Most of us will experience chronic disorders.

Chronic disorders

Most of us will experience chronic disorders. 50% of the population at any one time have a Chronic disorder. Some are mild, e.g. partial hearing loss, others are life threatening e.g. renal disease.

Type of person

No strong evidence. Taylor and Aspinwall (1990) - weak associations between negative affective styles and coronary heart disease, asthma, headaches, ulcers and arthritis. Link with Type A behaviour pattern and proneness to disease.

Good health weakly associated with positive emotional states (e.g. optimism and perceived control). Fewer symptoms or speedy recovery.

Problem, cancer can take a long time to develop before it is reported to health worker, so health problem could cause a person to adopt a behaviour style, rather than the other way around.

An example of where a positive style could cause hypertension is that of 'John Henryism'. This is where, for example, oppressed black people work hard to overcome deprivation, leading to hypertension. (See p122, in culture chapter).

Response to chronic disorders

High levels of anxiety produced by

• Waiting for test results
  a diagnosis of cancer
  invasive procedures
  the side-effects of treatment
  changes to lifestyle
  dependency on health workers
  fear of recurrence
  uncertainty

Taylor and Aspinwall, 1990
Depression reported by just under a third of hospital admissions.
Difficult to see the pure effects of depression, as symptoms of depression could also be symptoms of the disease

Uncertainty

Patients can deal with uncertainty by

• vigilance. Learning as much as they can about the illness.
  avoidance. attributing symptoms to less harmful conditions, or not seeing the doctor.

Patients experience some sense of control over their illness by these means.
Consider the uncertainty generated by AIDS (p172-4)
Other common problems include Mastectomy, Sexual problems (to be discussed later with regard to Renal disease.

If you are not sure of what AIDS is read box 12.1.


Cognitive Approaches to Health

Locus of Control

Rotter (1966) external locus of control and internal locus of control.

Health locus of control

Wallston et al (1978) expanded Rotter's scale.
Internality, belief in the power to make oneself well again
Chance, little control over becoming ill
Powerful others, belief that following doctor's orders will make one well.
Relationship between scale and outcome is not strong. Patients might be able to control diet, for example, but not alcohol consumption. More specific scales have been produced to look at control of pain, for example.

Breast self-examination

Self-efficacy

Bandura (1977) what we believe we are capable of. If we believe that we can do something we are more likely to do it.
Judgements of self-efficacy are based on our past performance. Other sources are:

• observations of the performance of others
  social and self-persuasion
  monitoring our emotional states

Wulfert and Wan (1993) study of college students. Well informed about AIDS but condom use was best predicted by self-efficacy. If the student felt they could use condoms without diminishing the sexual experience, then they used condoms.

End-stage renal disease

Psychological responses to dialysis

• Anxiety
  Depression
  Suicidal reactions
  Passive non-compliance with medical demands. Britton et al (1982) 50% difficulty with following diet, 15% non-compliance.
  Depressive reactions. e.g. anorexia and sleep disturbance.
  Sexual dysfunction. Loss of libido, impotence, difficulties in ejaculation in men, insufficient lubrication and loss of orgasmic response in women.
  Psychosocial problems. Work, family. Long (1989) 30% of their children show high levels of anxiety, depression and psychosomatic problems. 61% partners depressed over change in partner, 54% exhausted with trying to cope.

Stresses experienced

• A heightened sense of mortality
  feeling ill
  changed social life
  treatment

Psychological interventions

High resistance.
Avoid discussion about treatment, as non-compliance could be revealed. this would be perceived as lessening their chances of receiving a transplant. Interviews often take place whilst dialysis is taking place.

Interventions include

• Progressive muscle relaxation and biofeedback.
  Operant methods to control gagging and vomiting
  Token economies and behavioural contracting
  Hypnotherapy to control thirst
  Sex therapy
  Counselling and cognitive-behavioural therapy for depression
  ecological intervention to improve the psychosocial environment.

Interventions for Chronic Illness

I Use material from previous chapters.
Improving the communication between patient and health worker (Chapter 9).
Changing smoking habits (Chapter 7)
Adjusting lifestyles (Chapter 6)
Developing coping skills (Chapter 3)

Self-help groups

groups for cancer, hypertension, epilepsy etc. Successful, but not known why they work. Supported by health professionals as self-help groups are cheap.

Tend to attract white professional women who are in contact with health services, so many people are not helped by this means. (Taylor and Aspinwall 1990).

Denial

Denial can be useful. If patient denies that his illness is life threatening then they would be positive towards it. Unfortunately the effects are short lived. Levine et al (1988) heart attack victims who had higher levels of denial had fewer days in intensive care and fewer signs of cardiac dysfunction. A year later many of these patients had not adapted their lifestyles to the demands of the disease and were less likely to adhere to the treatment programme. They required more days back in hospital.

Locus of Control: improving health in a nursing home.

Langer and Rodin (1976) compared patients living in a nursing home living on two different floors. Experimental group told:

1. that they had the responsibility of caring for themselves
   they could decide how they wanted their rooms
   they could decide how they wanted to spend their time
   told it's their life
   told it was their responsibility to make complaints known

They were offered a plant, and given option of watching a movie on Thursday, Friday or not at all.

Control group given a similar talk, but personal responsibility and control were not emphasised.
Given a plant, told to see the movie on one particular night, told how the staff would make their rooms nice, etc.

Questionnaires given one week before and three weeks after.
93% of the experimental group improved their locus of control, compared with 21% of the control group. (Can you put forward possible explanations of the improvement in the control group?). Study table 12.1, labels are around the wrong way on figure 12.1.

Follow up study 18 months later (Rodin and Langer 1977). Experimental group were still improved. They were in better health and fewer had died.

Quality of life

Difficult to assess quality of life, because it is a subjective measure. For example, Jachuck et al, 1982) hypertension patients rated by doctors - 100% had an improved quality of life. 49% of patients thought that their quality of life had improved. 96% of relatives had seen no change or a slight deterioration.

Collins (cited by Taylor and Aspinwall, 1990) 90% of cancer patients reported positive consequences of their illness. Appreciated each day, didn't put things off, more effort into personal relationships, acquired a greater understanding and sympathy for the needs of others. They felt stronger and more self-assured. Similar results have been found for other life-threatening disorders. 

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