PATHOPHYSIOLOGY AND PSYCHODYNAMICS OF

DISEASE CAUSATION

PRESENTED BY: BHAWANPREET KAUR

INTRODUCTION The study of pathophysiology (or patho

biology) considers the changes that happen to normal anatomy and physiology due to illness and disease.

Any cellular change or damage can affect the whole body. Injury, malnutrition or invasion by pathogens can all disrupt homeostasis. Cells check for such imbalances during the cell cycle and replication and usually adapt successfully in response to such stresses.

However, sometimes the cell cycle fails to detect unwanted changes and the resulting mutation may cause disease.

CONTI… Pathology is the branch of medical sciences that

treats the essential nature of disease, especially the changes of structure and function in tissues and organs of the body that cause or are caused by disease.Pathophysiology involves the study of functional or physiologic changes in the body that result from disease processes.

This builds on knowledge of the normal structure, and function of the human body. As a disease develops, the changes in the normal anatomy and/or physiology of the body may be obvious or maybe hidden, occurring at the cellular level.

 

DEFINITION Subclinical Condition When not associated with clinical features, the

disease is called a “subclinical condition”.   CarrierA person with subclinical infectious disease who

can transmit the disease to others is called carrier.  

DisabilityThe inability to carry out the activities of daily

living like bathing, combing, cooking, dressing is called disability.  

HandicapWhen the disability prevents the individual from

engaging in his vocation, it is called handicap.

HealthHealth is a state of complete physical, mental

and social well being and not merely the absence of disease or infirmity.

Disease Disease is just the opposite of the health

“Disease is a condition in which body health is impaired, a departure from the state of health, an alteration of human body interrupting the performance of vital functions”.

Pathophysiology The term combines pathology and physiology. Pathology deals with the study of study of structural and functional changes in physiology deals with the functions of the human body.

DETERMINANTS OF HEALTH BIOLOGICAL DETERMINANTS BEHAVIORAL AND SOCIO-CULTURAL

CONDITIONS ENVIRONMENT SOCIO-ECONOMIC CONDITIONS Major importance of Socio-Economic Conditions Economic status Education Occupation Political System Health Services Aging of the Population Gender Other Factors

PSYCHODYNAMICSThe term psychodynamics implies that psychic, or mental, processes are dynamic as opposed to static they involve movement and force. A psychodynamic interpretation always contains the idea that an individual’s behavior and subjective experience are the outcome of a conflict, usually largely unconscious, between opposing forces in the mind.

 PYSCHO DYNAMIC OF DISEASE CAUSATION

CONCEPT OF CAUSATION Physiological Factors Germ Theory Of Disease Genetic Disorders Autosomal dominant Achondroplasia Adult Polycystic Kidney Disease Huntington’s Chorea Hyper Cholestrerolemia Marfan’s Syndrome Multiple Neurofibromatosis Osteogenesis Imperfect Spherocytosis Von Willebrand’s Disease

Autosomal Recessive Colour Blindness Cystic Fibrosis Glycogen Storage Diseases Oculocutaneous Albinism Phenylketonuria(PKU) Renal Glycosuria Sickle Cell Disease Tay- Sachs Diseases Wilson’s Disease (Sex – Linked ) X- Linked Recessive Bruton- Type Agammaglobilinemia Classic Haemophilia A Duchenne- Type Muscular Dystrophy

Chromosomal Disorders Chromosome disorders involve a

change in chromosome number or structure that results in damage to sensitive genetic mechanism or in reproductive disorders.

Trisiomy 21 (Down’s syndrome) Monosomy X (Turner’s syndrome) Poly somy X (Klinefelter’s syndrome)

EPIDEMIOLOGICAL TRIAD The Triangle has three corners (called vertices): Agent, or microbe that causes the disease. (The “what” of the Triangle) Host, or organism harboring the disease.(The “who” of the Tri-angle) Environment, or those external factors that cause or allow disease transmission (The “where” of the Triangle)

AGENT

ENVIRONME

NT

HOST

The Agent—“What” Bacteria Virus Fungi The Protozoa The Host—“Who” The Environment—“Where” Physical environmental Biological environmental

THE Steady State The person as a living system has both an internal and an

external environment. There are four concepts for that : 1.) CONSTANCY 2.) HOMEOSTASIS a) Physiological Homeostasis b) Psychological Homeostasis 3.) STRESS Types of stressors: 1. Physical — cold, heat and chemical agent 2. Physiological — pain and fatigue 3. Psychosocial — fear 4. Normal life transition 5. Others: frustration, war and terrorism, marriage, divorce,

retirement etc.

DYNAMIC BALANCE

4. CELLULAR ADAPTATION It is modification of cell morphology and function to

achieve a new steady but altered state, preserving the viability of cells, which includes Atrophy, Hypertrophy, Hyperplasia, Metaplasia and Dysplasia.

 ATROPHY HYPERTROPHY HYPERPLASIA a) Physiologic Hyperplasia b) Compensatory-Hyperplasia c) Pathologic Hyperplasia METAPLASIA DYSPLASIA

  INTRACELLULAR ACCUMULATIONS

1. Normal body substances (lipids, proteins) 2. Abnormal endogenous products ( metabolism) 3. Exogenous products (environmental agents) CAUSES OF CELL INJURY Physical agents, Electricity , Radiation, Chemical, Biologic agents , Mechanical forces Extremes of temperature Injury from nutritional imbalances Infectious Immunologic agents, Genetic defects, Aging. Oxygen Deprivation (Hypoxia, due to restriction of

blood “ischemia”),

TYPES OF INJURY1. REVERSIBLE CELL INJURY Cell swelling Cloudy swelling and hydropic

degeneration, Fatty changes Occurs in organs rich in mitochondria e.g. renal tubules,

cardiac muscles and hepatocytes. Organ is enlarged, soft, pale with tense capsule and

rounded borders. Swollen cells with granular cytoplasm - Nucleus is

normal. Hydropic degeneration renal tubules Hydropic

degeneration liver. Hydropic degeneration:- A severe form of cloudy

swelling. Cytoplasm accumulates vacuoles of water in the liver; it may be caused by alcohol, viral hepatitis.

2. IRREVERSIBLE CELL INJURYAPOPTOSIS (CELL DEATH )

It is single cell death in the middle of living tissue due to activation of internal “suicide” program with characteristic morphology (cell shrinkage) that does not cause tissue disruption or inflammation. It occurs in:

1) Embryogenesis, organogenesis,& developmental involution 2) Hormone-dependent physiologic involution. 3) Cell deletion in proliferating populations, such as intestinal

crypt epithelium, or cell death in tumors. 4) Deletion of auto reactive T cells in the thymus.5) Deletion of virally infected cells. 6) Mild injury (heat, radiation, cytotoxic cancer drugs, etc.) that

cause irreparable DNA damage (e.g., via the tumor suppressor protein)

NECROSIS Necrosis is the death of a group of cells within living

organism.   Types of Necrosis 1. Coagulative (most common) necrosis It implies preservation of the basic structural outline of

the cell or tissue for a span of days. The injury or the subsequent increasing acidosis denatures not only the structural proteins but also the enzyme proteins, thus blocking cellular proteolysis. The process of Coagulative necrosis, with preservation of the general tissue architecture, is characteristic of hypoxic death of cells in all tissues except the brain.

Infarction is Coagulative necrosis resulting from hypoxia.

2. Liquefactive Necrosis It’s characteristic of focal bacterial or fungal

infections, due to accumulation of white cells, and hypoxic death within the central nervous system. Liquefaction completely digests the dead cells.

3. Caseous Necrosis The term "Caseous" is derived from the cheesy,

white gross appearance of the central necrotic area. The necrotic focus is composed of structure less, amorphous granular debris within a ring of granulomatous inflammation. The tissue architecture is completely lost.

4. Fat Necrosis In this focal areas of fat destruction, typically

occurring after pancreatic injury > release of activated pancreatic enzymes into adjacent parenchyma or the peritoneal cavity. The released fatty acids combine with calcium to produce grossly visible chalky white areas (fat saponification).

5. Gangrenous Necrosis It is ischemic Coagulative necrosis (frequently of a

limb> dry gangrene); when there is superimposed infection with a Liquefactive component, the lesion is called "wet gangrene”. Gangrenous tissue must be removed surgically.

4. Gangrene It is the death of tissues in your body. It may be caused

by a lack of blood flow to a part of the body or by a bacterial infection. Blood helps the distribution of nutrients, oxygen and to the body parts. It also carries toxins and waste materials to the liver and kidneys to be removed from your body. When body flow is blocked the body suffers and tissue dies. If they don’t get the nutrients and oxygen by the blood then health problems like gangrene can develop.

Types: There are two main types: Dry gangrene: This is caused by disease, which

affects the blood circulation. Wet gangrene: This is caused by a wound infected

with bacteria.

1. Nor epinephrine - Excitatory or inhibitory 2. Dopamine - Excitatory 3. Serotonin - inhibitory 4. Melatonin - Sleep walk cycle 5. Acetylcholine - Excitatory or inhibitory 6. Gamma-amino butyric acid- inhibitory

NEUROTRANSMISSION

HORMONAL THEORY1. Sympathetic nervous system response: Its response is rapid and short-lived. Increase

heart rate, Peripheral vasoconstriction, raising blood pressure, blood glucose is increased, pupils dilated.

2. Sympathetic-adrenal-medullar response: Release of the hormones epinephrine and nor

epinephrine. Increase blood glucose increase metabolic rate. Mental acuity Increased ventilation This effect is called “fight-or-flight” response. 

“FIGHT-OR-FLIGHT RESPONSE”

This is the body’s response to perceived threat or danger.

During this reaction, certain hormones like adrenalin and cortisol are released, speeding the heart rate, slowing digestion, shunting blood flow to major muscle groups, and changing various other autonomic nervous functions, giving the body a burst of energy and strength.

The fight-or-flight response, also known as the acute stress response, refers to a psychological reaction that occurs in the presence of something that is terrifying, either mentally or physically.

CONTI… In response to acute stress, the body's sympathetic

nervous system is activated due to the sudden release of hormones.

The sympathetic nervous system stimulates the adrenal glands triggering the release of catecholamine's, which include adrenaline and noradrenalin.

This results in an increase in heart rate, blood pressure and breathing rate.

After the threat is gone, it takes between 20 to 60 minutes for the body to return to its pre-arousal levels.

PSYCHOANALYTICAL MODELSigmund Freud believed in theory of libido

development. Libido derived from Latin word for wish or desire-as a non specific sensual drive for bodily gratification.

THE ORAL STAGE THE ANAL STAGE THE PHALLIC STAGE ( OEDIPUS

COMPLEX) ( ELECTRA COMPLEX) THE LATENCY STAGE THE GENITAL/PUBERTY STAGE

ORAL STAGE (BIRTH-18 MONTHS)

It is earliest stage of development . The goal is immediate gratification of needs,

a sense of security & ability to trust others. Relief from anxiety through oral gratification

of needs &pleasure is obtained through stimulation of mouth as in thumb sucking.

It consists of two phases:-1.) Receptive phase-chewing2.) Sadistic phase -Biting

ANAL PHASE (18-MONTHS-3 YEARS)

In this stage major tasks are gaining independence & control with particular focus on excretory function. Gratification is obtained through holding & expelling feaces. The manner in which parents approach the task of toilet training may have long term effects child in terms of valves and personality characteristics, It consists of two phases:-

The destructive expulsive phase—child enjoys excretion

The mastering phase---child enjoys sphincter control

PHALLIC STAGE (3-6 YEARS) In this stage the focus of energy shifts to genital

area. Children display considerable sexual interest. Discovery of differences between genders results in a heightened interest in sexuality of self & others.

This interest may be manifested in sexual self exploratory play. Development of Oedipus complex occurs during this stage of development (desire to eliminate parent of same sex & to possess parent of opposite sex) guilt feelings result with emergence of superego during these years.

LATENCY PHASE (6-12 YEARS)

It is regarded as phase of sexual latency and the focus changes to group activities, learning, socialization.

The preference is homosexuals groups i.e. gang formation.

Children of same age show distinct preferences for same sex relationships even rejecting members of opposite sex.

GENITAL STAGE (12-20 YEARS) It is initiated by puberty and leads to

reawaking of sexual interest that is now conscious, increasing desire to achieve adult status. Sexual arousal occur through memories and sensation from earlier childhood periods, physical manipulation of genitals and hormonal secretions.

Heterosexual interests appear and focus on relationships with members of opposite sex.

THE NATURE OF MIND(FREUDS STRUCTURAL MODEL)

  Id- The id is the part of our mind where the drives are represented.

These are intimately connected with the physical body and its functions. According to Freud the Id operates on the pleasure principle. E.g. baby is crying for milk, he want milk in any condition ,he can compromise.

Ego-It operates on the reality principle. Ego considers the consequences of our actions. Ego is based on id as well as of reality. It is set of conscious, intellectual & self preservation functions. E.g. School going kid want new bag but he know his father cannot buy, he will compromise.

Superego-Within the ego there is substructure called the superego. It is the part of the ego, which the identification with our parents and their authority. It is called perfection principle. It is mainly unconscious. The superego corresponds closely to the conscience which is a set of positive values and moral ideals. E.g. a person always obey rules because of strict discipline at home.

PSYCHOPATHOLOGY

Mental Health:Mental health in a narrow sense, it is describe as a health mind. But it can’t be described without physical, social and spiritual health. Therefore mental is a part of general health. It requires a balance between the body, mind, spirit and environment in which a person lives.

Illness and other conditions upset the previously learned functions of the child for e.g. secure bladder control or revert babyish eating. This is described as regression.

Illness: Illness is a subjective state of the person who feels

aware of not being well. Meaning Of Illness:

Illness are also individualized to each person, who experience an alternation in health. So illness is the responses, the person has, to a disease; it is an abnormal process in which the person’s level of functioning is changed compared with a previous level.

The response is different for each person, and is influenced by self-perceptions; other perceptions, the effects of changes and body, structure and functions, the effects of those changes on roles and relationships and cultural and spiritual values and beliefs.

MEANING OF MENTAL ILLNESS

Mental illness occurs when a state of physical, mental, social and spiritual well-being is disturbed. Personality of a person and use of various defense mechanism, help the individual to adjust to various stressful situation of life.

When the capacity to adjustment of the individual is not able to adjust to the situation, he may develop maladaptive behaviour and become mental ill.

CAUSES OF MENTAL ILLNESSES1. ORGANIC CONDITIONS 2. HEREDITY 3. SOCIAL PATHOLOGICAL CAUSES 4. ENVIRONMENTAL FACTORS (Toxic

substances, Psychotropic drugs, Nutritional factors, Minerals Infective agents, Traumatic factors, Radiation)

HEALTH - ILLNESS SPECTRUM MODELS INTRODUCTION Models of why and how individuals carry out behaviours

to promote health and prevent illness are useful in helping healthcare providers understand health-related behaviours and adapt care to people from diverse economic and cultural backgrounds.

This knowledge can be used to overcome barriers to health from disparities in care resulting from such factors as:

1. The increasing number of people without health insurance.

2. Predicted upward trend in minority populations. 3. Lack of accessible and essential healthcare services for

low-income and rural populations.

I. THE HEALTH BELIEF MODEL The health belief model is concerned with

what people perceive, or believe, to be true about themselves in relation to their health.

This model is based on three components of individual perceptions of threat of a disease:

(1) Perceived susceptibility to a disease, (2) Perceived seriousness of a disease, (3) Perceived benefits of action.

1. Perceived susceptibility to a disease: It is the belief that one either will or will not

contract a disease. It ranges from being afraid of contracting a disease to completely denying that certain behaviours will result in illness.

2. Perceived seriousness of a disease: This component is related to how much the person

knows about the disease and can result in a change in health behaviour.

3. Perceived benefits of action: Is concerned with how effective the individual

believes measures will be in preventing illness.

Cues to action are also modifying factors and are provided by activities such as:

1. Others' advice, 2. Mass-media campaigns, 3. Literature, 4. Appointment-reminder telephone calls

or postcards, 5. Illness of a significant other.

II. THE HEALTH-ILLNESS CONTINUUM MODEL

The health–illness continuum is one way to measure a person's level of health. This model views health as a constantly changing state, with high-level wellness and death.

The continuum illustrates the ever-changing state of health person adapts to changes in the internal and external environments to maintain a state of well-being.

Health is a common theme in most culture. In fact all communities have their concepts of health as a part of their culture.

Health and illness are defined according to the values of society to which a person belongs. When a person is able to adjust and adapt to his environment he is said to be healthy. A person with good mental health functions comfortably with society. He is satisfied with himself and achievements.

CONCEPT OF HEALTH AND ILLNESS CONTINUUM

Health and disease lie along a continuum and there is no single cut-off point. The lowest point on the health and disease spectrum is death and highest point corresponds to the WHO definition of positive Health. It is thus obvious that health fluctuates within a range of optimum well being to various levels of dysfunction, namely the death.

The transition from optimum health to ill health is often gradual, and where state ends and the other begin is a matter of judgment. So the spectral concept of health of an individual is not static. It is a dynamic phenomenon and a process of continuous change, subject to frequent stable variations.

That is a person may function at maximum level of health today and diminished level of health tomorrow.

CONTI… It implies that health is a state not to be attained once

and for all, but ever to be renewed. There are degrees or ‘levels of health ‘as there are degrees or severity of illness. As long as we are alive there is some degree of health in us.

According to R. Dubois views health as adaptation, a function of adjustment. He believes a utopian state of health can never be so perfectly adapted to the environment that life will not involve struggle, failure and suffering. Human can adapt to environment but each new adaptation procedures new problems that demand new solutions.

CONTI… H. S. Sullivan defines mental or emotional illness as

inappropriate interpersonal behavior or behavior that is inadequate for the social context. Sullivan believes that each person has some small degree of illness. Physical or emotional even when he or she feels and looks well.

The illness may be minor aches, temper flares, inappropriate forgetfulness, or over use of certain defense mechanisms such as rationalization or forgetfulness. Similarly the emotionally ill person manifests some degree of health. Some appropriate thinking and behavior.

III. HIGH LEVEL WELLNESS MODELHalberd, Dunn (1961) described the model of high level wellness as functioning to one’s maximum potential while maintaining balance and purposeful direction in the environment.

Concept Of High Level Wellness Model  It can be applied to the individual, family,

community, environment and society. Dunn, model is holistic, allowing the nurse care for the total persons with regards for all dimensional factors affecting the person’s state of being as he or she strives to reach maximum potential. For example, intellectual dimension, social dimension, emotional dimension and spiritual dimension.

HIGH LEVEL WELLNESS INVOLVES:

(1) Direction in progress forward and upwards towards a higher potential of functioning.

(2) An open-ended and ever-expanding tomorrow with its challenge to live at a fuller potential.

(3) The integration of the whole being of the total individual—body, mind, and spirit—in the functioning process.

EIGHT POINTS OF HIGH LEVEL WELLNESS:

1. Willingness to face inconsistencies in our thinking.2. Willingness to hear and examine the other fellow's viewpoints

with an open mind.3. Willingness to encourage freedom of expression of those

around us.4. Willingness to adjust our own views.5. Willingness to make time for unhurried contacts with others

when such relationships are essential.6. Willingness and determination to give credit and recognition to

others when it is due them.7. Eagerness and determination to serve others as opportunities

arise.8. Willingness to give freedom to those we love.

THE SIX DIMENSIONS OF WELLNESS

EMOTIONAL

PHYSICAL

VOCATIONAL

SPIRITUAL

INTELLECTUAL

SOCIAL

RECENT AUSTRALIA STUDIES SUGGEST THAT THE "WELLEST OF THE WELL" POSSESS THE FOLLOWING QUALITIES, TO AN UNCOMMON DEGREE

(a) High self-esteem and a positive outlook; (b) A foundation philosophy and a sense of purpose; (c) Strong sense of personal responsibility; (d) Good sense of humour and plenty of fun in life;(e) Concern for others and a respect for the environment; (f) Conscious commitment to personal excellence; (g) Sense of balance and an integrated lifestyle; (h) Freedom from addictive behaviours of a negative or health-inhibiting

nature; (i) Capacity to cope with whatever life presents and to continue to learn;(j) grounded in reality;(k) Highly conditioned and physically fit; (l) Capacity to love and an ability to nurture;(m) Capacity to manage life demands and communicate effectively.

REFERENCES  Park's Textbook of Preventive and Social Medicine, 19th Edition, Bhanot, pp.

29-36, 80-82. Gupta Pixyish and Ghai O.P., "Textbook of Preventive and Social Medicine" 2nd

Edition, C.B.S. Publishers & Distributors, New Delhi, pp 10-11 Dr. Rao Sridhar, "Principles of Community Medicine" 4th Edition, Aitbs

Publishers, New Delhi, pp 1-5. Brunner, Sudharath, "Text Book of Medical Surgical Nursing" 11th edition,

William Wilkins Lippincott. Harrison's, "Principles of Internal Medicine", 17th Edition, Vol. I, Mac Grew

Hill, pp. 19-22. Davidson's, "Principles and Practice of Medicines", 18th Edition, Churchill

Living Stone ELBS, pp 45-56. K.Park. “Text book of preventive and social medicine”. 17th ed.2002.

Banarasidas bharath.Jabalpur.Pp 16-32, and 582- 581. Potter.A.Patricia and Perry Anne Griffins “fundamentals of nursing” 6thy

ed.2005.Mosby.St.louis Missouri. Pp 91 – 103. Niraj ahuja. “A short textbook of Psychiatry “. 1st edition.1995.Jaypee brothers.

New Delhi. Pp –1-2,4.

Stuart.Gail.W.Laria.Michele.T. Principles and practice of psychiatric nursing.8th edition.2007.Mosby: St. Louis.Pp 445 – 472.

THANKSSSS