Nociceptors in peripheral nerves first sense any noxious stimuli or injury.

A delta fibers- myelinated [fast, transmit sharp pain]

C fibers- unmyelinated [slow, transmit dull, aching pain] 

Gate Control Theory of Pain 

Proposed by Melzack and Wall in 1965. First theory to fully incorporate the psychological side of pain with the physiological side of pain. Also providing a physiological basis for the role of psychological factors in pain. 

- Therevis a mechanism in a part of the spinal cord called the dorsal horn that acts as a sort if gateway to the brain, allowing nerve impulses to get through or not. This depends on 1. Activity in peripheral nervous system & 2. Neural activity in the brain ( thoughts, expectations & emotion)

open the gate = Allows nerve impulses to transmit pain sensations to the brain causing you to feel pain [stimulation conditions] 

closes the gate = prevents nerve impulses from transmitting pain sensations to the brain & keeps you from feeling pain [ inhibition conditions] 

Physiological measures: muscle tension (EMG), heart rate, skin temperature, EEG, brain imaging

Behavioral measures: physical symptoms, pain behaviors (guarding, bracing, rubbing, grimacing, and sighing) 

-Self report measures 

Pain has no substantial cultural component, no ethic or racial differences but individuals from some cultures report pain sooner then individuals groom othe cultures. Women have greater sensitivity to pain.

-Norms for expressing pain at differ in different cultures.

-Different pain mechanisms 

-Book example: expectations for the experience of giving birth in different cultures. 

(Refer to model on slide) Psychological and physical experieces of pain are somewhat of a self fulfilling prophecy.

-more experience of pain = less activity = less happy/bad mood = anxiety = depression = more pain - fear of pain = avoiding activities = muscles weaken = more pain = anxiety = depression

Social learning models- pain bahavior gets reinforced (operant behavioral model) 

Reinforcement- if someone exhibits pain behaviors and expresses that they are in pain, the partner might feel compassionate in wanting to help out and lead the person to experience more pain/ perceive more pain and exhibit more pain behaviors. 

Pain can change our personality

*Minnesota Multiphasic Personality Inventory: chronic pain patients show elevated scores on:

-Hypochondriasis (overly concerned with health) 

-Hysteria (exaggerate symptoms) 

-Depression

*Chronic pain patients (3 types) 

-Dysunctional (give up a lot of activities, change routine, don't know how to function without chronic pain) 

-Interpersonal distressed (in a lot of pain and that causes interpersonal strange with interactions with others) 

-Adaptive copers (experience chronic pain but it doesn't influence their daily activities or relationships as much)

Pain control tehniques: hypnosis, relaxation (muscle, ontrolled breathing, hypnotherapy, meditation), distraction, surgery, pharmacology (morphine)

-CBT (Cognitive behvioral therapy): reconceptualize the problem from overwhelming to manageable, enhance expectations that this training will be succesful, clients role is to be active, resourceful, and competent, clients monitor maldaptive cognitions and stop negative self talk, success is due to the cliets efforts, relapse prvention is part of a pain control.  

-dorsal anteriror cortex (ACC) is where emotional reactions to physical pain registered.

-A functional magnetic resonance imaging (fMRI) study suggests that feelings of being socially excluded are registered in the same brain region (cyberball example)

-Doral ACC activity was positively correlated with self reported distress.

Persist over time, often ending in death.  Living longer = living with more illness in lifetimes.  Physiological symptoms may be distinct but there is so much commonality 46% of Americans have a chronic illness. 

(cardiovascular disase, asthma, cancer, diabetes, arthritis, HIV, senile dementia)

Common reaction to chronic illness is depression.

-1/3 of medical inpatients report at least moderate depression and up to 1/4 suffers from depression.

-can be a sign of impending physical decline; exacerbates the risk and course of some disorders.

-often delayed bc of the time it takes for patients to have a reaction.

-occurs late in adjustment process then denial & anxiety, but can also occur intermittenly.

-complicates treatment adhernce and medical decision making.

Acute: Onset is abrupt, duration limited, cause is single, diagnosis is usually accurate, prognosis is usually accurate, intervention is usally effective, outcome is a cure, uncertainty is minimal, and knowledge is proffessionals.

Chronic: Onset is usually gradual, duration is lengthy or indefinite, causes are multiple, diagnosis is often uncertain, prognosis is often uncertain, intervention is often indecisive, outcome is no cure, uncertainty is pervasive, and knowledge is complentary.

Type 1: "Juvenile diabetes", much less common, often genetic/heritable, failure to produce insulin. Glucose in the blood is controlled by insulin, so when there is  not enough there is more sugar in the blood and it is not being allowed to be absorbed.

Type 2: Insulin resistance (body fails to properly use insulin).  Consuming too much sugar, high sugar, high fat, and obesity. Aquired diabetes, most (95%) have type 2.

Quality of life- how much disease & its treatment interferes with the activities of daily living, such as sleeping, eating, going to work, & engaging in activities (assesses how people are living with chronic conditions)

-Role physical = have I cut down timedone les bc of pain/health conditions?

-Role emotional = Cant stand going to work (motional functioning in the work place compromised)

-Deisgn interventions, help pinpoint which problems are likely to emerge, assesses impact of treatments, compare therapies, inform decision makers about care that will maximize long term survival w/ the highest QOL.

Denial defense mechanism involving the inability to recognize or deal with external threatening events, an early reaction to the diagnosis of a chronic or terminal illness.

-Immediately after the diagnosis, denial cn serve as a protective function poses, reduce days in ICU, and mas the initial terror.

-Rehabilitative phase- dneial may have adverse effects (high deniers at this time show less dherence)

-Active oping vs. avoidance

-Flexibility in coping strategies

-Having a realistic sense of ones illness, the restrictions it imposes, and the required na

-Beliefs about the nature of the illness

-Self blame may be adaptive sometimes, whereas blaming another person never is

-A sense of control and self efficacy (not all studies find adaptive)

-Being optimistic = higher QOL

-Coping with heart failure

-Rated how well patients could manage illness about survival by both patient & spouse.

-Beyond patient & on a spouse level

-Men & women were rated as spuse doing poorly the partient dies quicker as well as patients who rate of support is low.

-Findings included that spousal support protects patient from early death beyond the self efficacy (unsupportive spouse = more likely to diie)

-cognitive behavioral stress management

-At diagnosis: 59% were optimistic about life

-Studied coping & stress levels

-Findings show that optimistic led to less didtresses

-Optimism regardless = less stress over time

-Asthma study: examined between acute & chronic stress in children who have asthma

-asthma symptoms after 14 days of stress/life skill questionaires

-Acute: report daily stress

-chronic: constant (more likely to have children with asthma)

-Another asthma study: family process play a role in the increase of illness

-ECP: white blood cell generators = increase in ECP = asthma

-ECP: white blood cell generators = increase in ECP = Asthma attacks in adolescences  

-Punched a biopsy in caregivers & control group, which then the healing was defined by photos

-Findings include that it took significantly longer for caregivers then controls to heal.

Prolonged fatigue states- fatigue, pain, poor concentartion, irritable mood

Functional somatic syndrome: Not psychosomatic ilnesses but disorders characterized by prolonged fatigue states. (difficult to treat, more common in women, accompanied by depression)

Depression: loss of motivation & pleasure

Chronic fatigue syndrome: un-refreshing sleep, headaches, fatgue present for at last 6 months (no distinguishing biological cause)

Fibromygalia: (Arthritic syndrome) widespread pai  with tenerness in multiple sites tender points.

-Irritable bowel syndrome: diarrhea/onstipation, abdomina pain, bloating

Anxiety: Panic attacks, avoidant behavior

Adherence to treatment regimens in the chronically ill

-High level of non adherence

-need to be followed for a long period of time

-complex regimens

-Interfere w/ other desirable life activities

-Involve lifestyle changes

-Uncertain relationships btwn regimens & outcome

-Side effects (especially w/ hypertensive meds)

-Cognitive and bahvioral interventions might be helpful

-Appropriate education

-self efficacy beliefs

-communication btwn patient & provider

Causes of death across lifespan

1. Heart disease

2. Cancer

3. Stroke

4. Chronic respiratory disease

5. Accidents (unintentional injuries)

6. Diabetes

7. Alzheimer's disease

8. Influeza/pneumonia

9. Nephritis

10. Septicemia

-Psychological experiences of death & dying vary across cultures (socially constructed)

-Healthcare providers can be ethnocentric w/ respect to cultural rituals (significance of emotions of grief)

-Religious & spiritual beliefs about death influence how we live & what we strive for.

-Moral & legal issues- euthanasia

-Ending the life of a person w/ a painful terminal illness for the purpose of terminating the individuals suffering (illegal in US)

-Physician assisted suicide- involves the physician providing the actual drug, although not actually administering it.

-Living will- A will prepared by a person with a terminl illness requesting the extrodinary life sustaining procedures not be used in the event that the ability to make this decision is lost.

-Patient Self determination act- passed by congress 1990, applies to medicare and medicaid health care facilities.

-must have written policies egarding patients wishes for ife prolonging therapy.

-Include provision of DNR NOT RESUSCITATE order in the care of cardiopulmonary arrest. 

-Patient Self determination act- passed by congress 1990, applies to medicare and medicaid health care facilities.

-must have written policies egarding patients wishes for ife prolonging therapy.

-Include provision of DNR NOT RESUSCITATE order in the care of cardiopulmonary arrest.

Kubler-Ross' Stages of adjustment to dying/criticism to stages

-Denial: A mistake must have been made

-Anger: Why me Why not him? Or her?

-Bargaining: A pact with God, good works for more time or for helath

-Depression: Coming to terms with lack of control, "anticipatory grief"

Acceptance: A tired, peaceful calm descends

Criticism: her work is invaluable & her work has not identified stages of dying.

-Institution for dyig patients that encourages prsonalize, warm palliative care

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(

-Psychological comfort is stressed

-patients encouraged to personaliize living areas

-patients establish their own routines

-staff interact in warm & caring ways

-hospice care is less stressful for families

-can provide palliativecare on a par with thatin hospitals

-success as a treatment model 

-Having a spouse dead you are about 40% more likely to die within 6 months of your spouses death then if your spouse does not die

-Diminishes over time substantially after 6 months

-Over a longer period of time, it reverses

-"mortality after the hospitalization of a spouse"

study: men & women differ in terms of their risk for following hospitalization of their spouse

-Men have increased risk following the potential loss/actual loss of their spouse.

-"Process Model" slide: outlines all of the studies that look at how difference in sex/gender cause susceptibility to variation in marital quality then men

-Moderating effect of gender

-Why women in marital conflict demonstrated persistently elevated CV activity? bc, their self construed ideas about themselves are characterized by relation interdependence, incorporate representations of close significant others into the self.

-women are highly interdependent relative to men

-communion greater biological reactivity (communion oriented interdependence) & anxiety.

-Men more  focused on the individual (agency) relative to women.

-How people come to terms with others they have lost in their lives.

-5 adjustments:

1. Chronic depression- 7.8% (pre loss)

2. Chronic grief- 15.6% (not depressed but stay grieved over time)

3.Common grief- 10.7%

 4. Depressed- improved-10.2%

5.Resilient- 45.9% (most common, regardleess of quality of relationship, showed no changes in depression over time)

-Risk for divorce study

-Increased epinephrine during a conflict discussion predictive of later distress; indicator of the SRS (stress horomone in the SNS)

-Early markers of divorce are there and noted biologically

-Study looked at BP activity among recently separated adults (more stressed emotionally = more the BP is activated)

-Divorce related questions were asked in addition to a variety of task (questions about relationship making them think about- where you met, when, when you knew the divorce was coming etc)

-Men who said that the task was very difficult = higher task rated emotional difficulty = greatest risk in BP

-suggest that men who were struggling are at greater reactivity

-women didnt show too much signifigance of an increase in BP no matter how difficult it seemed to be for them.

Reasoning: women are much better at talking with ppl about the details of their life & think about it more often while men often keep it inside and do not talk about it much.

-Men not as skilled as women at talking about emotions.

-People who are lonely tend to have poor health outcomes

4 Potential mechanisms:

1.Health behaviors

2.CV

3.Cortisol levels

4.Sleep

-Study 1: college students who felt lonely

-study 2: older adults in the home

-People who are lonely = poor sleep = more cardiovascular reactive to what is going on.