The relationship between physical and psychological health Russell Jones

1. The relationship between physical and psychological healthRussell Jones 15/03/2016

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3. THE LINK BETWEEN PHYSICAL & MENTAL HEALTH • People react to illness in different ways, most going through a dynamic process which changes over time. There may be initial worry about its cause, followed by the shock of diagnosis and a period of adjustment as coping strategies are formulated. • Families and carers may also enter a period of adjustment. • Most people given time and appropriate help can adjust to the most serious of conditions. 15/03/2016

4. DEVELOPING MENTAL HEALTH PROBLEMS AS A CONSEQUENCE OF A PHYSICAL CONDITION • Approximately one quarter of people may develop depression, anxiety, panic disorder by failing to adjust to their physical condition. • Depression is characterised by persistent and severe low mood, qualitatively different from ‘normal distress’ • Anxiety is characterised by severe agitation and apprehension which is qualitatively different from ‘normal worry’. • Both have major effects on function such as sleep, concentration, socialisation, work and normal daily activities. 15/03/2016

5. WHAT HAPPENS WHEN DEPRESSION & ANXIETY DEVELOP IN THE CONTEXT OF PHYSICAL ILLNESS? • Recovery from the physical condition is impeded • Pain can become more difficult to control • Confidence to participate in rehabilitation programmes is reduced • In extreme cases, the patient can come to believe they are a burden to family or staff and have suicidal thoughts. 15/03/2016

6. STRESS & PSYCHONEUROIMMUNOLOGY • The study of how the body’s immune system is affected by stress. • The immune system protects the body from disease-causing micro-organisms by means of specialised lymphocytes. • The system affects the individual’s susceptibility to infectious diseases, allergies, cancers, and autoimmune disorders [e.g rheumatoid arthritis, in which the immune system attacks normal tissue]. 15/03/2016

7. It is generally accepted that the mind as an organ, processes information and interacts with the body by producing chemical changes that initiate chain reactions, determining both our physical and mental health. • Nerve endings are found in the tissues of the immune system • CNS changes alter immune response and vice versa • An immune response alters hormone and neurotransmitter levels and vice versa • Irwin 2008. 15/03/2016

8. Some patients experience internal conflicts and struggle to express emotions such as anger, fear, frustration, sorrow. • They develop physical symptoms that are concomitants of the emotion but once the emotions are expressed directly, the somatising decreases. • Positive affect is thought to release endomorphins that have a tonic effect on organs which may contribute to health by diminishing autonomic and endocrine activity that otherwise may diminish immune function. • Harvard 35 year longitudinal study 1988 – students with more positive attitudes within personality tests experienced better health and longevity. 15/03/2016

9. EXAMPLES • Marucha 1998, dental wounds in students took 40% longer to heal if obtained days before a stressful exam, compared to wounds in the summer vacation. Slow healing wounds was associated with poorer immune system functioning. • Watson, 1999, breast cancer patients found that those more pessimistic about future events, were more likely to develop new tumours over a 5 year period. • Baum, 1999, metastatic breast cancer study. Weekly support groups versus standard care. Four years later, those not in the group had all died whilst one third of the intervention had survived. There was no difference in illness severity at outset • There is a strong link between neurotransmitters and the immune system. Negative emotional states such as anxiety or depression affect transmitter levels. 15/03/2016

10. Schleifer et al [1983] looked at the immune system of partners of women with breast cancer, and found significant suppression of lymphocyte function lasting 14 months after bereavement, and not due to pre-existing conditions. • Kiecolt [2002] observed that negative emotions were related to poorer response to vaccines, increased susceptibility to illness, and longer lasting infections. 15/03/2016

11. In patients assessed with abdominal pain, fewer than 50% have a specific diagnosis. Kroenke 1990. • Patients interpreting their gastroenteritis condition pessimistically and expressing anxiety were more prone to developing IBS. Spence 2007. • When diabetic patients are exposed to a stressor, they can experience a delay in glucose metabolism after eating. Wiesli 2005. • There is a relationship between depressive symptoms and enhanced inflammatory response which can be a potential pathway for cancer, stroke and diabetes. Fagundes 2013. • In later life, late onset depression is linked to dementia. Diniz 2013. 15/03/2016

12. WHY IS ILLNESS PERCEPTION SO IMPORTANT? Those who perceive their illness as more threatening are at higher risk of depression. Self care and management of chronic illness can also be affected by depression. Even a mild mental health problem in patients with physical illness can have major effects. For example a mild eating disorder in a diabetic patient may have serious long term consequences disproportionate to the nature of the severity of the eating disorder. 15/03/2016

13. HOW WELL DETECTED ARE MENTAL HEALTH PROBLEMS IN LONG TERM CONDITIONS Over half of all case of depression in the general hospital setting go unrecognised There is an overlap of symptoms, e.g. People with COPD may experience decreased appetite, tightness of chest and fatigue – symptoms also associated with anxiety and depression. Depressed people attending general practices usually present with non-psychological symptoms such as pain or poor sleeping. When a chronic physical disease is found to be present, there is the risk of overlooking the depression. 15/03/2016

14. Clinical barriers such as lack of time, lack of knowledge about depression can prevent detection of mental illness. Even if symptoms are discussed, staff might reasonably regard depression and anxiety as ‘normal’ reactions to being unwell. In turn, patients may be reluctant to seek help because of stigma or guilt. 15/03/2016

15. Communication….. • Effective communication is essential to ensure that patients’ problems and concerns are understood by those providing care, and that relevant information, advice and treatment are understood and acted upon by patients. • The most common challenges reported include imparting complex information, eliciting and dealing with psychosocial concerns, dealing with individuals who may lack capacity. 15/03/2016

16. Benefits of good communication • Studies have shown that no more than half of the information given to patients is recalled. • Patients may not have understood or recalled the advice given or they may have beliefs which conflict with the advice which were never elicited by the clinician. • A common problem is the use of jargon and technical terms. Verbal information should be backed up by written information, easy to follow. 15/03/2016

17. Essentials of communication • Developing trust through clinical competence and sincerity. • Expressing genuine interest in the patient • Eliciting patients’ beliefs & concerns • Acknowledging and responding to distress • Avoiding overly complex information • Using a collaborative, empowering approach • Respecting privacy & confidentiality 15/03/2016

18. Empowerment • Individual empowerment is about people having a sense of control over their lives through building people’s • confidence, boosting their self-esteem, developing their • coping mechanisms or enhancing their personal skills. • Having a sense of control is important as it has a direct • effect on mental and physical health. 15/03/2016

19. Empowerment strategy EXAMPLES • Dose Adjustment For Normal Eating [DAFNE] is a way of managing Type 1 diabetes and provides people with the skills necessary to estimate the carbohydrate in each meal and to inject the right dose of insulin. • DAFNE Mission Statement • Our vision is to improve outcomes for people with Type 1 diabetes through high quality structured education which is embedded in the Health Service. • The DAFNE Programme is a working collaborative of 75 diabetes services from NHS Trusts and Health Boards across the UK and Southern Ireland.  15/03/2016

20. QUESTIONS TO ELICIT SYMPTOMS OF DEPRESSION Have your symptoms got you down at all? Do you ever get the feeling that you can’t be bothered to do things? Are there things you look forward to, or does your illness stop you? Has this illness affected your confidence? Do things ever get so bad you can’t see a future? 15/03/2016

21. COMMON SCREENING TOOLS Patient Health Questionnaire Hospital Anxiety and Depression Scale 15/03/2016

22. MEDICALLY UNEXPLAINED SYMPTOMS Physical symptoms unexplained by organic process are extremely common. An estimated 20% of new illnesses in primary care, and as many as 40% of all new medical outpatient referrals are accounted for by patients with MUS. The more bodily complaints a person reports, the more likely they are to report psychological distress. 15/03/2016

23. HELPING DURING INITIAL CONSULTATION Patients tend to feel empowered if: They feel understood and respected, not dismissed. They receive an explanation of their symptoms Their psychological issues are acknowledged 15/03/2016

24. Patient:are you telling me it’s all in my mind? • Nurse: no, not at all. What I think is that your body is maybe telling you that you are under a lot of stress and really hurting….I’m asked to see lots of patients in this hospital and I’m yet to find an illness which isn’t worse with stress and worry. • Making the psychosocial history part of the initial inquiry is necessary to avoid possible hostility in a patient by showing a sudden interest in psychological factors, after physical investigations reveal unremarkable results. 15/03/2016

25. Those with MUS show an abnormal amplifying perceptual style, restrictive assumptions about health and body functions, and a tendency to over-interpret physical sensations as possible signs of organic disease. Some show a memory bias for illness-related stimuli In other words patients with MUS have a tendency to worry and focus upon symptoms which may not be helpful and result in an increase in the severity of symptoms. 15/03/2016

26. The emotional impact of being admitted to hospital Admission is stressful ! The environment is alien and people have to share toilet and bedroom facilities. Identity is affected as outdoor clothes and belongings are removed. Access to relatives and loved ones is restricted and people may have to interact with many different professionals. Those who smoke, drink, eat certain foods will find restrictions imposed. Older people may become easily confused by a new environment and moving to another ward can cause further disorientation. Not all wards have interview rooms for personal conversations…the curtains around the bed can diminish intimacy In the last decade, the average length of stay in acute hospital has fallen from 14 to 6 days! 15/03/2016

27. The physical health of people with mental illness • Major depression doubles the lifetime risk of developing type 2 diabetes • Depression is a risk factor for developing heart disease • People with schizophrenia are 3 to 4 times more likely to develop bowel cancer • People with schizophrenia have a 52% increase risk of developing breast cancer • Long term use of antipsychotic drugs increases the risk of developing metabolic syndrome which is characterised by weight gain, high blood pressure and glucose intolerance which can lead to diabetes. • Sudden death in schizophrenia increases incrementally with each additional psychotropic medication taken. 15/03/2016