Lecture 1
Chronic diseases have both genetic (vulnerability) and modifiable risk factors (even more important if genetic
risk factors are already present).
A behavioural risk factor (: physical inactivity, unhealthy diet, tobacco use) can be the trigger on a biological
risk factor (: high blood pressure, high cholesterol, overweight).
Four pillars of primary prevention:
1. Tobacco cessation
2. Weight loss
3. Healthy diet
4. Regular exercise
The complexer the chronic disease, the lower the quality of life.
Aspects that influence adjustment to chronic illness:
- Personal factors (gender, age and coping skills)
- Social and family support
- SES
- Cultural background
- Activities
- Personal goals
- Life stage
Biopsychosocial model: health and illness are a complex interplay between biological, social and psychological
influences.
- Biological factors:
- Genetics
- Physiology: immune or nervous system
- Pathogens and physical trauma
- Psychological factors:
- Behavior
- Cognition (only indirect effect on development of illness) → influences behavior
- Emotion and stress (only indirect effect on development of illness) → influences biological
- Social factors
- SES: access to healthcare, education, resources
- Cultural beliefs
- Social support
IBS
- Physiological background/cause
Chronic gastrointestinal disorder affecting the large intestine.
- Symptoms/physical complaints
Abdominal pain, bloating, diarrhea or constipation, mucus, fatigue and sleep issues
- Biopsychosocial model
Biological: infections can trigger, hypersensitivity to pain in intestines.
Psychological: stress can trigger, cognition (maladaptive thought patterns may increase pain perception),
depression and anxiety may intensify symptoms.
Social: cultural (stigma > hiding symptoms > isolation > stress), limited support > stress.
, - Medical treatment of disease
Dietary changes, medication
- Psychological impact
Anxiety and depression, social withdrawal, reduced quality of life
- Psychological intervention
CBT: helps identify and change unhelpful thoughts and behavior related to symptoms.
Stress management: mindfulness, relaxation exercises, breathing exercises and meditation.
Biofeedback: teaches control over bodily functions to reduce pain.
Psychotherapy: addresses underlying psychological issues
IBD
- Physiological background/cause
Inflammation of the GI tract (maag-darm kanaal), including Crohn’s disease and ulcerative colitis.
Tissue damage and increased risk of complications like colorectal cancer.
Flare ups and symptoms-free periods (remission).
- Symptoms/physical complaints
Abdominal pain, chronic diarrhea, weight loss and malnutrition, fatigue.
- Biopsychosocial model
Biological factors: unknown, likely combination of genetic, immune and environment
Psychological factors: stress triggers flare ups by affecting the immune system, maladaptive coping skills.
Social factors: lack of social support, SES, stigma
- Treatment of disease
Anti-inflammatory drugs, immune system suppressors, surgery, nutritional support.
- Psychological burden
Anxiety and depression, low quality of life, social isolation, body image issues
- Intervention
Psychoeducation
CBT: anxiety, depression, treatment adherence, pain management
Stress management techniques
Support groups and counseling
,Lecture 2
Chronic pain
- Physiological background/cause
Nociceptive pain:
- Somatic pain (deep or surface): caused by activation of pain receptors on skin or muscles.
- Visceral: pressure like, deep squeezing pain.
Neuropathic pain: damage or dysfunction of nerves (examples). Involves changes in the CNS which make the
nerves more sensitive to pain
- Diagnosis
Phases of pain assessment:
1. Performing a clinical interview in which the patient will have the opportunity to describe his or her
pain condition and how pain has impacted his or her life. Begin by obtaining a pain history. Ask about
past and present treatments and things that make the pain increase or decrease. Ask about goals for the
future. Ask about mental health history, current mood and past or present substance abuse.
2. Include self-report measures that have been validated with a chronic pain population.
Undimensional:
- Visual Analog Scale (VAS): often used but abstract
- Numeric Rating Scale (NRS): recommended (scale 1- 10)
- Adjective Rating Scale (ARS): less sensitive to change
Multidimensional:
- McGILL PAIN questionnaire
- Pain diary
- Pain behavior scale: observational
- Pain Coping Strategies Questionnaire: measures the use of coping strategies when pain is experienced
(cognitive and behavioral coping).
- Pain Catastrophizing Scale
- Psychological burden
Pain, catastrophizing, mood, QOL, social isolation, worthlessness, depression, physical deconditioning.
- Intervention
CBT:
- Cognitive restructuring
- Exposure
- Activity pacing
- Steps in problem solving
- Relaxation
ACT: improve QOL by increasing psychological flexibility.
Mindfulness-based cognitive therapy (MBCT): as effective as CBT
Multi-disciplinary group-based rehabilitation program: improvement in mental health.
E-health was also effective.
, Pain is:
1. A signal that something is happening/damaging your body
2. Tries to limit your activities to heal.
Classification of pain according to underlying cause:
- Mixed pain: both nociceptive and neuropathic elements (herniated disc)
- Nociplastic pain (sensitization): nociceptive pain with no threatened or damaged tissue, but with
damaged pain receptor system (fibromylagia).
- Idiopathic pain: pain in absence of evidence of injury or another organic pathology.
Classification according to frequency:
- Transient or brief: lasting only seconds or minutes (bumping knee).
- Intermittent: with or without specific trigger (migraine).
- Constant: chronic lower back pain.
In Somatic Symptom Disorder: a person has one or more significant physical symptoms accompanied by
excessive thoughts, feelings or behaviors related to those symptoms.
Acute pain - lasting < 3-6 months
Chronic pain = lasting > 3-6 months
- 9/10 cases pain is no longer associated with bodily injury (idiopathic)
- Result of ongoing activation of pain receptors which could lead to physiological or anatomical changes
in the CNS where pain information is processed (central sensitization)
Unidimensional models:
- Biomedical - ‘extent of pain reported should be proportional to the amount of detectable damage’.
- Psychogenic - focuses on identification of personality as maintaining factors for persistent pain without
clear medical explanation.
- Learning (behavioral) model - operant conditioning.
Disadvantage of these models: pain is ascribed to either physical or psychological but those influences each
other.
Multidimensional model:
- Gate control model - modulation of pain signal occurs at a site in the dorsal horn of the spinal cord,
where a type of “gate” mechanism exists (open = more pain (depression, anger, catastrophizing,
avoidance), closed = less pain (optimism, distraction, relaxation)). Psychological processes can also
modulate the experience of pain this way.
- Biopsychosocial model
Rheumatoid arthritis
- Physiological background/cause
The immune system begins to attack its own joints, usually symmetrically. Progressive.
- Prevalence
1% of population. More women than men.
- Symptoms/physical complaints
Pain, fatigue, stiffness, growth of abnormal tissue
- Diagnosis
Biological markers
- Disease Activity Score (DAS): swollen joint count, tender joint count etc.
Chronic diseases have both genetic (vulnerability) and modifiable risk factors (even more important if genetic
risk factors are already present).
A behavioural risk factor (: physical inactivity, unhealthy diet, tobacco use) can be the trigger on a biological
risk factor (: high blood pressure, high cholesterol, overweight).
Four pillars of primary prevention:
1. Tobacco cessation
2. Weight loss
3. Healthy diet
4. Regular exercise
The complexer the chronic disease, the lower the quality of life.
Aspects that influence adjustment to chronic illness:
- Personal factors (gender, age and coping skills)
- Social and family support
- SES
- Cultural background
- Activities
- Personal goals
- Life stage
Biopsychosocial model: health and illness are a complex interplay between biological, social and psychological
influences.
- Biological factors:
- Genetics
- Physiology: immune or nervous system
- Pathogens and physical trauma
- Psychological factors:
- Behavior
- Cognition (only indirect effect on development of illness) → influences behavior
- Emotion and stress (only indirect effect on development of illness) → influences biological
- Social factors
- SES: access to healthcare, education, resources
- Cultural beliefs
- Social support
IBS
- Physiological background/cause
Chronic gastrointestinal disorder affecting the large intestine.
- Symptoms/physical complaints
Abdominal pain, bloating, diarrhea or constipation, mucus, fatigue and sleep issues
- Biopsychosocial model
Biological: infections can trigger, hypersensitivity to pain in intestines.
Psychological: stress can trigger, cognition (maladaptive thought patterns may increase pain perception),
depression and anxiety may intensify symptoms.
Social: cultural (stigma > hiding symptoms > isolation > stress), limited support > stress.
, - Medical treatment of disease
Dietary changes, medication
- Psychological impact
Anxiety and depression, social withdrawal, reduced quality of life
- Psychological intervention
CBT: helps identify and change unhelpful thoughts and behavior related to symptoms.
Stress management: mindfulness, relaxation exercises, breathing exercises and meditation.
Biofeedback: teaches control over bodily functions to reduce pain.
Psychotherapy: addresses underlying psychological issues
IBD
- Physiological background/cause
Inflammation of the GI tract (maag-darm kanaal), including Crohn’s disease and ulcerative colitis.
Tissue damage and increased risk of complications like colorectal cancer.
Flare ups and symptoms-free periods (remission).
- Symptoms/physical complaints
Abdominal pain, chronic diarrhea, weight loss and malnutrition, fatigue.
- Biopsychosocial model
Biological factors: unknown, likely combination of genetic, immune and environment
Psychological factors: stress triggers flare ups by affecting the immune system, maladaptive coping skills.
Social factors: lack of social support, SES, stigma
- Treatment of disease
Anti-inflammatory drugs, immune system suppressors, surgery, nutritional support.
- Psychological burden
Anxiety and depression, low quality of life, social isolation, body image issues
- Intervention
Psychoeducation
CBT: anxiety, depression, treatment adherence, pain management
Stress management techniques
Support groups and counseling
,Lecture 2
Chronic pain
- Physiological background/cause
Nociceptive pain:
- Somatic pain (deep or surface): caused by activation of pain receptors on skin or muscles.
- Visceral: pressure like, deep squeezing pain.
Neuropathic pain: damage or dysfunction of nerves (examples). Involves changes in the CNS which make the
nerves more sensitive to pain
- Diagnosis
Phases of pain assessment:
1. Performing a clinical interview in which the patient will have the opportunity to describe his or her
pain condition and how pain has impacted his or her life. Begin by obtaining a pain history. Ask about
past and present treatments and things that make the pain increase or decrease. Ask about goals for the
future. Ask about mental health history, current mood and past or present substance abuse.
2. Include self-report measures that have been validated with a chronic pain population.
Undimensional:
- Visual Analog Scale (VAS): often used but abstract
- Numeric Rating Scale (NRS): recommended (scale 1- 10)
- Adjective Rating Scale (ARS): less sensitive to change
Multidimensional:
- McGILL PAIN questionnaire
- Pain diary
- Pain behavior scale: observational
- Pain Coping Strategies Questionnaire: measures the use of coping strategies when pain is experienced
(cognitive and behavioral coping).
- Pain Catastrophizing Scale
- Psychological burden
Pain, catastrophizing, mood, QOL, social isolation, worthlessness, depression, physical deconditioning.
- Intervention
CBT:
- Cognitive restructuring
- Exposure
- Activity pacing
- Steps in problem solving
- Relaxation
ACT: improve QOL by increasing psychological flexibility.
Mindfulness-based cognitive therapy (MBCT): as effective as CBT
Multi-disciplinary group-based rehabilitation program: improvement in mental health.
E-health was also effective.
, Pain is:
1. A signal that something is happening/damaging your body
2. Tries to limit your activities to heal.
Classification of pain according to underlying cause:
- Mixed pain: both nociceptive and neuropathic elements (herniated disc)
- Nociplastic pain (sensitization): nociceptive pain with no threatened or damaged tissue, but with
damaged pain receptor system (fibromylagia).
- Idiopathic pain: pain in absence of evidence of injury or another organic pathology.
Classification according to frequency:
- Transient or brief: lasting only seconds or minutes (bumping knee).
- Intermittent: with or without specific trigger (migraine).
- Constant: chronic lower back pain.
In Somatic Symptom Disorder: a person has one or more significant physical symptoms accompanied by
excessive thoughts, feelings or behaviors related to those symptoms.
Acute pain - lasting < 3-6 months
Chronic pain = lasting > 3-6 months
- 9/10 cases pain is no longer associated with bodily injury (idiopathic)
- Result of ongoing activation of pain receptors which could lead to physiological or anatomical changes
in the CNS where pain information is processed (central sensitization)
Unidimensional models:
- Biomedical - ‘extent of pain reported should be proportional to the amount of detectable damage’.
- Psychogenic - focuses on identification of personality as maintaining factors for persistent pain without
clear medical explanation.
- Learning (behavioral) model - operant conditioning.
Disadvantage of these models: pain is ascribed to either physical or psychological but those influences each
other.
Multidimensional model:
- Gate control model - modulation of pain signal occurs at a site in the dorsal horn of the spinal cord,
where a type of “gate” mechanism exists (open = more pain (depression, anger, catastrophizing,
avoidance), closed = less pain (optimism, distraction, relaxation)). Psychological processes can also
modulate the experience of pain this way.
- Biopsychosocial model
Rheumatoid arthritis
- Physiological background/cause
The immune system begins to attack its own joints, usually symmetrically. Progressive.
- Prevalence
1% of population. More women than men.
- Symptoms/physical complaints
Pain, fatigue, stiffness, growth of abnormal tissue
- Diagnosis
Biological markers
- Disease Activity Score (DAS): swollen joint count, tender joint count etc.
