information: care providers have to be extremely careful with what they say when talking to patients. More than half of the population will not know a lot of definitions. Terms such as "tumor", "benign" and "prognosis" can cause anxiety in the patient. The way in which information is provided also influences the behavior and thoughts of patients. Information can be brought in a positive or negative way. If messages are delivered to patients in a certain way during an intervention, the impact of the messages must be tested in pilot studies.
• Factors of the patient: as a patient, it is important to think in advance which questions you want to ask. Write it down if necessary. During the conversation, unexpected things can happen or you can hear emotional things that make you forget half.
• Bad news conversation: having a bad news conversation is stressful for both the patient and the caregiver. It is important that the patient is first prepared for the fact that bad news is coming and that the care provider then does not wait too long with the news itself. After that, it is best for the counselor to sympathize and then switch to practical matters. It is also important to provide the patient with information on paper, so that he / she can read it again later. Chadha and Repanos (2006) found that 64% of surgeons in their research felt confident in their ability to break bad news. Results from Ford et al. (1996) indicate that most people felt that the majority of time was spent giving biomedical information with relatively little emphasis on empathic responses or acknowledgement of distress. A large proportion of care providers have never had adequate training in conducting bad news conversations. In studies where workshops were given to care providers, a significant percentage improved in a positive way.

What happens beyond consultation?

Medical decision-making

Health care decisions are influenced by a lot of factors. Decisions are influenced by colleagues, the limited time and the way in which care providers look at patients and healthcare themselves. Diagnosing a disease can be done in different ways:

• Hypothesis testing: hypotheses are made and tested.
• Recognizing a pattern: the symptoms are compared with prototypes of diseases.
• Opinion revision or heuristics and biases: this is probably the least reliable approach to making diagnosis. A decision is made on the basis of partial evidence as a result of using heuristics.

Usually, care providers make correct and accurate decisions. However, their decision-making may be prone to error, particularly when decisions are made by heuristics due to lack of time or when optimal information may noy be available. These heuristics are also known as 'rules of thumb'. This can lead to errors quickly. A few examples:

• Availability: if a certain illness receives a lot of (media) attention, it is thought that this illness is very common. It is possible that a doctor recognizes a symptom and immediately thinks of this disease.
• Representativeness: a group of symptoms is compared to prototype syndromes without taking into account the prevalence of the diseases.
• Potential pay-off or differing diagnoses: if the diagnosis is unclear, the diagnosis assigned may be the one that carries the least cost and most benefit for the individual.

Taking medication

A large number of treatments consist of taking medicines. Medication has to be taken at certain times, in a certain amount and you have to take food intake into account. It is not as easy as it seems. Taking drugs for the HIV disease is very complex. There are a lot of factors that prevent people from taking their medication, such as:

• Social factors: little social support or low education.
• Psychological factors: anxiety and depression.
• Treatment factors: treatment not understood, side effects, complex intake schedule, few improvements.

Maximising medication use

One factor that may increase the recommended medication schedule is to discuss all treatments with the patient. The patient feels involved and feels that he also has a choice. If there is agreement between the hop provider and the patient about the treatment, there is a good chance that the patient will follow the recommended schedule.

Speaking to a patient in the correct language increases the understanding of the patient. In addition, it is helpful if the patient is aware of the fact that he can ask questions. Offering patients a list of possible questions has proven to be effective. The consultations took longer and patients had less need for information.

As a social worker you have to take into account that people only remember part of all the information you give them. Especially the information that is given at the beginning and at the end of a conversation is remembered mostly. A possible solution is to give people the standard information on paper, so that they can read it again at home.

Continue to take medication

By ensuring that the medication schedule requires as little memory as possible, people will not soon forget to take their medication. Another procedure is to receive a reminder in the form of a phone call, mail or e-mail. People can become dependent on this. When this form of reminder stops, the medication is regularly forgotten.

Changing behavior

Taking medication does not require a huge amount of behavioral change. Other medical interventions require an individual to adjust his behavior. If many demands are made on the patient, a lot of people will drop out. Stopping smoking is one of the most difficult behaviors to adjust, due to the addictive aspect and the cues in the environment. The percentage of people who adhere to the 'stop smoking' advice is very low. Changes in exercise routines are moderate and decrease over time. Lack of motivation is an important reason for non-compliance. According to Petter et al. (2009), programs with the aim of increasing therapy compliance must be based on self-regulation or the health action process model. According to the ERIC database, a number of components are central to behavioral change programs:

• Self-control strategies.
• Relapse prevention.
• Motivational strategies.
• Make change habitual.

How can coping be defined?

We have already seen that, according to the transactional model of Lazarus, stress is the result of the unfavorable combination of person and environment. People are able to change either the stressor or its interpretation, so that the situation becomes more positive. This is called coping.

Coping involves many actions and behaviors that are the result of a primary and secondary approach. Coping includes everything that someone does to make the situation more bearable, including the things that ultimately make it more difficult or tedious. Coping can be focused on the emotions that an event or situation entails, but it can also be directly focused on that situation itself. For example, if you are tense because you are going to a new school, you can try to get used to the idea and see the positive sides of it, but you can also address fear directly by talking to someone or by using drugs. use.

Different scientists distinguish different types and numbers of coping strategies, but a few common examples are:

• Seek social support.
• Confronting.
• Make a positive reinterpretation.
• Alcohol or drug use.

Adaptive coping

Problem-focused coping may be more effective if there is something that can be done to change the stressor. According to Lazarus, it is very difficult to determine which coping strategy will work. That simply differs greatly per person but especially per situation. Problem-focused and emotion-focused coping are independent of each other, but ultimately also work together on the overall picture.

Problem-focused coping occurs more often when something can be done to change or keep the stressful event under control.

A psychological way of coping is the 'fighting spirit'. The fighting spirit is characterized by thoughts such as 'I am determined to get through this situation' or 'I am going to overcome this illness'. People who deal with a disease in this way are more likely to fight instead of withdrawing and denying the disease. This method of coping is associated with better long-term disease outcomes in breast cancer. Helplessness and hopelessness is associated with less positive end results.

Meaning-oriented coping is about the values ​​and beliefs of a person and focuses on powers to gain personal and existential meaning within a negative and stressful situation.

Coping goals

Sometimes the coping strategy that someone applies is not at all effective for that situation. What you can ask yourself is 'why does someone use that strategy?' The way in which someone deals with a situation often has a lot to do with the way in which someone has dealt with such situations before, and with what happened then. But what is also very important is what the result is of the coping in the current situation.

A study by Laux and Weber (1991) into quarrels between married couples shows that people have an angry and offensive coping response when they feel that their self-confidence is threatened (or when they feel that this is the case). However, when there is a shared fear of something external, they often use a more encouraging form of coping.

What is the link between stress, personality and illness?

According to Alport (1961) you can define personality as the organization of psychophysical systems in a person that determines someone's characteristics, thoughts and behavior. Such approaches (trait approaches) view personality as a combination of stable dimensions.

Personality traits are an easy aid in stereotyping behavior (such as introverted behavior or type A behavior).

The Big Five

This well-known and popular way of categorizing personality uses the following five dimensions:

• Agreeableness: for example, co-operative.
• Conscientiousness: for example, responsible.
• Extroversion: for example social.
• Neuroticism: for example anxious.
• Openness: for example, openness to new experiences.

These characteristics make it possible for someone to live in a certain way. Every trait has its own associations with certain behavior. Usually they do not lead directly to illness but to certain health behaviors.

Neuroticism

Neuroticism is one of the three personality dimensions identified by Eysenck. It is a personality trait that is relatively unchanging and a broad dimension of the tendency to experience negative emotions and to show associated behaviors and beliefs. Individuals who score high on this trait often have a fear of a situation that is not frightening at all. They often interpret signals from the body as illness or symptoms. It is suggested that individuals who score high on neuroticism are exposed to more negative stressors by their nature. It is also suggested that individuals who score highly on neuroticism tend to use ineffective, emotion-focused coping strategies.

Conscientiousness and other big-five qualities

Conscientiousness is defined as being a responsible person, following social norms, persistent and disciplined. This has positive outcomes on stress and health. It also leads to the use of problem-oriented coping. It is linked to cognitive and evaluative aspects of well-being. Agreeableness is also adaptive because it leads to a flexible coping response to stressors. Extraversion is sometimes positive, but it also leads to more risky behavior such as smoking.

Optimism

Optimism means that someone assumes that desired things are possible, which ensures that people deal more effectively with stressful events and situations. The coping strategies are often better and are also maintained for longer. They are less likely to make internal, stable (it is unchangeable) and global attributions for negative things. Optimistic people often have a problem-oriented approach.

Pessimism is the general, negative view of things that comes with negative expectations and outcomes. Pessimism in young cancer patients is associated with a higher death rate.

What is close to optimism is unrealistic optimism, the idea that bad things happen to other people before you. This is a kind of protection mechanism and also works as a buffer.

It is suggested that people with (for example) diabetes cope better with their disease (and therefore have a more positive course of disease) when they are optimistic. Optimism ensures that someone has the feeling that they can control their illness, so that they adhere better to the diet and medication.

Hardiness

Hardiness is described as rich, varied and rewarding experiences in youth and feelings of commitment, control and challenge. The involvement ensures that potentially stressful situations are seen as meaningful and interesting by people with this appetite. Control means that these people (think they have) influence on their lives and that they see stressors as changeable. Changes are seen as normal or as an opportunity. It is thought that the way these people perceive and experience everything works as a buffer against stress. This buffer has the most effect with extreme stress. It is suggested that the absence of robustness is more important to look at than its presence.

Type A personality

A lot of research has been done on CHD (and its consequences, such as a heart attack) in relation to personality variables and emotions. The research into predisposition for CHD led to the formulation of the concept of type A personality. These type A personalities often show the following behaviors:

• Competitiveness.
• Do (too) much in (too) little time.
• They are easily irritated and quickly unkind or aggressive.
• Impatience.
• Performance-oriented behavior.
• A vigorous way of speaking.

Hostility and anger

Hostility is described as a trait that consists of emotional, behavioral, and cognitive components. The cognitive components are mainly having a cynical view of the world, being negative about many things and having negative expectations. The behavior is characterized by aggressiveness or anger. Anger is seen as a central component that is experienced by the individual and expressed in certain actions and expressions.

Hostile people more often exhibit risky unhealthy behavior, which in itself is a risk factor for, for example, heart disease. They can also benefit less from psychosocial institutions and social support from friends and colleagues. In this way they miss an important buffer for the negative consequences of stressful events. This is called the psychosocial vulnerability hypothesis. In addition, hostile people are more likely to experience stress. Together this makes them very vulnerable to coronary heart disease. Anger is associated with more alcohol consumption and more smoking.

All of these findings are particularly valid for people under 60 years of age, probably because before that time they often come into situations that trigger this personality trait. For example, working life has a large share because people want to work their way up and want financial security. There is competition and people are often busy.

Type C personality

Describing a personality type that makes people vulnerable to CHD encouraged researchers to look for types that are associated with other major causes of death.

Eysenck and Grossarth-Maticek also described personality types and the associated sensitivity:

• Type 1: vulnerability to cancer. This type is characterized by the containment of emotions and the ignorance in dealing with tensions between people, which leads to hopelessness, helplessness and ultimately to depression. The risk of cancer would, according to the researchers, be 120 times as high as in non-type 1 people.
• Type 2: vulnerability to CHD. These people show strong reactions of frustration, anger, hostility and emotional excitement. You can compare this type with the type A persons described above. The risk of CHD would be 25 times greater for this group than for other people.

In 1984, Temoshok described the association between the passive and helpless coping style and the increased chance of a bad outcome of illness. This type was called the type C personality and must meet the following characteristics:

• Cooperative and calming.
• Compliant and passive.
• Stoic.
• Self-sacrificing and unassertive.
• The tendency to inhibit or repress negative emotions.

In the past, many studies have confirmed that these people do indeed have an increased risk of cancer. Larger and methodologically better studies indicate that the link between these people and the development of cancer is limited and weak.

Type D personality

This type would be susceptible to cardiovascular disease prognosis and outcome. These types score high on scales that measure negative affectivity and social inhibition. Social inhibition is avoiding the risk of disappointment and rejection of others in social interaction. These types therefore experience more negative emotions but also contain them, which increases their risk of a heart attack or other cardiovascular event. The effect applies to men and women.

What is the link between stress and cognition?

Observed check

The so-called Locus of Control (LoC), as proposed by Rotter, means that behavior can act as a reward when the responsibility for events is seen as internal and not external. An internal LoC only predicts behavior if the outcome or reward is valuable to that person. According to Rotter, people with an internal LoC take responsibility for what happens to them, while people with an external LoC tend to shift it to environmental factors. This applies to both positive and negative outcomes. These views have a lot of influence on behavior. Someone who thinks that success depends on happiness is likely to make less effort to achieve something.

To associate LoC more specifically with disease outcomes, Wallson described a construct about the Loc with regard to health in 1978. They used a scale that has three categories, namely:

• An internal LoC: I have control over my health.
• An external LoC: no matter what I do, I have no control over my health.
• Powerful others: given my situation, I have to do what the specialists say.

These three types of control awareness are each associated with different types of coping, emotions, and behavior. Some scientists also believe that control awareness can be used to predict disease progression or outcome. The question is, however, which way the causality points. It is not yet possible to say whether optimists have a sense of control, or whether a sense of control makes someone optimistic.

When someone has an unrealistic optimistic thought, if it turns out that the thought was unrealistic, it can lead to the feeling of having failed (perceived failure). This feeling can lead to feelings like helplessness and depression. If someone in such a case would accept the truth and accept that he has no control, it would lead to more useful emotion-focused coping.

What is important is what people (think) have control over. Different types of control are described:

• Behavioral control: the idea that someone's behavior reduces the negative consequences of the event. For example, doing relaxation exercises when blood needs to be taken.
• Cognitive control: the idea that someone has thoughts or thought processes to reduce the negative effects of the stressor. For example, focus your thoughts on something nice in the future if you undergo a painful procedure.
• Control over decisions: when you have the option to choose between two or more options, it feels like you have more control over what is happening. It is then your own choice.
• Information control: the ability to look up information about what has happened or what needs to be done. The more information is available, the better someone can prepare.
• Retrospective control: this means that someone can indicate afterwards where the cause and the responsibility lie of what happened. Giving meaning to something can give a sense of order. For example, someone finds out if their physical disability is the result of a defect in the genes or a complication during birth. In the latter case you place the responsibility externally and some researchers say that this is less adaptive than placing the responsibility internally. But not everyone agrees on this.

Causal attributions are the ways in which a person attributes a cause or an event to feelings or actions of himself or others. There are internal attributions (where the cause is placed on itself) and external attributions (where the cause is placed on others).

There is evidence that social class can influence the level of feeling of control. Following a large-scale study, a distinction was made between mastery ("I can do everything I have in mind") and perceptions or constraints ("other people determine what I can and cannot do"). Mastery was lower and constraints were higher in people from a low social class. The opposite was the case with people from a high social class.

Hope

Hope is defined as a positive motivational state based on a sense of successful energy and plans to achieve a goal. Hope is about the motivation (agency) and the route (pathway) to achieve goals (outcomes), while optimism is about generalized positive outcome expectations.

What is the link between stress and emotions?

Anxiety and depression

Within many studies on the role of negative emotions in the onset of a range of illnesses, anxiety and depression were also examined. The role of depression in increasing likelihood of disease onset, however, is controversial and depends on many factors, including study methods, samples and the specific disease. Depression and anxiety seem to be more implicated in the progression or outcomes of disease.

Several reviews and meta-analyses have reported a significant link between depression and coronary heart disease (CHD) outcomes. A large UK study (Surtees et al. 2008) found that patients diagnosed with major depression were 2.7 times more likely to die from ischemic heart disease. The evidence associating emotions with increased cancer risk is much less consistent. Overall the evidence appears to be in support of depression influencing outcomes of the disease.

how can negative emotions affect health outcome? 

There are various possibilities by which depression and anxiety might affect health outcomes. One pathway is through coping responses. For example, stress may be maintained through rumination, whereby a person will repeatedly think about past events and worry about future events.

The second pathway through which depression may affect health outcomes is indirect, i.e. through behavior. Depression is seen to reduce the likelihood of healthy behaviour or even provoke unhealthy behaviour

Thirdly, there may be physiological pathways with depression that influence health outcomes. The serotonic dysregulation with depression is also responsible for making platelets in the blood more likely to clot.

post-traumatic stress disorder 

PTSD can increase the risk of experiencing further negative events. With PTSD the threat responses of the brain and the sympathetic nervous system are on constant high alert. As a consequence the individual is likely to be at risk for conditions known to be affected by chronic stress.

Coming out for your emotions (emotional disclosure)

Opposite to suppressing emotions is the manifestation of emotions. These two types of dealing with feelings also seem to be opposite in terms of their effect on health. Someone who has done a lot of research into this is Pennebaker. He says that writing about traumatic experiences can have a long-term positive effect on the functioning of the immune system.

Standing up for emotions should not be confused with expressing emotions (expressed emotion). Expressing emotions can involve both negative and positive emotions and is often a form of reducing stress. Expressing emotions has fewer positive effects and sometimes negative ones.

Congestive heart failure is a disorder in which the heart loses its ability to pump blood efficiently through the body. The consequence of this is that many organs do not get enough oxygen and nutrients, so there is a chance that these organs will be damaged and therefore no longer work effectively.

What is the link between social support and stress?

Social support

This possible source of support seems to have a huge impact on health. People with a strong social network live longer and healthier than people who are in social isolation. Social support can really be there, but someone can also feel that he has social support. Social support ensures that someone feels loved and appreciated. Whether someone feels socially supported has an effect on the way in which something bad happens. People who feel socially well supported generally respond with less stress than people who feel alone.

It is clear that social support influences the course of the disease, but a more difficult and dangerous proposition is that social support also influences mortality rates. Various studies (both early and recent and both small and large studies) confirm a relationship between social support and mortality.

How does social support influence a person's health status?

There are two important theories about how social support works:

• Direct effect of social support: regardless of the degree of stress, social support has a positive influence. The absence of social support is also harmful if there is no stress or illness. Social support also has a physical effect. It lowers blood pressure and has a positive effect on the immune system and endocrine systems.
• Social support as a buffer: social support protects people against stress because it acts as a buffer. It influences people's cognitive approach and because it influences someone's coping reaction.

In some cases, social support is actually negative. When someone's social network is very caring, this can lead to dependence.

Women receive and offer more support than men. In addition, women indicate that they have a larger circle of friends. In times of stress, women use the tend and befriend response, where care and support seeking are typical behaviors. In (collectivist) Asian cultures, people seek and expect no support. The group comes first and these individuals do not want to damage relationships by talking about their personal problems. In Western countries, individuals seek enormous support from friends and family.

Social support is also not always seen as support. Sometimes someone thinks his family is too involved or patronizing too much. It can also happen that social support does not fit well with someone's situation. For example, practical support is more useful when an event can be controlled, and emotional support is better when a situation cannot be influenced, such as the death of a dear person.

Finally, research into this subject usually depends on questionnaires that people fill out themselves. The question is therefore whether such lists actually measure the (feeling of) social support, or whether in some cases they actually measure an underlying characteristic.

What is the impact of illness?

People with a chronic illness have to face a number of difficulties, namely:

• Uncertainty: the period that someone finds out what the disease is, how bad the symptoms are and what this means for his life.
• Disruption: when someone finds out that their illness is serious. During this period someone experiences a lot of stress and someone is very dependent on the environment.
• Striving for recovery: during this period the individual tries to gain control of the disease and the symptoms and seeks a way to deal with this.
• Restoration of wellbeing: in this phase someone adjusts his emotional image. The disease and its consequences are accepted.

As with all phase models, not all individuals will move through stages smoothly nor achieve emotional equilibrium or a stage of acceptance and adaptation.

There are also a number of phases with regard to cancer:

1. Initial response: the initial response, for example disbelief and shock. Individuals try to defend themselves at this stage against the implications of the diagnosis and may not receive the information clearly.
2. Dysphoria: this phase can last two weeks. At this stage, individuals see their illness realistically, allowing them to experience symptoms of stress, insomnia, decreased concentration, and anxiety. When information becomes available about the treatment, feelings of hope and optimism will compete with stressful feelings.
3. Adaptation: this period can take weeks or months. In this phase, the patient adjusts more positively to his diagnosis and tries to develop coping strategies.

Research into cancer patients shows that some of them are entering the terminal phase, while they have not yet accepted their illness. Some patients accept their disease less and less as death threatens. It is also very dependent on the course of the disease, in which phase someone is. At one moment someone can be busy accepting his circumstances and the next moment the situation turns out to be worse than expected. There is much criticism of phase models, because these models have expectations about people's responses to certain diseases, while people's responses vary enormously from person to person.

Depression and anxiety

Depression and anxiety are common after heart disease and heart attacks. Emotional stress often persists for many months. The prevalence of emotional stress in cancer patients is 70%, with both anxiety and depression occurring. Five years after cancer recovery, depression also occurs, as well as anxiety. Diabetes is also accompanied by emotional stress, generalized anxiety disorder and symptoms of anxiety. With diseases associated with a certain stigma, such as HIV and AIDS, the social significance that goes with it can lead to stress. Both among children and adults, chronic diseases go along with a twice the prevalence of depression and anxiety. Chronic diseases can also lead to a feeling of being lost.

Emotional reactions to illness

Reactions to diagnosis

Most research has been done on cancer, but negative emotional reactions often occur in other conditions, including sudden brain damage, strokes, heart disease or a positive HIV diagnosis.

Loss of self

People who are ill experience a sense of loss of self. That may be because they have to stay indoors. People who are visibly ill experience the most stress and overall quality of life. Negative reactions from others or seeing themselves as a burden to others prevent them from living their lives normally.

Emotional reactions to COVID-19 pandemic 

The prevalence of depression, anxiety, stress and ptsd symptoms rose in the first half year of the COVID-19 pandemic.

Emotional reactions after treatment and admission

Anxiety prior to surgery is high in children and adults and affects outcomes after surgery, such as repair of wounds. Levels of anxiety in cancer patients increase at certain points in the treatment, for example when someone is waiting for the test result, or when a final stage of treatment has been reached and treatment stops with no prospect of cure. At all stages of treatment it is very important that there is good communication from the health professional. This determines whether a patient feels informed, cared for, and feels able to make choices about the treatment that meets needs and goals.

Reactions at the end of treatment

After treatment, patients may experience emotional ambivalence: on the one hand, treatment and side effects have stopped, but on the other, there is a sense of vulnerability and abandonment that results from decreased contact with health care. These feelings of abandonment have been reported in different groups of patients. 

Fatigue

Fatigue occurs in many conditions. There are also associations between fatigue, depression and anxiety. Such negative emotional correlates of fatigue can amplify the negative effects of illness on a person's life. Fatigue also contributes to weakness, making it a vicious circle.

The effect of negative emotional reactions to illness

Depressed people are less good at sustaining treatment, such as continuing to take medication, stopping smoking after a heart attack, or exercising as part of recovery. People with depression also take more risks, for example in unprotected sex. Anxiety is also associated with poor self-management. There is also evidence for the influence of the course of the disease. For example, experiencing stressful events predicts symptoms getting worse and relapse in MS. Depression also affects whether patients resume functioning before the disease, especially in terms of return to work and social activities. This may be due to the worsening of symptoms in depression or to reduced expectations of positive outcomes.There is evidence that depression is a cause of illness and defects and reduced survival, for example after a stroke. Emotion regulation is important in the outcome of diseases. In other words, how a person experiences, processes and deals with emotions influences adaptation, where avoidance and suppression are maladaptive, and recognition and expression are often adaptive.

Positive emotional responses to illness

A positive or optimistic view can be directly or indirectly linked to positive outcomes. Being optimistic is associated with less severe pain and less fatigue among cancer patients ten weeks after chemotherapy. Pessimists have more maladaptive coping strategies. The main benefits of positive emotions are the promotion of psychological resilience, the removal of negative emotions and the triggering of an upward spiral of positive feelings.

The most frequently mentioned positive consequences after stress or trauma are:

• Closer relationships with loved ones.
• Greater appreciation for life.
• A sense of increased personal power.
• Greater degree of spirituality.
• A change in life priorities and goals.

Whether people will experience positive consequences depends on how they approach the disease, what they have to deal with the disease themselves (self efficacy) and how much social support they receive.

Many people indicate that they have appreciated the life and things that they have since they are sick. They realize that small things can make a person happy, now that they know it can be over. People who overcome a disease are often happy because it feels like they are getting a second chance.

How can we cope with illness?

In 1984, Moos and Schaefer described three processes that a person goes through when he falls ill.

1. Cognitive approach: the patient examines the consequences of the illness for his or her life.
2. Adaptive tasks: the patient does things that are related to being sick, such as learning to deal with the disease and the possible treatment, and things to maintain his emotional balance and maintain his social relationship.
3. Coping skills: the patient falls into a way of dealing with the situation that is either approach- oriented, problem-oriented or emotion-oriented.

The adaptive tasks that are required after chronic illness are:

• Dealing with the symptoms of the disease and possibly with pain.
• Keep control of the disease, including managing symptoms, treatment, or preventing progress.
• Managing communicative relationships with health professionals.
• Preparing for an uncertain future.
• Maintaining self-image and self-confidence with challenges.
• Maintaining control and emotional balance over health and life.
• Dealing with changes in relationships with family and friends.

Coping by denial or avoidance

In the beginning, denying an event can be an easy and effective way to minimise any threat and cope with the distress felt. In the longer term, however, denying a threatened event appears to have negative effects. It often ensures that someone develops inefficient coping strategies. It leads to more depression and more sadness and worry. In adolescents, avoidance does not seem to have negative consequences, but depressive coping does. And in a group of patients with rheumatism, denial was even associated with positive outcomes. Perhaps denial is a good way to deal with long-term pain, the researchers explain these results.

Problem-focused and acceptance coping

When someone accepts their illness and then learns to cope with the illness, it is associated with less worry and sadness. Problem-focused coping is associated with a better, more positive state of mind, while emotion-focused coping is associated with a more negative state of mind. However, individuals do not use one coping strategy. Multiple types of coping strategies are often used simultaneously and this can change during the illness. Culture can also influence the type of coping strategies that are used. In addition, the time in which people live has a major impact on the prevailing beliefs and expectations. This also changes the outlook on the disease, the stigma and the possible treatments.

Religious coping and spirituality

Religious beliefs are associated with greater appreciation of challenges, greater optimism, hope and positive appreciation of events and personal growth, and better emotional and physical adjustments in the elderly. In the West, many people describe themselves as spiritual, but not religious. Spirituality is more individualistic than collectivist and more emotion-focused than problem-oriented, and more inward-looking. It is also more anti-authoritarian and more concerned with self-actualization.

What are the illness outcomes?

Finding benefit and post-traumatic growth

People experiencing significant health or life events often report positive psychological changes (post-traumatic growth). For example, they have strengthened personal relationships, a greater appreciation for life, a sense of increased personal strength, greater spirituality, and a valued change in life priorities and goals.

Acceptance coping is defined as accepting the reality of the situation and the fact that the situation is not easy to change.

Social comparison is the process by which a person or group of people compare themselves with others.

Research has shown that individuals with a lot of social support indicate a high degree of benefit finding, regardless of their degree of acceptance, coping, or social comparison.

The acceptance of illness

Acceptance is seen as positive for a person's mood and coping and various health outcomes including fewer disabilities due to pain, improved physical functioning and improved well-being. It is positive for adaptation and the quality of life.

What is the link between illness and quality of life?

Good health care is much more than the pursuit of good clinical results. Certainly when people are chronically ill and therefore have to stay in a hospital or other institution often or for a long period, it is important that they are made as comfortable as possible there. We have already seen in the previous parts how important a person's mental state is for the course and recovery of illness. The quality and accessibility of healthcare is also something that certainly contributes to this.

Quality of life (quality of life, QoL) is a judgment of the individual about his own life at a certain moment. Health-related quality of life refers to the experience of (dis) health or illness and is associated with a certain state of mental and physical functioning and how you feel at work, at school or as a parent.

According to the World Health Organization (WHO), QoL covers the following aspects:

1. Physical health: pain, energy, discomfort, sleep.
2. Psychological (psychological health): positive feelings, self-confidence, memory and concentration.
3. Level of independence: self-care, activities, mobility, medication, work capacity.
4. Social relationships: personal relationships, social support, sexual activity.
5. Relation to environment: relation to physical safety and security, financial resources, opportunities for learning, transport.
6. Spirituality, religion and personal beliefs

Research on QoL has so far mainly focused on the physical aspects of human well-being. And although it is certainly part of it, it does not say everything. The one man with a broken leg is not the other. There is also a psychological factor.

Influences on QoL

Age

The (limited) study of QoL in children is mainly aimed at children with a chronic disease such as asthma or epilepsy. Diseases that are chronic, but not immediate and not necessarily life threatening. According to Bowling, some diseases have an extra impact on children that you don't see in adults. With children, it often takes away the possibility of exercising or playing with peers. This can have a lot of influence on their self-confidence, mood and development. For children, having a disease can also lead to adulthood and an increased appreciation of life, which is sometimes called post-traumatic growth.

Of most influence on the QoL are the severity of (possible) attacks, the loss of independence, limitations in daily life,concerns about the reactions of others and concerns about side effects of medicines. The general QoL is less influenced by health and disease than by economic factors. The age at which someone has a stroke has no direct influence on the QoL. Older people are more likely to lose their independence and become dependent on others. Older people with a limiting illness are particularly concerned about their physical functioning and physical activity, social support and social contact. The type of disease has less influence on the QoL than these aspects. Non-limiting chronic diseases do not affect QoL. The reason why some people with a chronic illness report a higher quality of life than expected, is that when a situation is clear and understood as a permanent feature of one's life, adaptation is easier and better than when someone believes that his / her circumstances are temporary and can change.

Aspects of the disease and quality of life

Aspects of the disease are important: pervasive and persistent pain and disabilities are associated with a lower quality of life. The severity of the disease is not unavoidably or consistently associated with a lower QoL. What is of great influence is the way in which someone approaches his disease (appraisal) and how he deals with it (coping).

Neurological consequences such as memory loss or attention problems can have a negative influence on someone's physical and psychological functioning, two main elements of the QoL. These restrictions can also prevent someone from being able to assess their QoL as well.

Culture

In Western cultures, health and healthcare are seen as something individual, in non-Western cultures it is often a collective concern. Culture partly determines how people deal with pain, how they view modern or traditional treatments, how dependent they want and can be and how they are used to communicating. Compared to Western people, the Chinese beliefs are different in terms of social support and they mainly communicate by telling a specialist about their immediate complaints. The latter also influences their own description of their QoL.

Aspects of treatment and quality of life

Research into different types of treatment is usually done to see what effect a treatment has on a certain subpopulation or to see if different treatments have a different effect on QoL. Research into children with cancer, for example, shows that the children in remission have a higher QoL than the children who undergo intensive treatment.

A study with leukemia patients compared two types of bone marrow transplantation (BMT) with chemotherapy. A heavy form of chemotherapy preceded both forms of BMT. Subsequent research showed that people who had undergone BMT were more tired, had more social and sexual problems and that their work and leisure time were often disrupted by the consequences of the treatment. Receiving bone marrow from a close family member also appeared to have a greater negative effect on someone's QoL than when it was from an unknown donor.

When you compare people who have undergone MBT in their youth to people who have not undergone BMT in their youth, no difference in QoL is found. Even if the overall health of the BMT group was lower. You could conclude from this that undergoing severe treatment in youth does not have lasting effects on QoL.

Psychosocial influences on the quality of life

Among physically healthy people, depression and anxiety disorders appear to have a negative influence on QoL. Symptoms of anxiety and depression in people who have had a heart attack in the last 15 days are a good predictor for a lower QoL. Ethnic origin also appeared to have an impact on the QoL. Various studies have shown that non-white people generally have a lower QoL than white people.

Dealing with the situation in an evasive manner appears to make a positive contribution to the QoL when the situation is actually not controlled. When someone in such a situation wants to influence things that are beyond his control, that is only frustrating. For example, when people learn to accept their chronic pain, it has a positive influence on their QoL.

Of all the sources that people can possibly fall back on in difficult times, such as when they are sick, social support is one of the most important. All kinds of positive relationships have been found between (alleged) social support and coping with and adaptation to the disease.

However, the direction of causality is not always clear. When one of the two factors changes, for example when the QoL changes or the (alleged) social or emotional support, it is not always the case that the other factor also changes. From studies that look at the two factors in this way, you cannot always conclude that the two factors are inextricably linked.

Targets and QoL

The self-regulation theory of Carver and Scheier describes the process of achieving goals related to illness. It is proposed that the disturbance of personal goal attainment caused by chronic illness and its consequences is likely to influence a person's perceived QoL. Approaching the event (the disease), the disturbed approach to the goal, expectations of the final result, approximation of possible sources and the way of coping all influence QoL.

Thus, the disease-specific QoL can sometimes be predicted from the preceding QoL, avoidant coping and a less stressful approach to the whole. Setting goals for yourself, such as wanting to do things for others and having lots of fun, after a (heart) operation is associated with anxiety, depression and a low QoL (self report). Setting goals probably causes someone to give a different meaning to the disease. Someone rather sees the disease as 'something' that makes social contacts more difficult and means less to others.

Coronary angioplasty is a procedure where a small balloon is placed in a blocked coronary vein of a person with atheroma.

How can quality of life be measured?

There are various reasons for doing research on the QoL and determining the QoL of people. Institutions and specialists want to be able to properly inform people about the effects that a certain treatment is likely to have on them. They also want to be able to provide patients with information about what they can do best to minimize the unpleasant effects of the treatment, for example by pointing out the importance of social support.

Research into QoL can also provide a good picture of which alternative interventions are most suitable. Often interventions are compared in terms of costs and clinical outcomes, but especially when the clinical outcomes are equally good, it is important to choose the one that best fits the patient.

When someone is asked about his QoL, the specialist gets a better picture of the general condition of the patient. This can improve communication between patient and practitioner. The practitioner then has a better picture of what the points are that the patient has difficulty with. As a result, he can better adapt his information provision to the specific characteristics of the patient and better assist in choosing between different treatments.

An important side note when measuring QoL is that physical, emotional and social characteristics are not part of the QoL. They can explain why someone thinks their QoL is low, but they are independent of meaning. Then you may wonder whether you can better measure someone's general QoL, or whether you can better focus your research on disease-specific QoL. When you measure the general QoL, you can easily compare different disease groups. However, you may miss the points that are specific to a certain type of illness, such as the fear of cancer recurrence. Specific measurements do take that type of point into account, but then it is more difficult to compare diseases.

• Practicability: under some conditions it is difficult to perform a QoL. For example, in people with diseases where communication is disrupted, interviews cannot be conducted. By conducting the interviews with the authorized representative, a number of methodological problems arise. For example, results cannot be compared well with each other, or the results need to be standardized.
• Response shift: some individuals with limiting diseases sometimes indicate that they have a higher QoL than healthy people. Researchers think that this has to do with the response shift; changes in subjective reports from people whose health status has changed. They have probably changed beliefs because of their illness.
• Culture: the QoL has developed in the English language and must therefore be translated if it is taken in other countries. As a result, the meaning of questions is sometimes lost. They do not know certain concepts in other countries and certain diseases have a different prevalence. Cultural differences have an impact on statistical data, so that the conclusions are also influenced by cultural differences.
• Age: if a QoL is taken from a child, children's versions of the QoL must also be present. Other aspects of development are important for children and adults. In addition, children of a certain age are unable to understand certain things. Abstract domains such as feelings are only developed around the age of seven. If parents enter the QoL for the child, this will not fully match the feelings and thoughts that the child has.

What does the experience of pain entail?

Pain is not simply the presence or absence of pain stimuli. There are a number of physiological and psychological explanations for why and how we experience pain. People respond differently to acute pain than to chronic pain, so there are different ways of dealing with those two types of pain.

Most people have experienced pain sometimes. Experiencing pain is not pleasant for most people, but it is usually functional. It warns us of damage to the body. The pain causes you to handle that painful area with care. People with a congenital defect that prevents them from experiencing pain usually die at a young age. They do not respond to the symptoms of illness and therefore do not seek help themselves. This condition is known as congenital universal insensitivity to pain (CUIP).

Despite the protective and warning effects of pain, pain is very annoying and sometimes even unbearable if it lasts too long. Sometimes a place still hurts while the tissue is already healed and sometimes people feel pain in limbs that have been amputated. This last phenomenon is called phantom pain.

Types of pain

Acute pain: most people have acute pain that lasts no more than a few minutes, but the definition of acute pain describes pain that lasts for less than three to six months. Most types of acute pain are the result of an injury and therefore usually disappear automatically when the injury has recovered. Acute pain can also be a recurring phenomenon, for example when it comes to the pain of migraine.

Chronic pain: chronic pain is defined as pain that lasts longer than three to six months. Chronic pain often starts as acute pain that does not recover or slowly recovers. Two types of pain can be distinguished in this category:

• A gentle, calm pain: the pain is always about the same.
• Chronic, progressive pain: the pain gets worse over time.

You can also distinguish between the nature of the pain, such as the feeling of the pain itself (stinging, burning, nagging), the severity of the pain (ranging from mild to unbearable) and the pattern (short, long-lasting or recurring).

The prevalence of pain

Chronic pain is more common than most people think. For example, a large-scale study shows that 35 to 51% of the population have experienced some form of chronic pain. Lower back pain is common. Chronic pain is also common in young people between 12 and 19 years. The most common causes are injuries, health problems and sports injuries. Older people suffer more often from chronic pain, but the explanation for this is probably that the health of older people is less good than the health of young people. People with a physically demanding job also reported experiencing chronic pain more often. Divorced people indicated to have (had) pain more often than married people.

The most common places of pain are the back, the abdomen, and the head. Of all the reasons why people visit the doctor, 40% have to do with pain. Most people who go to the doctor with pain complaints also report that the pain limits their freedom of movement and physical possibilities.

Living with pain

Chronic pain has much more effect than just the bad feeling itself. When you have just as much pain and know that it will pass again, it is something completely different than when the pain will always be there. It can prevent people from doing physical and social activities and can make it impossible to carry out their work. The latter can in turn have financial consequences. No wonder that a lot of depression is found in people with chronic pain. The causal direction is not exactly known, people can become depressed by the pain and its consequences, but people can also pay more attention to the pain through depression. It is not unusual that depression causes someone to focus more on physical symptoms. Depression can also make people feel unable to do anything about the pain, so they make no effort to reduce the pain.

However, people with chronic pain can also mention positive consequences:

• Primary gain: when expressing the pain results in the reduction of an unpleasant consequence, for example someone in the family takes over a household task when the sick cannot do it because of the pain.
• Secondary gain: when the pain results in a positive outcome such as sympathy or concern from others.
• Tertiary gain: the feeling of pleasure or satisfaction that someone experiences when he helps someone suffering from chronic pain.

There are two sides to that tertiary profit. In the short term it makes both parties happy. Someone who no longer needs to help in the house is happy that his back pain is not getting worse at the time, and the person taking over the job is probably happy that he can do something for the other. But at some point the positive effect is no longer there. The person who no longer is helping will also miss out on necessary physical exercise and the person who takes over the task will eventually become overloaded if the other person isn't recovering. Moreover, the task transfer becomes normal for both parties over time. The person with pain no longer thinks that he will get out of that task and for the person who has taken over it no longer feels like helping immediately.

Brena and Chapman (1983) described the so-called "five Ds" that result from such an environment:

1. Dramatization of complaints.
2. Disuse through inactivity.
3. Drug misuse (as a result of over-medication as a response to pain behavior).
4. Dependency on others (due to learned helplessness and poor use of personal coping skills).
5. Disability due to inactivity.

How do people communicate pain?

Expression of pain is a form of communication and that is functional. Women during labour get more support when expressing pain, and that increases the chance for survival for mother and child. Communication of pain is especially important in a medical context, because then the patient will get enough pain medication. 

The expression of pain can be deliberate or incidental. Usually, people express there pain through facial expressions. 

What are the biological models of pain?

The simplest theory about pain is that there are pain receptors in the skin and other parts of the body and that, when activated, they cause pain. They send information to the pain center in the brain, which by activation provides the sensory experience of pain. This theory is also called the specificity theory. This theory was first proposed by Epicurus and later described by Descartes.

It was later discovered that people have three types of nerves that respond to pain, heat or cold. Goldscheider added in 1884 that someone only feels pain when a certain threshold value has been exceeded with regard to the stimulation of the pain receptors. With these types of theories, the amount of pain experienced is directly related to physical damage. However, we now know that this is not the case.

There are three important factors that have to do with it:

1. Pain while there are no pain receptors: the best example of this is phantom pain. Phantom pain means that people have sensations that can sometimes be extremely painful, that they feel in limbs that they no longer have. They feel tingling, cramping or stabbing in their leg that is amputated. They usually feel this from a week to half a year after the amputation, but in some cases the pain continues for years. This is more common with amputated arms than with amputated legs. The same effect occurs in people with spinal cord damage and people with paralysis.
2. Pain receptors that do not transmit pain: as previously described, some people are insensitive to pain stimuli. They do not notice that they have the symptoms of a disease and do not stop activities that seriously injure them. Usually the path that the pain stimuli must take is completely intact. It is therefore a reverse phantom pain effect. No pain is experienced while the pain receptors are intact.
3. The influence of psychological factors on the experience of pain: a number of psychological factors influence the pain experience.
   • The state of mind: anxiety and depression lower the pain threshold and cause someone to report pain more often. It also works the other way around: pain influences the state of mind.
   • Attention: when you give pain attention, the pain experience is increased. Someone who is injured during an important competition usually only feels the pain afterwards, when the adrenaline falls and there is attention again for things other than scoring points. Research into attention and pain with the so-called 'cold pressor test' in which participants have to put their hand in a bowl of ice water, showed that people who could focus on that lasted less than people who were distracted by a computer task.
   • Cognitions: when you think that the pain will get worse, that in itself is enough to actually experience the pain as increased.

Cognitive aspects that make a difference are:

• The cause to which you attribute the pain.
• Views on the possibility of ignoring pain.
• Views on the possibility of controlling pain.
• Expectations about when the pain will pass, the placebo effect.

People who think that their pain is due to psychological factors are more likely to do physical exercise than people who think their pain is physically determined. This last group of people is afraid that moving will make the pain worse. Certainly if there is a big difference between the expected pain and the actual pain, people will move less.

The extent to which someone can tolerate pain depends, among other things, on their previous experiences with pain, their previous behavior towards pain, the extent to which family members can tolerate pain, locus of control and expectations about their own pain tolerance.

Expectation of pain relief: the placebo response

One of the most fascinating phenomena associated with pain is the placebo response. There seems to be an advantage to simply receiving what appears to be a treatment, whether this is a tablet, an injection or other treatment. This is called the placebo effect. A placebo has no pharmacological effects. People with chronic pain who think that they will receive an anesthetic or a cure for their pain, but in reality receive a placebo, report a pain reduction of 50 percent on average in two thirds of the cases. This is apparent from research with people who suffer from chronic lower back pain. Two important mechanisms of the placebo effect are probably a classical conditioning reaction, and our expectations of pain or the reduction of pain. There are some guidelines for the use of a placebo:

• The intentions of the doctor must be good and respect the well-being of the patient.
• The placebo must be given for someone's suffering.
• The placebo should not be given if it is ineffective.
• The placebo cannot be given instead of another drug that the doctor expects to be more effective.
• The doctor should not hesitate to be honest about the nature and effects of the placebo treatment.
• If the patient is helped by the placebo, this should not be stopped in the absence of more effective treatment.

Social influence on pain

The experience of pain can be changed by the presence of others. Whether the reported experience of pain is different in the presence of others depends on the condition. Men report less pain when there is an attractive woman than when there is a man. It is not certain whether or not this reports the real experience of pain.

What is the psycho-biological theory of pain?

The 'Gate Control theory' of pain

So far we know that two processes are involved in pain experience, namely the sensory information of the pain site and the associated emotional and cognitive processes. The gate control theory of pain (GCT) takes both aspects into account and is recognized as a very good pain theory.

The essence of the model is that we experience pain as a result of two processes:

1. Pain receptors in the skin and other organs provide information about physical damage to a number of gate points in the spinal column. Within the gates, nerves make contact with other nerves that transmit the pain to the brain.
2. The moment the pain stimuli arrive in our brains, we also experience emotions and cognitions - fear, alarm. This information results in the activation of nerve fibres taking information from the brain down the spinal column to the gate at which the incoming pain signals enter the spinal column. 

The amount of pain that someone experiences depends on the activity of both systems. Activation of the sensory nerves opens the gates that activate the nerves to the pain centers, so that the pain is recognized as pain. However, the downward pathways activated by emotional and cognitive factors can also influence the position of the gate. Anxious thoughts can open the gate and increase our experience of pain.

There are different types of nerves that transmit information about pain at different speeds. For example, there are the A delta fibers that provide the experience of sharp pain. The A delta fibers respond to light touches, mechanical stimuli and temperature. The experience is short-lived.

The C polymodal fibers work slower and provide information about dull, throbbing pain. This pain is experienced for a longer period of time than the pain caused by the A delta fibers.

The A beta fibers provide tactile information, especially that of friendly touches. The information goes to the brain, so our first reaction is that we want to rub the painful area. The rubbing activates the A beta fibers and because that friendly touch information is processed first, it quickly has a slightly soothing effect.

The A and C fibers transmit pain to areas of the spinal cord called substantia gelatinosa. The nerve impulses cause the so-called substance P to be released. This substance in turn causes nerve fibers such as the T (from transmitter) fibers to be released that transmit the pain sensation to the brain.

Information from the A fibers goes to the thalamus so that someone can take action to get away from the source of pain. Information from the C fibers goes to the limbic system, the hypothalamus and the autonomic nervous system. The limbic system enables the emotional meaning and reaction and the hypothalamus regulates the activity of the autonomic nervous system so that someone can respond quickly to the pain.

The results of this are led down the spinal cord, which causes a number of chemicals to be released into the substantia gelatinosa. The most important and well-known substance is endorphin, which closes the door so that less pain is experienced. Activity in this system is influenced by a number of factors that all have an effect on the release of endorphins:

• Focusing on pain: worrying (catastrophizing) reduces the amount of endorphins released and opens the door.
• Emotional and cognitive factors: feeling optimistic and carefree about the meaning of the pain increases the release of endorphins and closes the door (anxiety, worry, anger or depression open the door).
• Physical factors: relaxation increases the release of endorphins and reduces the experience of pain.

What is meant by the neuromatrix?

Although the gate control theory offers a nice outcome as a theory of pain, it unfortunately cannot explain an important type of pain: phantom limb pain. Melzack has therefore made a more complex theory of pain mechanisms that attempt to explain this mysterious phenomenon. His model has three assumptions:

1. The same neural processes involved in pain perception in the intact body are involved in pain perception in the phantom limb.
2. All the qualities we normally feel of our body, including the pain, can be felt in the absence of the body's inputs.
3. The body is seen as a unity and is identified as the self, separated from other people and the world around it.

Melzich suggested that the anatomical substrate of the 'body-self' is a large network of neurons connected to the thalamus, the cortex and the limbic system in the brain. He called this system the neuromatrix. A neurosignature is a network of information about the origin and emotional responses of a pain stimulus. Neuro Signatures have two components:

1. The body-self matrix: integrates incoming sensory and emotional information;
2. The action neuromatrix: develops behavioral responses as a response to these networks.

How can people be helped to cope with pain?

The first-line treatment for acute pain is usually a pharmacological treatment ranging from aspirin to an opiate such as pethidine. Psychological interventions usually only appear later, when the pain is prolonged, when medication does not help or when anxiety is involved. This is often called the second line of intervention.

Measuring pain

The most used and fastest way to determine the severity of pain is to have people fill in a visual scale. For example, a scale from 0 to 100 where 0 stands for no pain and 100 for the worst pain that anyone can imagine. A disadvantage is that people often find it difficult to represent pain in numerical terms.

Another way is to let people choose from a number of words that describe pain, such as mild, disturbing, unbearable and so on. With this method it is often the case that people are very much in the middle of the scale and are insensitive to subtle differences in the descriptions.

A disadvantage of such measurements is that it merely measures the pain experience. The McGill pain questionnaire was developed with the intention of solving this problem. Measuring is more difficult because the method is complex. But it does provide a multidimensional description of the nature of the pain. The McGill questionnaire measures:

• The type of pain: all types of pain (stinging, throbbing, cramping, etc.) occur and it must be indicated on a scale with four points whether this is not the case at all or very bad or something in between.
• The emotional response to the pain: for example, whether you get tired of it, or scared, or whether it feels like punishment.
• The intensity of the pain: ranging from 'no pain' to 'worst possible pain ever'.
• The timing of the pain: whether the pain is short-lived, long-lasting, or whether it is a recurring and receding pain.

Although this questionnaire covers many aspects, it does not ask anything about a person's behavioral response to pain, and the relationship between pain and movements. Behavioral responses to pain can be verbal (sighing, supporting and complaining), motor behavior (leaving the face, being out of balance, becoming slow, not being able to sit, lying or standing and seeking help), treatment behavior (taking medication), and functional limitations such as resting and some activities cannot do.

Treating acute pain

There are a number of things that people can do to reduce acute pain. Most approaches focus on: increasing a person's sense of control over the pain and medical intervention. If someone thinks he has no control over the pain or what happens to him, it can increase the pain. When someone is in the hospital, he / she may be afraid that the hospital staff is so busy that they forget to give an anesthetic. Or they are afraid that their pain will be so bad that the anesthetic is not strong enough. One way to solve these problems is through patient-controlled anesthesia (PCA; patient-controlled anesthesia). This is a method whereby the patient can administer small amounts of an anesthetic to himself. Research shows that patients who can give themselves anesthesia are indeed less anxious and also experience less pain. The method also results in using smaller amounts of anesthesia than when a specialist determines the amount. This method can also be applied to children.

Learning coping skills such as distraction techniques and relaxation exercises is also a method that is used. The effect of distraction is that people do not fall into catastrophic thoughts and that they do not sit down until the pain comes. For example, by listening to music with a specific assignment, the concentration is shifted. When people try to focus their thoughts elsewhere, this actually makes the bad thoughts worse. It is best to perform a task that is not related to pain or emotion.

Relaxation means that people learn to relax the muscles in their body, especially those around the painful area. Firstly, this is effective because the relaxation of the muscles around the pain causes the pain to be experienced less intensely. Secondly, relaxation ensures that people can think of nicer things. So it also helps in the search for distractions. Relaxation has also been shown to stimulate endorphin release.

Hypnosis can also be used as a coping technique. Hypnosis is said to change patients' sensations, perceptions, thoughts, and behaviors. Most forms of hypnosis are aimed at relaxation, calmness and well-being. Or the patient is asked to think of pleasant things.

Treating chronic pain

Transcutaneous electrical nerve stimulation (TENS)

A popular way to manage pain is through electrical stimulation of A beta fibers. This method also stimulates C fibers to release endorphins. The method is known as transcutaneous electrical nerve stimulation (TENS) and uses a small electrical device that is placed on the painful area of ​​the skin. This allows a small electrical of low intensity to pass through the skin. The device is usually used several times a day and more than 15 minutes at a time. The studies investigating the effectiveness of TENS show varying results. Most studies indicate that TENS gives no better result than a placebo. However, the studies are small in size, not well controlled and with poor methodologies. More research is needed to confirm the results of TENS.

Relaxation and biofeedback

Relaxation can be used to relax the entire body or specific body parts. This way you can focus specifically on relaxing the forehead muscles, which can reduce headaches. To be able to relax certain parts, you also need to know which parts you are tightening. Relaxing specific muscle groups is often difficult but can be achieved with biofeedback techniques. These techniques use equipment that measures certain values ​​of, for example, tension in the body. For example, the heart rate or blood pressure can be measured. Because the patient always receives feedback from the body, the patient knows exactly what his condition is, and he knows immediately if the relaxation is successful. This prevents someone from always trying things that don't work. And the feedback works as a kind of reward system. For example, you hear a lower tone when you relax, this also ensures that the right techniques are conditioned.

An alternative way is to use an antidepressant in combination with the biofeedback method. The biofeedback method works with three methods:

• Electromyographic biofeedback (EMG): this measures the small amount of electrical current in the muscles. The voltage matches the muscle tension: higher voltage = higher tension.
• Galvanic skin response (GSR): measures general tension in the body by measuring subtle changes in sweat of the hand. More sweat relates to greater muscle tension, but this relationship is not one to one.
• Thermal biofeedback: based on a theory that warming the skin can reduce headache pain.

The effects of virtual reality feedback were also measured, in which children learned relaxation exercises while wearing a virtual reality system and were able to see positive, pain-free images of themselves. Biofeedback helps patients to make changes while being guided by feedback from physiological changes they produce. A specific problem where biofeedback is used successfully is with chronic headache. With other pains it is often no more effective than relaxation itself. Because relaxation is easier and cheaper, this is the preferred treatment. An alternative strategy is to combine relaxation with antidepressants. Indeed, antidepressants appear to reduce pain. It seems to work, like cognitive behavioral techniques, in reducing headache. A combination of antidepressants and cognitive behavioral techniques is the most effective treatment.

Behavioral interventions

Behavioral interventions for chronic pain mainly consist of operant conditioning. This principle is based on the assumption that we cannot understand the pain of another, but that we can only observe pain behavior. Fordyce therefore suggested that interventions should focus on seeing people's pain behavior. The pain behavior of people is partly caused by the reactions to pain that they see in others. Pain reactions can be very subtle, a slight change in facial expression or posture can betray someone in pain.

To prevent people from exhibiting pain behavior, you must ensure that this behavior is no longer rewarded and that other behavior is rewarded. For example, you can think of rewarding an appropriate amount of exercise, distracting someone from paying attention to rewards or previous reactions to pain and providing narcotic medication at regular intervals instead of when someone feels pain. In this way the new, effective behavior is encouraged. This method is particularly effective when the physical cause of the pain is low, or when there is nothing to do about it. It is more difficult to ignore pain or to approach it differently when a medical intervention would resolve everything.

Cognitive behavioral interventions

Cognitive behavioral interventions focus on changing behavior, but can also influence other parts of pain experience. Active participation in activities can distract a person's attention from negative cognitive and emotional responses. The resumption of activities that someone stopped earlier because the pain made this difficult increased one's self-confidence and optimism. Cognitive behavioral interventions address these effects even more directly. This method does not contradict the Gate Theory, but focuses on a number of factors that influence the gate.

The goals of cognitive behavioral therapy are:

• To help the patient realize that their pain can be regulated. Patients are helped to solve their own problems related to the pain so that they do not feel helpless and hopeless when it comes to dealing with the pain.
• Helping the patient to establish the relationship between thoughts, emotions and behavior. This allows them to see that doom-thinking has the effect that the pain is experienced as worse.
• The patient receives tips and learns strategies that help regulate pain, emotional stress and psychological problems. They teach effective ways of thinking, feeling and behaving.

The cognitive behavioral interventions can be offered both in groups and one to one, which benefits the price-quality ratio. The cognitive change must be learned through a number of phases, as has been discussed many times in previous paragraphs. Once people understand how their thoughts affect their experiences and behavior, they can learn more adaptive ways of thinking. These thoughts can be focused on the fact that the patient can cope with this pain earlier, or that it makes no sense to grind about it or get angry about it. Someone can also learn to think about relaxation as soon as the pain comes up.

A more complex way of cognitive behavioral intervention is trying to find out which thoughts cause emotional discomfort. These thoughts should then be seen as hypotheses instead of facts, so that the patient can look for indications that these hypotheses are incorrect. For example, as soon as you get a pain in your stomach you can immediately assume that this will take hours, but you can also take a deep breath and think that it will soon pass, just like it was last week. The exercises are usually built up gradually, so that people can get used to the new behavior and they can consciously learn about the effects of the new behavior.

Other ways of intervention that are also widely used are positive talk to yourself ("I can handle it, the pain is not forever"), taking a long, hot shower, imagining that you will get a narcotic and playing relaxation exercises or self-hypnosis instructions.

Many studies show time and (again) that cognitive behavioral interventions are very effective. It often appears to be more effective than pharmacological or educational therapy and other methods. However, cognitive behavioral therapy does not appear to be more effective than other therapies in reducing negative or catastrophic thoughts. The most important element is that people become more active than they were before, which improves their beliefs about their ability to move, exercise, pain control and the state of mind.

Temporomandibular disorder pain consists of conditions that cause pain in the temporomandibular joint.

There are clinics nowadays that specialize in pain relief. A range of specialists such as anaesthesiologists, physiotherapists, psychologists, doctors etc. are present in these clinics. Usually a personal program is drawn up that is aimed at pain relief and how to deal with pain.

Mindfulness-based interventions

Mindfulness interventions are becoming increasingly used in mental health settings. Meditating mindfulness daily is effective in reducing pain. Mindfulness works even better than CBT in reducing catastrophic beliefs about the nature and implications of pain and fatigue. CBT is therefore often combined with mindfulness.

What is meant by the need for theory-driven practice?

Important variables that influence behavior are included in theories about health. These theories are always evolving and becoming more extensive. As a result, the theories are recent and form a basis for interventions. An example is quitting smoking. Many professionals think it is best to scare them so that they will change. But psychological theories offer alternative factors that may make more sense:

• The health belief model suggests that we should not only convince smokers that smoking leads to illness, but that we should also convince them that the benefits of giving up smoking are greater than the benefits of continuing to smoke.
• The theory of planned behavior further emphasizes the role of attitudes and beliefs in behavioral change. It also indicates the role of peers and other important people in the development of personal smoking cessation strategies. Planning behavioral change is emphasized.
• Social cognitive theory suggests that people must first believe that they can stop smoking before trying. This can be done by observing coping models.
• Theories of addiction suggest that people need to avoid addictive substances gradually, but just above the onset of withdrawal symptoms. 

It is known that an intervention must contain a number of elements through which the reactions of a patient at the start of a disease can be optimized:

• The patient's beliefs about the disease must be discovered. If these are not correct or meaningful, it must be considered whether they can be changed and whether the patient is attempting to do so.
• It is important that patients learn how to deal with their (serious) illness as effectively as possible. Teach patients, depending on the context, problem-focused coping or emotion-focused coping.

The above points provide a structure from which an intervention can be built. The intervention must be adapted to the individual and is subject to changes by environment and people.

How can a theory be put into practice?

In addition to the theories, psychologists and health professionals are extremely important in putting a theory into practice. Many healthcare workers do not have the freedom to determine when and which intervention they perform. They are bound by rules and guidelines that prescribe what the intention is. There must be good evidence that the interventions and theories are effective. The most important tasks of the health psychologist are:

• Promoting and maintaining health.
• Preventing and managing illness.
• The identification of psychological factors that contribute to physical diseases.
• Improve the healthcare system.
• Formulating health policy.

However, the guidelines for the duties of health psychologists differ per country. Questions to be answered by health psychologists are: how do people adapt to a chronic illness? Which factors influence healthy eating? How is stress associated with heart disease? Why do patients often not take their medication as prescribed? The Netherlands does not have a training program for health psychologists, just like various southern European countries.

According to Lazarus, the lack of cooperation and communication between researchers and clinicians is a familiar and painful subject for most psychologists. It is therefore difficult to reach professionals. Psychology can, however, influence healthcare by publishing in relevant journals. The factors that contribute to the fact that clinical guidelines are not being sufficiently followed include weakness in communicating evidence to doctors, conflicting sources of information and opinions for doctors, difficulty getting the right people together to work together for change, and resistance to change. Other factors are personal attitudes and beliefs about target behavior, personal characteristics of the professional, the content of information, the transfer of information, and organizational issues.