Psychology and Health

2014 Syllabus

Structure of syllabus

• 6 modules

• Organised as such:o Introduction of the module

o development with specific topics to illustrate the issues in the module: examples, studies

o Conclusion: finding ways to improve the situation & address the issues raised

Module 1:

The patient-practitioner

relationship• Practitioner and patient interpersonal skills

o Non-verbal communications (e.g. McKinstry and Wang); verbal communications (e.g. McKinlay, 1975; Ley, 1988).

• Patient and practitioner diagnosis and styleo Practitioner style: doctor and patient-centred (Byrne and Long,

1976; Savage and Armstrong, 1990). Practitioner diagnosis: type I and type II errors. Disclosure of information (e.g. Robinson and West, 1992).

• Misusing health serviceso Delay in seeking treatment (e.g. Safer, 1979). Misuse:

hypochondriasis (e.g. Barlow and Durand, 1995), Munchausen syndrome (e.g. Aleem and Ajarim, 1995).

Module 2:

Adherence to medical advice• Types of non-adherence and reasons why

patients don’t adhereo Types and extent of non-adherence. Rational non-adherence (e.g.

Bulpitt, 1988); customising treatment (e.g. Johnson and Bytheway, 2000).

• Measuring adherence/non-adherenceo Subjective: self reports (e.g. Riekart and Droter, 1999). Objective:

pill counting (e.g. Chung and Naya, 2000); biochemical tests (e.g. Roth, 1987); repeat prescriptions (e.g. Sherman, 2000)

• Improving adherenceo Improve practitioner style (e.g. Ley, 1988), provide information

(e.g. Lewin, 1992), behavioural techniques (e.g. Burke et al., 1997).

Module 3: Pain• types and theories of pain

o Definitions of pain. Acute and chronic organic pain; psychogenic pain (e.g. phantom limb pain). Theories of pain: specificity theory, gate control theory (Melzack, 1965)

• Measuring paino Self report measures (e.g. clinical interview); psychometric measures

and visual rating scales (e.g. MPQ, visual analogue scale), behavioural/observational (e.g. UAB). Pain measures for children (e.g. paediatric pain questionnaire, Varni and Thompson, 1976)

• managing and controlling paino Medical techniques (e.g. surgical; chemical). Psychological

techniques: cognitive strategies (e.g. attention diversion, non-pain imagery and cognitive redefinition); alternative techniques (e.g. acupuncture, stimulation therapy/TENS)

Module 4: Stress• causes/sources of stress• Physiology of stress and effects on health. The GAS Model (Selye).

Causes of stress: lack of control (e.g. Geer and Maisel, 1972), work (e.g. Johansson, 1978), life events (Holmes and Rahe, 1967), personality (e.g. Friedman and Rosenman, 1974), daily hassles (e.g. Lazarus, 1981)

• Measures of stress• Physiological measures: recording devices and sample tests (e.g. Geer

and Maisel, 1972; Johansson, 1978); self report questionnaires (Holmes and Rahe 1967, Friedman and Rosenman, 1974, Lazarus, 1981)

• Management of stresso Medical techniques (e.g. chemical). Psychological techniques:

biofeedback (e.g. Budzynski et al., 1973) and imagery (e.g. Bridge, 1988). Preventing stress (e.g. Meichenbaum, 1985)

Module 5: Health promotion

• Methods for promoting healtho Fear arousal (e.g. Janis and Feshbach, 1953; Leventhal et al.,

1967). Yale model of communication. Providing information (e.g. Lewin, 1992).

• Health promotion in schools, worksites and communities

• Schools (e.g. Walter, 1985; Tapper et al., 2003). Worksites (e.g. Gomel, 1983). Communities (e.g. three community study, Farquhar et al., 1977).)

• Promoting health of a specific problem• Any problem can be chosen (e.g. cycle helmet safety: Dannenberg,

1993; self-examination for breast/testicular cancer; obesity and diet: Tapper et al., 2003; smoking: McVey and Stapleton, 2000)

Module 6: Health and safety• Definitions, causes and examples

o Definitions of accidents; causes: theory A and theory B (Reason, 2000); examples of individual and system errors (e.g. Three Mile Island, 1979; Chernobyl, 1986)

• Accident proneness and personality• Accident prone personality; personality factors e.g. age,

personality type Human error (e.g. Riggio, 1990); illusion of invulnerability (e.g. The Titanic); cognitive overload (e.g. Barber, 1988)

• reducing accidents and promoting safety behaviourso Reducing accidents at work: token economy (e.g. Fox et al.,

1987); reorganising shift work; safety promotion campaigns (e.g. Cowpe, 1989).

Sample exam questions

• http://www.examtestprep.com/CIE/A-AS-Level/Psychology-9698/

Helpful website• http://

homepage.ntlworld.com/gary.sturt/health/Health%20Psychology.htm

Doctor Patient relationship

Doctor-Patient Relationship

• Is it really important? You are there for treatment not to make friends & invite the doctor / nurse over for your birthday BBQ.

• YES – can affect health-seeking behaviour, compliance & be a matter of life and death

• Bad experiences linked to doctors being in a hurry, no eye contact, not listening to the patient, irritation when patients ask questions, seek information, refusing to involve patient in the treatment

• Different cultural background can be a problem

Communication skills

Patients perception of inadequacies of communication arise from:

• Content skills – what doctors say, e.g., the substance of the questions asked, the answers received, the information given, the differential diagnosis list, and the doctors medical knowledge base

• Process skills – how doctors say it, e.g., how the doctor asks questions, how well he listens, how he sets up explanation and planning with the patient, how he structures his interaction and makes that structure visible to the patient through signposting or transitions & how he build relationships with patients

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Non-Verbal Communication

• Birdwhistell (1970) estimated that only 30 to 35% of the social meaning of a conversation is carried by words alone.

• Non-verbal communication includes features of speech such as:o tone of voice, o inflection, o rates of speaking, o duration and pauses.

• Other forms of non-verbal communication are conveyed by gestures, dress, physical proximity, facial expressions, posture and orientation.

Argyle (1975) four major uses

To assist speech, for example in synchronising conversation or supplementing speech by putting stress on certain words, or pausing between words or varying the tone and speed of speech

As a replacement for speech

To signal attitudes, e.g. trying to look cool

To signal emotional states, i.e. we can tell how a person is really feeling by looking at their facial expression or posture.

• McKinstry and Wang (1991)o Non-Verbal Communication

• Specifically: Appearance and first impressions

• Study consisted of showing pictures of doctors to patients attending surgeries

• Same male and female doctor• Dressed formally (white coat over suit

or skirt)• Dressed informally (jeans, open-necked,

short-sleeved shirt, or pink trousers, jumper & gold earrings)

• Task: rate how happy they would be to see the doctor in the picture or how much confidence they would have in the doctor’s ability

Results• Acceptability higher for:

o Male doctor wearing white coat, suito Female doctor wearing white coat and skirt

• Acceptability lower for:o Male doctor wearing jeans (59%), wearing an earring (55%) & having long hair

(46%)o Female doctor wearing jeans (63%) & jewellery (60%)

• Expectations are that doctors should wear:o White coat – 15%o Suit – 44%o Tie – 67%

• Conclusion???: traditionally dressed images received higher preference ratings than the casually dressed ones, esp. for older & professional-class patients

Evaluation• Can you think of any??

• Positive:o Showed importance of appearance & first impressions in developing

confidence in doctorso Consistency / reliability – same male, same female used

• Negativeo Reductionist / simplistic – NVC more complicated / complex than

dress alone – other factors eye contact, facial expressions (Argyle (1975)

o Lacks ecological validity – use of pictures & not real personso Sampling issues – done in Western Europe (UK); will it have same

results in Africa? / other countries?

Touch• Jourard (1966) considered where it is acceptable

to be touched and by whom.

• Doctors need to be careful not to alarm the patient by touching them in a 'no go' area without their permission.

Cultural differences• Jourard (1966) also found cultural differences in

the amount of touching. Observing people in cafes around the world he counted the number of times people touched each other during the course of one hour. His results were:

TouchPlace Number of touches

San Juan (Puerto Rico) 180

Paris 110

London 0

Verbal Communication

Verbal Communication• McKinlay, 1975 – assessment of lower-class

women understanding of 13 technical terms in a maternity ward

• Words used• Antibiotic Mucus Breech• Protein Enamel Purgative• Glucose Suture Membrane• Umbilicus

• Do you know what these words mean?

Results• On average, each of the term was understood by

less than 40% of the women• Health workers themselves expected even lower

levels of understanding by the women (even lower than 40%)

• But they used these terms with their patients!!• WHY???• Medical language makes health workers look

more knowledgeable, more important & keep conversations brief because the women are afraid to ask questions without looking stupid (Banyard, 2004, p. 131)

Evaluation • Ecologically valid – use of real terms in real

settings with patients and health workers

• Unethical – disrupting health service for a survey

• Useful – will help improve communication between health workers & patients

• Not generalisable – used only women, not their partners / husbands / boyfriend, only setting of the maternity ward, not any other setting

Ley, 1988• Study:

o What do people remember of real consultations?

• Method:• Talked to people after they had visited the doctor &

asked them what they recalled about medical information given to them by their doctor. Asked to repeat what the doctor had told them to do.

• This was compared with what was actually said to them.

Results• People remembered 55% of what they were told

• In detail:• Good recall of first thing told (Primacy Effect)• Recall did not improve with repetition (no matter how

often doctor told them the info.)• Remembered information which had been categorised• Remembered more if they had some medical knowledge

• Patient recall is increased by categorisation, signposting, summarising, repetition, clarity and use of diagrams

Evaluation • Useful for practice - led to development of a

manual for doctors to use to communicate with patients / led to 70% increase in recall

• Ecologically valid - used real patients who have been to see real doctors for real illness

• Sampling / site of study - study done in a particular country

Diagnosis and Style

Byrne and Long 1976

• Physicians can be doctor-centred or patient-centred.• Study:• 2,500 tape recorded medical consultations in several

countries including England, Ireland, Australia and Holland.

• Most styles were doctor-centred. Physicians asked questions that required only brief replies (e.g. yes no, etc.). Focus on first symptom or problem that was reported by the patient. Often ignored attempts by patient to mention other symptoms.

• Patient-centred approach - doctors ask open-ended questions, requiring the patient to give lengthy replies. Medical jargon was avoided. They allowed patients to participate in the decision making process.

(Byrne & Long, 1976)• Doctor-centred style – impersonal, intent on

establishing link between symptoms and organic disordero Ask closed yes-no questions, focus mainly on first

problem, tend to ignore attempts to discuss other problems

• Patient-centered – personal style, less controlling role o Open questions to allow patient to share more information and

introduce new facts, tended to avoid jargon, share decision making

Evaluation• All western countries, so does not generalise to

non-western countries.

• Ethical considerations – confidentiality.

Savage and Armstrong (1990)

• Savage and Armstrong (1990) found that patients were more satisfied with a ‘directed consultation’ rather than a ‘sharing consultation’.

Savage and Armstrong (1990)

• Directed consultation – statements made such as “you are suffering from…”, “it is essential that you take this medication”, “you should be better in …. days”, “come and see me in …. days”.

• Sharing consultation – “what do you think that is wrong?”, “Would you like a prescription?”, “Are there any other problems?”, “When would you like to come and see me again?”

Savage and Armstrong (1990)

• 359 randomly selected patients – free to choose their doctor. 200 results used.

• 2 questionnaires – one immediately and one a week later.

• Results – overall a high level of satisfaction, but higher for directed group. Higher for ‘satisfaction with explanation of doctor’ and with ‘own understanding of the problem’. More likely to report that they had been ‘greatly helped’.

Evaluation

• Random selection – ensures objectivity, less bias

• Ecological validity – real patients, real situations

Errors in diagnosis• Type I error (false positive) – declaring an illness

when one does not exist

• Type II error (false negative) – declaring that a person is well when he is ill

• Screening involves relatively cheap tests that are given to large populations, none of whom manifest any clinical indication of disease (e.g., Pap smears).

• Testing involves far more expensive, often invasive, procedures that are given only to those who manifest some clinical indication of disease, and are most often applied to confirm a suspected diagnosis.

Robinson and West (1992)

• Computer Doctors • To get over the problem of embarrassment a

computer could be used.• Patients at a genito-urinary clinic (specialises in

venereal disease) gave more information to a computer than they subsequently gave to the doctor.

• Patients are less worried about social judgements and embarrassing details with a computer. They admitted having more sexual partners, having attended before, and revealed more symptoms.

Evaluation • VALIDITY – study is valid as it measures exactly

what it sets out to measure: how much information patients are prepared to give to doctors

• USEFULNESS – study is useful for medical practitioners.

• Can you guess what measures a hospital or clinic should put in place based on the results of the study?

• Use computers or electronic means for patients to give details of their conditions

Using and Misusing Medical Services

Some background…• Who uses health services?

• Age: children and the elderly have more contacts per year than adolescents and young adults

• Gender: women have more contacts than men. Difference starts in adolescence & remains even when contacts for pregnancy & childbirths not counted

• Sexual orientation: many homosexual men & women avoid contacts with health services through fears of discrimination & lack of confidentiality

Why the gender differences???

• Women sicker / physically weaker than men?

• Women use more prescription drugs than men• Women have higher rates of acute illnesses

(respiratory infections) & nonfatal chronic illnesses (arthritis & migraine headaches)

• Women more likely to report health problems than men?

• Women in some cultures such as North America and even Seychelles taught to be tough, macho and to ignore pain.

Delay in seeking treatment

• Three phases

• 1. appraisal delay - the time it takes for a person to interpret their symptoms as a sign of illnesso Am I sick No Delay (YES Enters Treatment)

• 2. illness delay - the time it takes between realising that you are ill and deciding to seek medical adviceo Do I need professional care? No - Delay

(YES Enters Treatment)

• 3. utilisation delay - the time it takes between deciding to go, and turning up at the surgery. Different people will delay at different points in this process, and different symptoms and conditions will also bring about different patterns of response.o Is the care worth the financial, human, emotional &

social costs? No - Delay (YES Enters Treatment)

Safer, 1979• Delay in seeking treatment • To discover which psychological factors affect delay at

each of the 3 delay stages

• Waiting rooms of 4 clinics in a large inner city USA hospital. 93 patients of mixed age, gender and ethnicity.

• Interviewers approached patients who were there to report a new symptom or complaint and 45mins worth of questions.

• P’s were asked about when they first noticed the symptom, when they decided they were ill and when they decided to seek medical help. They were also asked a series of other questions looking at factors that may have contributed to their choices.

Results• Mean total delay was 14 days.

• Key factors were:• Presence of severe pain + whether patients had read

about the symptoms and bleeding correlated with appraisal delay.

• Whether the symptom was new, imagined consequences and gender affected illness delay.

• Cost of treatment, pain of symptoms and perceived curing of the problem affected utilisation delay

Evaluation• ETHICS – asking people personal questions about

their illnesses / confidentiality issues / consent

• METHODOLOGY – consistent method = reliable / used self reports = unreliable, subjective

• SAMPLING – mixed sample (age, race, gender) but also small / may not be generalisable to other populations

• USEFULNESS – helpful to find factors to help people seek treatment

Somatoform Disorders

• Soma – Meaning Bodyo Preoccupation with health and/or body appearance and functioning

o No identifiable medical condition causing the physical complaints

• Types of DSM-IV Somatoform Disorderso Hypochondriasis

o Somatization disorder

o Conversion disorder

o Pain disorder

o Body dysmorphic disorder

Hypochondriasis • Clinical Description

– Physical complaints without a clear cause

– Severe anxiety focused on the possibility of having a serious disease

– Strong disease conviction

– Medical reassurance does not seem to help

• Statistics

– Good prevalence data are lacking

– Onset at any age, and runs a chronic course

– Affect both men & women equally

– Sometimes, misdiagnosis when health worker cannot find any explanation for the illness behaviour and comes to the conclusion that it is 'all in the patient's head'.

Barlow and Durand, 1995

• Misuse: hypochondriasis • Preoccupation with physical symptoms. Key feature = combines

the fear with conviction that one has an organic disease (Mai, 2004).

• Fear of aging and death. Greater importance on physical health, but do not have better health habits than someone who does not have a disorder.

• “Doctor shopping", as well as deterioration with doctor relationships with frustration and anger towards each other are common. Deterioration due to medical examination proving that nothing is wrong & patient continues to believe s/he is sick, not getting proper care, & resist referral to mental health professionals. Social relationships become strained.

• One interprets physical symptoms & feelings as signs of a serious medical illness in spite of medical assurance that they are not.

• May be especially concerned about a particular organ system (such as the cardiac or digestive system).

• Usually present their medical record in great detail.

Causes• No exact cause

• Possibilities:• Serious illnesses, particularly in childhood, & past experience

with disease in a family member

• Psychosocial stressors, in particular the death of someone close to the individual,

• People highly sensitive to physical pain. They pay attention more closely to changes in their body, freak out when something had changed & often make a bigger deal out of it than it really is

• Misinterpret symptoms. People with Hypochondriasis think they are ill or something is wrong with them, until they have proof that there is not.

Munchausen Syndrome

Nurse Beverley Allitt• In the UK, between February and April of 1991, there

were 26 unforeseen failures of medical treatment and unaccountable injuries on Ward 4 of Grantham and Kesteven General Hospital.

• In total four children died and nine were injured.

• Investigations found that nurse Beverley Allitt had altered critical settings on life support equipment & administered lethal doses of potassium & insulin to children in her care (The Allitt Inquiry, 1991). She was diagnosed as suffering from Munchausen syndrome by proxy and was sentenced to thirteen concurrent life sentences.

Aleem and Ajarim, 1995

• 22-year-old single female (university student) referred to hospital as a possible case of immune deficiency

• Problems started at 17yrs with amenorrhea - had only 2 cycles & then failed to menstruate

• Numerous medical problems over the years (thrombosis, swellings in groin area, multiple scars over abdominal wall tender, hot area (4 x 5 cm) over right breast).

• Other examinations normal, but bacterial cultures found in samples taken. When treated, left breast developed lesions - suspicion raised.

• Offered psychiatric help• Seemed to have shallow affect, but seemed stressed• One day when she was absent, syringe with faecal matter

found in her bed• When confronted, was angry, left hospital & never came

back

Aleem and Ajarim, 1995

• Diagnostic features of Munchausen syndrome.• Pathologic lying (pseudologia fantastica)• Peregrination (traveling or wandering)• Recurrent, feigned or simulated illness

• Supporting features• Borderline and/or antisocial personality traits• Deprivation in childhood• Equanimity (a state of psychological stability & composure

which is undisturbed by experience of or exposure to emotions, pain)for diagnostic procedures & treatments or operations

• Evidence of self-induced physical signs• Knowledge of or experience in a medical field• Most likely to be male• Multiple hospitalizations• Multiple scars (usually abdominal)• Police record• Unusual or dramatic presentation

• Information is very limited on prevalence of Munchausen syndrome

• Thought to be a rare disorder

• May have been over-reported because patients often change their names & identities & present to different physicians at different hospitals

• Most case reports come from North America & Western Europe - so seems more common in highly educated societies

• Only 1 case in Saudi Arabia but possibility of more cases

Evaluation • Case study of 1 person / patient = not

generalisable to other people / population

• Cross-cultural study – shows that condition also exists in Saudi Arabia & not just Western European cultures

• Ethical issues – nurses searched the bed, was informed by another patient, lost to follow-up