Psychology of Patient Care

• Goal of psychology is to “understand and predict human behaviour”

• Application to pharmacy practice situations

• Role of theory:– in understanding/explaining behaviour– in intervening to change behaviour– in providing practical approaches to PC

Psychological Theory Applied to Pharmacy Practice

View “Person” as a…

Anatomical being

Biological being

Temporal being

Thinking being

Psychological being

Social being

Relevant Theory

Neuropsychological

Behaviouralism

Developmentalism

Cognitivist

Psycho-analytic

Socio-psychological

Neuropsychological Approaches

• Focus on genetic components

• Deterministic model of human behaviour: highly predictable outcomes from interventions

• Reductionist approach to human behaviour

• Major focus of pharmacologic therapies

Behavioural Approaches

• Views human beings as biological entities struggling for survival in complex systems

• Personality is a a learned behaviour that confers an adaptive value

• Human responses are stable and predictable in stable and predictable situations

• Environment “causes” personality

Developmentalist Approaches

• Psycho-social development is rooted in physiological development

• Time is a major determinant of behaviour and personality

• Clearly demarcated “stages of development” that must be crossed in a linear way

Cognitivist Approaches

• Human beings are unique in their ability to reason and to think

• Behaviour is governed by thoughts aimed at achieving goals - problem behaviours are a reflection of problem goals

• Few, if any, instincts or unconscious motivators

• Changing thinking can change feelings

Psychoanalytic Approaches

• Principle of psychic determinism: “nothing happens by chance”

• Theories of personality structure and formation

• Ego defences as primary determinants of behaviour and personality

Socio-psychological approaches

• Behaviour is governed by social influences

• Issues of conformity, attitude formation and group processes

• How do “others” influence behaviour (and thoughts, attitudes and feelings)…the role of social influence in personality development and behavioural expression

Role of Theory

• Represents a continuum

• No one theory appears to adequately account for the complexity of human behaviour

• No model for integrating all theories

• Emphasis and application of key points to specific situations

Case Study: Anxiety

CW is a 22 year old engineering graduate student. Despite achieving good grades throughout high school and her first two years of university, she is complaining of numerous somatic symptoms: she has mid-night awakenings, sweaty palms, racing pulse and palpitations. At times the sensation is unbearable, and she cannot sleep. Her MD has ruled out any physical pathology and has prescribed lorazepam SL 1-2mg tid prn and hs.

Background Terms:

Stress: An external stimulus interpreted as dangerous

Fear: Short-term physiological/psychological response to stress

Anxiety: Longer-term physiological or psychological response to stress

Anxiety Disorders

• Most common mental illness in N. America

• <25% of Americans receive any kind of treatment

• Mortality/morbidity significance

• Examples (DSM IV): panic, phobia, OCD, post-traumatic stress, generalized anxiety

• Why does it only affect some people?

Neuropsychologic Approach

• Genetic component to anxiety: some people are “born worriers”

• MRI studies suggest differences in the way anxious and non-anxious people’s brains respond to stress

• Anxiety = breakdown in mechanism that keeps normal anxious response from spinning out of control

Neuropsychological Interventions

1) Block stimulation of cortex

2) Block release of neurotransmitters from the amygdala or other areas of the brain

3) Block end-organs (e.g. adrenal cortex, cardiac tissue, respiratory system etc.)

4) Target neurotransmitter cascade through CNS – role of pharmaceuticals

Issues with Medications in Treatment of Anxiety

• Side effects (including dependency)

• Onset of action

• Reduction of efficacy over time

• “Masking” of symptoms rather than treating underlying problem

• Short term efficiency vs. long term efficacy

• Does this approach make sense?

Behavioural Approach

Rather than “block” anxiety-provoking stimuli, try to get patient accustomed to it so they don’t experience it in the same manner through use of:

• habituation techniques

• conditioning techniques (“desensitizing”)

• reward structures

Developmentalist Approach

• Anxiety can be seen as a mis-fit between stage of development and the environment

• Use developmental theory to align environment to individual’s stage and needs

• e.g. Stage 6 (Early Adulthood (20-35))

- major crisis is “intimacy vs. isolation”

- address this issue to deal with anxiety

Cognitivist Approach

Rather than “train” people to deal with anxiety, encourage them to use the power of the mind to reason through it.

- identify triggers

- identify goals for responding to triggers

- use cognitive models to understand how anxiety can be “thought- through”

Psycho-analytic Approach

Recognize that you are anxious because you WANT to be anxious (ie. Anxiety confers some benefit to you)

- identify structure of personality and how this has lead to certain, ritualized ego defences that manifest as anxiety

- understanding this provides key to treatment

Socio-psychologic approach

• Determine how individual’s thoughts, feelings and behaviours are influenced by the real or imagined presence of others

• Define the construal: the way in which people perceive, comprehend, and interpret their social world

• Key is the peer group

So how does a tiny little pill like that actually work?

Neuropsychologic: targets receptors

Behavioural: stimulus-response conditioning

Cognitive: mask symptoms to provide zone for development of self awareness

Developmental: mask symptoms

Psychoanalytic: mask symptoms

Social-psychological: mask symptoms

Are there alternatives to the little white pill?

Neuropsychological: other little white pills

Behavioural: biofeedback

Developmental: lifestyle changes

Cognitive: talk-therapy

Psychoanalytic: hypnosis, analysis

Socio-psychological: peer grouping

Summary

• Anxiety is one of a cluster of conditions that form a large part of professional practice

• Anxiety is a multi-faceted medical problem

• Focus on neuropsychological approach solely is unsatisfactory and ineffective

• Other interventions must be exercised in combination

Summary

• Major issues in pharmacy practice include:

- mental health issues

- lifestyle modification issues (smoking, diet, unsafe sexual practices, etc.)

- motivation for compliance to medication/lifestyle modification regimes

Applying psychological theory to pharmacy practice

• “Walk around the problem”: consider both the physiological/pharmacological issues and the psychological issues

• No single, perfect formula or solution to complex human, behavioural issues - instead, must rely upon using a variety of methods to address individual needs

Case Study