THE COPING PROCESS IN PATIENTS OF CHRONIC ILLNESS:Asthma

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Health Psychology PSY408

Lesson 28

THE COPING PROCESS IN PATIENTS OF CHRONIC ILLNESS

Crisis theory proposes that coping begins with the patient's cognitive appraisal of the meaning or

significance of the health problem to his or her life. The outcome of this appraisal leads the individual to

formulate an array of adaptive tasks and to apply various coping skills to deal with these tasks. Let's see

what these tasks and skills are.

The Tasks and Skills of Coping

According to Moos (1982), people who are ill need to address two types of adaptive tasks in the coping

process:

· Tasks related to the illness or treatment, which involve learning to (1) Cope with the symptoms or

disability the health problem causes. (2) Adjust to the hospital environment and medical procedures needed

to treat the problem and (3) Develop and maintain good relationships with their practitioners.

· Tasks related to general psychosocial functioning, which involve striving to (1) Control negative feelings

and retain a positive outlook for the future, (2) Maintain a satisfactory self-image and sense of competence,

(3) Preserve good relationships with family and friends, and (4) Prepare for an uncertain future.

These tasks can be very difficult for patients, particularly when their health problems may lead to disability,

disfigurement, or death. Still, many people with poor prognoses [or their health manage to adapt

successfully and make the most of their new life circumstances.

Crisis theory proposes that patients encounter these adaptive tasks in any health problem they experience.

But the relative importance or salience of each task for each illness or injury depends on the nature of the

condition and the patient's personality and environmental circumstances. A person who becomes blind may

have little physical discomfort, but may experience difficulty maintaining a job or social relations. A woman

who has a mastectomy may need to focus on adapting to her new self-image. A professional athlete,

construction worker, or other physically active individual is likely to experience more difficulty adapting to a

wheelchair than a more sedentary person.

Family members must make similar adjustments, and these individuals are critically important in helping

patients achieve each goal. Patients are likely to adapt well to a chronic condition if their family members

participate actively in their treatment regimens, encourage them to be self sufficient, and respond to their

needs in a caring and sensitive manner.

What coping skills do patients and their families employ to deal with these adaptive tasks? The next section

describes several useful strategies that they commonly use.

Coping Strategies for Chronic Health Problems

· Denying or minimizing the seriousness at the situation. As we have seen, this approach can be beneficial

in the early phases of adjusting to a health problem. Patients may benefit from this approach by using it

selectively to put aside their emotions temporarily, thereby saving them from feeling overwhelmed and

giving them time to organize other personal coping resources.

· Seeking information about the health problem and treatment procedures.

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· Learning to provide one's own medical care such as self-administering insulin shots. With this

approach, patients gain a sensed control and personal effectiveness with respect to their conditions.

· Setting concrete, limited goals such as in exercising or in going to shows or social gatherings, and

maintaining regular routines as well as possible. By doing this, patients and their families have things to look

forward to and opportunities to achieve goals they consider meaningful.

· Recruiting instrumental and emotional support from family, friends, and practitioners by expressing

needs and feelings.

· Considering possible future events and stressful circumstances in order to know what lies ahead and to

be prepared for unexpected difficulties.

· Gaining a manageable perspective on the health problem and its treatment by finding a long-term

"purpose" or "meaning" for the experience. Patients often do this by applying religious beliefs or by

recognizing how they have been changed in positive ways by the experience.

As we can see, each of these skills can help in achieving the goals of adaptive tasks and in leading to a

positive outcome of the crisis. Is one approach best? Generally speaking, although moderate or temporary

use of any specific skill can be beneficial, using any single skill exclusively may undermine the coping

process. Some coping skills may be more appropriate for dealing with some tasks than with others. As a

result; people generally use these skills selectively, often in combination.

For instance, seeking information may help patients deal with the symptoms, and setting reasonable goals

may help them do exercises and reduce their incapacitation. Individuals who have adjusted successfully to

each phase of the crises are ready to deal effectively with subsequent phases in their adjustment to their

health problems.

Long-Term Adaptation to Chronic Health Problems

Chronic disorders last for a very long time--and patients and their families need to adapt to the illnesses

whether they worsen, stay the same, or improve over time. The term adaptation refers to "the process of

making changes in order to adjust constructively to life's circumstances". For chronically ill individuals and

their families, the adaptive changes they make can enhance their quality of life by promoting their effective

physical, psychological, and social functioning.

What does "quality of life" mean?

Quality of life refers to the degree of excellence people appraise their lives to contain. People around the

world appraise excellence with similar criteria, such as performing daily activities, energy or discomfort,

positive and negative feelings, personal control, interpersonal relations, pleasant activities, personal and

intellectual growth, and material possessions.

When chronically ill people can expect to live for many years, they need to make many decisions, such as

career selections, that involve examining their options based on realistic assessments of their conditions.

People who continue to rely heavily on avoidance coping strategies, such as denial, are less likely to adapt

effectively than those who use strategies that allow them to consider their situations more carefully and

objectively.

Impacts of Different Chronic Conditions

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What is it like to live with a chronic health problem? To some extent, the answer depends on the illness.

Beginning with this section, we will consider the impact of specific chronic medical conditions and

treatments on patients and their families. The particular health problems we will examine were selected to

illustrate disorders of different body systems and widely different adjustment difficulties. Some of the health

problems tend to develop at much earlier ages than others; some require much more complex treatment

regimens than others; and some produce more pain and disability than others.

People who are disabled by illness are more likely than others to adjust poorly to their condition and

become clinically depressed. After we discuss these disorders, we will consider psychosocial approaches to

help chronically ill people adapt to their condition.

Although the medical problems we will discuss here include some that can be life-threatening, none of these

chronic conditions is among the most deadly illnesses people around the world develop-- particularly heart

disease, cancer, stroke, and AIDS.

We will use a life-span perspective to organize the health problems: illnesses that generally begin in

childhood will be presented first, and illnesses that usually begin in old age will be considered last. As we

have seen, the impact of a health problem and the way people cope with it depend partly on the patient's

age. We will start by considering the impact of asthma, a chronic respiratory disorder that generally begins

in the early childhood years.

Asthma

We all experience respiratory disorders at one time or another. If we are fortunate, these disorders are

limited to occasional bouts with colds and the flu. But millions of people are not so fortunate-- they surfer

from chronic respiratory problems. In some cases, these problems involve constant breathing impairments

that vary in intensity from one day to the next. In other cases, the victims breathe normally most of the time

but suffer recurrent episodes of impaired breathing. Some chronic respiratory disorders become severe

enough to disable their victims and may even claim their lives. This can happen with asthma.

What Is Asthma?

Imagine being at home reading one evening and noticing that a slight whistling, wheezing sound starts to

accompany each breath you take. Soon the sound becomes louder and your breathing becomes labored.

You try opening your mouth to breathe, but very little air goes in or out. When your chest begins to

contract from the effort and your heart pounds rapidly you are quite frightened and worry. "Will my next

gasp for air be my last?" This is what a major asthma attack is like. Victims of extreme attacks may begin to

turn blue and look as if they are about to die, and some do die.

Asthma is a respiratory disorder involving recurrent episodes of impaired breathing when the airways

become obstructed. This disease in very prevalent around the world; in the United States alone, about 17

million people (6% of the population) suffer from asthma. Prevalence rates are much higher for children

than adults. Although the disorder may emerge at any age, it is most likely to develop by age 5 in children

and between the ages of 30 and 40 among adults.

Fortunately, most childhood cases of asthma become less severe over time, and 25 to 50% of the children

who develop asthma no longer have symptoms by the time they reach adulthood. Each year, over 5,400

asthmatics in the United States die from asthma attacks; the death rates from attacks have increased since

1980 and are higher among African Americans than white individuals.

Because African Americans have lower incomes than whites and are less likely to have regular physicians,

they tend to use hospital emergency rooms as their main source of treatment for asthma and seek help

mainly when attacks are severe.

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Asthma is clearly a major health problem. Let's see what causes asthma attacks.

The Physiology, Causes and Effects of Asthma

Asthma episodes typically begin when the immune system is activated to react in an allergic manner,

producing antibodies that cause the bronchial tubes and other affected body tissues to release a chemical

called histamine. This chemical causes irritation to those tissues. In an asthma attack, these events cause the

bronchial tubes to become obstructed as their smooth muscles become inflamed, develop spasms, and

produce mucus. These events last, perhaps, an hour or two and can lead to tissue damage, thereby

increasing the likelihood of more frequent and severe future attacks. For some asthmatics airway

inflammation becomes constant.

What Causes Asthma Attacks to Happen?

We do not have a full answer to this question, but we do know that attacks usually occur in the presence of

certain conditions, called triggers. Asthma triggers can include personal factors, such as having a respiratory

infection or feelings of anger or anxiety; environmental conditions, such as air pollution, pollen, or cold

temperature; and physical activities, such as strenuous exercise. The triggers that lead to attacks are different

for different asthmatics, and some individuals have attacks only when two or more triggers occur at the

same time. The main triggers for many asthmatics are allergens-- substances, such as pollens or molds, that

are known to cause allergic reactions. But other asthmatics do not have any known allergies, and other

factors, such as physical exercise or cold air, are the main triggers for them. Tests for allergic reactions

usually involve injecting a small amount of the allergen under the skin and checking to see if the skin in that

area becomes inflamed.

Medical Regimens for Asthma

Medical approaches provide the cornerstone of treatment for asthma. Asthma regimens consist of three

components, the first being to avoid known triggers of attacks. The second component involves

medication. To treat an acute attack, patients mainly use bronchodilators, which open up constricted

airways. To prevent attacks patients can use anti-inflammatories, such as inhaled or oral corticosteroids and

cromolyn, which reduce bronchial inflammation or block the release of histamine and other chemicals that

cause inflammation.

The third component of asthma regimens involves exercise. In the past, physicians advised many

asthmatics to avoid exercise because it could induce an attack. But it now appears that the less these people

exercise, the worse their conditions get. Many physicians today recommend treatment regimens that

carefully combine fitness training and the use of medication.

Asthma's potential for producing disability and, sometimes, death makes it important that patients adhere to

their regimens. Although adhering to asthma regimens reduces attacks and incidents of wheezing, many

asthmatics fail to take medication to prevent attacks and use medication during an attack incorrectly.

Psychosocial Factors in Asthma

Many people with asthma report that the triggers of their attacks often involve their emotional states, such

as being worried, angry, or excited. Experimental research has shown that emotional arousal; such as when

watching an exciting movie, can trigger attacks in some children. Studies have also found that suggestion

can induce symptoms in some asthmatics.

In one study, researchers had asthmatics inhale several doses or a placebo solution, with each succeeding

dose labeled as containing an increasingly strong level of an allergen. Nearly half of the subjects developed

symptoms, either as full asthmatic attacks or as spasms of the bronchial muscles. Another study confirmed

the effect of suggestion, but also showed that the asthmatic reaction could be negated if the subjects were

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first given another placebo that was described as a new asthma drug. In other words, the first suggestion

blocked the second one.

For example, studies have shown that false feedback indicating that the airways are becoming obstructed

increases breathlessness in people with asthma.

Although there is little question that psychosocial factors can influence asthma attacks, we do not know

how these factors work and which asthmatics are more affected by them. It is possible that psychosocial

factors make asthmatics more sensitive to allergens or other conditions that trigger their attacks.

Asthma attacks are frightening for the patient and family alike; and frequent episodes are costly to the

family and disrupt these people's lives and functioning. Living with this disorder adds to the stress that

asthmatics and their families' experience, and studies have found that asthma is sometimes related to

maladjustment in patients and their families.

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