CHAPTER 14Psychoneuro-immunology, AIDS, Cancer, and Arthriti

CHAPTER 14
Psychoneuro-immunology, AIDS, Cancer, and Arthritis
Slides prepared by Krista K. Trobst, Ph.D.
York University
© 2020 McGraw-Hill Education Limited
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Learning Objectives
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Explain psychoneuroimmunology.
Understand AIDS and its consequences.
Describe cancer and the psychosocial factors involved.
Define and understand arthritis.
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Chapter 14 Flowchart
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What is Psychoneuroimmunology?: Part I
Interactions among behavioural neuroendocrine, and
immunological process of adaptation
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Learning Activity 15 A – Vocabulary Parking-Lot
Psychoneuroimmunology.
Immunocompetence
AIDS and its consequences.
Cancer and the psychosocial factors involved
Arthritis.
Autoimmune Disorders
What is Psychoneuroimmunology?: Part II
Assessing Immunocompetence:
Indicators of immune functioning:
cells and antibodies
A state of Immunocompetence - immune system is working
effectively
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What is Psychoneuroimmunology?: Part III
The immune system:
the surveillance system of the body

profile of the immune system:
natural:
defence against a variety of pathogens
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What is Psychoneuroimmunology?: Part IV
The immune system:
Profile of the immune system (cont…):
specific:
lymphocytes have receptor sites on their cell surfaces that fit
with only one antigen and respond to only one kind of invader
humoral and cell-mediated immunity
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What is Psychoneuroimmunology?: Part V
Stress and immune functioning:
commonplace stressors can adversely affect the immune system
Stress and immunity in humans:
more than 300 studies examining the relationship
different stressors create different demands on the body and
immune system
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What is Psychoneuroimmunology?: Part VI
Interventions to enhance immune functioning:
Relaxation:

mutes effects of stress on the immune system
research shows higher NK cell activity after relaxation
intervention
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What is Psychoneuroimmunology?: Part VII
Stress and the developing immune system:
may be vulnerable to stress, depression and grief
these experiences may permanently affect the immune system in
ways that persist into adulthood
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Psychoneuroimmunology
DRUGS.
PSYCHOLOGY
GENETICS.
GUT MICROBIOME
STRESS
PERIPHERAL NERVOUS SYSTEM
PsychoNeuro-
immunology

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Endocrine
System
NUTRITION
Environmental Exposures
SOCIAL SUPPORT
Figure of Factors that Influence Psychoneuroimmunology
SLEEP.
What is Psychoneuroimmunology?: Part VIII
Health Risks:
Psychological stressors leads to health risks
Both children and adults are affected by stress
Vulnerable to infectious disease such as colds, flues, herpes
virus infections such as, cold sores, genital lesions, chicken
pox, mononucleosis
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What is Psychoneuroimmunology?: Part IX
Autoimmune Disorders
Immune system attacks body
Grave’s disease, chronic active hepatitis, inflammation of the
liver, lupus, inflammation of connective tissue, M.S. destruction
of myelin sheath, rheumatoid arthritis, IBD, such as Cohen's or
ulcerative colitis and Type 1 diabetes
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What is Psychoneuroimmunology?: Part X
Health Psychology in Action: Academic Stress and Immune
Functioning
School-related stress
Elevation in cortisol before exams
Hormone variable in women
Genetics and autoimmunity
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What is Psychoneuroimmunology?: Part XI
Health Risks
immune modulation produced by psychological stressors leads
to actual effects on health
Negative affect and immune functioning:
depression is a culprit in the stress-immune relationship

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What is Psychoneuroimmunology?: Part XII
Stress, immune functioning and interpersonal relationships:
marital disruption and conflict
care giving
loneliness
protective effects of social support
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What is Psychoneuroimmunology?: Part XIII
Coping and coping resources:
Optimism:
active coping strategies are protective against stress
Personal control/benefit finding:
finding benefits in stressful events may improve immune
functioning
other coping styles (like exercise) may be related to the stress -
immune functioning relationship
Stress management
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What is AIDS?: Part I
History of HIV Infection and AIDS:
Acquired Immune Deficiency Syndrome (AIDS)
first appearance is unknown
began in Central Africa, 1970s

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What is AIDS?: Part II
History of HIV Infection and AIDS:
In Africa, spread rapidly through heterosexual population:
high rate of extra-marital sex
low rate of condom use
high rate of gonorrhea
medical clinics reused needles to promote vaccinations
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What is AIDS?: Part III
AIDS and HIV infection in Canada:
first diagnosed case: 1982
by 2000, 16,000 people in Canada had AIDS
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What is AIDS?: Part IV
Viral agent is a retrovirus:
human immunodeficiency virus (HIV)
attacks immune system, especially the helper T-cells and
macrophages
transmitted by exchange of cell-containing bodily fluids, such

as semen and blood
highly variable time between contracting virus and developing
AIDS symptoms
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What is AIDS?: Part V
HIV is transmitted by:
drug users:
needle sharing exchanges fluids
homosexual men:
anal-receptive sex (exchange of semen)
heterosexual population:
vaginal intercourse, women more at risk than men
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HIV??AIDS Exposure categories
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What is AIDS?: Part VI
How HIV infection progresses:
mild early symptoms:
swollen glands, flu-like symptoms

3 to 6 weeks:
infection abates, asymptomatic period (can be many years)
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What is AIDS?: Part VII
How HIV infection progresses (cont…):
amount of virus gradually rises
immune system increasingly compromised
opportunistic infections, such as Kaposi’s sarcoma, occur
common symptom for women: gynecologic infection
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What is AIDS?: Part VIII
Antiretroviral therapy:
highly active antiretroviral therapy (HAART)
treatments are complex, adherence variable
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What is AIDS?: Part IX
Who is at risk for getting AIDS?

AIDS growing fastest among Indigenous peoples and other
minorities
adolescents and young adults (multiple partners)
child and adolescent runaways
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What is AIDS?: Part X
Psychosocial Impact of HIV infection:
depression and thoughts of suicide
stigma associated with AIDS
people react negatively toward people with AIDS
initial response produces positive changes in health
interventions that reduce depression are valuable
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What is AIDS?: Part XI
Disclosure:
major barrier to controlling spread of HIV:
- not disclosing HIV status
those who don’t disclose:
- less likely to use condoms
benefits of disclosure:
- positive health consequences

- more CD4 cells than non-disclosers
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What is AIDS?: Part XII
Women and HIV:
lives are often chaotic and unstable
getting food and shelter for families often more salient than
HIV status
depression likely
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What is AIDS?: Part XIII
Employment and HIV
Factors that effect women who are seropositive
They are often older and struggle to adjust to the disease
Higher education, those with better self-rated health and have
AIDS for a short period of time remain employed
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What is AIDS?: Part XIV
Interventions to reduce the spread of AIDS:
Education:
provide knowledge to target populations
Health beliefs and AIDS risk-related behaviour:

perceptions of self-efficacy are critical
Targeting sexual activity:
interventions have focused on communication
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This provides the opportunity to review the Health Belief Model
introduced in Chapter 3.
Health belief model A theory of health behaviours; the model
predicts that whether a person practices a particular health habit
can be understood by knowing the degree to which the person
perceives a personal health threat and the perception that a
particular health practice will be effective in reducing that
threat.
What is AIDS?: Part XV
Interventions to reduce the spread of AIDS (cont...):
cognitive-behavioural interventions:
- stress management techniques
- reducing sexual activity
- improving ability to negotiate condom use with partners
targeting IV drug use
HIV prevention programs
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What is AIDS?: Part XVI
Coping with HIV+ status and AIDS:
- AIDS is now a chronic disease
- employment:
- men with HIV usually continue working
- unemployed may not return to work
Coping skills:
- coping effectiveness training is successful
- social support
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Spotlight on Canadian Research
HIV Canadian women-heterosexuals contact
Sex education and condom use
HIV prevent programs
Behavioural intervention indicate adolescents, bisexual men,
inner-city women, college students, and mentally ill adults are
at risk for AIDS
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What is AIDS?: Part XVII
Psychosocial factors that affect the course of AIDS:
negative beliefs about self:
- correlated with decline in helper T cells
psychological inhibition accounts for differences in physical
health
depression and bereavement of a partner can have adverse
effects on the immune systems of HIV+ men

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What is AIDS?: Part XVIII
Psychosocial Factors that Affect the Course of AIDS (cont...)
Stress increases illness rate of immune decline
Traits such as hope, self-compassion and optimism help aid
adjustment
Self compassion correlated with lower stress, anxiety, and
shame, and greater likelihood of disclosing HIV to others
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What is Cancer?: Part I
What is Cancer?
Dysfunction of DNA-part of the cellular programming that
controls cell growth and reproduction
Cancer is the leading cause of death
1998-2007, incidences of certain cancers-(thyroid and liver)
increased risk of death in Canada
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Figure 14.5
What is Cancer?: Part II
Why is cancer hard to study?
many cancers are species-specific; some species are more
vulnerable to cancer
mice contract many cancers
monkeys get few
develop in different ways in different species
many cancers have long/irregular growth cycles
high within-species variability
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What is Cancer?: Part III
Who gets cancer?
many cancers have a genetic basis
some cancers are ethnically linked
some cancers are culturally linked through lifestyle
risk for developing some cancers changes with SES
single people have more cancers than married people
cancers more common in chronically malnourished
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What is Cancer?: Part IV
Psychosocial factors and cancer:

positive association between depression and cancer
relationship between cancer development and use of denial or
repressive coping
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What is Cancer?: Part V
Mechanisms linking stress, coping and cancer:
Psychological stress:
adversely affects ability of NK cells to destroy tumours
NK cell activity is important in survival rates for certain
cancers, such as breast cancer
alterations in biological stress regulatory pathways may affect
course of cancer
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What is Cancer?: Part VI
Adjusting to cancer:
Coping with physical limitations:
pain and discomfort
down-regulation of immune system
fatigue
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What is Cancer?: Part VII
Adjusting to cancer:
Treatment-related problems:
cosmetic problems
surgical removal of organs
body image concerns
use of prosthesis
conditioned nausea and vomiting
conditioned immune suppression
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What is Cancer?: Part VIII
Psychosocial issues and cancer:
intermittent and long-term depression
Issues involving social support:
social support can be problematic
may improve immunologic responses to cancer
married patients have better survival rates
young children may show fear/distress
older children have new responsibilities
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Figure 14.6 The impact of psychosocial stress and stress
management on immune responses in people with cancer
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What is Cancer?: Part IX
Life partner and sexual relationships:
strong life partner relationship is important
sexual functioning is particularly vulnerable
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What is Cancer?: Part X
Psychological adjustment and treatment:
post traumatic stress disorder in survivors of childhood
leukemia
level of psychological distress important for maintaining quality
of life
Self-presentation of cancer patients:
vocational disruption and job discrimination
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What is Cancer?: Part XI
Coping with cancer:
- patterns of coping:
- seeking or using social support
- focusing on the positive
- distancing
- cognitive escaping-avoiding
- behavioural escaping-avoiding
Finding meaning in cancer:
- growth in personal relationships
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What is Cancer?: Part XII
Interventions:
cognitive-behavioural approaches
mindfulness-based stress reduction
exercise
writing
psychotherapeutic interventions
individual therapy
family therapy
group interventions
support groups
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What is Arthritis?: Part I
100 different diseases known as autoimmune disease (body
falsely identifies its own tissue as foreign matter and attacks)
Aboriginal people with arthritis more likely to have other risk
factors for poor health
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What is Arthritis? Part II
Rheumatoid Arthritis (RA):
crippling form of arthritis believed to result from an
autoimmune process:
affects small joints of hands, feet, wrists, knees, ankles and
neck
main complications:
pain, limitations in activities and need to be dependent on
others
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Stress may play a role: in particular, disturbances in
interpersonal relationships.
Figure 14.7 Proportion of total number of individuals with
arthritis by age group, household population, Aged 18 Years
and Older

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What is Arthritis?: Part III
Stress and RA:
stress may aggravate RA
Treatment of RA:
aspirin, rest, supervised exercise
cognitive-behavioural interventions
enhancement of perceived self-efficacy
Juvenile RA:
onset between 2 and 5 years
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What is Arthritis?: Part IV
Osteoarthritis:
Most common form of arthritis in Canada
4.4 million Canadians in 2010 and double by 2040
Onset usually after 45
2040, over 70% of seniors will be living with osteoarthritis
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What is Arthritis?: Part V

Osteoarthritis:
obesity is the only modifiable risk factor
the articular cartilage (smooth lining of a joint) begins to crack
or wear away because of overuse
affects weight-bearing joints
treatment involves keeping weight down, exercise, aspirin
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Figure 14.8 Prevalence of osteoarthritis by age structure, 2010-
20140
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What is Arthritis?: Part VI
Other forms of arthritis:
Gout:
build-up of uric acid crystals
treated by diet, fluid intake and exercise
leads to life-threatening consequences only if left untreated
Lupus:
skin rash can appear on the face, leading to chronic
inflammation, pain, heat, redness and swelling
can be life-threatening
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Summary: Part I
Explain psychoneuroimmunology.
Stressors, depression and anxiety compromise immune
functioning. Coping, relaxation, and stress management may
buffer this.
Understand AIDS and its consequences.
AIDS results from HIV and is marked by the presence of
infectious diseases when immune system compromised. Higher
risk for men who have sex with men, needle-sharing, and
Aboriginal peoples.
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Summary: Part II
Describe cancer and the psychosocial factors Involved.
A set of more than 100 diseases marked by malfunctioning DNA
and rapid cell growth and proliferation. Related to depression.
Define and understand arthritis
An autoimmune disease involving inflammation of the joints,
includes more than 100 diseases.
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Related Videos
AIDS

https://www.youtube.com/watch?v=FDVNdn0CvKI
Cancer
https://www.youtube.com/watch?v=WPgJafGz4fg
Arthristic
https://www.youtube.com/watch?v=Yc-9dfem3lM
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CHAPTER 13
Heart Disease, Hypertension, Stroke, and Diabetes
York University
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Learning Objectives
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Describe coronary heart disease.
Explain hypertension.
Understand stroke.
Describe diabetes.
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Coronary heart disease
Atherosclerosis
Cholesterol level
Cardiac rehabilitation
C-reactive protein
List causes and treatments of Coronary heart disease
Hypertension
systolic and diastolic
Sphygmomanometer
Acculturation
List causes and treatments of hypertension
Learning Activity 13 A
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Stroke
Stroke warning signs (symptoms)
Causes and treatments
Diabetes
Insulin
Symptoms and cause of diabetes
Types of Diabetes and its differences
Treatments
Learning Activity 13 A
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What is Coronary Heart Disease (CHD)?: Part I
Second leading cause of death
Disease of modernization—tied to current lifestyles
Inflammatory processes implicated
Risk factors include high blood pressure, diabetes, stress,
inactivity, high cholesterol
Family history component
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What is Coronary Heart Disease (CHD)?: Part II

a general term referring to illnesses caused by atherosclerosis,
the narrowing of coronary arteries, the vessels that supply the
heart with blood
may be caused by inflammatory processes, high blood pressure,
diabetes, cigarette smoking, obesity, high serum cholesterol
level and low levels of physical activity
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Figure 13.1 Age-standardized all-cause mortality rates and
number of deaths among Canadians aged 20 years and older
with diagnosed ischemic heart disease (HD) and those who had
an acute myocardial infarction (AMI), Canada, 2000-2001 to
2012-2013
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What is Coronary Heart Disease?: Part III
Role of stress:
chronic and acute stress have been linked to CHD
CHD more common in individuals low in socioeconomic status
(SES)
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What is Coronary Heart Disease?: Part IV
Role of stress:
job factors linked to CHD
balance of demand and control in daily life is associated with
CHD
social instability tied to higher rates of CHD
Tension, psychological stress, and negative affectivity
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What is Coronary Heart Disease?: Part V
Women and CHD:
leading killer of women in the Canada and most developed
countries
women seem to be protected at younger ages relative to men
higher levels of HDL
estrogen diminishes sympathetic nervous system arousal
higher risk of cardiovascular disease after menopause
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What is Coronary Heart Disease?: Part VI
Cardiovascular reactivity, hostility and CHD:
anger and hostility are risk factors for CHD and is a predictor of
survival

Hostile people often have:
developmental antecedents
difficulty expressing vs. harbouring hostility
hostility within social relationships
mechanisms linking reactivity and psychological factors
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Hostility and Cardiovascular Disease
Research has implicated cynical hostility as a psychological
culprit in the development of cardiovascular disease. Many
studies have employed measures of hostility to look at this
association. Some sample items are below:
I don’t matter much to other people.
People in charge often don’t really know what they are doing.
Most people lie to get ahead in life.
People look at me like I’m incompetent.
Many of my friends irritate me with the things they do.
People who tell me what to do frequently know less than I do.
I trust no one; life is easier that way.
People who are happy most of the time rub me the wrong way.
I am often dissatisfied with others.
People often misinterpret my actions.
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What is Coronary Heart Disease?: Part VII
Depression and CHD:
depression is a significant risk factor that can lead to

development and progression of CHD
there is a link between depression and metabolic syndrome
depression is tied to elevated C-reactive protein, a marker of
inflammation
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What is Coronary Heart Disease?: Part VIII
Other psychosocial risk factors and CHD:
vigilant coping
anxiety (implicated in sudden cardiac death)
helplessness, pessimism and a tendency to ruminate over
problems
attempting to dominate social interactions
loneliness
vital exhaustion
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What is Coronary Heart Disease?: Part IX
Modification of CHD risk-related behaviour:
dietary intervention
programs to stop smoking
aerobic exercise in particular
Modifying hostility:
relaxation training
speech style interventions

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What is Coronary Heart Disease?: Part X
Management of heart disease:
patients often delay before seeking treatment
about 10% of physician visits are CHD related
Initial treatment
cardiac rehabilitation:
process by which patients attain their optimal physical,
medical, psychological, social, emotional, vocational and
economic status
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What is Coronary Heart Disease?: Part XI
Treatment by medication:
Beta-adrenergic blocking agents—resist NS activation
Aspirin is commonly prescribed—thins blood, decreases clots
Statins—for cholesterol
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What is Coronary Heart Disease?: Part XII
diet and activity level
stress management
targeting depression
evaluation of cardiac rehabilitation
problems of social support
cardiac invalidism
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What is Hypertension?: Part I
Hypertension:
high blood pressure
How is hypertension measured?
levels of systolic and diastolic pressure are measured by a
sphygmomanometer
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What is Hypertension?: Part II
What causes hypertension?
90% is essential (unknown)

5% is caused by failure of the kidneys
Genetic and emotional factors
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What is Hypertension?: Part III
How is Hypertension Measured?
Systolic and diastolic pressure measured by sphygmomanometer
Systolic blood pressure is the greatest force developed during
contraction of the heart
Diastolic: is the pressure in arteries when the heart is relaxed
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What is Hypertension?: Part IV
How is Hypertension Measured?
Systolic has a greater value in diagnosing hypertension
Mild hypertension- systolic -140-159
Moderate hypertension- systolic 160-179
Severe hypertension- systolic above 180
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What is Hypertension?: Part V

What Causes Hypertension?
early blood pressure reactivity is a predictor of hypertension as
an adult
lifestyle
genetic factors
emotional factors
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What is Hypertension?: Part VI
Relationship Between Stress and Hypertension:
Repeated stressful events
Combination of high demand/low control
chronic social conflict
job strain
associated with:
crowded, noisy locales
migration from rural to urban areas
women – extensive family responsibilities
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Figure 13.2 Factors That Contribute to the Development of
Hypertension and its Complications
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What is Hypertension?: Part VII

How do we study stress and hypertension?
bring people with hypertension into labs to respond to stressful
tasks
identify stressful circumstances (such as high pressure jobs) and
examine rates of hypertension
ambulatory monitoring
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What is Hypertension?: Part VIII
Psychosocial factors and hypertension:
originally thought that a constellation of personality factors
made one susceptible to hypertension with suppressed anger
thought to be the dominant characteristic
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What is Hypertension?: Part IX
Current Views Regarding Personality and Hypertension:
personality factors alone are insufficient for developing
hypertension but may still play a role
expressed anger and the potential for hostility
number of conflict-ridden interactions in daily life

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What is Hypertension?: Part X
Acculturation and Hypertension among Asian Canadians:
acculturation is the adjustment to a new culture
hypertension associated with acculturation in Asian Canadians
because their traditional lifestyle harder to maintain
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What is Hypertension?: Part XI
Treatment of hypertension:
low-sodium diet
reduction of alcohol
weight-reduction in overweight patients
exercise
caffeine restriction
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What is Hypertension?: Part XII
Treatment of Hypertension:
Drug treatments:

Diuretics – decrease volume of blood
Beta-adrenergic blockers & vasodilators
central adrenergic inhibitors
Statins
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What is Hypertension?: Part XIII
Treatment of Hypertension:
Cognitive-behavioural treatments:
relaxation
stress management
exercise
anger management
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What is Hypertension?: Part XIV
Evaluation of cognitive-behavioural interventions:
seem to be very successful
reduce drug requirements
sometimes the combination of cognitive- behavioural techniques
and medications appears to be the best approach
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What is Hypertension?: Part XV
Problems in treating hypertension:
“The hidden disease”
often symptomless, so diagnosis occurs during standard medical
examinations
early detection is important
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What is Hypertension?: Part XVI
Problems in treating hypertension:
Untreated hypertension:
lowers quality of life
compromises cognitive functions
related to fewer social activities
Adherence to all aspects of treatment is essential but rates tend
to be low.
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What is a Stroke?: Part I
3rd leading cause of death in Canada
Disturbance in blood flow to the brain and is responsible for

nearly 14,000 Canadian deaths each years.
Some strokes occur when blood flow to localized areas in the
brain is interrupted due to arteriosclerosis or hypertension
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Stroke Warning Signs
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The Centers for Disease Control and Prevention says these are
the five warning signs of stroke:
Sudden numbness or weakness in the face, arm, or leg,
especially on one side of the body
Sudden confusion, trouble speaking, or difficulty understanding
speech
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance, or lack of
coordination
Sudden severe headache with no known cause
What is a Stroke?: Part II
Risk factors for stroke:
overlap with those for heart disease
high blood pressure, heart disease, cigarette smoking, high red
blood cell count and transient ischemic attacks
negative emotions, sudden change in posture to a startling event
and psychological distress
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What is a Stroke?: Part III
Consequences of stroke:
stroke affects all aspects of life—personal, social, vocational
and physical:
motor problems
cognitive problems
emotional problems
relationship problems
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What is a Stroke?: Part IV
Types of rehabilitative interventions:
psychotherapy and treatment of depression
cognitive-remedial training
movement therapies
use of structured, stimulating environments to challenge
capabilities
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Figure 13.3 All-cause mortality rates and number of deaths
among people aged 20 years and older with a stroke occurrence

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What is Diabetes?: Part I
Diabetes is a chronic condition of impaired carbohydrates,
protein, and fat metabolism that results from insufficient
secretion of insulin or from insulin resistance
One of the most common chronic diseases in the country and
spreading across the world
Many individuals who have diabetes remain undiagnosed
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Figure 13.4 The Potential Health Complications of Diabetes are
Extensive, Life-Threatening, and Costly
Risk Factors for Type II Diabetes
You are at risk if
You are overweight.
You are over age 65.
You have an apple-shaped figure.
You get little exercise.
You have high blood pressure.
You have a sibling or parent with diabetes.
You had a baby weighing over 9 pounds at birth.
You are a member of a high-risk ethnic group, which includes
Indigenous, Black Canadians, Latin American, Asian, and
Pacific Islanders.
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What is Diabetes?: Part II
Type I Diabetes
insulin-dependent
abrupt onset of symptoms resulting from lack of insulin
production by the beta cells of the pancreas
result of viral infection, autoimmune reactions, and genetics
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What is Diabetes?: Part III
Type II Diabetes
Non-insulin dependent
A disorder of middle-age, striking those over age 40
Obesity major contributor
Increasingly common in children and adolescents
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What is Diabetes?: Part IV
Type II Diabetes:
Health implications of diabetes:
leading cause of blindness among adults

kidney failure
foot ulcers
eating disorders
nervous system damage
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What is Diabetes?: Part V
Type II Diabetes:
Stress and Diabetes:
Type II diabetics are sensitive to stress
Lack of social support even more problematic
Stress may play a role in onset
Anger and hostility are associated
Sympathetic nervous system reactivity
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What is Diabetes?: Part VI
Type II Diabetes:
Managing Type II Diabetes:
often unaware of health risks they face
must reduce sugar and carbohydrate intake
encouraged to achieve normal weight
encouraged to exercise
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What is Diabetes?: Part VII
Type II Diabetes:
Interventions with Diabetics:
cognitive-behavioural interventions to improve adherence to
their regimen
weight control improves glycemic control
self-management and problem-solving skills
social skills training
behaviour modification
pharmacological therapy
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What is Diabetes?: Part VIII
Type II Diabetes:
Diabetes prevention:
diabetes is a major public health problem
lifestyle intervention and medication can greatly reduce the
incidence of diabetes
control obesity
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What is Diabetes?: Part IX
Special Problems of Adolescents with Diabetes
often have Type 1 so their disease is severe
developing years; independence, and self-concept
struggles with adherence
may rebel against diet and authority
emotionally stable conscientious adolescents are more likely to
follow the complex regimen
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Summary: Part I
Describe coronary heart disease.
Number two killer in Canada, a disease of lifestyle and
associated with hostility and stress.
Explain hypertension.
High blood-pressure, related to genetics, sodium
intake, low SES, stress and hostility.
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Summary: Part II
Understand stroke.
Results from a disturbance in blood flow to the brain.
Describe diabetes.
Type I develops in childhood and Type II develops over 40,
related to glycemic control. Epidemic in Indigenous peoples.

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York University
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CHAPTER 12
PSYCHOLOGICAL ISSUES IN ADVANCING AND
TERMINAL ILLNESS
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Learning Objectives
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Describe how death differs across the lifespan.
Know the psychological issues in advancing illness.
Identify the stages in adjustment to dying.
Understand the concerns in the psychological management of
the terminally ill.
Describe the alternatives to hospital care for the terminally ill.

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Learning Activity 12 B
Vocabulary Parking-Lot
Terminal illness
Thanatologists
Life expectancy – Canada – 78 -80 yrs China – 76 yrs, Japan –
84yr, India – 69, Korea – 83, Africa – 75yrs, Europe – 79,
Abrabian – 75yrs, USA – 79
Sudden Infant Death Syndrome (SIDS):
Euthanasia
Kϋbler-Ross’s 5 stages of adjustment to death
Palliative care
Hospice care
Home care
3
4
How Does Death Differ Across the Lifespan?: Part I
100 years ago people died primarily of infectious diseases like
pneumonia, influenza, and tuberculosis
Now most die from chronic or terminal illness
Life extectancy in Canada is 84 for women and 80 for men—

longer than for most other developed countries
5
6Rank and CauseNumber of DeathsMalignant neoplasms
(cancer)79 084Diseases of heart (heart disease)51
396Cerebrovascular diseases (stroke)13 551Accidents
(unintentional injuries)12 524Chronic lower respiratory
diseases 12 293Diabetes mellitus (diabetes)6838Alzheimer’s
disease6521Influenza and pneumonia6235Intentional self-harm
(suicide)3978Chronic liver disease and cirrhosis3385
Deaths: Ten Leading Causes in Canada, All Ages, 2016
How Does Death Differ Across the Lifespan?: Part II
Death in infancy or childhood:
Canada infant mortality rate is high (4.5 per 1,000) compared to
many developed countries
Mortality rate associated with socio-economic status
1996 the rates of infant mortality in Canada were close to
Sweden rates 4.0 per 1,000
7
7
How Does Death Differ Across the Lifespan?: Part III
Sudden Infant (0-2yrs) Death Syndrome (SIDS):
causes are not entirely known
infant simply stops breathing
gentle death for child

enormous psychological toll for parents
sleeping position has been reliably related to SIDS
8
8
How Does Death Differ Across the Lifespan?: Part IV
Causes of death:
Death between ages 1 to 15 years
#1 cause of death is accidents, drowning, poisoning, injuries,
falls, and motor vehicle accidents (42% of deaths)
#2 cause of death is cancer (especially leukemia)
Both of these causes are on the decline
9
9
How Does Death Differ Across the Lifespan?: Part V
Children’s understanding of death:
young children (< 5 years) associate death with sleep, not as
something final and irreversible
children 5-9 years understand it’s final, but do not understand
biological death
at ages 9 or 10, death is seen as universal and inevitable
10
10

How Does Death Differ Across the Lifespan?: Part VI
Death in young adulthood:
For those aged 15 to 24, death is due to:
#1 unintentional injury (car accidents)
#2 suicide
#3 cancer
#4 homicide
11
11
How Does Death Differ Across the Lifespan?: Part VII
Reactions to young adult death:
death of a young adult is considered tragic
young adults feel shock, outrage and an acute sense of injustice
medical staff often find this group difficult to work with
12
12
How Does Death Differ Across the Lifespan?: Part VIII
Death in middle age:
death becomes more common and often more fearful as
mortality becomes more feasible
people develop chronic illnesses that ultimately kill them
13

13
How Does Death Differ Across the Lifespan?: Part IX
Premature death:
death before the projected age of 81
usually occurs due to heart attack or stroke
lifestyle issues often contribute
most people say they would prefer a sudden, painless, non-
mutilating death
14
14
How Does Death Differ Across the Lifespan?: Part X
Death in old age:
dying is not easy, but it may be easier in old age
initial preparations may have been made
some friends and relatives have died
may have come to terms with issues
typically die of degenerative diseases
psychosocial factors predict declines in health
15
15
What Are the Psychological Issues in Advancing Illness?: Part I
Continued treatment and advancing illness:

treatments may have debilitating side effects
patients find themselves repeated objects of surgical or
chemical therapy
16
16
What Are the Psychological Issues in Advancing Illness?: Part
II
What is a Good Death?:
free from avoidable suffering
Ten core themes:
17Pain freePositive relationship with
providerReligiosity/spiritualityQuality of lifeTreatment
preferencesEmotional wellbeingDignitySense of life
completionFamilyPreferences for the dying process
17
What are the Psychological Issues in Advancing Illness? Part III
Is there a right to die?
Historically tremendously controversial and largely illegal (for
patient, but more importantly for whomever assisted)

2015 Supreme Court of Canada ruled that physicians may aid
competent patients with grievous, enduring, and terminal pain
in ending their lives
Still illegal in most countries
18
18
IV
Moral and legal issues:
Euthanasia: assist death
Ending the life of a person with a painful terminal illness
Advance care directives (living will):
A request that extraordinary life-sustaining procedures not be
used if person is unable to make this decision on his/her own
19
Gloria Taylor, first to win legal right to die
19
20
A Letter to My Physician Concerning my Decision about
Physician Aid-in-Dying

V
Psychological and social issues related to dying:
Changes in the patient’s self-concept:
difficulty maintaining control of biological functions
mental regression, inability to concentrate
Issues of social interaction:
fear that their condition will upset visitors
withdrawal for fear of depressing others and fear of becoming
an emotional burden
21
21
VI
Communication issues:
many people feel it is proper to avoid the topic
medical staff, family and patient may believe that others don’t
want to discuss death
22
22
Are There Stages in Adjustment to Dying?: Part I
Kϋbler-Ross’s 5 stages of adjustment to death:
Denial: a mistake must have been made; test results were mixed

up
Anger: Why me? Why not him? Or her?
Bargaining: a pact with God, good works for more time or for
health
Depression: a time of “anticipatory grief”
Acceptance: tired, peaceful (not always pleasant), calm
descends
23
23
Are There Stages in Adjustment to Dying?: Part II
Differing evaluations of Kϋbler-Ross’s theory:
her work is invaluable
her work has not identified stages of dying:
there is not a predetermined order
some patients never go through a particular “stage”
her work does not fully acknowledge the importance of anxiety
24
24
What are the Concerns in the Psychological Management of the
Terminally Ill?: Part I
Medical staff and the terminally ill patient:
The significance of hospital staff to the patient:
dying need help for simple things, such as brushing teeth or
turning over
they assist with pain management
they are the patient’s source of realistic information

they are privy to a most personal and private act—dying
25
25
Terminally Ill?: Part II
Risks of terminal care for staff:
emotionally and physically draining for hospital staff
they provide palliative care, care designed to make the patient
comfortable, rather than curative care, care designed to cure the
patient’s disease
26
26
Terminally Ill?: Part III
Achieving an appropriate death:
Avery Weisman’s goals for the staff caring for the dying:
informed consent
safe conduct
significant survival
anticipatory grief
timely and appropriate death
27

27
Terminally Ill?: Part IV
Individual counseling with the terminally ill:
therapy for dying patients is becoming an increasingly available
and utilized option
thanatologists, those who study death and dying, suggest
behavioural and cognitive-behavioural therapies -
clinical thanatology involves symbolic immortality
28
28
Terminally Ill? Part V
Family therapy with the terminally ill:
family and patient may have different ways of adjusting to the
illness
The management of terminal illness in children:
most stressful of all terminal care
hardest to accept and psychologically painful
family may need counselling as well
29
29

Terminally Ill? Part VI
The adult survivor—little to do but grieve.
grief: psychological response to bereavement
feeling of hollowness
preoccupation with image of deceased person
expressions of hostility towards others
guilt over death
Most widows and widowers are resilient to their loss.
30
30
Terminally Ill? Part VII
The child survivor:
may expect the dead person to return
may believe a parent left because the child was “bad”
may feel “responsible” for a sibling’s death
31
31
What Are the Alternatives to Hospital Care for the Terminally
Ill? Part I
Hospice care:
designed to provide palliative care and emotional support to
dying patients and their families

may be provided in the home, but commonly provided in free-
standing or hospital-affiliated units called hospices
oriented toward improving a patient’s social support system
32
32
The role of Hospice Palliative Care in End-of-Life Care
33
Ill?: Part II
Home care:
care for dying patients in the home
choice of care for many terminally ill patients
psychological factors are legitimate reasons for home care
very stressful for family members, especially primary caregiver
34
34
Summary: Part I
Causes differ over the life cycle and concepts of death
change over the life cycle.

Treatment-related discomfort and decisions to continue
treatment; advanced care directives. Patients’ self-concept
continually changing.
35
1
2
Summary: Part II
Kϋbler-Ross’s theory of dying suggest 5 stages but not all
go through these in sequence.
the terminally ill.
Medical staff responsible for most care. Psychological
counselling needed for patient and family members,
especially children.
36
3
4
Summary: Part III
Hospice care and home care alternatives have beneficial
psychological effects on dying patients and their survivors.
37
5

York University
1
CHAPTER 12
PSYCHOLOGICAL ISSUES IN ADVANCING AND
TERMINAL ILLNESS
1
Learning Objectives
1
2
3
4
5
the terminally ill.
2
2
Learning Activity 12 B
Vocabulary Parking-Lot
Terminal illness
Thanatologists

Life expectancy – Canada – 78 -80 yrs China – 76 yrs, Japan –
84yr, India – 69, Korea – 83, Africa – 75yrs, Europe – 79,
Abrabian – 75yrs, USA – 79
Sudden Infant Death Syndrome (SIDS):
Euthanasia
Kϋbler-Ross’s 5 stages of adjustment to death
Palliative care
Hospice care
Home care
3
4
How Does Death Differ Across the Lifespan?: Part I
100 years ago people died primarily of infectious diseases like
pneumonia, influenza, and tuberculosis
Now most die from chronic or terminal illness
Life extectancy in Canada is 84 for women and 80 for men—
longer than for most other developed countries
5
6Rank and CauseNumber of DeathsMalignant neoplasms
(cancer)79 084Diseases of heart (heart disease)51
396Cerebrovascular diseases (stroke)13 551Accidents
(unintentional injuries)12 524Chronic lower respiratory

diseases 12 293Diabetes mellitus (diabetes)6838Alzheimer’s
disease6521Influenza and pneumonia6235Intentional self-harm
(suicide)3978Chronic liver disease and cirrhosis3385
Deaths: Ten Leading Causes in Canada, All Ages, 2016
How Does Death Differ Across the Lifespan?: Part II
Death in infancy or childhood:
Canada infant mortality rate is high (4.5 per 1,000) compared to
many developed countries
Mortality rate associated with socio-economic status
1996 the rates of infant mortality in Canada were close to
Sweden rates 4.0 per 1,000
7
7
How Does Death Differ Across the Lifespan?: Part III
Sudden Infant (0-2yrs) Death Syndrome (SIDS):
causes are not entirely known
infant simply stops breathing
gentle death for child
enormous psychological toll for parents
sleeping position has been reliably related to SIDS
8
8
How Does Death Differ Across the Lifespan?: Part IV

Causes of death:
Death between ages 1 to 15 years
#1 cause of death is accidents, drowning, poisoning, injuries,
falls, and motor vehicle accidents (42% of deaths)
#2 cause of death is cancer (especially leukemia)
Both of these causes are on the decline
9
9
How Does Death Differ Across the Lifespan?: Part V
Children’s understanding of death:
young children (< 5 years) associate death with sleep, not as
something final and irreversible
children 5-9 years understand it’s final, but do not understand
biological death
at ages 9 or 10, death is seen as universal and inevitable
10
10
How Does Death Differ Across the Lifespan?: Part VI
Death in young adulthood:
For those aged 15 to 24, death is due to:
#1 unintentional injury (car accidents)
#2 suicide
#3 cancer
#4 homicide

11
11
How Does Death Differ Across the Lifespan?: Part VII
Reactions to young adult death:
death of a young adult is considered tragic
young adults feel shock, outrage and an acute sense of injustice
medical staff often find this group difficult to work with
12
12
How Does Death Differ Across the Lifespan?: Part VIII
Death in middle age:
death becomes more common and often more fearful as
mortality becomes more feasible
people develop chronic illnesses that ultimately kill them
13
13
How Does Death Differ Across the Lifespan?: Part IX
Premature death:
death before the projected age of 81
usually occurs due to heart attack or stroke
lifestyle issues often contribute

most people say they would prefer a sudden, painless, non-
mutilating death
14
14
How Does Death Differ Across the Lifespan?: Part X
Death in old age:
dying is not easy, but it may be easier in old age
initial preparations may have been made
some friends and relatives have died
may have come to terms with issues
typically die of degenerative diseases
psychosocial factors predict declines in health
15
15
What Are the Psychological Issues in Advancing Illness?: Part I
treatments may have debilitating side effects
patients find themselves repeated objects of surgical or
chemical therapy
16
16

II
What is a Good Death?:
free from avoidable suffering
Ten core themes:
17Pain freePositive relationship with
providerReligiosity/spiritualityQuality of lifeTreatment
preferencesEmotional wellbeingDignitySense of life
completionFamilyPreferences for the dying process
17
What are the Psychological Issues in Advancing Illness? Part III
Is there a right to die?
Historically tremendously controversial and largely illegal (for
patient, but more importantly for whomever assisted)
2015 Supreme Court of Canada ruled that physicians may aid
competent patients with grievous, enduring, and terminal pain
in ending their lives
Still illegal in most countries
18
18

IV
Moral and legal issues:
Euthanasia: assist death
Ending the life of a person with a painful terminal illness
Advance care directives (living will):
A request that extraordinar y life-sustaining procedures not be
used if person is unable to make this decision on his/her own
19
Gloria Taylor, first to win legal right to die
19
20
A Letter to My Physician Concerning my Decision about
Physician Aid-in-Dying
V
Psychological and social issues related to dying:
Changes in the patient’s self-concept:
difficulty maintaining control of biological functions
mental regression, inability to concentrate
Issues of social interaction:
fear that their condition will upset visitors
withdrawal for fear of depressing others and fear of becoming
an emotional burden

21
21
VI
Communication issues:
many people feel it is proper to avoid the topic
medical staff, family and patient may believe that others don’t
want to discuss death
22
22
Are There Stages in Adjustment to Dying?: Part I
Kϋbler-Ross’s 5 stages of adjustment to death:
Denial: a mistake must have been made; test results were mixed
up
Anger: Why me? Why not him? Or her?
Bargaining: a pact with God, good works for more time or for
health
Depression: a time of “anticipatory grief”
Acceptance: tired, peaceful (not always pleasant), calm
descends
23

23
Are There Stages in Adjustment to Dying?: Part II
Differing evaluations of Kϋbler-Ross’s theory:
her work is invaluable
her work has not identified stages of dying:
there is not a predetermined order
some patients never go through a particular “stage”
her work does not fully acknowledge the importance of anxiety
24
24
Terminally Ill?: Part I
Medical staff and the terminally ill patient:
The significance of hospital staff to the patient:
dying need help for simple things, such as brushing teeth or
turning over
they assist with pain management
they are the patient’s source of realistic information
they are privy to a most personal and private act—dying
25
25
Terminally Ill?: Part II

Risks of terminal care for staff:
emotionally and physically draining for hospital staff
they provide palliative care, care designed to make the patient
comfortable, rather than curative care, care designed to cure the
patient’s disease
26
26
Terminally Ill?: Part III
Achieving an appropriate death:
Avery Weisman’s goals for the staff caring for the dying:
informed consent
safe conduct
significant survival
anticipatory grief
timely and appropriate death
27
27
Terminally Ill?: Part IV
Individual counseling with the terminally ill:
therapy for dying patients is becoming an increasingly available
and utilized option
thanatologists, those who study death and dying, suggest
behavioural and cognitive-behavioural therapies -

clinical thanatology involves symbolic immortality
28
28
Terminally Ill? Part V
Family therapy with the terminally ill:
family and patient may have different ways of adjusting to the
illness
The management of terminal illness in children:
most stressful of all terminal care
hardest to accept and psychologically painful
family may need counselling as well
29
29
Terminally Ill? Part VI
The adult survivor—little to do but grieve.
grief: psychological response to bereavement
feeling of hollowness
preoccupation with image of deceased person
expressions of hostility towards others
guilt over death
Most widows and widowers are resilient to their loss.
30

30
Terminally Ill? Part VII
The child survivor:
may expect the dead person to return
may believe a parent left because the child was “bad”
may feel “responsible” for a sibling’s death
31
31
Ill? Part I
Hospice care:
designed to provide palliative care and emotional support to
dying patients and their families
may be provided in the home, but commonly provided in free-
standing or hospital-affiliated units called hospices
oriented toward improving a patient’s social support system
32
32

The role of Hospice Palliative Care in End-of-Life Care
33
Ill?: Part II
Home care:
care for dying patients in the home
choice of care for many terminally ill patients
psychological factors are legitimate reasons for home care
very stressful for family members, especially primary caregiver
34
34
Summary: Part I
Causes differ over the life cycle and concepts of death
change over the life cycle.
Treatment-related discomfort and decisions to continue
treatment; advanced care directives. Patients’ self-concept
continually changing.
35
1
2
Summary: Part II

Kϋbler-Ross’s theory of dying suggest 5 stages but not all
go through these in sequence.
the terminally ill.
Medical staff responsible for most care. Psychological
counselling needed for patient and family members,
especially children.
36
3
4
Summary: Part III
Hospice care and home care alternatives have beneficial
psychological effects on dying patients and their survivors.
37
5
York University

CHAPTER 5
Health-Compromising
Behaviours
1
Learning Objectives
Identify the characteristics of health-compromising behaviours.
Describe and define substance use disorder.
Understand how alcohol use disorder and problem drinking
compromise health.
Explain how smoking is harmful for health and what factors
influence smoking.
Describe eating disorders.
1
2
3
4
5
2
2
Introduction Chapter Flowchart
3

3
What are the Characteristics of Health-Compromising
Behaviours?: Part I
4
4
Behaviours?: Part I
Many of these behaviours share a window of vulnerability in
adolescence:
drinking to excess
smoking
using illicit drugs
having unsafe sex
engaging in risk-taking behaviours
5
5

Behaviours?: Part II
behaviours are tied to the peer culture
image of these behaviours as “cool”
behaviours, though dangerous, are pleasurable
problem develops gradually
6
6
Remember in Chapter 4 the discussion of tanning.
Problem with the lack of sunscreen Use: Tans are perceived as
attractive and adolescents and young adults are especially
concerned with appearance. For this reason, they will engage in
health-compromising behaviours.
Behaviours?: Part III
substance abuse of all kinds is predicted by some of the same
factors
most problem behaviours more common in lower social-class
individuals, associated with health attitudes
development of eating disorders
7
7
Remember in Chapter 4 the discussion of tanning.
Problem with the lack of sunscreen Use: Tans are perceived as
attractive and adolescents and young adults are especially
concerned with appearance. For this reason, they will engage in
health-compromising behaviours.

What is Substance Use Disorder?: Part I
Arises when a substance is used repeatedly and causes
functional or clinical impairment
Three criteria:
Risky use refers to continuing to use a substance despite
experiencing problems associated with it
Impaired control involves using a substance in greater
quantities or more frequently than intended—associated with
craving – a powerful urge to use a substance
Social impairments involve failure to meet obligations (social,
recreational, or occupational)
8
8
What is Substance Use Disorder?: Part II
Pharmacological Effects Criteria
Physical dependence:
Tolerance
Addiction:
Withdrawal
Psychoactive substances
Illicit Drug Use
DSM-5
9
9

What is Substance Use Disorder?: Part II
Pharmacological Effects Criteria:
Physical dependence:
body adjusts to substance and incorporates its use into normal
functioning of the body’s tissues
Tolerance:
larger doses needed to produce same effects
10
10
What is Substance Use Disorder?: Part III
Pharmacological Effects Criteria (cont…):
Addiction:
person has become physically or psychologically dependent on a
substance following use over a period of time
Withdrawal:
unpleasant symptoms, both physical and psychological, that
people experience when they stop using a substance on which
they have become dependent
11
11
What is Substance Use Disorder?: Part IV
Costs of substance use disorder are substantial:

Health care resources
Law enforcement
Loss of productivity at work and home
Death
Disability
12
12
What is Substance Use Disorder?: Part V
Harm-Reduction:
Public health response to substance misuse that focuses on the
risks and consequences rather than the use itself
Model guiding Canada’s national drug strategy
Philosophy that completely eliminating substance use in society
is unrealistic
Promotes safe substance use
Methadone maintenance
Needle exchange programs
13
13
Figure 5.1 Percentage of people reporting cannabis use aged 15

years or older in Canada, first quarter 2018 and first quarter
2019
14
What is Substance Use Disorder?: Part VI
Illicit Drug Use:
In Canada, 15% of population used illicit drug at least once in
2016
Three classes of illicit drugs:
Opiates (e.g., oxycontin, heroin)
Cocaine
Amphetamines (e.g., meth, ecstasy)
Psychoactive substances – affect cognitive and affective
processes and change how a person behaves.
15
15
What is Substance Use Disorder?: Part VII
Illicit Drug Use (cont…):
misuse of prescription opioids a public health crisis
Canada second only to US in scope of the problem
Use increased > 200% between 2000 and 2010 as has
emergency room visits related to their use
Over 3000 Canadians died of opioid overdose between January
and September 2018
16
16

What is Substance Use Disorder?: Part VII
Consequences of Illicit Drug Use:
Legal and economic issues
Physical problems (e.g., lung damage, nasal damage, infection,
HIV)
Stimulants increase heart rate and blood pressure and increase
risk for heart attack and stroke
17
17
What is Substance Use Disorder?: Part VIII
Consequences of Illicit Drug Use:
Short-term mental health problems such as anxiety and
confusion
Long-term mental health problems such as personality and
memory changes
Lowers inhibitions and increases engagement in risky
behaviours
18
18

19
Figure 5.2 Percentage Distribution of People in Treatment by
Primary Drug Type, by Region and Share of First-Time Entrants
for Each Drug Type
How does Alcohol Use Disorder Compromise Health?: Part I
Scope of the problem:
third leading cause of preventable death
alcohol consumption is linked to more than 200 diseases,
including high blood pressure, stroke, cirrhosis of the liver,
fetal alcohol syndrome and some cancers
20
20
How does Alcohol Use Disorder Compromise Health?: Part II
Scope of the problem:
A large proportion of traffic-related deaths are related to
alcohol
Through disinhibition alcohol use is also associated with many
homicides, suicides, and assaults
many drinkers keep their problem hidden
21
21
How does Alcohol Use Disorder Compromise Health?: Part III
Medical diagnosis of Alcohol Use Disorder (AUD) when
problem drinking becomes severe but not related to use alone.

Four categories of criteria in DSM-5:
Risky drinking
Impaired control
Social impairment
Pharmacological effects
Total of 11 criteria, only need 2 to meet AUD criteria
22
22
How does Alcohol Use Disorder Compromise Health?: Part IV
Origins of alcoholism and problem drinking:
genetic (50% of vulnerabilities)
gender – more men but gender gap is narrowing
physiological, behavioural and sociocultural factors are
involved
23
23
At this point, it is possible to preview Chapter 7, Moderators of
the Stress Experience. In the discussion of Coping with Stress,
Taylor et al. brings up the topic of Personality and Coping. One
of the topics described is that of Psychological Control.
Perceived control is the belief that one can determine one’s own
behaviour, influence one’s environment, and bring about desired
outcomes. It is closely related to self-efficacy. The East
German migrants who found that they could not find work in
West Germany often turned to alcohol for solace unless they
had high feelings of self-efficacy. This is discussed in Chapter

7.
How does Alcohol Use Disorder Compromise Health?: Part V
Drinking and stress:
drinking buffers stress
many start drinking to enhance positive emotions and decrease
negative ones
Individuals with more stress and less social support are more
likely to become problem drinkers
AUD typically co-occurs with anxiety and/or depression
24
24
Perceived control is the belief that one can determine one’s ow n
7.
How does Alcohol Use Disorder Compromise Health?: Part VI
Social origins of drinking:
AUD tied to social and cultural environment
Two periods of enhanced vulnerability:
dependence starting in adolescence when brain is more
vulnerable to reward circuitry which can diminish the ability to
control alcohol use
late middle age to cope with stress
Depression and alcohol use linked and likely bidirectional

25
25
Perceived control is the belief that one can determine one’s own
7.
How does Alcohol Use Disorder Compromise Health?: Part VII
Treatment of alcohol abuse:
was once seen as intractable problem
alcohol abuse can be modified successfully
some use of cognitive-behavioural modification
preliminary evidence online CBT may have efficacy
without employment or social support, prospects for recovery
are dim
some “age out” and stop drinking in later life
26
26
How does Alcohol Use Disorder Compromise Health?: Part VIII

Treatment programs:
self-help groups such as AA (Alcoholics Anonymous)
inpatient/outpatient programs
detoxification – requires medical supervision
short-term, inpatient therapy
continuing outpatient treatment
27
27
How does Alcohol Use Disorder Compromise Health?: Part IX
Treatment programs (cont.):
Cognitive-behavioural treatments:
self-monitoring, contingency contracting
motivational enhancement
medications
stress management techniques
family therapy and group counseling
Relapse prevention a major difficulty
28
28

Table 5.1 Patterns of Hazardous or Harmful Drinking among
Canadian Undergraduates
29
Table 5.2 Percentage of Students Who Reported Binge Drinking
at a Campus Event During a One-Month Period
30
Table 5.3 Alcohol-Related Problems of University Students
Who Had a Drink During a One-Year Period
31
How does Alcohol Use Disorder Compromise Health?: Part X
Evaluation of alcohol treatment programs:
success involves environmental factors, outpatient services,
family/social support
Minimal interventions:
can make a dent in drinking-related problems
social engineering
banning alcohol advertising
raising the legal drinking age
strictly penalizing drunk driving
32

32
How does Alcohol Use Disorder Compromise Health?: Part XI
Can recovered alcoholics ever drink again?
Alcoholics Anonymous philosophy:
An alcoholic is an alcoholic for life
Moderation Management (MM):
goal setting, self-monitoring, and self-control of drinking
most effective with less heavy drinkers
33
33
How does Alcohol Use Disorder Compromise Health?: Part XII
Preventive approaches to alcohol abuse:
appealing to adolescents to avoid drinking
social engineering programs (increase taxes, restrict
advertising, educational programs)
beundrunk.com promotes responsible drinking by Manitoba
Liquor Control Commission
34
34

How does Alcohol Use Disorder Compromise Health?: Part XIII
Drinking and driving:
pressure municipal and provincial governments for tougher
alcohol control measures
hosts/hostesses/friends intervening to recognize those too drunk
to drive
need for stiffer penalties
designated drivers
35
35
How does Alcohol Use Disorder Compromise Health?: Part XIV
Modest alcohol intake adds to a long life:
reduced risk of heart attack
lower blood pressure
increase in HDL (“good” cholesterol)
fewer strokes
Moderate drinking among younger adults may enhance risks of
death, probably due to alcohol-related injuries
36
36
How is Smoking Harmful for Health and What Factors Influence
Smoking?: Part I
leading cause of premature death in Canada
increases the risk of many diseases and disorders
smokers are generally less health-conscious than non-smokers
dangers not confined to the smoker; hazards of secondhand

smoke
may lower cognitive performance in adolescents
37
37
38
Table 5.4 Premature deaths caused by smoking and exposure to
secondhand smoke, 1965-2014
How is Smoking Harmful for Health and What Factors Influence
Smoking?: Part II
Synergistic effects of smoking:
smoking enhances the impact of other risk factors in
compromising health:
smoking and stress, increased weight and less exercise, breast
cancer, depression, and anxiety
39
39

Figure 5.3 Percentage of Never and Ever Smokers, Aged 15+,
Canada (1999 – 2012)
40
40
A Brief History of the Smoking Problem
For years, smoking was considered to be a sophisticated and
manly habit
19th & 20th century often depicted men retiring to the drawing
room after dinner for cigars
20th century – advertisement built on this image
By 1965, 61% of the adult male population in Canada was
smoking
41
A Brief History of the Smoking Problem (cont….)
1962 – report of the Royal College of Physicians of the UK
concluded that cigarette smoke may be an important cause of
lung cancer
1963 – Minister of Heath in the Canadian House of Commons
announced smoking was linked to cancer
1964 – surgeon general’s warning included extensive publicity
campaign to high light the dangers of smoking
42

Table 5.5 Smoking Status by Age Group and Sex, Aged 15+
Years, Canada (2012)
43
Why do people smoke?
How can you prevent smoking
44
44
Why do people smoke?
Genetics: smoking runs in families
Factors associated with smoking in adolescents:
peer and family influences
weight control
self-image

mood
nicotine addiction
45
45
Table 5.6 Health Beliefs and Attitudes by Smoking Status,
Youth Grades 5 to 9, Canada (2004 – 2005)
46
Figure 5.4 Teenage Smoking
47
47
48

Interventions to Reduce Smoking
Changing attitudes toward smoking
the therapeutic approach to the smoking problem:
nicotine replacement therapy
multimodal interventions
social support and stress management
maintenance
relapse prevention
49
49
Harm-Reduction Approaches to Smoking
nicotine replacement (patch, gum)
pharmaceutical nicotine
smokeless cigarettes
electronic cigarettes (vaping)
50
50
Smoking Prevention: Part I
Advantages of smoking prevention programs:
potentially effective, cost-effective and easily implemented
Social influence interventions:

modelling
51
51
Smoking Prevention: Part II
Social Influence Interventions
Three components:
Information about the negative effects of smoking constructed
to appeal to adolescents.
Materials are developed to convey a positive image of the non-
smoker as independent and self-reliant.
The peer group is used to reinforce not smoking rather than
smoking.
52
52
Smoking Prevention: Part III
Social Influence Interventions
Hard to know if these programs work:
Learn to turn down cigarettes but may not do so
Might delay smoking without reducing overall rates
Difficult to validate self-reports of smoking
53
53

Smoking Prevention: Part IV
The life-skills training approach:
encourage self-esteem and coping enhancement as well as social
skills in adolescents
has shown success in the reduction of smoking onset over time
but the data is mixed
54
54
Social Engineering and Smoking
restrict smoking to particular places
regulation of access of tobacco by the Food and Drug
Administration
heavy taxation
55
55
Figure 5.5 Percentage of Non-Smokers Exposed to Second-Hand
Smoke at Home by Age (2011)
56

What are Eating Disorders?: Part I
Anorexia Nervosa:
an obsessive disorder amounting to self-starvation
dieting and exercising to the point that body weight is grossly
below optimum level
57
57
What are Eating Disorders?: Part II
Developing Anorexia Nervosa:
genes
disruption in serotonin, dopamine and estrogen systems which
are implicated in both anxiety and food intake
environmental risks (e.g., stress)
behavioural manifestations
58
58
What are Eating Disorders?: Part III

Anorexia Nervosa (cont.):
Treating Anorexia:
bring weight to safe level
family therapy
prevention
stressing the health risks of eating disorders
59
59
What are Eating Disorders?: Part IV
Bulimia:
an eating syndrome characterized by alternating cycles of binge
eating and purging through such techniques as vomiting,
laxative abuse, extreme dieting and drug or alcohol abuse
Developing Bulimia?
food becomes a constant thought
overvaluing body appearance
symptoms of depression
60
60
What are Eating Disorders?: Part V
Treating Bulimia:
convince bulimics that the disorder threatens their health and
that psychological interventions can help
combine medication and cognitive-behavioural therapy
use other behavioural treatments
use relapse prevention techniques

61
61
Summary: Part I
Identify characteristics of health-compromising behaviours.
Those that threaten or undermine good health in present or the
future. Many of these behaviours begin in adolescence.
Describe and define substance use disorder.
It occurs when an individual’s recurrent use of a substance
causes clinically and/or functionally significant impairment or
psychological distress.
1
2
62
62
Summary: Part II
Understand how alcohol use disorder and problem drinking
compromise health.
Accounts for multiple deaths
Has a genetic component
Creates a range of behaviour problems
Tied to socio-economic status
Buffers stress
Treatment efficacy for cognitive behavioural approaches.
3
63

63
Summary: Part III
Explain how smoking is harmful for health and what factors
influence smoking.
Account for more than 45000 deaths in Canada, although
attitudes are changing, smoking highly resistant to change.
Describe eating disorders.
Anorexia and bulimia involve an obsession with weight control.
4
5
64
64
York University
1
CHAPTER 10

Pain and its Management
1
Learning Objectives
Understand the significance of pain.
Explain why pain is difficult to study.
Identify the clinical issues in pain management.
Describe the techniques used to control pain.
Explain how chronic pain is managed.
2
1
2
3
4
5
2
3
Learning Activity 11
Vocabulary parking-lot
Hypnosis
Hypnotherapy
Acupuncture

Biofeedback
Gate control theory of pain
Body-self neuromatrix
Polynorphins
Three kinds of pain perception:
mechanical nociception
thermal damage
polymodal nociception
4
Learning Activity 11
Vocabulary parking-lot
Chronic pain
Acute pain
Physiology of pain
A-delta fibers
A-beta fibres
C-fibers
Phantom Limb Pain
Beta-endorphins
Proenkephalin
Gate control theory of pain
body-self neuromatrix

Polynorphins
mechanical nociception
thermal damage
polymodal nociception
4
5
6
Introduction
Chronic pain is an epidemic burden
Approximately 20% of Canadians have chronic pain with higher
rates after age 65

Back pain, migraines, and arthritis most common
Costs in health care utilization and lost productivity are
approximately $10 billion/year
Pain management efforts have created an opioid epidemic
7
What is the Significance of Pain?
Some pain is critical for survival as it provides feedback about
the functioning of our bodies
Medical consequences:
pain is the symptom most likely to lead an individual to seek
treatment and it often interferes with functioning.
pain has psychological significance, increasing depression and
anxiety
chronic pain patients are at significantly higher risk of suicide
8
8
Why is Pain Difficult to Study?: Part I
pain is a psychological experience
pain is influenced by the context in which it is experienced
pain has a cultural component
there are gender differences in pain
ways of coping influence pain
9

9
Why is Pain Difficult to Study?: Part II
Measuring pain:
verbal reports
pain behaviour:
behaviour that arises as a manifestation of chronic pain
assesses how pain has disrupted the lives of patients
10
10
11
McGill Pain Questionnaire
Why is Pain Difficult to Study?: Part III
Physiology of pain:
pain and emotions greatly intertwined
pain is a protective mechanism
pain is accompanied by motivational and behavioural responses
12

12
Why is Pain Difficult to Study?: Part IV
Physiology of pain (cont.):
mechanical nociception: mechanical damage to body tissue
thermal damage: damage due to temperature exposure
polymodal nociception: pain triggers chemical reactions from
tissue damage
13
13
Why is Pain Difficult to Study?: Part V
Physiology of pain (cont.):
Two major types of peripheral nerve fibers involved in pain:
A-delta fibers:
small, myelinated fibers that transmit sharp pain
C-fibers:
unmyelinated fibers that transmit dull, aching pain
14
14

Table 10.1 Summary of Peripheral Nerve Fibres Involved in
Nociception and Their Function in the Experience of Pain
15Peripheral Nerve FibreDescriptionType of PainFunctionPain
Gate ModulationA-delta fibresSmall, myelinated fibresTransmit
first pain and sharp pain rapidlyAffects sensory aspects of
painOpens gateC-fibresUnmyelinated fibresTransmit secondary
dull or aching painAffects motivational and affective elements
of painOpens gateA-beta fibresLarge-diameter myelinated
fibresTransmit information about vibration and
positionConcurrent stimulation can suppress pain transmitted by
C-fibresCloses gate
Why is Pain Difficult to Study?: Part VI
Theories of Pain
Gate control theory:
neural “pain gate” that can open and close to modulate pain
signals to the brain
physical, emotional, and cognitive factors contribute to the
experience of pain by opening or closing the gate
16
16
17
Table 10.2 Factors That Open or Close the Pain GateType of
Factor Factors That Open the GateFactors That Close the Gate
PhysicalExtent of injury

Inappropriate activity levelMedications
Counter stimulation (e.g., massage, heat)EmotionalAnxiety or
worry
Tension
DepressionPositive emotions (e.g., joy, interest)
RelaxationCognitiveFocusing on pain
BoredomDistraction or intense concentration on other things
Involvement and interest in life activities
Why is Pain Difficult to Study?: Part VII
Phantom Limb Pain
Immersive Virtual Reality: enables the viewer to see a complete
representation of the body and movement engaging in several
virtual tasks
Mirror box: which creates an illusion of the arm that is missing-
increasing control over the phantom limb that is missing
18
Why is Pain Difficult to Study?: Part VIII
Neuromatrix Theory of Pain
The body-self neuromatrix generates nerve impulses that are
synthesized into a characterise pattern called neurosignature.
Each pain experience results in an experience that reflects a
multitudes of sensory, emotional, cognitive factors
19
The Neuromatrix Theory of Pain

20
Why is Pain Difficult to Study?: Part IX
Neurochemical bases of pain and its inhibition:
Landmark study: D. V. Reynolds 1969 was able to demonstrate
by stimulating an area of a rat’s brain that the brain can
modulate the experience of pain by sending blocking messages
through the spinal cord.
SPA: Stimulation-Produced Analgesia
21
21
Why is Pain Difficult to Study?: Part X
Neurochemical bases of pain and its inhibition:
Akil, Mayer, and Liebeskind (1972, 1976) determined that the
neurochemical basis of this effect is endogenous opioids:
Three types:
Beta-endorphins
Proenkephalin,
Polynorphins
22
22

What are the Clinical Issues in Pain Management? Part I
Acute and chronic pain:
acute pain usually results from injury
23
23
What are the Clinical Issues in Pain Management?: Part II
Chronic pain usually begins as an acute episode but does not
decrease with the passage of time
Three types of chronic pain:
chronic benign pain
recurrent acute pain
chronic progressive pain
24
24
What are the Clinical Issues in Pain Management?: Part III
Acute vs. chronic pain:
present different psychological profiles as chronic pain often
brings psychological distress and depression
chronic pain patients develop maladaptive coping strategies

(e.g., wishful thinking, social withdrawal)
pain techniques work with acute but not chronic pain
25
25
What are the Clinical Issues in Pain Management?: Part IV
Acute vs. chronic pain:
chronic pain involves a complex interaction of physiological,
psychological, social and behavioural components
chronic pain also often has widespread effects on not only the
individual but also their families and society
26
26
What are the Clinical Issues in Pain Management?: Part V
Who becomes a chronic pain patient?
acute pain patients and patients for whom pain interferes with
life activities
Lifestyle of chronic pain:
disruption of a person’s life
some receive compensation for their pain
27

27
What are the Clinical Issues in Pain Management?: Part VI
The toll of pain on relationships:
affects marriage and other family relationships
social relationships can be threatened
many patients are clinically depressed and contemplate suicide
28
28
What are the Clinical Issues in Pain Management?: Part VII
Pain and personality:
pain-prone personality:
a constellation of personality traits that predispose a person to
experience chronic pain
anxiety disorders, substance use disorders and other psychiatric
problems often co-occur with chronic pain
29
29
What are the Clinical Issues in Pain Management?: Part VIII
Pain profiles:
the “neurotic triad”: MMPI profiles in which the first three
scales are all elevated (Depression, Hysteria, and
Hypochondriasis). Seen in highly neurotic individuals.

This is a common profile among individuals with chronic pain
which historically was taken as evidence that it is neurotic
individuals who develop chronic pain.
We now know that these elevations often develop after the onset
of chronic pain rather than being precursors.
30
30
What Techniques Are Used to Control Pain?: Part I
Pharmacological control of pain:
NSAIDS
opioids (e.g., OxyContin)
local anesthetics
spinal blocking agents
antidepressants
31
31
What Techniques Are Used to Control Pain?: Part II
Surgical control of pain:
cutting or creating lesions in the so-called pain fibers at various
points in the body
Sensory control of pain:
counterirritation:
inhibiting pain in one part of the body by stimulating or mildl y

irritating another area
32
32
What Techniques Are Used to Control Pain?: Part III
Biofeedback:
a method of achieving control over bodily processes
used to treat chronic disorders such as, temporomandibular joint
pain, hypertension and a broad array of pains
Does Biofeedback work?
only modest efficacy in reducing pain
33
33
What Techniques Are Used to Control Pain?: Part IV
Relaxation techniques:
enable patients to cope with stress, anxiety, reducing pain
What is relaxation?
shifting the body into a state of low arousal
controlled breathing and meditation
Does relaxation work?
distinct from placebos and activate higher-order brain regions
34

34
What Techniques Are Used to Control Pain? Part V
Hypnosis:
one of the oldest techniques for pain
How does hypnosis work?
relaxation and suggestion
Hypnotherapy has successfully controlled:
irritable bowel syndrome, acute pain due to surgery, childbirth,
dental procedures, burns, headaches and medical procedures
35
35
What Techniques Are Used to Control Pain?: Part VI
Acupuncture:
- developed in China over 2,000 years ago
- long, thin needles are inserted into designated areas of the
body
36
36
What Techniques Are Used to Control Pain?: Part VII

Acupuncture:
How does acupuncture work?
not really known, although may be due to:
counterirritation
preparation reduces fear and increases tolerance of pain
release of endorphins
reduces post-operative knee pain and cancer pain
37
37
What Techniques Are Used to Control Pain?: Part VIII
Distraction:
focusing attention on an irrelevant and attention-getting
stimulus in order to reduce pain
focus directly on the events but reinterpret the experience
Does distraction work?
is effective but most useful in conjunction with other techniques
38
38
What Techniques Are Used to Control Pain?: Part IX
Coping techniques:
increasingly used to help chronic pain patients manage pain
e.g., some CBT techniques, focus on sensory aspects of the
pain sensation and not the pain itself, active coping skills,
expressive writing

39
39
What Techniques Are Used to Control Pain?: Part X
Guided imagery:
imagine a picture that brings one happiness during the painful
experience
induced relaxation can control slow-rising pains
some patients rouse themselves by imagining a combative,
action-filled scene
40
40
What Techniques Are Used to Control Pain?: Part XI
Cognitive-Behavioural Therapy:
- re-conceptualize the problem
- expect that this training will be successful
- re-conceptualize patient’s own role
- monitor thoughts, feeling and behaviors
- teach adaptive responses
- attribute success to patient’s own efforts
- prevent relapse
41

41
How is Chronic Pain Managed?: Part I
Pain management programs:
Initial evaluation:
perform a qualitative and quantitative assessment of pain
explore how the patient has coped with the pain in the past
evaluate patient for emotional and mental functioning
42
42
How is Chronic Pain Managed?: Part II
Individualized treatment:
use profile of patient pain
Components of chronic pain management programs :
education, training and group therapy
involvement of family
evaluation of pain management program
43
43
Summary: Part I

Understand the significance of pain.
Pain leads people to seek medical attention.
Explain why pain is difficult to study.
Subjective, and results from physical, emotional, and cognitive
factors.
44
1
2
44
Summary: Part II
Identify the clinical issues in pain management.
1.5 million Canadians suffer from chronic pain that disrupts
their lives. Psychological pain profiles can be helpful in
determining management.
Describe the techniques used to control pain.
Pharmacologic, surgical, and sensory stimulation techniques
used most often. Psychological techniques also successfully
used (biofeedback, relaxation, hypnosis, etc.)
45
3
4
45
Summary: Part III

Explain how chronic pain is managed.
Coordinated pain management programs used to create a
biopsychosocial approach to pain.
46
5
46
Related Videos
Phantom limb pain
https://www.youtube.com/watch?v=2ojt26LFL_o
Neuromatrix Theory of Pain
https://www.youtube.com/watch?v=oQLFfvGM7nI
47
York University

CHAPTER 9
Patient-Provider Relations
1
Learning Objectives
2
1
2
3
4
5
Define health care provider.
Explain why patient-provider communication is important.
Describe how to improve patient-provider communication.
Understand non-adherence and explain how it can be reduced.
Understand the placebo effect.
2
3
Vocabulary Parking lot
health care provider
Patient consumerism
Holistic health care

Patient-Centred Communication
Advanced-practice nurses:
RN
nurse-practitioners RN+
Telehealth (broad services)
Placebo Effect
Non- adherence
Complementary and alternative medicine (CAM)
Class Activity – 10 B
Define health care provider?
Explain why patient-provider communication is important?
- Understanding interaction patient- provider
- Detail information about patient situation
- Patient can detail of symtoms
-
4
1
2
4
Chapter 9 Flowchart
5

What is a Health Care Provider?
Not only physicians.
Advanced-practice nurses:
RN
nurse-practitioners RN+
Telehealth (broad services)
Physicians’ Assistants as providers:
perform a wide range of medical services
CAM Practitioners
6
6
Explain Why Patient-Provider Communication is Important:
Part I
Judging quality of care:
we complain most about jargon, little feedback, and
depersonalized care
most of us can’t judge the quality of our care based on its
technical merits
instead we use the manner in which care is delivered as the
criteria
empathic and caring delivery is judged as competent
7

7
Part II
Patient consumerism:
patients have a desire to be involved in decisions that affect
their health
increasing interest in establishing and maintaining good health
to convince a patient to follow a treatment plan requires the
patient’s cooperation
patients often have considerable expertise about their health
problems
8
8
9
Patient consumerism—the practice, broadly speaking, of
bypassing physicians when obtaining medical information,
goods, and services—has been gaining ground for decades, with
a giant boost from the Internet. The trend has advantages and
challenges.

The goal of consumerism in healthcare is to lower costs and
improve care quality; the theory is that if patients shop around
for services they'll ...
Part III
The Setting:
physician visits average 12-15 minutes
patient likely to be interrupted in first 23 seconds of dialogue
often poor correspondence between symptoms reported by
patient and those recorded by the physician
things like pain and fever may present difficulties in clear
communication and these difficulties in communicating are
often enhanced due to anxiety or embarrassment
10
10
Part IV
Structure of Health Care Delivery System:
primary health care providers, including physicians, are usually
the first point of entry for individuals into our publicly funded
health care system
primary health care facilitates and coordinates the provision of
the services
11

11
Part V
Structure of Health Care Delivery System (cont…):
many do not have a family physician
getting needed referrals to specialists difficult without family
physician
many cannot see their doctor on the day they are sick or need
medical care
some dissatisfaction with health care system drives people to
use Complementary and Alternative Medicine
12
12
Figure 9.1 Access to Health Care in Canada and other
Developed Countries, 2015
13
Part IV
Changes in the philosophy of health care delivery:

physician’s role is changing
patients must assume more responsibility
14
14
Part V
Holistic health movement and health care:
health is a positive state to be actively achieved
Western medicine incorporating Eastern approaches
greater emotional contact between patient and provider
15
15
Part VI
Provider behaviours that contribute to faulty communication:
Barriers
- not listening
- use of jargon (professional word)
- baby talk
- elder-speak
- stereotypes of patients
16

CHAPTER 14Psychoneuro-immunology, AIDS, Cancer, and Arthriti

CHAPTER 14Psychoneuro-immunology, AIDS, Cancer, and Arthriti

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