UNIT 4: CHRONIC

AND TERMINAL
ILLNESS
Coronary Heart Disease (CHD)- stress and CHD, personality, cardiovascular
reactivity, and CHD, depression and CHD, other psychosocial risk factors and
CHD, management of heart disease
Type II Diabetes- health implications of diabetes, management of diabetes
HIV infection and AIDS- psychosocial impact of HIV infection, Coping with
HIV+ status and AIDS, psychosocial factors
Cancer- psychosocial factors of cancer and its impact on course of cancer,
adjusting to cancer, psychosocial issues and cancer; Therapies
Coping with chronic illness- coping strategies, patient’s beliefs about
chronic illness; Psychological management of the terminally ill-
counselling with the terminally ill, the management of terminal illness in
children
Hospice care
Coronary heart disease (CHD) is a general term that refers to
illnesses caused by atherosclerosis, the narrowing of the coronary
arteries, the vessels that supply the heart with blood
When these vessels become narrowed or closed, the flow of oxygen
and nourishment to the heart is partially or completely obstructed
Temporary shortages of oxygen and nourishment frequently cause
pain, called angina pectoris, that radiates across the chest and arm
When severe deprivation occurs, a heart attack (myocardial
infarction) can result
Risk factors for CHD include high cholesterol, high blood pressure,
elevated levels of infl ammation, and diabetes, as well as behavioral
factors of cigarette smoking, obesity, and little exercise
Identifying people with metabolic syndrome also helps predict heart
attacks
Metabolic syndrome is diagnosed when a person has three or more of
the following problems:
 Obesity centered around the waist
 High blood pressure
 Low levels of HDL, the socalled good cholesterol
 Difficulty metabolizing blood sugar, an indicator of risk for diabetes
 High levels of triglycerides, which are related to bad cholesterol
Biological reactivity to stress contributes to the development of
CHD, that is, the increases and decreases of physiological activity
that can accompany stress
The cumulative effects of reactivity damage the endothelial cells that
line the coronary vessels
 This process enables lipids to deposit plaque, increasing inflammation and leading to
the development of lesions

Reactivity is reflected not only in initial reactions to stress but can

also be reflected in a prolonged recovery period; some people
recover from sympathetic activity due to parasympathetic counter-
regulation quite quickly, whereas others do not
STRESS AND CHD
Stress is an important culprit in the development of CHD and may
interact with genetically based weaknesses to increase its likelihood
Acute stress involving
 Emotional pressure
 Anger
 Extreme excitement
 Negative emotions
 Sudden bursts of activity can precipitate sudden clinical events, such as a heart attack,
angina, or death

The stress reactivity associated with these events can lead to plaque
rupture and risk of a clot
Stress has been linked directly to increased infl ammatory activity as
well
Low social status is implicated in the development and course of
coronary artery disease
These patterns reflect the greater chronic stress that people
experience, the lower they are on the socioeconomic ladder
People who think of themselves as low in social standing are also
more likely to have cardiovascular profiles reflecting the metabolic
syndrome
A genetically based predisposition to cardiovascular reactivity, which
emerges early in life, can be exacerbated by low socioeconomic
status
A harsh (cold, nonnurturant, neglectful, and/or conflictual)
family environment in childhood increases risk in its own right, and
the stress and difficulty developing social support that can result
from these early harsh circumstances also increases cardiovascular
risk
Low SES also predicts a worsened course of illness and poor
prospects for recovery
Stress in the workplace can lead to the development of coronary
heart disease
Job-related risk factors are
 Job strain
 Especially the combination of high work demands and low control
 A discrepancy between educational level and occupation (for example, being well-
educated and having a lowstatus job)
 Low job security
 Little social support at work
 High work pressure

More recently, research has suggested that an imbalance between

control and demands in daily life more generally (not only at work)
is a risk for atherosclerosis
People whose lives are characterized by high levels of demands
coupled with low levels of control both in and outside the
workplace are at higher risk for atherosclerosis
Social instability is linked to higher rates of CHD
People who are occupationally, residentially, or socially mobile have
a higher frequency of CHD than do people who are less mobile
PERSONALITY,
CARDIOVASCULAR
REACTIVITY, AND CHD
Negative emotions, including anger and hostility, increase risk for
metabolic syndrome and for CHD
Anger not only increases the risk of heart disease but also predicts
poor likelihood of survival and acts as a potential trigger for heart
attacks
Anger has also been implicated in hypertension and to a lesser degree
in stroke and diabetes, suggesting that it may be a general risk factor
for CHD, cardiovascular disease, and their complications
A particular type of hostility is especially implicated, namely, cynical
hostility, characterized by suspiciousness, resentment, frequent
anger, antagonism, and distrust of others
People who have negative beliefs about others, such as the
perception that other people are being antagonistic or threatening,
are often verbally aggressive and exhibit subtly antagonistic behavior
People who are high in cynical hostility may have difficulty
extracting social support from others, and they may fail to make
eff ective use of available social support
They also have more conflict with others, more negative affect,
and more resulting sleep disturbance, which may further
contribute to their heightened risk
Hostility combined with defensiveness may be particularly
problematic
Hostility Topics to study
* Expressing vs Harbouring Hostility
* Hostility and Social Relationships
* Hostility and Reactivity
DEPRESSION AND CHD
Depression affects the development, progression, and mortality from
CHD
The relation of depression and CHD risk is now so well established
that many practitioners believe that all CHD patients should be
assessed for possible depression and treated if there are symptoms
Depression is not a psychological by-product of other risk factors for
CHD but an independent risk factor, and it appears to be
environmentally rather than genetically based
The risk that depression poses for heart disease is greater than that
posed by second hand smoke
Even depressed monkeys have an elevated risk for CHD
Depression is also linked to risk factors for
 Coronary heart disease (Ohira et al., 2012)
 Metabolic syndrome (Goldbacher, Bromberger, & Matthews, 2009)
 Inflammation (Brummett et al., 2010)
 The likelihood of a heart attack (Pratt et al., 1996)
 Heart failure among the elderly (S. A. Williams et al., 2002)
 Mortality following coronary artery bypass graft surgery (Burg, Benedetto,
Rosenberg, & Soufer, 2003)
OTHER PSYCHOSOCIAL
RISK FACTORS AND CHD
Vigilant coping – chronically searching the environment for potential
threats (Gump & Matthews, 1998)
Anxiety predicts a worsened course of illness (Roest, Martens,
Denollet, & de Jonge, 2010) and sudden cardiac death (Moser et
al., 2011)
Reason: Reduction in the vagal control of heart rate (Phillips et al.,
2009)
A composite of depression, anxiety, hostility, and anger may predict
CHD better than each factor in isolation suggesting that negative
affectivity is a broad general risk factor for CHD
Vital exhaustion - a mental state characterized by extreme fatigue,
feelings of being dejected or defeated, and enhanced irritability to
cardiovascular disease
In combination with other risk factors, vital exhaustion predicts the
likelihood of a heart attack and of a second heart attack after initial
recovery
Social isolation in its own right confers increased risk for CHD, as
does chronic interpersonal conflict
On the protective side, positive emotions, emotional vitality,
mastery, optimism, and general well-being protect against depressive
symptoms in heart disease, risk factors for CHD, recovery following
surgery, and the course of CHD itself
MANAGEMENT OF HEART
DISEASE
The Role of Delay
Initial Treatment
Treatment by Medication
Diet and Activity Level
Stress Management
Targeting Depression
Problems of Social Support
TYPE II DIABETES
RISK FACTORS FOR TYPE
II DIABETES
You are at risk if:
 You are overweight
 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 African Americans,
Latinos, Native Americans, Asian Americans, and Pacific Islanders
HEALTH
IMPLICATIONS
OF DIABETES
Diabetes is associated with a
thickening of the arteries
due to the buildup of wastes
in the blood
Show high rates of coronary
heart disease
Diabetes is the leading cause
of blindness among adults,
Accounts for nearly 50
percent of all the patients who
require renal dialysis for
kidney failure
Diabetes can be associated with nervous system damage, including
pain and loss of sensation
Foot ulcers may result, and in severe cases, amputation of the
extremities, such as toes and feet, is required
Type II diabetes is also associated with depressed mood
Diabetes is a risk factor for Alzheimer’s disease and vascular
dementia (Alzheimer’s disease is increasingly recognized to be a
metabolic disorder involving the brain’s inability to respond to
insulin)
Diabetics have a shortened life expectancy
Diabetes has psychosocial fallout as well, including difficulties in
sexual functioning, risk for depression, and cognitive
dysfunction, especially concerning memory
Psychological distress is an independent risk factor for death
among diabetic patients
Diabetes is one component of the so-called deadly quartet, the other
three of which are intra-abdominal body fat, hypertension, and
elevated lipids
This cluster of symptoms is potentially fatal because it is strongly
linked to an increased risk of heart attack and stroke
STRESS AND DIABETES
Type II diabetics are sensitive to the effects of stress
People at high risk for diabetes show abnormal glycaemic
responsiveness to stress, which may foster the disease
Stress also aggravates Type II diabetes after the disease is
diagnosed
Just as sympathetic nervous system reactivity is implicated in the
development of CHD and hypertension, it is involved in the
pathophysiology of Type II diabetes
THE MANAGEMENT OF
DIABETES
The key to the successful control of diabetes is active self-management
Can be prevented by changes in the lifestyle of high-risk individuals
Exercise, weight loss among those who are overweight, stress
management, and dietary control are encouraged
Dietary intervention involves reducing sugar and carbohydrate intake
Obesity especially seems to tax the insulin system, so patients are
encouraged to achieve a normal weight
Exercise is especially important because it helps use up glucose in the
blood and helps reduce weight
Adherence to lifestyle change is problematic
Type II diabetics are often unaware of the health risks they face
Many diabetic patients do not have enough information about glucose
utilization and metabolic control of insulin
Education is an important component of intervention
Several additional factors are critical to adherence
Good self-control skills = Glycemic control by virtue of their greater
adherence to a treatment regimen
Social support improves adherence, but this is not as true for diabetes
Social contact can lead to temptations to eat that compromise diabetic
functioning
However, spousal support for exercise improves adherence
Cognitive behavioural interventions have been undertaken to improve
adherence
Nonadherence results from running out of medications or forgetting
to take them, and so these are obvious targets for intervention
Training patients to monitor blood sugar levels effectively
Personal digital assistants that prompt people about aspects of their
self-care have been used
Depression complicates prognosis and also interferes with the
active self-management role
Interventions that target a sense of self-efficacy improve adherence
and the ability to achieve control over their blood sugar levels
Anger may undermine glycemic control
Diabetes regimen is complex, involves lifestyle change, and
implicates multiple risk factors, multifactor lifestyle interventions
have been used to approach this regimen
Because of problems involving adherence, a focus on maintenance
and relapse prevention is also essential
The fact that stress and social pressure to eat reduce adherence has
led researchers to focus on social skills and problem solving skills
so that diabetics can manage high risk situations
Prevention is Better than cure
HIV AIDS+
THE PSYCHOSOCIAL
IMPACT OF HIV
INFECTION
Depression commonly accompanies an HIV diagnosis
 Little social support
 Who feel stigmatized by their sexual preference or race
 Engage in avoidant coping
 Have more severe HIV symptoms

Depression can reduce receptivity to interventions, as well as

lowering quality of life
Interventions that reduce depression are, thus, useful
Bereavement itself can increase the likelihood that the disease will
progress
Bereavement counselling can be important for reducing risk
Thoughts of suicide are common especially among socially isolated
infected people
Over the longer term, most people cope with AIDS fairly well
The majority of people who are HIV seropositive make positive
changes in their health behaviors almost immediately after diagnosis
 Changing diet in a healthier direction
 Getting more exercise
 Quitting or reducing smoking
 Reducing or eliminating drug use

Coping skills training and the practice of meditation may also

improve adjustment to the disease
Many of these changes also improve psychological well-being, and
they may affect the course of infection as well
Disclosure
Not disclosing HIV status or simply lying about risk factors, such as
the number of partners one has had, is a major barrier to controlling
the spread of HIV infection
Those less likely to disclose their HIV+ status to sex partners also are
less likely to use condoms during intercourse
People with strong social support networks are more likely to
disclose and are, in turn, more likely to receive social support
Thus, disclosure appears to have psychosocial benefits
In addition, disclosure can have health benefits
Research shows that those who had disclosed their HIV+ status to
their friends had significantly higher levels of CD4 and helper cells
than those who had not
Whether to disclose HIV-seropositive status is influenced by cultural
factors
In the case of HIV, however, there may be a desire to protect family
members, which acts as a barrier to disclosure
Nondisclosure may mean that these young men are unable to get the
social support they need from their families
Women and HIV
Lives of HIV-infected women, particularly those with symptoms, are
often chaotic and unstable
Many of these women have no partners, they may not hold jobs, and
many depend on social services and Medicaid to survive
Some have problems with drugs, and many have experienced trauma
from sexual or physical abuse
To an outsider, being HIV+ would seem to be their biggest problem,
but in fact, getting food and shelter for the family is often more
difficult
Poverty acts as a barrier to adherence, and unless food insufficiency
is addressed, other interventions may not be successful
Low-income women who are HIV+ especially experience stress
related to family issues and any resulting depression can exacerbate
the disease
Many women are able to find meaning in their lives, often prompted
by the shock of testing positive
COPING WITH HIV+
STATUS AND AIDS
Coping with a life-threatening illness is always challenging
They are more likely to have a history of traumas and co-existing
mental health problems, such as anxiety disorders, depression, and
substance abuse disorders
Consequently, they may not have particularly good coping skills
HIV infection is a chronic rather than an acute condition, psychosocial
issues raised by chronic illness come to the fore
One such issue is employment
Interventions may be needed to help those who can return to work do
so
People with HIV must continually cope with the fear, prejudice, and
stigma that they encounter from the general community, which can
increase psychological distress
COPING SKILLS
Stress and its neuroendocrine consequences foster a more rapid
course of illness in people who are infected with HIV and lead to
more opportunistic or more aggressive symptoms
Coping effectiveness training is helpful in managing the
psychological distress that can be associated with HIV+ status
In one study, a cognitive-behavioral stress management program
designed to increase positive coping skills and the ability to enlist
social support led to improved psychological well-being and
quality of life among HIV + people (Lutgendorf et al., 1998)
Perceiving that one has control over a stressor is usually associated
with better adjustment to that stressor
Written disclosure is a successful coping intervention
A study by K. J. Petrie and associates found that writing about
emotional topics led to higher CD4 lymphocyte counts, compared to
writing about neutral topics, among HIV-infected patients
Social Support
Social support has been tied to greater adherence and lower viral load
Thus, addressing social support needs can have multiple positive
repercussions
Gay men infected with HIV who have emotional, practical, and
informational support are less depressed and men with strong partner
support are less likely to practice risky sex
Intervention programs that include male partners and those that focus
on building and maintaining relationship skills build on these insights
Support from family appears to be especially important for
preventing depression
Not all families are helpful, however, and so other sources of support
are vital
The Internet represents an important resource for people infected
with HIV
Those who use the Internet to help manage their HIV+ status
typically are more knowledgeable about HIV, have more active
coping skills, engage in more information-seeking coping, and have
more social support than those not using the Internet
CANCER
PSYCHOSOCIAL FACTORS
AND CANCER
Woody Allen remarked in the film Manhattan, “I can’t express anger.
That’s one of the problems I have I grow a tumour instead.”
For decades, there has been a stereotype of a cancer-prone
personality as a person who is easy going and acquiescent, repressing
emotions that might interfere with smooth social and emotional
functioning
STRESS AND CANCER
Stress generally has not been linked to the onset of cancer
Lack or loss of social support may affect the onset and course of
cancer
The absence of close family ties in childhood predicts some cancers
and the absence of a current social support network has been tied to
a worsening course of illness
Experiencing major social stressors such as divorce, infidelity, marital
quarrelling, and financial stress increases risk for cervical cancer
A long-term study of cancer incidence, mortality, and prognosis in
Alameda County, California, found that women who were socially
isolated were at greater risk of dying from cancer of all sites
Coping via repression has been tied to the likelihood of cancer
PSYCHOSOCIAL FACTORS
AND THE COURSE OF
CANCER
Researchers have examined the role of psychosocial factors if the
cancer progresses rapidly or slowly
Avoidance, or the inability to confront the disease, has been tied to
a more rapid course of the disease
Depression is implicated in the progression of cancer, both by itself
and in conjunction with other risk factors
Research has found an 18.5-fold increase in risk for smoking-
related cancers among smokers who were depressed, as well as a
2.9-fold increase for non-smoking-associated cancers
People who were depressed or anxious prior to having cancer may be
especially benefitted by interventions
Cancer progression may be related to use of denial or repressive
coping strategies
Avoidant or passive coping is also a risk factor for psychological
distress, depression, poor sleep, and other risk-related factors
Repressive coping appears to be especially common in children with
cancer, so this coping style warrants particular consideration in their
case
Negative expectations regarding one’s situation have been related
to a more rapid course of illness in young cancer patients
How exactly do these psychosocial factors affect the course of
cancer?
Researchers believe that altered functioning of the HPA and
sympathetic stress systems adversely affect immune functioning in
ways that permit cancer to flourish
In particular, natural killer cells, which are involved in the
surveillance and destruction of tumour cells, are believed to play a
role in tumour surveillance in the body and affect whether a cancer
takes hold after exposure
ADJUSTING TO CANCER
The psychosocial toll of cancer is enormous
Two out of every three families will have a family member who
develops cancer, and virtually every member of these families will be
affected by the disease
More than one-third of cancer victims live at least 5 years after their
diagnosis, thus creating many issues of long-term adjustment
Coping with Physical Limitations
Physical difficulties usually stem from the pain and discomfort
cancer can produce, particularly in the advancing and terminal
phases of illness
Fatigue is an especially common and debilitating symptom
Nutrition can be compromised by cancer and its treatments
Treatment-Related Problems
Some cancers are treated surgically
Removal of organs can create problems in appearance, as for patients
with head-and-neck cancers
In some cases, organs that are vital to bodily functions must be taken
over by a prosthesis
For example, a patient whose larynx has been removed must learn to
speak with the help of a prosthetic speech device
Men with prostate cancer often go through treatments that
compromise sexual functioning
Cancer patients receive debilitating follow-up treatments
Patients undergoing chemotherapy may experience nausea and
vomiting, and anticipatory nausea and vomiting that occurs before
the chemotherapy session begins
Expectations that post-chemotherapy nausea will occur can increase
its likelihood, and so targeting these beliefs can be a valuable
addition to interventions
PSYCHOSOCIAL ISSUES
AND CANCER
Interventions Involving Stress
Issues Involving Social Support
INTERVENTION AND
THERAPIES WITH
CANCER PATIENTS
Psychoeducation
 Treatment Adherence

Individual Therapy
 MBSRT
 Improving health behaviours (Exercise)
 Pain Management (Relaxation, Hypnotherapy, CBT, Visual imaging, Self-Hypnosis)

Group Therapy
Family Therapy
SELF STUDY TOPICS
Coping strategies, patient’s beliefs about chronic illness – Pg 218-
219
Psychological management of the terminally ill- counselling with
the terminally ill, the management of terminal illness in children
– Pg 242 - 244
HOSPICE CARE
An alternative to hospital and home care, designed to provide warm,
personal comfort for terminally ill patients; may be residential or
home-based
In recent decades, hospice care has emerged as a type of care for the
dying
The idea behind hospice care is the acceptance of death, emphasizing
the relief of suffering rather than the cure of illness
Hospice care is designed to provide palliative care and emotional
support to dying patients and their family members
About 1.58 million people received services from hospices in 2010,
making hospice care a significant contributor to the delivery of
services to advancing in terminally ill patients (National Hospice and
Palliative Care Organization, 2011)
In medieval Europe, a hospice was a place that provided care and
comfort for travelers
In keeping with this original goal, hospice care is both a philosophy
concerning a way of dying and a system of care for the terminally ill
Hospice care may be provided in the home, but may also be provided
in free-standing or hospital-affiliated units called hospices
Typically, painful or invasive therapies are discontinued
Instead, care is aimed toward managing symptoms, such as reducing
pain and controlling nausea
Most important, the patient’s psychological comfort is stressed.
Patients are encouraged to personalize their living areas as much as
possible by bringing in their own familiar things
Thus, in institutional hospice care, each room may look very
different, reflecting the personality and interests of its occupant
Patients also typically wear their own clothes and determine their
own activities
Hospice care is oriented toward improving a patient’s social support
system
Restrictions on visits from family or friends are removed as much as
possible
Staff are especially trained to interact with patients in a warm,
emotionally caring way
Usually, counselors are available for individual, group, or family
intervention