Presented by: Dhanya Charly

MPhil Trainee, Dept. Of Clinical

Unit 12: Other general Psychology
clinical conditions Chaired by: Ms. Leeshma P.
Clinical Psychologist, Recovery
Facilitation Project

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 Other general clinical conditions: Application of
psychological techniques and their rationale in
the clinical care of patients in general medical
Syllabus settings where psychological services appears to
affect the outcome of medical management
positively, for example in diabetes, sleep
disorders, obesity, dental anxiety, burns injury

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 • Diabetes is a chronic disease that occurs either
when the pancreas does not produce enough
insulin (insufficient secretion) or when the body
cannot effectively use the insulin it produces
Diabetes (insulin resistance)

• The body needs glucose to fuel metabolic

processes; Increased glucose in the blood over a
long period of time →hyperglycemia →diabetes
mellitus

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 • In 2014, 8.5% of adults aged 18 years and older had diabetes.

• In 2019, diabetes was the direct cause of 1.5 million deaths and 48% of
all deaths due to diabetes occurred before the age of 70 years.

• In 2017 there were 9 million people with type 1 diabetes; the majority
Prevalence of them live in high-income countries.
(WHO, 2020)
• Between 2000 and 2016, there was a 5% increase in premature
mortality rates (i.e. before the age of 70) from diabetes.

• In high-income countries the premature mortality rate due to diabetes

decreased from 2000 to 2010 but then increased in 2010-2016.

• In lower-middle-income countries, the premature mortality rate due to

diabetes increased across both periods.
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 • The pancreas, located below the stomach, produces different types
of secretions. The islet cells of the pancreas produce several
hormones, two of which, glucagon and insulin, are critically
important in metabolism.
• Glucagon stimulates the release of glucose and therefore acts to
elevate blood sugar levels.
The Physiology • Insulin decreases the level of glucose in the blood by causing tissue
cell membranes to open so glucose can enter the cells more freely.
of Diabetes • Disorders of the islet cells → difficulties in sugar metabolism.
• Diabetes mellitus is a disorder caused by insulin deficiency. If the
islet cells do not produce adequate insulin, sugar cannot move from
the blood to the cells for use. Lack of insulin prevents the body
from regulating blood sugar level. Excessive sugar accumulates in
the blood and also appears in abnormally high levels in the urine.
(Brannon et al., 2014) • Both coma and death are possibilities for uncontrolled diabetes.

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 • Heredity: Genetic transmission of diabetes.
• Type 1: viral infection that stimulates the immune system to attack
pancreas cells
• Type 2: diets high in fat and sugar, stress, and an overproduction of a
protein that impairs the metabolism of sugars and carbohydrates
• Some evidence suggests that chronic stress, negative emotions, and
What causes other psychosocial vulnerabilities increase risk for developing diabetes
(Knol et al., 2006; Golden et al., 2008; Mezuk et al., 2008), although
Pancreas to reduce other evidence suggests that these factors can lead to poor medical
insulin production? outcomes in established diabetes but not the initial development of
diabetes (Chida & Hamer, 2008).
• Smoking may also contribute to the development of diabetes (Willi et
al., 2007).
• The importance of diet, exercise, and weight as causes of type 2
diabetes is demonstrated by the success of related lifestyle
interventions involving diet and exercise in treating ‘‘pre-diabetic’’
conditions and preventing their progression to diabetes (Davidson et
al., 2009; Magkos et al., 2009; Orozco et al., 2008).

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Type 1 Diabetes (previously known as insulin-
dependent, juvenile or childhood-onset)
• Characterized by deficient insulin production
and requires daily administration of insulin.
• Symptoms include excessive excretion of
urine (polyuria), thirst (polydipsia), constant
hunger, weight loss, vision changes, and
fatigue. These symptoms may occur suddenly.
• Autoimmune processes have destroyed cells of
the pancreas that normally produce insulin. If
daily administration of insulin not done, leads
to complications.
• Ketoacidosis: high levels of fatty acids in the
blood lead to kidney malfunctions, thereby
causing wastes to accumulate and poison the
body. Symptoms of ketoacidosis are subtle at
first, but advance to nausea, vomiting,
abdominal pain, and labored breathing. If
untreated, ketoacidosis can lead to coma and
death in a matter of days or weeks
Type 2 Diabetes (formerly called non-insulin-
dependent, or adult-onset)
• Results from the body’s ineffective use of
insulin. More than 95% of people with
diabetes have type 2 diabetes. This type of
diabetes is largely the result of excess body
weight and physical inactivity.
• Symptoms may be similar to those of type 1
diabetes but are often less marked. As a result,
the disease may be diagnosed several years
after onset, after complications have already
arisen.
• Until recently, this type of diabetes was seen
only in adults but it is now also occurring
increasingly frequently in children.
(WHO, 2022)
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(Brannon et al., 2014)

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Pathogenesis of Diabetes Mellitus

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• Gestational diabetes: develops in some during
pregnancy. Gestational diabetes ends when the
pregnancy is completed, but the disorder
complicates pregnancy and presents a risk for the
development of Type 2 diabetes in the future.

• Impaired glucose tolerance (IGT) and impaired

fasting glycaemia (IFG): intermediate conditions in
the transition between normality and diabetes.
People with IGT or IFG are at high risk of
progressing to type 2 diabetes, although this is not
inevitable.

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 • Adults with diabetes have a two- to three-fold increased risk
of heart attacks and strokes
• Combined with reduced blood flow, neuropathy (nerve
damage) in the feet increases the chance of foot ulcers,
infection and eventual need for limb amputation.
• Diabetic retinopathy is an important cause of blindness and
occurs as a result of long-term accumulated damage to the
Impact on Health small blood vessels in the retina. Close to 1 million people
are blind due to diabetes
• Diabetes is among the leading causes of kidney failure
• People with diabetes are more likely to have poor outcomes
for several infectious diseases, including COVID-19
(WHO, 2022)

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 • Reviews of studies on this issue found most people with
diabetes tested their glucose levels incorrectly,
administered wrong doses of insulin, and failed to follow
the recommended diets carefully (Wing et al., 1986).
• Poor literacy limits understanding of the disease and
Non-Compliance regimen (Rothman et al., 2004)
with treatment in • Diabetics rely on symptoms they perceive, such as
Diabetes dizziness or emotional states, to assess their glucose levels
(Cox et al., 1993; Meltzer et al., 2003). Not accurate
always.
• More difficulty following dietary and exercise advice than
the more ‘‘medical’’ aspects

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 Type 1 Diabetes (T1D)
• Most children and adults with T1D typically manifest
lower scores on measures of intelligence and academic
achievement, attention, psychomotor speed, and executive
functions. Particularly in those who develop diabetes early
in life, before the age of 6 or 7 years.
Neurocognitive • Chronically elevated blood glucose level → risk of
Consequences of cognitive dysfunction and microstructural changes in white
matter tracts
Diabetes (Ryan &
Duinkerken, 2016) • Brain Volumetric Changes
• Microstructural abnormalities
• Mild Cognitive Dysfunction
• Gray Matter Volumetric Reductions Appear in Multiple
Brain Regions
• Microstructural Changes in White Matter

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Cognitive function in children
with type 1 diabetes: a meta-
analysis (Gaudieri et al., 2008)
Pediatric diabetes generally relates to
mildly lower cognitive scores across most
cognitive domains.
Cognitive effects are most pronounced and
pervasive for early onset diabetes, with
moderately lower performance compared
with control subjects.
Type 1 diabetes-associated
cognitive decline: a meta-
analysis and update of the
current literature (Tonoli et
al., 2014)
Small to modest decrease in cognitive
performance in T1D patients compared with
non-diabetic controls.
Children with T1D performed worse while
testing for executive function, full
intelligence quotient (IQ), and motor speed
Adults with T1D performed worse while
testing the full, verbal and performance IQ,
part of the executive function, memory,
spatial memory, and motor speed.
Episodes of severe hypoglycemia, chronic
hyperglycemia, and age of onset can be
significant factors influencing cognitive
function in T1D.
Risk factors for decline in IQ
in youth with type 1 diabetes
over the 12 years from
diagnosis/illness onset (Lin et
al., 2015)
Young people with type 1 diabetes showed
greater decline in verbal IQ (VIQ) and full-
scale IQ (FSIQ), but not performance IQ
(PIQ), than HCs.
Within the diabetes group, a younger age at
diabetes onset was associated with a decline
in PIQ and FSIQ (P ≤ 0.001).
A history of hypoglycemic seizures was
associated with a decline in VIQ (P = 0.002).
Long-term metabolic control was not
associated with changes in IQ.
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 Type 2 Diabetes (T2D)
• Adults with T2D manifest cognitive dysfunction
characterized by poorer performance on tasks requiring
attention, psychomotor speed, planning and executive
functions, and learning and memory. They are also at
increased risk of developing dementia. Poorer metabolic
Neurocognitive control accelerates the rate of cognitive decline over time,
Consequences of and research suggests that improving metabolic control may
slow the rate of decline.
Diabetes (Ryan & • Generalised Cognitive Dysfunction
Duinkerken, 2016) • Accelerated Cognitive Decline over time
• White Matter Network Connectivity Affects Speed of
Information Processing
• Risk factor for Dementia: increased relative risk of vascular
dementia as well as a somewhat lower, albeit significant,
risk of Alzheimer’s disease (Cheng et al., 2012).
Contradicting results have also been present.

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 Role of Psychologists and
behavioral scientists:
preventing the onset of
cognitive complications or in
ameliorating their severity by
implementing behavioral
strategies known to increase
adherence to medical
regimens and improve
(Popa-Velea et al., 2016)
metabolic control

(Ryan & Duinkerken, 2016)

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 • Greater their self-efficacy for following the
diabetes regimen, the higher their subsequent
self-reports of adherence and the better their
actual glucose control
• Difficulty to cope with their condition and
Psychosocial suffer from emotional distress and even
depression.
factors in Diabetes • Negative mood, reduced feelings of control or
care efficacy in managing diabetes, and disruption
of daily activities can all interfere with
adherence and control of blood sugar, and
worsen mood still further.
• Stress impairs blood sugar control especially
those who have sedentary lifestyles

(Sarafino & Smith, 2012)

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 Stress
Impact of Stress on
Diabetes
Adrenal glands release epinephrine and cortisol into the
bloodstream.

Epinephrine causes the pancreas to decrease insulin production;

cortisol causes the liver to increase glucose production and body
tissues to decrease their use of glucose.

These biological stress responses can worsen the glucose regulation

problems of diabetics

Stress can also affect blood glucose levels indirectly by

reducing adherence to diabetes regimens
(Sarafino & Smith, 2012)
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 • Prevalence of isolated depressive symptoms reaches
30%.
• Criteria for the major depressive episodes can be met in
as high as 10%;
• Middle age patients are at a higher risk.
Diabetes and
• Depression’s expression is mediated by socio-
Depression economic status, perceived social support, and gender,
especially in women.
• Coexistence of depression can increase the care
expenses in diabetes, and also mortality by a factor of
4.5. Mainly due to poor compliance (equivalent to a
bad self-management of the disease and to an increased
number of unaddressed complications).
• Depression promotes low compliance, but also derives
from the consequences of a low compliance. → Poor
prognosis

(Popa-Velea et al., 2016)

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Quality of Life
Restrictions in spontaneous decision-making and
social implications;
• difficulties in leaving home without insulin and
food;
• anxiety caused by the administration of insulin in effects, or in learning to adjust doses;
public;
• daily testing of serum glucose levels;
• frequent and equally distributed meals;
• planned physical effort;
• planned pregnancy;
• food restriction (intake should always be
correlated with the insulin dose; consumption of
alcohol is restricted);
• risks of insulin administration itself: hypo- or
hyperglycemia; difficulties in learning to
distinguish between the types of insulin and their
lipodystrophy at the injection site.
• sleep disorders, such as insomnia, can be caused
by rapid changes in glucose levels during sleep or
by discomfort/ pain associated with peripheral
neuropathy
- inability to control the disease: is modulated by
factors such as low self-efficacy, external locus of
control, low hardiness, low/ absent coherence,
pessimism or unrealistic optimism.
(Popa-Velea et al., 2016)
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 Management

Counselling
• Expressing empathy(via elements such as active (verbal and nonverbal)
listening, expressing comprehension and respect for the patient’s
suffering);
• Highlighting the differences between present Self and ideal Self(and
contribution of the disease to this discrepancy);
• Addressing implicit resistance to change (by inviting the patient to take
into account an alternative perspective and emphasize its positive
consequences);
• Aiming at increasing self-efficacy and confidence, by acknowledging
successes and encouraging the desire for future changes
(Popa-Velea et al., 2016)
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 Management

CBT
• Specify the problem: avoids the tendency of patients to “catastrophize” it (to see
it as ubiquitous and overwhelming);
• Goal setting: SMART goals
• Identify barriers to goal attainment
• Elaborate strategies to overcome barriers: clinicians should ask patients
questions, so that they themselves can formulate ideas and alternatives.
• Behavioural Contract
• Track outcomes (monitor difficulties, reward successes and analyze failures,

(Popa-Velea et al., 2016) work on the initial strategy and restructure it, if necessary) and offer continuous
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support.
 Management

Family Approach to Diabetes Management (FADM)

• Emphasis on helping families changing their offspring’s inadequate
behaviors related to diabetes management into more responsible, goal-
oriented ones.
• Modifying the family members’ roles and responsibilities regarding
diabetes management.
• Especially effective in teenagers, as it is a directive and intensive
approach, based on the concept of mutuality.
(Popa-Velea et al., 2016)
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Challenges and Limitations

• Lack of addressability to the psychologist, even

when symptoms (e.g. depression) manifest;

• Lack of patient motivation(especially via

unrealistic expectations);

• Limits of the therapies themselves(as some

require certain abilities from the patient, such
as insight, or the genuine intention for a
lifestyle change).

(Popa-Velea et al., 2016)

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 • Sleep is a circadian state characterized by
partial or total suspension of consciousness,
voluntary muscle inhibition, and relative
insensitivity to stimulation. NREM & REM; 5
stages.
• Sleep disorder can be defined as a persistent
disturbance of typical sleep patterns (including
the amount, quality, and timing of sleep) or the
Sleep Disorders chronic occurrence of abnormal events or
behavior during sleep
• Prevalence: Insomnia (6-15%); Sleep apnea
(2-4%); Restless legs syndrome (6%);
Narcolepsy (0.04%); Sleep paralysis (6%);
Nocturnal terrors, the confusional arousals and
nightmares (2.2-5%); in general population
(Ohayon, 2007).

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DSM 5

ICD 10

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Causes
Biological Rhythms
• Sleep-wake behaviour has an endogenous circadian (daily) rhythm. Under
normal conditions, the sleep-wake circadian rhythm is synchronized with
other circadian rhythms including core body temperature, cortisol, and
melatonin.
• Circadian rhythm disorders occur when individuals attempt to sleep at times
that are inconsistent with their underlying biological clocks.
• Bright light significantly affects the circadian sleep-wake rhythm.
• Two common environmentally caused circadian rhythm problems are shift
work and time-zone changes.

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Sleep Fragmentation
• Sleep is fragmented when it is disrupted by intermittent arousals.
• Sleep fragmentation is a better predictor of daytime sleepiness than the
amount of total sleep (Martin, Engleman, Deary, & Douglas, 1996).

• Two common causes of sleep fragmentation sleep apnea and periodic

limb movement disorder.

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Substances
Both prescription and non-prescription substances can cause sleep
disturbances.
• Hypnotics
• Alcohol
• Stimulants

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Behavioural, Cognitive, and Environmental Factors
• Insomnia may begin with a precipitating event. The interaction between a
precipitating event and predisposing and/or maintaining factors determines
the extent and the course of insomnia.
• Factors that maintain sleep problems could be behavioural, cognitive, or
environmental.
• Inadequate sleep hygiene
• Conditioning factors
• Tendency to overestimate latency to sleep onset and to underestimate total
sleep time
• Stress
• Environmental factors such as noise level, light intensity, room temperature,
and safety
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Psychosocial factors
• Male children with shorter or longer sleep durations than expected for their age
were at increased risk of death at any given age in adulthood (Duggan et al.,
2014).
• Insufficient sleep (less than 7 hours a night) affects cognitive functioning, mood,
job performance, and quality of life (Karlson, Gallagher, Olson, & Hamilton,
2012; Pressman & Orr, 1997).
• Insomnia compromises well-being on the short term and quality of life on the long
term (Karlson, Gallagher, Olson, & Hamilton, 2013)
• Habitual sleep of more than 7 hours every night → health risks (van den Berg et
al., 2008a). Long sleepers, like short sleepers, also have more symptoms of
psychopathology, including chronic worrying (Grandner & Kripke, 2004).
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• Chronic insomnia can compromise the ability to secrete and respond to insulin
(suggesting a link between sleep and diabetes)
• Increases the risk of coronary heart disease (Ekstedt, Åkerstedt, & Söderström, 2004);
• Increases blood pressure and dysregulates stress physiology (Franzen et al., 2011);

• Can affect weight gain (Motivala, Tomiyama, Ziegler, Khandrika, & Irwin, 2009);
• Can reduce the efficacy of flu shots;
• It is tied to adverse immune changes including chronic inflammation (Motivala, 2011).

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Assessment
• Sleep diary: Tracking sleep patterns may help a doctor reach a
diagnosis.
• Epworth Sleepiness Scale: A validated questionnaire that is used to
assess daytime sleepiness.
• Polysomnogram: A test measuring brain and muscle activity
including breathing during sleep
• Multiple Sleep Latency Test:A test for daytime sleepiness, usually
administered the day after overnight polysomnography.
• Actigraphy: a test to assess sleep-wake patterns, usually for a week or
more. Actigraphs are wrist-worn devices, about the size of a
wristwatch, that measure movement.
• Mental health exam: Because insomnia may be a symptom of
depression, anxiety, or another mental health disorder, a mental status
exam, mental health history, and basic mental evaluations may be part
of the assessment for a person complaining of insomnia

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 • Medication: Certain disorders like narcolepsy, are best
treated with prescription drugs such as Modafinil.
Temazepam is a benzodiazepine group of drug used for
Management insomnia.
• Sleep Education: In sleep education the patient is
provided information regarding normal sleep hours,
sleep disorders, misconception about sleep, major
concepts related to biology of sleep, its physiological
pathway, how it can be affected etc.
• Sleep Hygiene: Sleep-enhancing directives include
maintaining a regular sleep-wake schedule; keeping a
steady programme of daily exercise; protecting
bedroom against excessive noise, light, cold and heat;
eating light food before retiring if hungry; and setting
time aside to relax before getting into bed. Finally to
keep the person from developing conditional arousal
associated with the bed and bedroom. There are certain
don‘ts of sleep hygiene. They include avoiding
strenuous exercise immediately before bedtime;
abstaining from alcohol, tobacco, coffee, tea in the
evening; not watching television in bed; and not
chronically taking sleeping pills.

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• Cognitive Behavioral Treatment for insomnia (CBT-I) has been
found to be as effective as hypnotic medications for short-term
treatment of insomnia (Morgenthaler, Kramer et al., 2006; Smith et
al., 2002), and more effective than medications for the longer term
management of insomnia (Morin, Colecchi, Stone, Sood, & Brink,
1999). A recent National Institute of Health (NIH) state-of-the-
science conference statement on insomnia also concluded that
cognitive–behavioural treatments of insomnia are as effective in the
short term and more effective in the long-term for the treatment of
insomnia (NIH, 2005).
• Behaviour Therapies (e.g., extinction, graduated extinction,
preventive education) have also been empirically validated in the
treatment of bedtime problems and night waking in young children,
resulting in a recent standards of practice statement for their efficacy
by the American Academy of Sleep Medicine (AASM;
Morgenthaler, Owens et al., 2006).

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• Evidence-Based Therapy: Sleep restriction–sleep compression
therapy and multicomponent cognitive– behavioral therapy are found
to be most effective in treating insomnia, sleep apnea etc

• Mindfulness based interventions (Britton, Haynes, Fridel, &

Bootzin, 2010), relaxation therapy, control of sleep-related behaviors
(such as the routine a person engages in before going to sleep), and
cognitive-behavioral interventions. All these treatments show success
in treating insomnia (Irwin et al., 2006).

• Hypnosis: Research suggests that hypnosis may be helpful in

alleviating some types and manifestations of sleep disorders in some
patients. "Acute and chronic insomnia often respond to relaxation and
hypnotherapy approaches, along with sleep hygiene
instructions."Hypnotherapy has also helped with nightmares and sleep
terrors. There are several reports of successful use of hypnotherapy for
parasomnias specifically for head and body rocking, bedwetting and
sleepwalking.

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 • The condition of having excess body fat
resulting in overweight, variously defined in
terms of absolute weight, weight–height ratio,
distribution of subcutaneous fat, and societal
and aesthetic norms.
• The basic causes are genetic, environmental,
behavioral, or some interaction of these.
Overeating may have a psychological cause
Obesity (binge-eating disorder; food addiction; night-
eating syndrome), but in some cases, it may be
due to an organic disorder (hyperphagia).
• Obesity predisposes one to heart disease,
diabetes, and other serious medical conditions
(morbid obesity), and obese individuals may
develop emotional and psychological problems
relating to body image.

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 • BMI: defined as body weight in kilograms (kg) divided
by height in meters squared (m2 )—that is, BMI ¼
kg/m2 .
• Neither weight charts nor BMI measures body fat, but
this index can provide a standard for measuring
overweight and obesity.
• Overweight is usually defined as a BMI of 25 through
29.9 and obesity as a BMI of 30 or more. (A 5’10”
Measuring Obesity man with a BMI of 30 would weigh 207 pounds, and a
5”4” woman with a BMI of 30 would weigh 174
or Overweight pounds.)
• Another measure that can be useful in assessing
overweight is fat distribution, measured as the ratio of
waist to hip size. People who have waists that approach
the size of their hips tend to have fat distributed around
their middles, whereas people who have large hips
compared with their waists have lower hipto-waist
ratios.
• Cultural definitions of overweight

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 • Globally, more than 1.9 billion adults are overweight
and 650 million are obese
• Approximately 2.8 million deaths are reported as a
result of being overweight or obese
• Energy dense food (i.e. unhealthy food habits),
Prevalence of sedentary life style, lack of health care services and
financial support →high risk of obesity in developing
obesity in India: A countries → diabetes, ischemic heart disease, etc
systematic review • In India, more than 135 million individuals were
affected by obesity
(Ahirwar & • In India, abdominal obesity is one of the major risk
Mondal, 2019) factors for cardiovascular disease (CVDs).
• Various studies have shown that the prevalence of
obesity among women were significantly higher as
compared to men.
• can be preventable by spreading public awareness about
obesity and its health consequences.

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• In the United States, adult obesity increased by
50% from the early 1980s to the late 1990s
(NCHS, 2011).
• animals such as dogs, cats, and rats that live in
close proximity to humans have also become
fatter over the past several decades
(Klimentidis, 2011).
• Researchers have proposed several reasons for
the dramatic increase in obesity over the past
two decades, including an increase in
consumption of fast food and sweetened sodas,
growing portion sizes, and a decrease in
physical activity.

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What causes • The Setpoint Model: weight is regulated around a
obesity? setpoint, a type of internal thermostat. When fat
levels rise above or fall below a certain level,
physiological and psychological mechanisms are
activated that encourage a return to the setpoint.
• Genetic Explanations
• The Positive Incentive Model

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Psychosocial consequences
• Social discrimination and psychological distress.
• The social consequences associated with obesity include bias,
stigmatization, and discrimination, consequences that can be highly
detrimental to psychological well-being (Stunkard & Sobal, 1995).
• Obesity was associated with a 37% greater risk of major depressive
disorder, as well as increased suicidal ideation and attempts among
women but not among men, for whom obesity was associated with a
reduced risk of major depression.
• Higher levels of body image dissatisfaction.

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Psychosocial Stress and
Overweight and
Obesity: Findings From
the Chicago Community
Adult Health Study
(Cuevas et al., 2019)
Multiple types of stressors may be risk
factors for obesity, and cumulative
exposure to these stressors may increase
the odds of obesity. Reducing exposure to
stressors at the population level may have
the potential to contribute to reducing the
burden of obesity.
• The study explores the association between overweight/obesity and
cumulative exposure to a wide range of psychosocial stressors,
among a multiracial/ethnic sample of adults.
• Secondary data from the Chicago Community Adult Health Study (n
= 2,983)
• Conducted multinomial logistic regression analyses to quantify
associations between eight psychosocial stressors, individually and
in combination, and measured overweight and obesity, adjusted for
sociodemographic factors, alcohol use and smoking.
• In separated covariate-adjusted models, childhood adversities, acute
life events, financial strain, and relationship were associated with
increased odds of obesity.
• In a model adjusted for all stressors simultaneously, financial strain
was the only stressor independently associated with overweight and
obesity.
• Participants with stress exposure in the highest quintile across 2, 3,
or ≥4 (compared to no) types of stressors had significantly higher
odds of obesity.
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 • The most commonly cited mechanisms linking ACEs to obesity are
Adverse Childhood social disruption, health behaviors, and chronic stress response.
Experiences (ACE) • Ten observational studies (n=118,691) were quantitatively
summarized and demonstrated a positive association between ACE
and Adult Obesity: and adult obesity with a pooled odds ratio of 1.46 (CI=1.28, 1.64)
A Systematic with moderate heterogeneity (I2=70.8%).
Review of Plausible • Results found a 46% increase in the odds of adult obesity following
Mechanisms and exposure to multiple ACEs.
Meta-Analysis of • Based on qualitative synthesis and review of the most recent relevant
literature, they propose biologically plausible explanations for the
Cross-Sectional significant positive relationship between ACEs and adult obesity.
Studies (Wiss et • Reducing exposure to ACEs, improved screening and detection of
al.,2020) trauma, better access to trauma-informed care, and improvements to
the food environment are likely to improve downstream health
outcomes related to eating behavior.

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 • Individuals seeking treatment for weight loss have consistently demonstrated a
higher prevalence of distress than their nontreatment-seeking counterparts.
• Goldsmith et al. (1992) reported that 55.6% of their participants who were seeking
weight-loss treatment met criteria for current or past psychiatric illness, especially
major depression and dysthymia.
• Binge eating, which occurs in 30% of obese individuals seeking weight loss
treatment (Spitzer et al., 1992), also has been linked to elevated levels of
depression.
Psychopathology • Marcus et al. (1992) found that obese binge-eaters had substantial depressive
symptomatology compared with their nonbinging counterparts. Additionally,
comorbid to obesity Kuehnel and Wadden (1994) reported that individuals diagnosed with binge eating
disorder had significantly higher levels of depression than both nonbingers and
problem eaters. This binge eating mediated pattern of results has been confirmed in
numerous additional studies (Costanzo et al., 1999; Musante, 1998).
• The results of these studies suggest that when attempting to understand the
relationship between obesity and symptoms of psychological distress, it seems
useful to consider mediating variables, such as treatment seeking status or binge
eating, to explain the presence of psychological symptomatology.
• Brownell (1995) have proposed several additional risk factors that may determine
which obese individuals will suffer negative psychological consequences. These
include social class, degree of obesity, and body-image dissatisfaction.
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 • Sample: 124 individuals with morbid obesity
• The data were collected by body image index and
psychological well-being questionnaire
• The results showed a significant relationship between body
image and psychological well-being (r=0.43) (P<0.001),
and between the total score of the body image and all the
subscales of psychological well-being except autonomy
Body Image and and purpose in life (P<0.05). There was also a significant
Psychological relationship between the total score of psychological well-
being and all the subscales of body image (P<0.05).
Wellbeing in However, there was no significant difference between the
mean scores of the body image and those of psychological
Obesity well-being in different categories of body mass index
(BMI) (P>0.05).
• It is suggested that preventing and supporting intervention
should be performed as effective methods for encountering
and coping with psychological effects of obesity.

(Yazdani et al., 2018)

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 • Lifestyle modification (including caloric restriction,
increased physical activity, and behavioral modification
instruction)
• Pharmacotherapy
• Bariatric surgery: advised for persons older than 18 years and
with a BMI ≥ 40 kg/m2 or those with a BMI ≥ 35 kg/m2 in
the presence of weight-related comorbidities
Management • Pre and Post surgery multidisciplinary assessments
• Recommend the use of a formal psychosocial evaluation of
patients who presented with symptoms of
psychopathology(National Institutes of Health Consensus
Development Conference on Gastrointestinal Surgery, 1992)
• Recommendations for the preoperative psychosocial
evaluation of candidates for surgery (the American Society
for Metabolic and Bariatric Surgery, 2016)

51
 • To identify significant psychological contraindications
for surgery (e.g., substance abuse, or severe, poorly
controlled depression).
• To help the patient understand the environmental and
behavioral contributors to the development of extreme
obesity and provide psychoeducation on the dietary and
Psychological behavioral requirements of the procedure.

Screening prior to • A standard psychological interview is necessary, but not

sufficient, for evaluating bariatric surgery candidates.
Bariatric Surgery • A detailed assessment of eating behaviors, stress and
coping, social support, expectations for weight loss,
health outcomes and psychosocial impact
• To evaluate the capacity to provide informed consent.

(Sarwer & Heinberg, 2020)

52
 • Self-monitoring
• Goal setting
• Stimulus control
BT for • Contingency management
• Behavioural substitution
Obesity • Skills for increasing social support
• Problem solving, and
• Relapse prevention

53
CBT-OB • Combines the traditional procedures of standard
behavioural therapy for obesity with a battery of
specific cognitive strategies and procedures.
The primary goals
of CBT-OB are to • Address the cognitive processes that previous research
help patients to has found to be associated with treatment
discontinuation, the amount of weight lost and long-
achieve, accept
term weight-loss maintenance.
and maintain
healthy weight
• Delivered at three levels of care, outpatient, day hospital
loss; and residential, and includes six modules, which are
introduced according to the individual patient’s needs as
adopt a lifestyle
part of a flexible, personalized approach.
conducive to
weight control; • RCT has found that 88 patients suffering from morbid
obesity treated with CBT-OB followed a period of
residential treatment achieved a mean weight loss of
develop a stable 15% after 12 months, with no tendency to regain weight
“weight-control between 6 and 12 months
mindset”.
(Grave et al., 2020)

54
55
56
 a persistent and irrational fear of dentists or of
dental treatment, resulting in the avoidance of
dental care or marked distress and anxiety during
dental visits. It may be related to a prior negative
Dental Anxiety/ dental experience, fear of pain, perceived lack of
Dental Phobia/ control, or feelings of helplessness or
embarrassment (APA, 2015)
Odontophobia
• Mild odontophobia, also called “dental
anxiety”, is the most frequent among the
population;
• Moderate odontophobia, called “dental fear”;
• Severe dental phobia, the real “dental
phobia”, decidedly rarer and more difficult to
manage by the dentist

Three classes of dental phobia can be

recognized (Stefano, 2019)
57
 Cause of Dental Anxiety
• Previous negative or traumatic experience,
especially in childhood (conditioning
experiences)
• Vicarious learning from anxious family
members or peers
• Individual personality characteristics such as
neuroticism and self-consciousness
• Lack of understanding, exposure to frightening
portrayals of dentists in the media, the coping
style of the person, perception of body image,
and the vulnerable position of lying back in a
dental chair
• Sensory triggers: sights of needles and air-
turbine drills, sounds of drilling and
(Hmud & Walsh, 2007) screaming, the smell of eugenol and cut
dentine, and also sensations of high-frequency
vibrations in the dental setting
(Appukkuttan D.P., 2016)
58
Psychosocial Factors

(Seligman et al., 2017) (Appukkuttan D.P., 2016)

59
 • Physiological impacts: signs and symptoms of the
fright response and feelings of exhaustion after a dental
appointment
• Cognitive impacts: an array of negative thoughts,
beliefs, and fears.
• Behavioral impacts: avoidance, and other behaviors
Impact of Dental related to eating, oral hygiene, self-medication, crying,
and aggression.
Anxiety
• A significant impact on general health due to sleep
disturbance was also reported, which influenced both
established and new personal relationships.
• Social interactions and performance at work were
affected, due to feelings of low self-esteem and self-
confidence

60
 • Semi-Structured Interview Commonly
• Corah’s Dental Anxiety Scale (CDAS) 4 items used;
Reliable
• Modified Dental Anxiety Scale (MDAS) 5 items
and Valid in
• Kleinknecht et al’s Dental Fear Survey (DFS) 20 items multiple
• Spielberger State–Trait Anxiety Inventory languages
Identifying patients • Stouthard et al’s Dental Anxiety Inventory, and
with Dental Anxiety • Gatchel’s 10-point fear scale.
• the Dental Anxiety Question
• a Finnish single dental anxiety question
• a single-item dental anxiety-and-fear question, and
• the visual analog scale

61
62
 • Psycho-therapeutic interventions and pharmacological
interventions or both.

Management of
Dental Anxiety

(Newton et al., 2012)

63
 • Communication skills, rapport, and trust building: iatrosedative
technique

• Behavior-management techniques

• Relaxation techniques: deep breathing, muscle relaxation

Psychotherapeutic • Jacobsen’s progressive muscular relaxation
Interventions • Brief relaxation or functional relaxation therapy
• Autogenic relaxation
• Ost’s applied relaxation technique
• Deep relaxation or diaphragmatic breathing
• Relaxation response
(Appukkuttan D.P., 2016)

64
 • Guided imagery
• Biofeedback
• Hypnotherapy
• Acupuncture
• Distraction
Psychotherapeutic • Enhancing control
Interventions • “Tell-show-do”, signaling
• Systematic desensitization or exposure therapy
• Positive reinforcement
• Cognitive therapy
• Cognitive behavioral therapy (CBT)

(Appukkuttan D.P., 2016)

65
Morgan et al., 2016

66
Psychological interventions for
dental phobia significantly
reduced self-reported dental
anxiety and increased dental
attendance, with medium to large
effect sizes.

Approximately 77% of participants

were seeing the dentist regularly
after four years or more

(Kvale et al., 2004)

67
Technological • Computer-controlled local anesthetic delivery
advancements in • Electronic dental anesthesia
administering local • Computer-assisted relaxation learning
anasthesia

(Appukkuttan D.P., 2016)

68
 • Relative analgesia
• Conscious sedation and
• General anaesthesia
Pharmacological
• In general, pharmacological approaches are
Treatment seen as less acceptable in the management of
dental fear when compared to psychological
techniques both by individuals with extreme
dental fear and members of the general public

(Newton et al., 2012)

69
Burns Injury
• A burn is an injury to the skin or
other organic tissue primarily
caused by heat or due to radiation,
radioactivity, electricity, friction or
contact with chemicals.
• Thermal (heat) burns occur when
some or all of the cells in the skin
or other tissues are destroyed by:
• hot liquids (scalds)
• hot solids (contact burns), or
• flames (flame burns).
(WHO, 2018)
An estimated 180 000 deaths every year are
caused by burns – the vast majority occur in
low- and middle-income countries.
Non-fatal burn injuries are a leading cause of
morbidity including prolonged hospitalization,
disfigurement and disability, often with
resulting stigma and rejection.
Burns are among the leading causes of
disability-adjusted life-years (DALYs) lost in
low- and middle-income countries.
In India, over 1 000 000 people are moderately
or severely burnt every year.
Females have slightly higher rates of death
from burns compared to males (open fire
cooking, unsafe cookstoves, Open flames used
for heating and lighting and self-directed or
interpersonal violence)
70
• Burn injuries, particularly severe burns, are
accompanied by an immune and inflammatory
response, metabolic changes and distributive
shock that can be challenging to manage and
can lead to multiple organ failure.
• Impact on physical and mental health
• Burn injury leads to long-term profound
alterations that must be addressed to optimize
quality of life
• Burn depth is an important factor in assessing
patient care needs and, in particular, surgical
needs;
• The deeper the burn the more challenges there
are to achieve good scar outcomes.

71
 • First-degree burns (superficial
thickness, affecting the epidermis
only): typically benign, very painful,
heal without scarring and do not
require surgery.

• Second-Degree Burns (partial

thickness): extend into the
underlying skin layer (dermis);
these burns frequently form painful
blisters. These burns range from
superficial partial thickness, which
are homogeneous, moist,
hyperaemic and blanch, to deep
partial thickness, which are less
sensate, drier, may have a reticular
pattern to the erythema and do not
blanch.
(Jeschke et al., 2020)
• Third-degree (full thickness) and
fourth-degree burns require surgery
and, paradoxically, usually present
with almost no pain.
72
(Jeschke et al., 2020)
73
 • PTSD, Depression, Anxiety
• Psychological and Social Impact of Living with Scars:
Individual and Social Perspective
• Body-Esteem and Self-Esteem: Altered appearance;
Functional impairment if burn affects joints; → Negative self-
perception and difficulties in social interactions, Occupational
functioning → Risk to develop Depression and Anxiety
Psychological • Social Self-Consciousness of Appearance: Stigmatization
Impact resulting from reactions from other people such as
prejudices, discrimination, being ignored, intrusive
behaviors such as staring, intrusive questions and remarks,
bullying
• Self-consciousness → may perceive stigmatization which
may affect self-esteem in a negative way. This in turn can
induce avoidant behavior or sometimes (symptoms of)
social anxiety.

(Van Loey, 2020)

74
 • Burn Severity and Scarring: Objective severity
showed to be a poor predictor of psychological
adjustment
• Facial Involvement: staring, intrusive questions,
Factors remarks, and prejudices.
• Concealed scars: dilemma as to when to show the scars
Impacting and when not to; avoidance of situations (pools,
beaches), intimacy and sexuality (impact the ability to
Adjustment enjoy intimacy because one may not feel attractive and
avoid being touched).
• Gender: a higher risk for women to develop appearance
concerns compared to men because appearance is more
valued by women
• Importance of Appearance

(Van Loey, 2020)

75
Management • Social Skills Training
• CBT: CBT showed to have the strongest
evidence of effectiveness and can support
patients to come to terms with the visible
difference, it can help in decision-making, and
showed to be effective in overcoming social
anxiety (Rumsey et al., 2018)
• YPFaceIt: Online program including elements
of CBT and social skills training, has shown
improvement in persons with a visible
difference (Williamson et al., 2015)
• Peer Support Groups

(Van Loey, 2020)

76
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