Cheng Zhang Habituation (↓ strength of behaviour; low intensity stimuli; stimulus specific generalisation; ↓NTs)/sensitisation (opposite) learning to notice or ignore – simplest form of learning Classical conditioning: •
UCS (stimulus that evokes an innate response) UCR (the innate response to UCS)
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UCS + CS (stimulus with association with UCS elicits a CR) UCR
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CS CR
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Examples: Pavlov’s dogs; Little Albert (classical conditioning of fear of white rat with association with hitting a metal rod)
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Strongest when repeated CS-UCS pairings; UCS more intense; forward pairing i.e. CS UCS; time interval between CS and UCS is short
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Extinction = CS presented repeatedly in absence of UCS causing CS to weaken and disappear
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Spontaneous recovery = reappearance of a previously extinguished CR after a rest period
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Stimulus generalisation = similar stimuli elicit response, but weaker
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Stimulus discrimination = respond to various stimuli differently (CR in one stimulus but not another)
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Higher-order conditioning = neutral stimulus becomes CS after paired with already established CS
Operant (instrumental) conditioning: •
POSITIVE AND NEGATIVE = presentation or removal of a stimulus
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Reinforcement = response strengthened by outcome that follows it
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Positive reinforcement = positive event follows response
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Primary reinforcers satisfy biological needs e.g. food; secondary associated with primary e.g. money
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Negative reinforcement = negative event removed by response
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Reinforcer = outcome that increases frequency of response
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Punishment = outcome weakens the frequency of a response
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Positive/aversive punishment = discomfort follows response
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Negative punishment/response cost = positive state removed after response
Learning:
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Shaping (learn complex behaviours in small steps) and chaining (reinforce each response with the opportunity to perform the next response to learn a sequence of reponses)
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Operant extinction (response weakens and disappears as no longer reinforced); operant generalisation and discrimination
Reinforcement schedules: •
Fixed (interval/ratio) schedule = reinforcement occurs after fixed no of responses or after fixed time interval
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Variable (interval/ratio) schedule
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Continuous reinforcement = more rapid learning but extinction more rapid
Two factor theory of phobias •
Factor 1: classical conditioning of fear e.g. CS (car) + UCS (car accident) CR (conditioned fear of cars)
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Factor 2: operant conditioning of avoidance e.g. avoid cars fear is reduced tendency to avoid cars strengthened i.e. avoidance of cars negatively reinforced
Observational learning/social learning/vicarious conditioning •
Watching/imitating others and noting consequences of their actions
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Vicarious reinforcement: if their behaviours are reinforced we tend to imitate the behaviour
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Example: Bobo doll experiment – those who observed violence to Bobo doll were more violent to the doll
Health behaviour = any activity undertaken by a person believing himself to be healthy, to prevent disease or to detect it at asymptomatic stage Effect of education of health behaviour = Effect smoking in schools (Nutbeam) showed no effect of education on outcome Effect of pos reinforcement and limitations = Effect pos reinf on health behaviours (Kegels) showed that reward > information > discussion for compliance. Limitation is positive reinforcement is too costly. Effect of fear arousal (Janis & Fesbach) showed that negative reinforcement more effective on behaviour if the fear induced was lower. Expectancy value theory = potential for behaviour to occur function of the expectancy the behaviour will lead to a particular outcome and the value of that outcome. Outcome efficacy = individual’s expectation that the behaviour will lead to a particular outcome NEED TO KNOW Self efficacy = belief that one can execute the behaviour required to produce the
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Depends on:
1. Mastery experience/performance experiences (previous successes/failures on similar tasks) 2. Social learning (obs of behaviours and consequences to similar models in similar situations) 3. Verbal persuasion or encouragement 4. Physiological arousal (enthusiasm or anxiety) NEED TO KNOW Health belief model and Theory of planned behaviour Abstinence violation effect = person upset and self-blame over relapse – views as proof of their incapability to resist temptation. Relapse prevention – need coping response for increased selfefficacy to decrease probability of relapse. Sensation = sense organs translate env stimuli to nervous impulses to brain (sense organs respond to constant stimulus by decreasing activity); Perception = making sense of what our senses tell us (higher processing) •
Absolute threshold = lowest intensity stimulus is detected 50% of time
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Difference threshold = smallest difference between two stimuli detected 50% of the time
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JND = smallest increase of decrease in intensity of a stimulus that a person is able to detect
Attention •
Focusing on certain stimuli; filtering out other stimuli
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Affected by stimulus characteristics: intensity, novelty, movement, contrast, repetition
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Affected by personal factors: motives, interests, threats to well-being
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Cocktail party effect; Attentional capacity model (avail attention depends on level of arousal); Dichotic listening task (focus on one convo, not consciously aware of input to unattended ear but can affect interpretation of information in the attended ear)
(Gestalt laws of perceptual organisation: similarity, proximity, closure, continuity) (Perceptual constancy: visual, shape, brightness, size compensation) Bottom-up processing: progression of recognising and processing info from individual components of a stimuli and moving to the perception of the whole Top-down processing: sensory info is interpreted in light of existing knowledge, concepts, ideas, and expectations Perceptual schema = mental representation or image containing the critical and distinctive features of a person, object, event or other perceptual phenomenon. Provide mental templates that allow us
Cheng Zhang to identify and classify sensory input. Perception differs across cultures e.g. object on woman’s head. Critical periods in perceptual development = certain kinds of experiences must occur if perceptual abilities and brain mechs that underlie them are to develop normally e.g. kittens raised in vertical environment unable to see horizontal objects Humphreys and Riddoch hierarchical model of object recognition Early visual processing ↔ view-pt dep. object descrip ↔ perceptual classif ↔ semantic classif ↔ naming
Gate theory of pain: A gating mechanism – gate open = high pain (stimulatory input from brain and other peripheral fibres on the gating mech); gate closed = low pain (inhibitory input on gating mech) Example: Beecher: wound severity and pain relationship between soldiers and civilians – psychological factors influence pain perception Measurement of pain 1. Subjective •
Verbal measures: unstructured; verbal rating scales e.g. mild, mod, severe; visual/graphical scales e.g. 0-10 numeric; visual analog scale; simple descriptive pain intensity scale
2. Behavioural •
Based on behaviour e.g. facial expression, crying, breathing patterns e.g. Neonatal/infant pain scale (NIPS) recommended for <1 year old
3. Physiological measures •
e.g. Galvanic skin response (GSR); Heart rate, Breathing rate
Factors affecting the perception of physical symptoms 1. Attention 2. Environmental cues e.g. coughing in lectures i.e. attention directed to internal sensations if level of external stimulation is low or overwhelming 3. Expectation – what people are told affects perception (if you’re told it’ll hurt you’re more likely to feel pain) – Example: Anderson & Pennebaker – effect of expectancy of perception hand on vibrating sandpaper, told felt pleasant/painful/no info 4. Emotional factors – Example: Arntz – attention vs anxiety low attention reduces pain, the level of anxiety has no affect Also, physiological state, and beliefs/labels affect how symptoms are perceived – Example: Ruble – effect of label on symptom perception given ‘label’ of menstruation due date, those closer to due date reported more premenstrual symptoms Placebo effect
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Improvement in condition of a sick person occurs in response to treatment but cannot be considered due to the specific treatment used
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Associated with patient factors (no clear responder personality); treatment factors – injections > pills, larger pills more effective, green/brown pills more effective; therapist factors e.g. status of practitioner, confidence in practitioner
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Possible MOA: Expectancy; Classical conditioning; Anxiety/attention; Release of endogenous opiates
Acute vs. chronic pain Acute = <1 month from injury to resolution: usually obvious tissue damage; increased nervous system activity; pain resolves on healing; serves a protective function Chronic = >3-6 months: pain beyond expected period of healing; usually no protective function; degrades health and function Illness representations (NEED TO KNOW) = patient’s own implicit commonsense beliefs about their illness 1. Identity (the label) 2. Cause 3. Time-line (patient’s view how long it will last and acute, chronic or episodic) 4. Consequences (patient’s view of effects they expect from illness and views on outcome) 5. Curability/Controllability (patient’s expectations as they recover from or control illness) Factors influencing illness representations e.g. previous experience; social learning; culture; personality/individual differences; transmission of information e.g. medical student’s disease Leventhal’s self-regulatory model = interpretation of health threat action plan/coping strategy appraisal of coping strategies/actions and reflecting on need for modification Nature vs. Nurture Temperament = innate aspects of an individual’s personality Reciprocal socialisation = children socialise parents and vice versa – behaviours of both rely on interconnection, mutual regulation and synchronisation Development of attachment •
Birth to 3mths: prefer people to inanimate objects
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3-8mths: smiles to main caregivers
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8-12mths: selectively approaches main caregivers; shows fear of strangers and separation anxiety
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>12mths: attachment behaviour can be measured reliably
Secure attachment in infancy protective factor leading to resilience throughout lifespan Piaget’s model of cognitive development = children’s thinking changes qualitatively with age •
Sensorimotor stage (birth to 2): differentiate self from objects; recognises self as an agent of action; acts intentionally; understand the world mainly through sensory experiences and motor interactions with objects; achieves object permanence i.e. understands object continues to exist even if it cannot be sensed
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Preoperational stage (2-7): learns to use language and to represent objects by images and words; thinking still ego-centric; no understanding of principle of conservation i.e. principle of objects stay same even through outward appearance may change; animism (attributes life-like qualities to physical objects and natural events)
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Concrete operational stage (7-12): can think logically about objects and events; can perform basic mental operations concerning problems that involve concrete/tangible objects and situations; understands concept of reversibility (can reverse actions mentally); easily solve conservation problems; trouble with hypothetical and abstract reasoning
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Formal operation (12 and up): can think logically about abstract propositions and test hypotheses systematically; concerned with hypothetical, future and ideological problems
Accommodation = process where new experiences cause existing schemas to change Assimilation = process where new experiences are incorporated into existing schemas Kohlberg’s theory of moral reasoning (basis for judging what is moral) •
Level 1 – preconventional morality: whether you think you will be rewarded or punished
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Level 2 – conventional morality: conform to social expectations and adopt others’ values e.g. parents
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Level 3 – post-conventional morality: moral principles internalised as one’s own belief/value system
Criticisms: western cultural bias and male bias Transactional def of stress = Stress is a condition that results when the person/environment transactions lead the individual to perceive a discrepancy between the demands of the situation and the coping resources available Problem-focused vs emotion focused coping o
Problem focused coping: efforts directed at changing the environment or changing one’s own actions or attitudes
1. Increasing predictability: Johnson – effect of information demonstrated sensory info (about
Cheng Zhang the sensations that may be experienced) more effective at lowering distress than procedural info (about the procedure to be undertaken). Dual process hypothesis = procedural and sensory info work in different ways – procedural allows patients to match ongoing events with their expectations in non-emotional manner; sensory maps a non-threatening interpretation on to these expectations. Auerbach – amount of info and distress found people who preferred less info had lower distress when less info was given; people who preferred more detailed info had lower distress with more specific info. Distress levels were higher when preferences were not matched. 2. Increasing control: If people feel they have more control there is less distress. Langer and Rodin Nursing home study (flower power study) showed those given more control had better health and well-being. Trash – traffic light study asked patients to signal discomfort during procedure by pressing buttons – felt they had control so less pain was felt.
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Emotion focused: efforts designed to manage the stress-related emotional physical responses e.g. meditation, relaxation techniques, deep-breathing, praying
Martelli – problem focussed vs emotion focussed showed people who preferred less info did better with emotion focussed coping, people who preferred more info did better with problem based coping. Optimal coping strategy depends on individual’s own copy style and the situation Effect of social support on coping i.e. stress buffering (e.g. time with post-op patient vs pre-op on recovery) Helping children to cope with treatment: •
Children’s distress during routine immunisation correlated with distress shown by parents
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Video explaining procedure reduced distress; Children <7 benefit more from info presented shortly before a procedure; Older children benefit most from info presented 4-7 days before a procedure.
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Tell (simple language, matter-of-fact, what will happen); Show (demonstrate on inanimate object); Do (when child understands what is going to be done)
Freud’s psychodynamic theory of personality: personality is energy system •
Id (uncoordinated instinctual trends; exists totally in unconscious mind; pleasure principle)
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Ego (organised realistic part of psyche; conscious level primarily; reality principle – tests reality and decides when Id can satisfy needs)
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Superego (critical and moralising function; morality principle)
Five factor model of personality (OCEAN – big 5 supertraits) 1. Openness (appreciation of art, emotion, adventure, imagination) 2. Conscientiousness (tendency to show self-discipline) 3. Extraversion (energy, positive emotions, tendency to seek stimulation and company) 4. Agreeableness (tendency to be compassionate and co-operative) 5. Neuroticism (tendency to experience unpleasant emotions easily) Attachment theory as result of early experiences with caregivers Locus of control = an expectancy concerning the degree of personal control we have in our lives: internal (life outcomes are under personal control) or external (outcomes have less to do with own efforts than with influence of external factors) IQ = intelligence quotient: 100 is average; normally distributed; ((mental age/chronological age) x 100); may be culturally biased; gender differences in performance on certain intellectual tasks – not general intelligence e.g. M>F on spatial tasks; F>M on perceptual tasks and verbal fluency •
Twin studies show genetic factors (1/2 to 2/3 of IQ variation); environmental factors (1/3 to ½)
Crystallised and fluid intelligence (breakdown of Spearman’s g factor – i.e. belief that intelligence is general) •
Crystallised intelligence improves with age = ability to apply previously acquired knowledge to current problems
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Fluid intelligence declines with age = ability to deal with novel problem-solving situations for which personal experience does not provide a solution
Empathising and systematising theory (Baron-Cohen) – divides ppl into 2 groups •
Empathisers – able to identify and approp respond to emotions and thoughts of others; tend to be adept at reading non-verbal communication and judging character
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Systemisers – those comfortable analysing how systems work and behave, final goal of predicting and controlling system behaviour or building a new system
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3 basic brain types: E-type is predominantly female; S-type is pred male; B-type is balanced
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Hence autism/Asperger’s more common in males (extreme male brain – lack E, very S)
Kubler-Ross’ stage model of adjustment to dying – 5 reactions Denial Anger Bargaining Depression Acceptance Lack of evidence for stages
Cheng Zhang 5 Myths of coping with loss (Wortman and Silver) – why Kubler-Ross model is not perfect 1. Distress or depression is inevitable 2. Distress is necessary and failure to experience distress is indicative of pathology 3. The importance of ‘working through’ the loss 4. Expectations of recovery (Pollard and Kennedy – long term follow up in SC injury shows may not be realistic as no decline in depression over 10 years) 5. Reaching a state of resolution Moos’ Crisis Theory of coping with serious illness – factors affecting adjustment •
Illness related factors: pain, disability, uncertaintly/progressiveness, disfigurement/visibility (stigma)
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Background/personal factors: age of onset, pre-existing personality, gender, religious views, attribution of blame Bulman and Wortman – attribution of blame and adjustment to SCI found patients who blamed themselves for injury rated as coping better, pre-existing health beliefs
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Physical and social env: accommodation, physical aids/adaptations, social support, stigma
The above all affect coping process (coping appraisal – primary = threat/demand; secondary = coping resources adaptive tasks (coping with symptoms/disability; controlling negative feelings) coping skills (seeking info; denying seriousness; seeking emotional support) outcome of crisis) WHO model of disability: psych factors can be integrated to increase predictive validity; model includes body functions and structures (impairment); activities (limitation); participation (restriction) and environmental and personal factors health condition (disorder/disease) Attitudes and prejudice; Self-fulfilling prophesy •
Attitude = positive or negative evaluative reaction to a stimulus; stronger influence on behaviour when contradictory situation factors are weak
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Prejudice = a negative prejudgement of a group or its individual members; Stereotype = schemas about characteristics ascribed to a group of people based on qualities e.g. race, gender, ethnicity; Discrimination = behaviours that follow from negative evaluations or attitudes towards members of particular groups
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Self-fulfilling prophesy – when told something about someone we’re more likely to view them in that way (the prophesy/prediction directly/indirectly causes itself to be true)
Social loafing = tendency for people to expend less individual effort when working in a group than when working alone.
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More likely to occur when:
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Person believes individual performance is not being monitored
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Task (goal) or group has less value or meaning to the person
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The person generally displays low motivation to strive for success
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The person expects that other group members will display high effort
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Depends on gender & culture: occurs more strongly in all-male groups and in individualistic cultures
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May disappear if individual performance is measured or if members value highly their group of the task goal
Ringelman – tug of war study shows in collective tasks people only put forth as much effort as they expect is necessary to reach their goal – more pullers = proportionally less added weight pulled (hyperbolic curve) Conformity = adjustment of individual behaviours, attitudes and beliefs to a group standard •
Asch – conformity
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Factors that affect conformity: Group size (but no increase >5 members); presence of a dissenter greatly reduces conformity; Culture (greater in collectivistic cultures; Public response; Lack of prior commitment; Cohesion; Status; Unanimity
Milgram – Obedience shock generator to apply punishment for mistakes – gradually upping voltage •
Factors influencing obedience: Remoteness of victim; Closeness and legitimacy of authority figure; Diffusion of responsibility (obedience increases when someone else does the dirty work); NOT personal characters!
Group decision making •
Group think = tendency of group members to suspend critical thinking because they are striving to seek agreement
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Group polarisation = tendency of people to make decisions that are more extreme when they are in a group opposed to a decision made alone or independently
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Symptoms of group think: direct pressure (applied to people who express doubt); mind guards (people who prevent negative info from reaching the group); members display self censorship and withhold their doubts; an illusion of unanimity is created
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Most likely to occur when a group: is under high stress to reach a decision; is insulated from outside input; has a directive leader; has high cohesiveness
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Deindividuation e.g. protestors at Millbank; factors: group size (larger groups more extreme decisions); physical anonymity (not identifiable); arousing and distracting activities
Cheng Zhang (chanting, dancing) Darley & Latane - Helping behaviour more people helped student having epileptic seizure in adjacent room if they believed it was just them and the other student, fewer people helped if they believed they were in a group of 4 and hardly anyone helped if group >4. If they didn’t act in first 3 minutes, they never acted.
Bystander effect (Kitty Genovese): presence of multiple bystanders inhibits each person’s tendency to help, due to social comparison or diffusion of responsibility (see above case) – 5 steps in process (LEARN) 1. Notice the event 2. Decide if the event is really an emergency (social comparison – see how others are responding) 3. Assuming responsibility to intervene (diffusion of resp – believing others will help) 4. Self-efficacy in dealing with the situation 5. Decision to help (based on cost-benefit analysis)
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Increasing helping behaviour:
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Reducing restraints on helping – reduce ambiguity and increasing responsibility; enhance guilt and concern for self-image
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Socialise altruism - teaching moral inclusion; modelling helping behaviour; attributing helpful behaviour to altruistic motives; education about barriers to helping
Leadership styles (Kurt Lewin) – 3 styles •
Autocratic/authoritarian
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Participative/democratic
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Laissez-faire or ‘free rein’
Nisbett and Wilson – effect of extraneous fectors on decision making - people are affected by irrational extraneous factors in their decision making; they are not consciously aware of these factors and if asked to comment on decision making process will give a post-hoc rationalisation which they believe to be accurate Slovic – confirmatory bias and overconfidence experienced horserace handicappers given list of variables relating to past performance of horses and riders and asked to predict race outcome based
Cheng Zhang on 5 most important items, then 10, 20 and 40. Confidence increased with items of info but accuracy stayed constant. Sunk cost fallacy: sunk costs are any costs that have been spent on a project that are irretrievable – rationally the only factor affecting future action should be future cost/benefit ratio but often the more invested in the past, the more we are prepared to invest in the future – also known as ‘concorde effect’. Anchoring effect: psychological heuristic that influences way people assess probabilities. People start with an implicitly suggested reference point (the anchor) and make adjustments to reach their own estimate; adjustments are crude and imprecise – individuals are anchored by the starting point and are poor at adjusting estimates from the given starting point e.g. given probability of treatment success (the anchor/starting point) then make adjustments to it to come to own estimate Gambler’s fallacy = a logical fallacy involving mistaken belief that past events will affect future events when dealing with independent events Baye’s theorem for conditional probabilities allows objective assessment of probabilities Framing effect = how options are framed affects decision making e.g. ‘lives saved’ vs. ‘lives lost’ Availability heuristic: probabilities are overestimated/judgements based on how easily and or vividly they can be called to mind. Individuals typically overestimate the frequency of occurrence of catastrophic, dramatic events Representative heuristic: subjective probability that a stimulus belongs to a particular class based on how ‘typical’ of that class it appears to be (regardless of base rate probability) e.g. numbers appearing in lottery 1,2,3,4,5,6 Improving decision making •
Recognise that heuristics and biases may affect our judgement even though we may not be conscious of it
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Counteract the effect of top-down info processing by generating alternative theories and looking for evidence to support them rather than just looking for evidence which confirms our preferred theory
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Understand and employ statistical principles e.g. Baye’s Theorem; Law of large numbers (larger sample size more representative)
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Use of algorithms (e.g. rules of probability – procedure, if followed exactly, will provide most likely answer based on evidence)
Stages of memory process Registration (input from senses to memory system) Encoding (processing and combining of info received – effortful processing is initiated intentionally; automatic processing occurs without intention) Storage (holding input in the memory system) Retrieval (recovering stored info from memory system – can be activated by cues; process is conscious/effortful or unconscious/automatic)
Cheng Zhang Sensory memory, working memory, long-term memory (based on duration of memory retention) •
Sensory memory = earliest stage; sensory info stored for very brief period – either forgotten or encoded into long-term memory; <0.5s for visual info; 3-4s for auditory info; what we attend to passes into working memory
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Working memory = short-term memory store; limited content capacity; chunking allows more to be remembered; new info pushes out old; rehearsal can maintain info in memory; info in store can be actively manipulated – hence working memory.
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Baddeley model of working memory (see notes)
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Central executive (main component) = manipulation of info and direction of attention to relevant info; suppression of irrelevant info and undesired actions; supervision of info integration; co-ordination of multiple tasks to be executed in parallel; co-ord of subsystems of working memory
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Visuospatial sketchpad = storage of visual and spatial info e.g. representing mental maps
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Phonological loop = storage of auditory/verbal info; prevent decay by silently articulating in a loop
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Episodic buffer = temporarily integrates phonological, visual and spatial info in a unitary, episodic representation – hence interface with episodic long-term memory (i.e. recollection of specific events that integrate time, place and emotions)
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Long-term memory = store of all things in memory not currently used but available for future use; allows use of past info to deal with present; can hold unlimited amount of info (see notes for types of memory)
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Retrieval from long-term memory may be: •
Explicit/declarative (conscious)
Episodic (biographical events) – relate to our personal experience; ‘memories’ Semantic (words, ideas, concepts) - memory for facts; ‘general knowledge’ Implicit/non-declarative (unconscious) – familiar with something, know how to interact with object or in situation but don’t have to think about it e.g. procedural memory (for actions and behaviours), emotional conditioning, conditioned reflex, priming effect. Example – walking, eating. Associative networks = stored ideas are connected by links of meaning, strengthened through rehearsal and elaboration – each concept represented by a node; priming = activation of one concept by another e.g. bus linked to school linked to student linked to bus linked to yellow linked to blue etc Schemas and memory encoding = schema is a mental framework about some aspect of the world, used to organise current knowledge and provide a framework for future understanding. Automatic thought acquired through experience e.g. schema for how to behave at weddings based on past
Cheng Zhang knowledge e.g. TV portrayals. Expertise = process of developing schemas that help encode info into meaningful patterns. Schemas affect our memory by: •
Selection (info does that fit is ignored
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Abstraction (inclined to recall overall gist and forget the detail)
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Interpretation (schemas provide existing knowledge to help understand new situations)
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Normalisation (memories distorted to fit existing expectations)
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Retrieval (schemas help fill gaps in our memory by making a best guess)
Misinformation effect = distortion of a memory by misleading post-event information Loftus and Palmer - eyewitness testimony showed manipulating the way a question is asked affects the recall of the event e.g. car accident and using ‘smashed’, ‘collided’, ‘hit’ or ‘bumped’ had effects on estimation of speed/whether broken glass was (falsely) recalled. Fear/stress also aids recall. Retrieval cues assist recall. Probability of recalling a word related to order in list (primary and recency effect; serial position effect); personal salience of words; delay/time; distraction Executive function = involve planning, decision making, error-correction, new sequences of action, technically difficult situations, problem-solving, resisting temptation/habitual response. Phineus Gage destruction of one or both frontal lobes lead to personality change (irritable, impatient, quick tempered) and unable to complete tasks at work Dysexecutive syndrome = impulsivity; disinhibition; emotional bluntness; attentional problems; perseveration; inability to plan; copes with written and structure but not unstructured tasks; difficulty grasping complex or abstract ideas Strategies for enhancing memory •
Rote: frequent repetition (verbal); forms a separate schema not clearly linked with existing knowledge and is less efficient with less deep processing
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Assimilation: fitting new info into existing schemas; learning by comprehension; can only be used where there is a link between old and new knowledge; deep processing and wholly declarative
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Mnemonic device: artificial device for reorganising or encoding info to make it easier to remember; useful when info doesn’t fit existing schemas; e.g. hierarchies, chunking, visual imagery, acronyms – need to recall artificial structure to access information
Non-adherence = not ‘sticking fast’ to; 10% prescribed meds never started; 34% medication courses not completed; only ¾ prescriptions dispensed. Consequences: increase hospital admissions (20% due to non-adherence); rejection of transplants; occurrence of complications; development of drug resistance; increased mortality Macintyre – agreement between patient and professional ratings of adherence showed only 50% patients rated non-adherent by doctors also rated so by nurses; best concordance with actual adherence is self-report; many ratings of adherence by doctors and nurses inaccurate
Cheng Zhang Causes of non-adherence (no consistent relation with age, SES, intelligence, personality):
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Regime/treatment related factors e.g. physical aspects (packaging, font size); complexity; duration; cost; side-effects
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Patient practitioner interaction e.g. communication style; understanding and recall of information; satisfaction
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Factors affecting recall of information:
Individual factors: Anxiety; Medical knowledge Presenting factors: 1. Amount of information Ley and Spelman – amount of info and recall showed increased no of statements lead to decreased percent mean recall 2. Order (serial position effect – primary and recency effect) 3. Stressing importance 4. Specificity 5. Mode of presentation – !!most patients want written info!! Ley – effect of readability on adherence showed increased percent understanding led to decrease mean percent medication error 6. Follow up •
Psycho-social variables e.g. health beliefs (N.B. health beliefs model); illness representations (patient’s own implicit commonsense beliefs about their illness); self-efficacy; social support (psychosocial influences at multiple levels: individual, close relationships, context, culture)
Improving adherence: Simplify/improve regime; Improve interaction especially communication style and presentation; Identify and modify beliefs; Involve significant others and wider network Stress models: As a stimulus; As a response; Transactional model as a transaction between person and environment (discrepancy between the demands of the situation (primary appraisal) and the coping resources available (secondary appraisal)) Stressors = stimuli that place demand on us and require us to adapt in some manner (microstressors; major negative events; catastrophic events) Psycho-physiological response to stress and behavioural pathways linking stress to disease •
Presence of negative emotions:
1. Alarm phase – activation of sympathetic NS to increase arousal 2. Resistance phase – endocrine system releases stress hormones including cortisol; hormone
Cheng Zhang stores depleted 3. Exhaustion phase – increased vulnerability to disease in weak body systems •
Stress causes immunosuppression e.g. decreased production of IL1 leading to poorer wound healing
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Stress leads to behaviour changes and psychological changes, which both lead to disease
Type A behaviour pattern = individuals who tend to live under great pressure and demand much of themselves and others; high levels of competitiveness, ambition, aggressiveness, hostility and goaldriven. Have double the risk for CHD – driven by negative emotions e.g. anger and overreaction to stressful events Depression also linked with CHD (1.64-1.9x higher RR); CHD patients with depression 2-2.5x higher risk of first 2 year mortality – reasons range from physiological changes e.g. platelet activity to behavioural changes e.g. levels of physical inactivity Social support and health Holt-Lunstad – social relationships and mortality risk showed stronger social relationships linked with increased likelihood of survival. A lack of social support linked to suppressed immune function (physiological and due to non-adherence); perceived social support may buffer effects of depression. Coping with stress (again!) 1. Problem-focussed e.g. finding out info on a disease, learning new skills to manage it 2. Emotion-focussed e.g. disclosing trauma; acceptance; controlling feelings 3. Seeking social support Recurrent coronary prevention project RCCP – Friedman is trial of counselling to alter type A behaviour – the counselling group had lower cumulative cardiac recurrence rates. 4 Main schools of psychological treatment (goal of all psychotherapy to help ppl change maladaptive thoughts, feelings and behaviour patterns) •
Psychodynamic/psychoanalytic techniques (5 major ones)
1. Free association (clients verbally report without censorship thoughts, feelings, images that enter their awareness) 2. Dream interpretation 3. Resistance (analysis of defensive manoeuvres that hinder process of therapy) 4. Transference (analysis of client responding to analyst irrationally as if she/he were important figure from client’s life) 5. Interpretation
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Systemic therapy: symptoms are not assigned to one individual labelled ‘the problem’ but examined and understood in the context in which they have arisen; seen as problems in interact and comm. between people rather than existing in people; solution focused
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Behavioural therapies: believe behaviours are the problem and not merely symptoms of underlying problems. Problem behaviours learned e.g. same way as classical conditioning of phobia development. Systematic desensitisation used (!!exposure therapy!!) – patient trained in vol muscle relax; construction of stimulus hierarchy; relaxation of client and progressive association with stimulus hierarchy to prevent anxiety response and break CS-CR link. Also used for classical aversion therapy e.g. CS (slides of children) + UCS (electric shock) to condition anxiety response to reduce sexual attraction to children. Operant conditioning techniques e.g. therapists reward desired behaviour and withhold reward of undesired behaviour. When whole environment is used token economy.
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Cognitive therapy: based on cognitive psychology theory viewing people as information processing systems. Deals with beliefs (activating events BELIEFS consequences). Problem solving. Example: I believe I am a failure. I fail at something. This confirms I am a failure. Deal with the belief!
Beck’s schema theory of depression (see notes) Eysenck – evaluation of psychotherapy vs. spontaneous recovery rate of spontaneous recovery in absence of treatment just as high as success rates reported by psychotherapists – called for more objective measures in clients’ improvement. Medication vs psychological therapy: At least 75% antidepressant effect also produced by placebos. Drug therapies do not cure disorder, do not teach client coping and problem solving skills to deal with life problems, high relapse rate and aversive discontinuation syndrome when drugs stopped. CBT shown to have significantly lower relapse rates than antidepressants. NICE guidelines 1 st line CBT for depression, social anxiety, PTSD, OC, bulimia, panic disorder, specific phobia. Only 2% of people prefer medication alone as treatment. IAPT = improving access to psychological therapies – only 4% of people who need CBT get it