Health Psychology

Lecture 8

Chronic Illness and AIDS

Lecture 8 - Outline

• Part 1– Living with chronic illness

• Part 2– AIDS

• Part 3– Male Circumcision

What is the difference between acute and chronic illness?

Acute Chronic

Onset abrupt usually graduated

Duration limited lengthy, indefinite

Cause single multiple, changes

Diagnosis usually accurate often uncertain

Prognosis usually accurate often uncertain

Intervention usually effective often indecisive

Outcome cure no cure

Uncertainty minimal pervasive

Knowledge professionals complementary

The context of chronic illness

With chronic disease, the patient’s life is irreversibly changed. Neither disease nor its consequences are static.

They interact to created illness patterns requiring continuous and complex management. Furthermore, variations in patterns of illness ands treatments with uncertain outcomes creates uncertainty about prognosis. The key to effective management is understanding the different trends in the illness patterns and their pace. The goal is not cure but maintenance of pleasurable and independent living

(Holman & Lorig, 2000)

Chronic Illness as a Crisis

• Serious chronic illness is a crisis– Disruption and change (identity, location, role, social

support, future goals)

– Increased demands (ongoing response to illness)

– Uncertain outcomes

– No cure, requires ongoing management

Initial reactions to chronic illness

• Shock• Denial• Loss and grief• Anxiety and depression

– 20-25% experience psychological symptoms

• If these reactions last too long, they can have an unhelpful effect on the illness

Chronic Illness as a “Crisis”

• Illness can be considered a crisis because it represents a turning point in an individual’s life.

• Disruption to established patterns of personal and social functioning produces a state of psychological, social, and physical disequilibrium

• Adaptation = finding new ways of coping with drastically altered circumstances.

Crisis Theory (Moos, 1982)

• A model describing the factors that affect people’s adjustment to having serious illness.

• Coping process (3 stages) is influenced by 3 factors– Illness-Related Factors– Background and personal Factors– Physical and Social Environment Factors

• Coping process influences outcome of crisis

“The Coping Process”

Contributing Factors

• Illness-Related Factors– Degree to which an illness is hidden

– Degree to which illness intrudes on lifestyle

• Background and Personal Factors– Age, gender, social class, philosophical or religious

commitments, self-esteem

• Physical and Social Environment Factors– Social support

The Coping Process

• Cognitive appraisal– Meaning or significance of the illness– Meaning of Illness Questionnaire

• Adaptive tasks– Formulation of tasks to help cope with illness

• Illness-related• General psychosocial functioning

• Coping skills– Denial, information seeking, goal setting, recruiting

support

Major Adaptive Tasks with Chronic Illness

Outcome of Crisis

• Adaptation and Adjustment– Physical, vocational, self-concept, social, emotional,

compliance

• Quality of Life– Degree of excellence people appraise their lives to contain– Excellence usually = fulfillment or purpose– Health-related quality of life (physical status and

functioning, psychological status, social functioning, disease or treatment-related symptomatology)

Psychosocial Interventions

• Education and support services– Most common intervention to help people adjust

– Majority choose not to attend such groups

– Current trend to examine other ways of offering support (workbooks, telephone linkups, websites)

• Psychotherapy, CBT, family therapy, etc– Costly, not always necessary

AIDS

• Example - living with a chronic illness– What is AIDS?

– Epidemiology

– Causes of HIV/AIDS

– Treatment of HIV/AIDS

– Role of psychology in the HIV epidemic

– Living with HIV/AIDS

– Palliative care

– Bereavement

What is AIDS?

• Acquired Immune Deficiency Syndrome– Infectious disease (unlike cancer, CVD)– Immune system destroyed by HIV– Characteristic set of illnesses as a result

Epidemiology

“deadliest plague in history”– Now one of 10 leading cause of death in US– Primary cause of premature death– 12-18 million have died of AIDS– 40 million HIV+ people in the world (2001)

Epidemiology

Patterns of infection around the world– Pattern I (USA, Canada, Western Europe, Australia)

• Women account for < 20% of AIDS cases• Education campaigns reduced rate of infection

– Pattern II (Africa, India, some SE Asia)• Women account for ~50% of AIDS cases• 80% of AIDS cases are in developing countries

– Pattern III (Russia, Sth America, Asia) • Characteristics of epidemic not yet clear

What causes AIDS?

Human Immunodeficiency Virus (HIV)– HIV causes AIDS by attacking helper T cells

– Course of the HIV infection• Stage 1 - brief flu like illness (1 week after infection)

• Stage 2 - latent period (asymptomatic)

• Stage 3 - AIDS-related complex (cluster of symptoms)

• Stage 4 - AIDS (T-lymphocyte count below 200)

How is the virus transmitted?

3 bodily fluids (rich in white blood cells)– Blood (needle sharing, blood transfusion, mother

to fetus)

– Semen (unprotected sex)

– Vaginal fluids (unprotected sex)

How is the virus transmitted?

5 factors increase the likelihood of infection– Infection dose

– Concentration of virus in infectious fluids• Semen more dangerous than vaginal fluids

– Co-factors (e.g., genital ulcers)

– Immune status of the recipient

– Clinical status of the carrier• most infectious at early stages

Treatment of HIV/AIDS

… there is still no cure!

– Antiretroviral agents• Inhibit HIV replication• Increased helper T cell count

– Many opportunistic diseases can be treated with medication (antibiotics)

Role of Psychology

Primary Prevention

– Condom Use• Health Belief Model• Theory of Reasoned Action/Planned Behavior

– Needle sharing• Drug laws (Glascow vs. Edinburgh)• CBT (relapse prevention)

Role of Psychology

Secondary Prevention

– Testing• Test positive (own reaction, others’ reaction)• Test negative• Not tested

– Atoni et al (1990) … see Sarafino, p. 453

Role of Psychology

Helping people with HIV

– Psychological impact of HIV unclear

– Compliance with medical regimes

– Palliative care

Role of Psychology

Kubler-Ross - Stages of Adjusting to Dying

Role of Psychology

Bereavement

– Grief (feeling) and mourning (expression of feeling)

– AIDS unique• Gay men receive less social support when partner dies• Numerous AIDS deaths (demoralization)

– Urging to “get on with life” unproductive

Press Release

Male Circumcision = HIV Prevention?

Press Release

In a paper to be published soon, an Australian obstetrician has suggested that the foreskin accounts for 80 per cent of infections from males.

The evidence? Comparisons of infection rates between those countries that practice circumcision - Thailand, India and Cambodia - and those that don’t - The Philippines, Bangladesh and Indonesia.

The rates are 10 to 50 times higher in the latter than the former! Too simple to be true? And the answer: a worldwide circumcision drive? Too painful to contemplate?

Press Release

Why do you think it is that people don't want to hear about it?

“Well, I mean it's so laughably simple, I think. That's probably one of the things against it. One would have thought that, you know, years ago people ought to be asking, if I can use the pun, the seminal question of how is it that HIV virus actually gets into the male reproductive tract? How does it get into the female reproductive tract? And we've been so obsessed with developing vaccines and developing drugs that might combat the infection that we've forgotten the simple first principle of how does the virus enter the body?”

ABC radio, March 2000

Evidence?

H1: Male circumcision lowers HIV risk

How could you test this hypothesis?

Design at least 2 studies to test this hypothesis.

The “Disinhibition Effect”

• An increase in unsafe behaviors in response to the introduction of a preventive or therapeutic intervention

• Applies to any field of public health, not just HIV

- seat belts/reckless driving- chest x-ray/tobacco use- anesthesia for childbirth/sexual activity