1. Frank McDonald Consultation-Liaison Psychologist The Townsville Hospital July 2007 www.fmcdonald.com

2. Overview  Do psychological factors like stress, negative emotions e.g. worry & depression influence wound healing? (Short answer: Yes – evidence ++)  Who does & who doesn’t cope with demands of wound healing?  Your professional & personal input

3. Influences on wound-healing  Clinical experience tells you – pts under roughly comparable medical conditions & care vary considerably in their rate of wound recovery  Differences, in part, can be explained by psychophysiological responses  Notably, psychological states & profiles that impact upon inflammatory & immunity causal pathways

4. Influences on wound-healing  Broad classes of psychological factors studied to date: those that travel via  1. biological paths e.g. stress/hyperarousal, depressed mood, anxiety, response to pain  2. behavioural paths – health-risk behaviours that  w. distress, despair, demoralisation  Smoking (vasoconstriction)  Alcohol & drug abuse   Nutrition (need for protein etc)  Reduced compliance/self-care behaviours  Sleep disturbances (compromises immunity)

5. Influences on wound-healing  Understanding & being alert to relevant factors guides your interventions  One key issue: stress  This can be large enough to be health risk (Rozlog et al. 1999). Impacts on speed of wound healing (Kiecolt- Glaser et al., 1995) & recovery from surgery (Broadbent et al., 2003) as measured by in-hospital time, re-admission rates, complications, pt discomfort & delay in return to activity

6. Influences on wound-healing  High or chronic stress impairs inflammatory stage of wound repair  Excess stress activates HPA axis producing hypersecretion of cortisol (Selye, 1976) & pro- inflammatory cytokine production (Glaser et al., 1999) at wound site  Even mild stress (like students doing exams who are used to them) can slow healing of puncture wounds by 40% (Marucha et al., 1998)  Similar %age for couples experiencing hostile marital interactions (Kiecolt-Glaser, 2005)

7. Influences on wound-healing  So, no surprise that surgery (for most a major stressor due to its higher stakes), is well-proven cause of psychological & physical stress,  even more potent release of cortisol ( Kiecolt- Glaser et al., 1998)  Further indirect proof of stress on wound repair: burns units have poorer outcomes when co-morbid psych conditions not addressed (Tarrier, et al. 2003)

8. Influences on wound-healing  Negative emotions such as depression & anxiety also have well-studied influences on wound healing  These can disrupt activity of macrophages & lymphocytes in healing process (Cole-King et al., 2001)  Depression associated with widespread impairment of both cellular & humoral immunity (Herbert & Cohen, 1993)  In turn, pt susceptible to more infection

9. Influences on wound-healing  Other negative, distressing influences:  social isolation (DeVries, 2007);  Greater acute pain on days 1 and 2 post-surgery pain & greater persistent post-surgical pain averaged over 4 weekly pain ratings (McGuire et al., 2006);  pain associated with procedures (Krasner, 2005)  chronic wound pain (Price, 2005)  Pain may act on both stress / inflammation pathway & immune pathway

10. Who doesn’t cope?  Vulnerabilities identified by research to date:  Acute stress (this worthy of attention because success in later stages of wound repair highly dependent on initial events. Often the largest differences between better & worse outcomes in stress and wound studies apparent early in process) e.g. in days after surgery or procedure  Chronic stress/hyperarousal (anti-inflammatory agents which are meant only for brief release e.g. to ease pain, weaken immune system over time)  Depression  Anxiety

11. Who doesn’t cope?  Poor social connectedness or disrupted social bonds (e.g. bereaved, divorced) dysregulates immune function (Bartrop et al., 1977; Kiecolt-Glaser,1987)  Lifestyle /behavioural issues e.g.  Reductions in deep sleep (depletes growth hormone needed for wound repair)  Poor diet (  vitamins, trace elements)

12. Who copes?  Pts administered psychological interventions pre- & post-operatively that target 3 things: emotional support, positive expectancy & coping strategies (Mumford et al.,1982)  Strategies that mentally prepare patients for upcoming events like ostomies, surgery, amputations with information about what to expect re the procedure & wound healing. May cause emotional reaction but stimulates person to mobilise resources & not rely too long on denial (Janis, 1958)

13. Who copes?  Pts taught a quietening response to counter to arousal pre- & immediately post-operatively e.g. via recordings, as in Holden-Lund’s (1988) broadly efficacious protocol using 4 x 20 min. recordings Tape 1. Afternoon prior surgery intro’d concept of relaxation and notion of surgical recovery and wound healing in general + 10 minute progressive relaxation exercise. Other tapes had 5 minute relaxation & mental journey thru body to healing area & to picture normal phases of successful wound healing as guided by suggested images

14. Who copes?  Tape 2. Inflammatory phase  Tape 3. Proliferative phase  Tape 4. Maturation phase  Interventions like these highlight timing issue - when tissue demands greatest, when arousal greatest. Early is better  Research beginning to suggest arousal may be more important than negative emotions e.g. Segerstrom & Miller (2006). So stress & immune system links more relevant to w.h. may turn out to be mental states (like cognitive appraisal & motivation) that reduce arousal

15.  So problem is not just disease management (biomedical aspects) – but pressure on pt to cope  Everyone with chronic conditions suffers psychologically & socially – degree depends on number & intensity of challenges faced Your professional & personal input

16.  How can we help patients meet psychosocial needs?  3 levels: i. your professional & personal input ii. encouraging & supporting self-management iii. specific psychological strategies shown to alleviate condition & associated problems Your professional & personal input

17.  Professional contributions can significantly improve patients’ psychological state: 1. Patients’ sense of control & esteem can be heightened by progress & improvements with physical therapy, exercise, speech therapy, occupational therapy & medications

18. Your professional & personal input 2. Patients benefit from attentions of concerted professional team approach e.g. primary care physicians & nurse educators  Appreciate being able to discuss & manage their various concerns with appropriate range of specialists

19.  First thing pt & family need to adapt is correct information about their condition, its prognosis & treatment. Can prevent or reduce significant anxiety, give direction & hope  Assistance with goal-setting e.g. graphical or verbal feedback about progress towards goals because pts often don’t notice (e.g. photos of wound’s progress) Your professional & personal input

20.  Personal contributions also can significantly improve patients’ psychological state  Patients do better with professionals whom they say: “generally are able to empathise & communicate a sense of how difficult things must be” “are willing to listen & my answer questions without judging me – allowing me to be more informed & knowledgeable about my illness” Your professional & personal input

21.  “see the whole person - not the hole in the person. They see me not just from the perspective of their profession”  “enquire about common problem areas associated with my illness & so might ask ‘This illness may affect the things you feel you are capable of doing & in turn your self-esteem. How are going in that area?’ ” Your professional & personal input

22.  “are willing to bring up issues I may be reluctant to – like sexuality or the anger / ‘ why me? stuff ’ I was half-denying”  “give a sense of hope to recently diagnosed pts about the promise of new therapies & treatments. They understand the importance of conveying a positive attitude” Your professional & personal input

23.  “enquire about degree of support & understanding from partner, family, friends or boss”  “refer to other professionals, like psychiatrists or psychologists, when they do not have the time or skills to get into things - without implying ‘you’re not coping with this as well as you should’ ” Your professional & personal input

24. Specific psychological strategies  Studies point to importance of positive, supportive interactions with family or friends during healing e.g. Detillion (2004). So thinking of ways to reduce isolation often related to institutional settings may help  Restoring the person to a supportive family situation, if possible, seems especially important in wound care. Alternatives if home is hostile, demanding or restraining

25.  Anxiety management (e.g. coping with worry strategies – catastrophe scale, stimulus control techniques, problem- solving / ‘decatastrophising’ etc.)  Coping strategies for symptoms of disease e.g. via sleep- wake cycle therapy (See Victoria Health website for fact sheet on sleep hygiene)  Increasing either mastery or pleasure activities to at least one per day to counter self-esteem & non-severe mood problems (See Activity Scheduling/Pleasant Events handout www.fmcdonald.com) Specific psychological strategies

26.  Pt self-monitoring of self-care activity + rewards e.g. diabetes adherence  Stress Management (often within support group framework)  Social Support sessions with family & friends + active listening by leaders Specific psychological strategies

27.  Pain-coping skills  Progressive Muscle Relaxation. Isometric Relaxation  EMG & Thermal Biofeedback + Autogenic training  Hypnosedation (e.g. in burns rx)  Guided imagery e.g. for symptom control  Attention re-focussing (stimuli outside body, on to activity) Specific psychological strategies

28.  Dissociation (self-hypnosis/meditation. Meditation especially helpful with refractory depression)  Self-encouragement via self-reward contingencies  Communication skills training/assertiveness training to improve communication with health care professionals, carers, workmates Specific psychological strategies

29. Final word – Science and Art of Wound Care  Ultimately wound care professionals can help pts by applying care based on the best available evidence enhanced by a healthy dose of positive psychosocial support