Health Intervention

 A paper I wrote in 2011 for my Honours Health Psychology class at UCT.

Health Intervention for a Patient with Addison's Disease 

Addison’s disease is rare chronic health condition in which the adrenal cortex is no longer supplying the body with hormones vital for survival. Individuals diagnosed with the condition are prescribed a strict steroid replacement therapy which is designed to prevent morbidity and mortality. A health-behaviour intervention for a patient with Addison’s disease, with a middle- to high- socioeconomic status living in South Africa, is thus focused on promoting adherence through promoting high self-esteem and perceived self-efficacy and moving the individual from a possible denial mind-set to one of acceptance.  

Addison’s Disease

First described in 1855 by Thomas Addison, and subsequently named after him, Addison’s disease is a rare and chronic health condition affecting approximately 5 or 6 people per million each year. It is most common in people aged between 30 and 50 years although it can occur in individuals at any age. 

Also known as adrenal insufficiency, Addison’s disease is brought on through the failure of the adrenal cortex to produce and secrete sufficient amounts of glucocorticoids, mineralocorticoids and androgens. While the most common cause of the disease in developed countries is nonspecific autoimmune destruction of the adrenal glands, Tuberculosis has been an important cause of the disease in the last century as well as in developing countries today. 

In South Africa, which is both a developed and developing country, a client from a higher socioeconomic status group is most likely to have Addison’s disease caused by autoimmune destruction of the adrenal glands rather than Tuberculosis.

Until the introduction of glucocorticoid replacement therapy, the one year survival rate for individuals diagnosed with the disease was less than 20% (Bergthorsdottir, Leonsson-Zachrisson, Odén, & Johannsson, 2006) and few lived beyond 13 years (Arlt & White, 2010). Today, individuals with Addison’s disease are prescribed a strict daily regime of glucocorticoids and mineralocorticoids (Arlt, 2009). The aim of the prescribed steroid replacement therapy is to replicate the necessary amounts of the hormones, namely cortisol and aldosterone, which are no longer being produced by the adrenal glands (Baker & White, 2003).

The 21st century preference in treating Addison’s disease is that of a conservative replacement therapy which aims to prevent secondary complications associated with glucocorticoid excess. While as recently as ten years ago, standard replacement therapies prescribed dosages of 30mg and upwards of cortisone daily, today replacement dosages are around 20mg (Arlt & White, 2010). Depending on the needs and experiences of the individual, the prescribed dosage is split into two or three divided dosages to be taken over the course of the day. For example, a patient may choose to take 15mg in the morning and 5mg 6 hours later or 10mg in the morning followed by 5mg 4 hours later and another 5mg 4 hours after that (Arlt, 2009). Aldosterone, in the form of Florinef, is prescribed at 0.1mg in the morning (Baker & White, 2003).

At present there exists no objective method of accurately measuring glucocorticoid activity in individuals with Addison’s disease and so physicians rely on their clinical judgement and interactions with the patients to determine the correct dosage. Should the individual fall ill with an inter-current illness, such as a respiratory infection, or experience large stressors (including surgical procedures) then dosages should be increased or doubled until a full recovery is made (Arlt, 2009). 

Adverse Health Behaviour: Non-Adherence to Prescribed Medication

Risks Associated with Non-Adherence 

Individuals with Addison’s disease who do not adhere to the prescribed steroid replacement therapy run a number of risks to their personal health including the possibility of mortality (Arlt, 2009).

An Addisonian crisis, also known as an adrenal crisis, is a potentially life-threatening event caused by insufficient ingestion of cortisone by the patient. Such a crisis, which requires emergency medical treatment, most often occurs prior to diagnosis or through a patient not increasing his or her cortisone intake when experiencing a stressful event (Baker & White, 2003). 

Apart from the possibility of experiencing an adrenal crisis, low levels of cortisol and aldosterone have many unpleasant consequences for the individual. Low levels of cortisol can lead to recurring headaches, a loss of appetite, severe nausea, low blood sugar and general muscle weakness while low levels of aldosterone can cause low blood pressure and can lead to dehydration (Baker & White, 2003). Daytime fatigue, insomnia, irritability, restlessness and apprehension as physical symptoms have also been linked to a poor adherence to steroid replacement therapies (Ur, Turner, Goodwin, Grossman, & Besser, 1992).

A poor adherence to steroid replacement therapy has also been linked to a number of psychological symptoms. Depression, delirium, psychosis, chronic self-mutilation (Anglin, Rosebush, & Mazurek, 2006), mood swings as well as inappropriate anger (Baker & White, 2003) have all been associated with Addison’s disease. Attributed to a combination of “electrophysiological, electrolyte and metabolic abnormalities, glucocorticoid deficiency, increased endorphins, and an associated Hashimoto encephalopathy” (Anglin, et al., 2006, p. 450), these behavioural and mood symptoms clear completely with the introduction and adherence to an appropriate medication regime (Tobin & Morris, 1988). 

A patient who does not adhere to an appropriate steroid replacement therapy but instead exposes the body to excess glucocorticoids may develop other health problems including hypertension, diabetes mellitus and obesity. Each one of these health conditions alone is a strong risk factor for cardiovascular disease and, together, may increase the individual’s chance of early mortality (Bergthorsdottir et al., 2006).

Potential Causes of Non-Adherence

Denial. Individuals who feel that they have been incorrectly diagnosed or who refuse to accept a diagnosis because of the stigmas attached may have no intention of changing their health behaviours or adhering to prescribed medication regimes. Termed ‘deniers’ or ‘distancers’, these individuals associate the need to partake in a daily medication regime with an acceptance of the diagnosis rather than a useful strategy to avoid uncomfortable or distressing symptoms. They are also usually uneducated about the chronic illness with which they have been diagnosed (Adams, Pill, & Jones, 1997). 

Low self-esteem. An individual with a low self-esteem will have an overall negative core belief about him or herself that greatly influences his or her behaviour. The automatic and negative distorted thought patterns which are associated with a low self-esteem can lead the individual to feel he or she is incapable of taking up or maintaining a specific health-related behaviour and thus not attempt the behaviour at all. Low self-esteem has also been linked to maladaptive health-behaviours including outright avoidance (Fennell, 1998).  

Perceived low self-efficacy. Perceived self-efficacy is an individual’s belief in their ability to achieve their goals. It has been shown to be more important than the perceived importance of the intended behaviour in predicting adherence to health-related behaviours. Perceived low self-efficacy has been linked to maladaptive health behaviours including poor adherence to nutritional goals (Von Ah, Ebert, Ngamvitroj, Park, & Kang, 2004). 

Planned Intervention

A number of intervention strategies can be used simultaneously to promote adherence to the prescribed medication regime for an individual diagnosed with Addison’s disease. This intervention focuses on the client with autoimmune-related Addison’s disease from a medium- to high- socioeconomic status group living in South Africa.  

Motivational Interviewing. When working with an individual client in the context of promoting positive health behaviours, motivational interviewing techniques have been shown to be particularly effective. This is true even when clients can be described, by the Transtheoretical model, as being at a pre-contemplative stage for change (Resnicow, DiIorio, Soet, Borelli, Hecht, & Ernst, 2002) or ‘deniers’ (Adams, et al., 1997). Motivational interviewing can, through providing a non-judgemental and supportive place for expression, move individuals from pre-contemplation to maintenance (Prochaska, Redding, & Evers, 2008) or acceptance (Adams, et al., 1997) and thus promote medication regime adherence in patients with chronic health conditions.

The goal of motivation interviewing is to help the client work through their ambivalence about changing their behaviours (Resnicow, et al., 2002). One important way of doing this may be through educating the individual about the chronic illness with which they have been diagnosed as well as the risks of non-adherence to any prescribed medication regimes. 

Recently conducted research has shown that individuals diagnosed with a chronic ill-health condition were more likely to report an increase in intentions to adhere to prescribed medications when their information concerns had been met. The primary concern that participants in the study had was over the perceived need for the prescription medication (that is, the participants questioned the appropriateness of both the prescription and the diagnosis). Participants were also concerned about the side effects or safety of the prescribed medication as well as the costs involved (Kreps, et al., 2011).

Health practitioners working within the ethos of the motivational interviewing technique would address the information concerns of the clients in a neutral manner (Resnicow, et al., 2002) although the use of strategic motivational messages in these cases has also been shown to be effective (Kreps, et al., 2011). 

One way for a therapist to address information concerns a client may have may be through providing information documents such as the Addison’s Disease Owner’s Manual (see Baker & White, 2003) which can be found online. 

Clients can also be encouraged, through reflective listening techniques and positive affirmations from the therapist, to talk through their reasons for maintaining their current health-adverse behaviours. Through examining how their current behaviour may be conflicting with their health goals, as well as the ability to achieve those goals, clients may choose to adjust their behaviours (Resnicow, et al., 2002).

Goal-setting and specific behaviour planning have been shown to be an important driving factor in motivating health-behaviour changes especially in individuals with chronic illnesses. Clients should be encouraged to define specific and personal health goals and decide on the behaviour changes required to achieve those goals. Writing up a plan of action for the behaviour implementation as well as rehearsing the required behaviour between sessions is an important part of the process of behaviour change (Schreurs, Colland, Kuijer, de Ridder, & van Elderen, 2003).

In the case of an individual with Addison’s disease, the client may describe a goal of not experiencing the fatigue associated with poor adherence to the prescribed medication regime. In order to achieve this goal, the individual may have to try a number of behavioural strategies such as adjusting the medication dosages (where appropriate) or setting up an alarm system to remind him or her to take the prescribed medication at the appropriate times.

Cognitive Therapy. Cognitive therapy has been shown to be effective in the treatment of low self-esteem and can thus be used to indirectly influence adherence to medication regimes. Through the technique of ‘guided discovery’, clients are helped to become aware of their negative core beliefs about themselves and the processes and biases in thinking that maintain those beliefs. With the help of a trained therapist, clients are encouraged to re-evaluate the evidence that apparently supports these negative beliefs and question the associated automatic negative thinking patterns. Clients are then directed to formulate more realistic and helpful core belief systems that reflect their individual skills, strengths and positive qualities. 

Behavioural experiments (where the client actively engages in activities to challenge old beliefs) can prove a useful technique to improve a client’s self-esteem (Fennell, 1998).

Four-Component Approach. The four-component approach has been shown to be effective in improving the self-efficacy in individuals with chronic ill-health conditions. As part of an intervention strategy, the therapist would focus initially on facilitating the client in achieving a reasonable goal or mastering an achievable skill. Clients are then exposed to other individuals who have successfully mastered the behaviour or skills. Positive feedback from both professionals and individuals within the client’s social network help to reinforce and encourage the continuation of the desired behaviour. Finally, the therapist helps the individual to interpret the physical and mental changes associated with the behaviour as positive (Allegrante, Lorig, & Marks, 2005). 

Conclusion

A number of intervention strategies exist to help the individual client to adhere to a strict regime of prescribed medication, as is the case where a client has Addison’s disease. A combination of these strategies can be used, depending on the individual needs and circumstances of the client. 

 

References

Adams, S., Pill, R., & Jones, A. (1997). Medication, chronic illness and identity: The perspective of people with asthma. Social Science and Medicine, 45, 189-201.

Allegrante, J., Lorig, K., & Marks, R. (2005). A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: Implications for health education practice (Part II). Health Promotion Practice, 6, 148-156.

Anglin, R. E., Rosebush, P. I., & Mazurek, M. F. (2006). The Neuropsychiatric Profile of Addison’s Disease: Revisiting a Forgotten Phenomenon. Neuropsychiatry Clinical Neuroscience, 18, 450-459.

Arlt, W. (2009). The approach to the adult with newly diagnosed adrenal insufficiency. The Journal of Clinical Endocrinology and Metabolism, 94, 1059-1067.

Arlt, W., & White, K. (2010). Adrenal crisis in treated Addison’s disease: a predictable but under-managed event. European Journal of Endocrinology, 162, 115–120.

Baker, S., & White, K. (2003, May 15). Addison's disease Owner's Manual. Retrieved August 28, 2011, from Addison's disease Self Help Group: http://www.addisons.org.uk/info/manual/page1.html

Bergthorsdottir, R., Leonsson-Zachrisson, M., Odén, A., & Johannsson, G. (2006). Premature Mortality in Patients with Addison’s Disease: A Population-Based Study. Journal of Clinical Endocrinology & Metabolism, 91, 4849-4853.

Fennell, M. (1998). Cognitive therapy in the treatment of low self-esteem. Advances in Psychiatric Treatment, 4, 296-304.

Kreps, G. L., Villagran, M. M., Zhao, X., McHorney, C. A., Ledford, C., Weathers, M., et al. (2011). Development and validation of motivational messages to improve prescription medication adherence for patients with chronic health problems. Patient Education and Counseling, 83, 375-381.

Prochaska, J., Redding, C., & Evers, K. (2008). The transtheoretical model and stages of change. In K. Glanz, B. Rimer, & K. Viswanath, Health behavior and health education: theory, research, and practice (pp. 97-121). California: Wiley.

Resnicow, K., DiIorio, C., Soet, J., Borelli, B., Hecht, J., & Ernst, D. (2002). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21, 444-451.

Schreurs, K., Colland, V., Kuijer, R., de Ridder, D., & van Elderen, T. (2003). Development, content, and process evaluation of a short self-management intervention in patients with chronic diseases requiring self-care behaviours. Patient Education and Counseling, 51, 133-141.

Tobin, M. V., & Morris, A. I. (1988). Addison's disease presenting as anorexia nervosa in a young man. Postgraduate Medical Journal, 64, 953-955.

Ur, E., Turner, T. H., Goodwin, T. J., Grossman, A., & Besser, G. M. (1992). Mania in association with hydrocortisone replacement for Addison's disease. Postgrad Medical Journal, 68, 41-43.

Von Ah, D., Ebert, S., Ngamvitroj, A., Park, N., & Kang, D. (2004). Predictors of health behaviours in college students. Journal of Advanced Nursing, 48, 463-474.