The Bio-psychosocial Report
Social Context
Anna is a 64 years old woman who has Parkinson’s Disease (PD). She lives with her husband, Peter, in a detached house that they own without mortgage in South Shields and only 8% of the houses in this area, South Tyneside, is owned outright (1)[Statistics, 2011 #2;SIGN, #37]. Sally et al reports that social renters are more likely to report ill-health, including general health as well as limiting long-term illness (2). Long term condition is prevalent; statistics illustrates that as high as 23.6% people in South Tyneside have a limiting long-term Illness which affect their daily activities(3). Moreover, incidence of chronic illness is higher in women and those of lower social class(4).
Peter (67) is a business owner and is the caregiver of Anna. They are in social class II(5). They own a car which give them easy access to the hospitals. South Tyneside is the 23rd most deprived area in England (6)but Anna is financially stable. In Anna’s view, being financially stable makes it easier for her to deal with her PD. People with better income may have an access to protection against health damaging features(2) such as damp and cold home which have been shown to cause illness(7). In addition, life expectancy is higher in those of higher social class (8).
Biographical disruption
Biographical disruption is the changes of identity, dependence and social support required by the patients that occur as they suffer long term condition(9). After diagnosis, patients often face with the challenges of adapting to their new lifestyle(10).
Parson’s role of sickness(11) may not apply to those who are chronically ill because some conditions are progressive and they might never recover and therefore unable to go back to work. Statistics illustrates that limiting long-term condition is more prevalent in those who are unemployed compared to those who are employed (20% and 9% respectively)(12)
Anna was an educational welfare officer and left her job after she was diagnosed with PD because her condition was restricting her from working and she really missed her job. She feels that she become much less independent because her family have to take care of her but she does not want to be a burden on them.
She is unable to enjoy her favourite sport which is swimming because of the muscle rigidity. She feels as if something has been taken away from her and that more will be taken away too as the condition progresses.
Stigma
“Stigma is a mark of social disgrace(13)”(p. 18). People who have PD are portrayed as being frail(14). Anna’s condition is very well managed and so most people do not notice that she has PD. Once they know, people treat her as if she is about to fall whenever she walks and constantly ask her if she is feeling well. She is sometimes uninvited to social events because people think that she is too unwell. She wished that she has not told anyone about her condition because she does not want to be treated differently.
Perception of health
Anna thinks that she is healthy even with the conditions she is living with. To her, health is not just about being physically healthy but also mentally healthy. Being healthy means that you should still be able to take part in normal activities and being a valid member of society. Anna’s definition of health fits the functional and idealist model of health(13) or the biopsychosocial model of health (15).
Family
According to South Tyneside 2011 census, only 7% of the urban households are composed of married couple with non-dependent children(16). Anna lives with her husband not far from her children and both her children are non-dependent. Although her children visit often, Peter is usually the first person Anna approaches regarding her health concern before going to healthcare professionals, this is referred to as ‘lay referral’ system(17).
Though Peter has diabetes, he never fails to take good care of Anna. She has very good support from her family throughout her illness experience, especially during the drug psychosis, which was her hardest time since she was diagnosed. Having good family support can have beneficial effect and a study done by Simpson et al shows positive relationship between social support and psychological outcome(18).
Figure 1: Family TreeMedical context
She was diagnosed with Parkinson’s and mitochondrial disease(MT). She is very concerned that the MT might be passed on to her children but there are still no signs of them developing MT though she was told that her MT is not hereditary. However, in her mind, Parkinson’s affects her more than mitochondrial disease because it affects her physical activity and make her movement very slow and lethargic. Thus, this report will emphasise on PD rather than MT.
Common clinical features of people with PD are displayed in Figure 2(19). Anna has short, shuffling step and her trunk is bent forward but she does not have pill rolling tremor.
Prior to being diagnosed, Anna gained the knowledge about PD from Peter’s business partner who also has PD. He explained to her about the core symptoms, the main one being lack of movement and rigidity. Anna started to notice that she has similar symptoms as her movement was slower and she was momentarily “freezing” when she was in the shower which made her worried that she might have PD. Her trigger to seek help was having “perceived interference with social/ leisure activity”(17) because walking became difficult for her and she decided that she will consult with the doctor when she went to the 6 monthly appointment for the mitochondrial disease.
Pathophysiology
Parkinson’s disease occurs as a result of deficiency of dopamine in striatum(20) due to degeneration of substantia nigra pars compacta (SNPC) which contains dopaminergic neurons that projects to striatum(21). Function of SNPC is to disinhibit intended movement and inhibit unintended movement via direct and indirect pathway respectively. In PD, there is a reduction in dopamine release to the striatum, resulting in less excitation of direct pathway and less inhibition of indirect pathway. The frontal cortex is therefore less excited(22) and Parkinsonian symptoms arise due to inability to control and coordinate the movements.
Risk factors
Figure 5: PD risk factors(23)
Majority of PD cases are idiopathic but studies have shown some risk factors associated to increased risk of developing PD (figure 5). Male is more likely to develop PD than female(24) and chance of developing PD might increase with age because as you get older, there is more neurodegeneration from environment and genetic component(25). There is also a link between genetic and environmental factors. For example, a study done by Ritz et al shows that pesticide exposure may result in an increased likelihood of developing PD in those with a genetic variability in the dopamine transporter(26). In addition, Tanner et al also reports that some pesticides may inhibit mitochondrial complex I which might be the cause of PD(27). Head trauma has also shown to increase the risk of developing PD. This is because it might have caused brain injury and accelerated the pre-existing neurodegeneration cascade(28, 29). Anna had a traumatic fall before she was diagnosed with PD due to MT. This may have caused her to have PD. Moreover, Anna once read an article about relationship between PD and fall and is very convinced that she has PD because of this fall.
Illness experience
Bio-psychosocial impact
Her PD is well-managed with medication and she hopes that it progresses slowly. However, the treatment itself affected her relationship with her husband when she had a drug-induced psychosis. She started to doubt that her husband was having infidelity when in fact he was talking to their daughter. Her children were very worried that Anna might commit suicide. She felt very ashamed and guilty for what she put her family through because she is normally not aggressive and violent. This event psychologically affected Peter and he was very stressed which may have an effect on his health.
Peter is Anna’s informal caregiver and study shows that being a caregiver can have adverse physical and psychological impact on health(30). Therefore, it is very important that Peter’s health is well taken care of, especially when he himself has a long-term condition to ensure that he does not neglect his own health and his condition is well managed.
People with PD are prone to falling(31). With both PD and MT, Anna has to be much more aware of her surroundings, especially if she is in a strange environment. She has had quite a few traumatic falls and they had both physical and psychological impact on her.
Model of disability
Functional model of disability or the International classification of functioning (ICF) is the incorporation of both medical and social model of disability. By employing the ICF, Anna’s disability can be discussed in 3 categories(32) (table 1).
Table 1: ICF and patient study examples
Comorbidity
“Comorbidity is the simultaneous presence of two or more morbid conditions or disease in the same patients”(33). Anna has comorbidity because she is currently living with MT and PD. For Anna, she feels that she has no control over MT because there is neither cure nor medication for MT. Although PD has no cure, it is treatable with levodopa medication. This gives her a sense of control over her health so she feels better mentally and the effectiveness of the PD medication makes her feel better physically as well.
Diagnosis
Initially, the doctor did not think she has PD because she has no noticeable clinical features and that her symptoms are due to MT. However, after gait assessment, she has reduced swinging of her arms. The doctor then carried out further investigation to confirm that she has PD. There is no specific investigation for PD but the diagnosis, following the NICE guideline(34), is made clinically by assessing her muscular rigidity, muscle tone and slowness of her movement. Furthermore, clinical history and CT/MRI scans can also be used to differentiate PD from other forms of Parkinsonian symptoms(35).
In 2010, she was diagnosed with PD. Her initial thought after being diagnosed was “maybe I do not have MT and it has been PD all this time!”. However, the muscle biopsy confirmed that she does have MT.
Treatment
“It’s a life saver and I could not manage without it”, said Anna. Anna is currently taking Stalevo. According to the NICE guideline, levodopa is the first line drug for treating PD but drug dose should be monitored carefully to prevent motor side effects(36). She complies to her prescription very strictly because anytime she missed her dosage, her movement become very slow and rigid. She believes that the side effect of the medication causes her to have minimal dyskinesia. However, research shows that levodopa medication can cause patient to have Levodopa-Induced-Dyskinesias(LID) but Stalevo could potentially reduce the incidence of LID because it contains entacapone which extends the half-life of levodopa(37).
Coping mechanism
Anna’s coping mechanism is problem-focused. She does not concern about the future and she will deal with whatever happen when it happens because she believes that every day she wakes up is the best she will ever be as her condition will only continue to deteriorate so she tries to make the best out of every day.
Doctor-patient relationship
There are different models of doctor-patient relationship, each with different level of patient and doctor control (table 2). For Anna, her doctor uses the mutualistic approach. It was shown that treating patient with respect and fairness and getting patient to be more active increase patient activation(38). Moreover, mutualistic approach enables patients to feel more comfortable and therefore feel at east to discuss their condition. When the patient is involved, there is also increase in concordance and compliance to treatment(13).
“Mutualistic relationship involves mutual respect”(13) (p. 74). This model usually results in shared decision-making (SDM). Doctor should regard patient’s belief and knowledge as important and according to the GMC, “doctors should Respect patients’ right to reach decisions with you about their treatment and care”(39). “I have a right to express my opinion regarding my treatment and I feel like I am part of the team”, said Anna. The doctor usually provides her with a detailed information about the treatment options for her to decide and together they come up with a shared decision.
Table 2: Doctor-patient relationship models(13)
Public Health
Health Promotion and disease preventions
Health promotion is defined as “the process of enabling people to increase control over, and to improve, their health (6)” (p.148). Health promotion is an overlapping area of health education, prevention and health protection(40). Exercise has a beneficial effect for general health(41) and also for PD(42) (43) so her doctor encouraged her to keep active by exercising regularly. In term of health education, she subscribed to the Parkinson’s UK membership and receives magazine containing the up-to-date information about Parkinson’s. This expands her understandings about her condition.
Figure 6: Health promotion(40)
Primary, secondary and tertiary prevention
Table 3: health preventions(44)Only 5% of Parkinson’s is caused by genetics, the other 95% is idiopathic(45). Therefore, its primary prevention requires further research.
Although the chance of passing PD to your children is minor, genetic testing is available for those who are susceptible of having high risk of developing PD(45).
PD is a neurodegenerative disease but many researchers have established studies showing ways in which PD progression can be decelerated. The NICE guideline states that “physiotherapy should be available to patients with PD” and there are evidence suggesting the effectiveness of physiotherapy for PD(46) . Anna had physiotherapy and she also exercises every day by mostly stretching and bending because she believes that it helps with her posture and lack of energy. RCT done by Canning et al(42) shows that exercise has psychological and physical benefits on the patients. In addition, resistance and stretching exercise increases the muscle strength in PD patients which could help with their mobility(43) but the most effective technique of exercise for PD is still in question.
Community Visit
Parkinson’s UK (PDUK) is the charity that operates to help those with PD to improve their care and quality of life. We are very fortunate to have a chance to attend one of the support group sessions run by them where they provide drawing lessons to those with PD. Each session provides different activities and their aim is to get patients together and prevent them from social isolation. Community support has more to do with supporting the social aspect of the illness, although they also provide activities such as exercise and dancing classes which have been shown to improve PD(47).
NHS service mainly deals with the medical aspect of the condition. For example, when she had a drug psychosis, the PD nurse withdrew the medication gradually and the psychosis went away. Although she does not attend support groups because she fears to see those who might be worse than her, Anna found using online PDUK forums particularly useful where she shared her story and reading response from those with the same experience made her feel at ease. It has been shown that meeting with others with the same condition with the same medication side effects help to reassure the patients and is therefore beneficial(48). In conclusion, PD nurse deals with medical side effect but the online support group benefits Anna mentally.
Reflection
Communication
When I asked the patient “who do you live with”, she became tearful and I, having no experiencing of dealing with this situation, did not know how to respond but instead I sat quietly. I was very upset that I did not know how to comfort her. She then continued to say that she lives with her husband and drug psychosis has a huge impact on their relationship. We mainly learn about the diseases and how to treat them so I have never really considered that illness could have such a huge impact the family member of the patients, especially with long term condition. This experience has taught me to be more sensitive towards patients’ illness experiences and to treat patients as individuals and according to the GMC, doctors should also consider the biopsychosocial aspect of the illness experience to help the patient manage with the condition. In my future practice, I would ensure that I pay more attention towards the other aspect of the illness rather than just treating the clinical conditions that the patients present with. Moreover, in the future, as a doctor I will encounter many difficult situations such as sensitive or emotional patients, I will certainly be sympathetic and supportive towards my patients.
GP visit
In my GP visit, a 17-year-old patient came in with her mother, presenting with a lump in her neck. We were given a chance to take a history from her but she did not appear to be too concerned about it. However, when she was questioned by the GP, she burst into tears. I was surprised and started to question myself what I did differently from the GP to get such a different response from the patient. To my realisation, although the patient insisted that she was not worried, the GP could tell from her facial expression and asked “you looked very concern, would you mind telling me why?”. It became clear that I was focusing on the history taking structure too much that I perhaps did not recognise the patient’s body language. From this experience, I have learned that it is important to look out for the non-verbal cues when taking history and react to them appropriately because it might tell you how the patients really feel. In the future practice, I would ensure that I do not neglect the non-verbal messages expressed by the patients to be able to understand fully their idea, concern and expectation.