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?
Onset
Duration
Cause
Diagnosis
Prognosis
Intervention
Outcome
Uncertainty
Knowledge
Acute
abrupt
limited
single
usually accurate
usually accurate
usually effective
cure
minimal
professionals
Chronic
usually graduated
lengthy, indefinite
multiple, changes
often uncertain
often uncertain
often indecisive
no cure
pervasive
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
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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
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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”
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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)
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Epidemiology
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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
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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”
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An increase in unsafe behaviors in response to the
introduction of a preventive or therapeutic intervention
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Applies to any field of public health, not just HIV
- seat belts/reckless driving
- chest x-ray/tobacco use
- anesthesia for childbirth/sexual activity