What is insomnia?

Many people, about 20-25% of the population, are dissatisfied with their sleep. Among these, some have a specific sleep disorder called insomnia. Insomnia is defined as persistent trouble getting to sleep or staying asleep that affects daytime functioning or causes distress. When the sleep difficulty occurs at least three nights per week and continues for at least three months, it is called chronic insomnia disorder. At least 10% of the adult population have chronic insomnia.

Common triggers of insomnia include stress at home, work or school; relationship changes; loss; health conditions; anxiety; depression; and pain. Stimulants such as caffeine and nicotine can also lead to sleep difficulty.

Chronic insomnia can be maintained by factors other than those that triggered it initially. Racing thoughts, worries about not sleeping, staying in bed when not sleeping, and irregular sleep schedules often serve to sustain the cycle of insomnia. Sometimes, the fear of not sleeping or trying too hard to sleep is enough to prevent sleep from arriving.

Insomnia can be a serious problem. It causes daytime fatigue, irritability, impaired attention and concentration, reduced enjoyment of relationships and decreased work productivity. It has also been found to increase the risk of depression, Type 2 diabetes and heart disease.

What psychological approaches work in treating primary insomnia?

Good sleep hygiene is important for a good night’s sleep (e.g., cutting down on caffeine or alcohol at bedtime, avoiding light and noise, increasing exercise). If you already have good sleep hygiene and still have insomnia, then the following approach may be helpful for you.

The recommended first treatment for chronic insomnia is called “cognitive behavioural therapy for insomnia”, or CBT-I. This psychological treatment has been shown through research to effectively improve sleep. People also feel less fatigued, they function better, and their mood improves.

The behavioural, cognitive and relaxation components of CBT-I are outlined here:

• The behavioural components help you learn how to connect your bed with good sleep and to regulate your sleep schedule. For example, you discover what to do when you can’t sleep, when to go to bed and when to get up in order to get solid sleep.
• The cognitive therapy component helps you control the worry and racing thoughts that interfere with sleep. For example, you learn how to deal with concerns about getting through the next day if you can’t sleep.
• Relaxation techniques reduce bedtime mental and physical tension.

How effective are psychological methods of treating insomnia?

Research demonstrates that 70–80% of people with insomnia benefit significantly from 4 to 6 sessions of CBT-I, and continue to have improved sleep for months or years.

CBT-I is as effective as, or more effective than, sleep medications and produces longer lasting improvements in sleep. CBT-I is also effective in reducing the use of sleep medications, which can interfere with alertness and motor coordination and cause dependency.

CBT-I is more effective for chronic insomnia than either sleep hygiene alone or relaxation techniques alone.

You can consult with a registered psychologist to find out if they offer psychological treatments for insomnia, specifically CBT-I. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Judith Davidson, Queen’s University.

Revised: August 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

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What is attention-deficit/hyperactivity disorder (ADHD)?

ADHD is characterized by developmentally inappropriate levels of inattention, hyperactivity, and impulsivity, that impair a person’s functioning. Some individuals have problems with all three types of symptoms, whereas others have problems primarily with inattention, or primarily with hyperactivity/impulsivity. Related to problems with inattention, people with ADHD often have difficulty following instructions, keeping things organized, and following through on tasks. Related to problems with hyperactivity and impulsivity, they also may tend to act without thinking, interrupt others, talk excessively, or feel fidgety or restless. ADHD begins in childhood and many individuals continue to show ADHD symptoms into adulthood. ADHD occurs in approximately 5-8% of school-aged children and adolescents, and is more common in males than females.

In addition to the problems with inattention, hyperactivity, and impulsivity, people with ADHD often have academic or employment problems and difficulties in their social interactions and relationships. ADHD often co-occurs with problems such as oppositional defiant or conduct disorder, learning disorders, and depression or anxiety disorders.

ADHD appears to have a biological basis, and for some people, it is an inherited condition. However, the specific cause of the disorder is not known and it may differ for different people; it is likely that multiple possible causes or contributing factors exist. The family environment does not cause ADHD, but it may affect the way that symptoms are expressed, as well as help people manage their ADHD.

There is no one test for ADHD that can determine whether someone has the disorder or not. Instead, assessment requires gathering information from several sources (e.g., parents, teachers, observations, testing), across multiple domains (e.g., home and school), and using standardized measures. Assessment should also carefully consider of other possible causes of ADHD symptoms, such as other disorders or stressors. A thorough assessment can be a complex process, and psychologists are well qualified to conduct such assessments.

What psychological treatments are used to treat ADHD?

For most school-aged children and adolescents, the best treatment for ADHD is a combination of behaviour therapy and medication. Behaviour therapy is particularly important in addressing family stress and social behaviour problems in individuals with ADHD, and may help to prevent or treat other problems that can occur with ADHD.

Behaviour therapy involves many techniques and focuses on establishing clear behavioural expectations for the individual and providing frequent and consistent feedback about behaviour, which could include rewards and consequences. Behaviour therapy can also include modeling, problem-solving, and skills training. For children, behaviour therapy is often conducted both in the classroom and at home, and parents and teachers are essential in implementing the therapy. For adolescents and adults, cognitive-behavioural therapy focused on the individual’s self-management of their own behaviours may be useful.

Where do I go for more information?

More information regarding ADHD and effective treatments (psychological and medication) can be found on a website developed by the US National Institute of Health at http://www.nimh.nih.gov/health/publications/adhd-listing.shtml

There is also a website of factsheets operated by Children and Adults with ADHD, an advocacy group, at https://chadd.org/understanding-adhd/adhd-fact-sheets/

Information about psychological interventions for ADHD can also be found in this article: Evans, S.W., Owens, J.S., Wymbs, B.T., & Ray, A.R. (2018) Evidence-based psychosocial treatments for children and adolescents with attention deficit/hyperactivity disorder, Journal of Clinical Child & Adolescent Psychology, 47:2, 157-198, DOI: 10.1080/15374416.2017.1390757

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to  https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Amori Yee Mikami, Department of Psychology, University of British Columbia.

Revised: January 2021

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
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What is chronic pain?

Pain that does not go away and lasts for a few months or more is called chronic pain. Often chronic pain is the result of a known disease or injury and may last longer than the usual healing time associated with the disease or injury.

Sometimes medical tests cannot determine the cause of chronic pain. In most cases, the best way to assist a person with chronic pain is to help him or her learn how to manage it.

Pain can have different characteristics (e.g., burning, stabbing, and throbbing), tends to be accompanied by negative emotions (e.g., anger, fear) and can affect a person’s physical, mental, and emotional well-being. It can also affect a person’s physical functions making it harder for him or her to walk, bend, lift or sit. It can interfere with daily activities such as bathing, cooking, cleaning and working.

Pain can disturb sleep or appetite and decrease energy levels. It can interfere with roles and relationships with friends and family. Mentally, chronic pain can make it harder to concentrate or remember things. Emotionally, people with chronic pain can feel irritable, anxious and depressed. Psychologists play a central role in helping people manage chronic pain and the many consequences it has upon their well-being.

How common is pain among seniors?

Pain becomes more common as people get older. Research has shown that, during any one year, most seniors experience at least one significant pain problem, many of which are chronic. Common pain problems among seniors are:

• pain from arthritis;
• back pain;
• leg pain;
• pain following shingles;
• pain following a stroke;
• cancer pain;
• post-polio syndrome; and
• pain associated with other conditions such as chronic bronchitis, emphysema, stomach ulcers, fibromyalgia, and osteoporosis.

What are some common myths about pain and aging?

There are a number of myths about aging and pain. For example, many people (including some health professionals) sometimes say that “pain is a natural part of growing old”. This is not true. Pain is not caused by age. Pain is more common in older adults because the diseases or injuries that most often cause pain are more common in older adults.

It is important that the disease/injury and the pain be treated – no matter the person’s age. If we think of pain as a “natural part of growing old”, we may not treat a senior’s pain as seriously as we treat a younger adult’s pain.

Other common myths are that:

• “older adults suffer less from pain than younger adults”;
• “older adults can’t handle stronger painkillers or can easily become addicted to painkillers”; and
• “pain medications always interfere with physical and mental functioning”.

Further, some older adults might feel less entitled than younger adults to ask questions of their health care providers and some health care providers might provide less information to them.

None of these myths and views about pain and aging are true or helpful and could prevent a senior from seeking and receiving the full range of pain treatment options available.

Is pain among seniors under-treated?

Perhaps because of some of the myths just described, pain among seniors is under-assessed and under-treated. Seniors are under-represented in clinics specializing in the treatment of pain. When a senior has another condition which affects his or her ability to communicate (e.g., Alzheimer disease), health professionals may not identify a pain problem.

Educating health professionals about how to evaluate pain in older adults is important and methods designed to identify and assess pain in people with severe dementia have been developed and are being evaluated in Canada and elsewhere. Older adults should seek treatment for their pain and ask questions about the range of medical and psychological treatments available.

Treating chronic pain among seniors

Similar to younger adults, seniors can benefit from treatments such as physiotherapy, occupational therapy, massage therapy, psychological therapy, and medications to manage their pain. However, research has shown that coordinated combinations of treatments for pain (e.g., psychological therapies combined with physiotherapy and medical management) show the best results.

The combination of different types of treatment is sometimes referred to as inter or multi-disciplinary treatment because it is delivered by a team of different health professionals such as physicians, psychologists, physiotherapists and occupational therapists.

Working with professionals who have special expertise in the treatment of pain among seniors is important. For example, because seniors’ bodies tend to process medication more slowly than those of younger adults, medications might have to be administered differently. Similarly, a pain management psychologist working with seniors must understand the problems unique to older age groups.

There are many benefits to treating chronic pain. These may include:

• increased energy level;
• improved physical functioning (e.g., sitting, walking, standing);
• better sleep and appetite;
• greater activity and independence;
• more social involvement and better relationships with others;
• better concentration; and
• improved mood, self-esteem and sense of well-being.

What can psychologists do to help people with chronic pain? Is treatment effective?

Psychologists treating older adults for chronic pain often work within inter-disciplinary health care teams or coordinate treatment with the other health care services that the older adult might receive.

Because pain can be made better or worse by many factors, it is very important that the treating psychologist, or other pain specialist, communicate with the other health care professionals involved in the older adult’s care. Communication can only take place with the patient’s agreement (or in the case of persons with severe cognitive impairments, with the agreement of a close relative or legal guardian).

Psychological interventions focus on helping the older adult improve quality of life in spite of pain which, in turn, can decrease the burden of the pain experience. These interventions typically include cognitive-behavioural techniques which look at how physical sensations, feelings, thoughts and behaviours affect each other and our day-to-day functioning.

For example, a person with chronic pain may stop taking his or her regular walk to the community centre. Without the walks to the community centre, the person may become even less fit, may have a lower mood, and have fewer social contacts – all of which can worsen quality of life and the experience of pain. Psychological interventions can improve quality of life, and sometimes decrease pain, by helping the person with pain:

• cope with depressed, anxious or irritable mood;
• improve communication with others;
• improve his or her social supports;
• learn techniques and strategies to improve sleep and achieve relaxation; and
• learn how to pace and organize activity.

Where do I go for more information?

The Canadian Psychological Association has a number of fact sheets that describe treatments for a number of conditions including chronic pain, depression, insomnia, and generalized anxiety disorder. These treatments can be used and adapted to address some of the problems often seen in older adults with chronic pain.

For information about chronic pain, contact the Canadian Pain Coalition (http://www.canadianpaincoalition.ca/ ; 905-404-9545). The primary Canadian organisation dedicated to the study of pain is the Canadian Pain Society http://www.canadianpainsociety.ca.

For information on pain from arthritis, contact the Arthritis Society at http://www.arthritis.ca.

For information on pain from osteoporosis, contact the Osteoporosis Society of Canada at http://www.osteoporosis.ca.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association, in cooperation with the Canadian Coalition for Seniors Mental Health, by Drs. Thomas Hadjistavropoulos and Sheryl Green, Department of Psychology, University of Regina.

Revised: February 2017

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is depression?

Almost everyone feels sad or “depressed” at certain times. Clinical depression (also called Major Depressive Disorder or MDD) is a more serious condition that is confirmed by the presence of at least five symptoms for at least a two week period.

The possible symptoms of Clinical depression include sadness, loss of interest in usual activities, changes in appetite, changes in sleep, changes in sexual desire, difficulties in concentration, a decrease in activities or social withdrawal, increased self-criticism or reproach, and thoughts of, or actual plans related to suicide.

Clinical depression may vary in its severity and its duration. In its extreme form Clinical depression can be life threatening and may require hospitalization.

Whereas Clinical depression is a more severe form of depression which can be fairly time-limited, Dysthymic Disorder (also called Dysthymia) is a less-severe, but more chronic type of depression.

Dysthymia is recognized when three of the symptoms listed above are present for at least two years. Some individuals also experience what is called “double depression”; when a person has ongoing Dysthymia, but from time to time also meets the criteria for Clinical depression.

Major Depressive Disorder is also distinguished from Manic Depression (also called Bipolar Disorder) in that in MDD the individual only experiences periods of depression, and potentially returns to normal functioning in between times. In Bipolar Disorder, however, the individual will cycle between depression and periods of hypomania or full manic problems (euphoria, high energy, lots of activity).

Approximately 1% of Canadian men and 2% of Canadian women are clinically depressed at any point in time and about 5% of men and 10% of women will experience clinical depression at some point in their life. Women are at about twice the risk of men to experience clinical depression. These rates of depression are fairly consistent in various countries around the world.

Depression is often a recurring condition, as a person who has had one episode of clinical depression is at high risk for repeated experiences, and this risk of recurrence increases with each subsequent episode. Prevention, early assessment and intervention are thus recognized as critical aspects of health care.

Although the causes of clinical depression are complex and vary from individual to individual,  a variety of factors increase the risk of a person experiencing clinical depression. Women may face an increased time of risk after childbirth.  Other risk factors include having a parent who has been clinically depressed, physical illness or ongoing disability, the death or separation of parents, major negative life events (in particular, events related to interpersonal loss or failure), pervasive negative thinking, physical or emotional deprivation, and previous episodes of depression. The most common framework is called the Biopsychosocial model, which incorporates biological, psychological and social categories of risk.

It is also increasingly recognized that some factors can increase resilience or reduce the risk of depression, such as regular activity, sound sleep, positive social relationships.  Models of clinical depression now often include both risk and resilience factors.

Some individuals experience depression in a regular seasonal pattern. Finally, some medical conditions and the effects of some medications can either look like, or induce, a depressive episode.

What psychological approaches are used to treat depression?

Given the large number of people who experience depression and its profound negative effects, psychologists have devoted considerable effort to study depression and develop effective treatments. These efforts have resulted in a number of treatments with evidence to support them. Many of these treatments emphasize one or more of the recognized risk factors discussed above.

Cognitive therapy is the most well-studied psychological treatment for depression and has the most consistent evidence to support its use.

Cognitive therapy involves the recognition of negative thinking patterns in depression and correcting these patterns though various “cognitive restructuring” exercises. Cognitive therapy also uses behaviour change strategies, and is also sometimes referred to as “cognitive- behavioral therapy”.

Cognitive therapy has been shown to successfully treat approximately 67% of individuals with clinical depression. The evidence suggests that cognitive therapy reduces the risk of having a subsequent episode of depression.

Behaviour therapy helps patients increase pleasant activities and overcome avoidance and withdrawal through efforts to become more engaged in the world.

Behaviour therapy also teaches strategies to cope with personal problems and new behaviour patterns and activities. Behaviour therapy is offered in individual or group therapy and has comparable success to cognitive therapy.

Interpersonal therapy is another treatment for depression, based on the idea that interpersonal stresses and dysfunctional relationship patterns are the major problems experienced in depression.

Interpersonal therapy teaches the individual to become aware of interpersonal patterns and to improve these patterns through a series of interventions. Interpersonal therapy has a success rate that is comparable to behaviour therapy and cognitive therapy.

Other psychological treatments exist in addition to the above treatments, and have promise in treating depression. These treatments have some evidence to support their use although they are not as well-established as the first three treatments.

Short-term psychodynamic therapy is a treatment which focuses on the identification of core conflictual themes in the way a person thinks about themselves or their interpersonal relations, some of which may be unconscious.

This treatment approach uses the therapeutic relationship as a model for other relationships and uses corrective experiences in therapy to lead to other changes in the depressed person’s life. Evidence suggests that the efficacy of this therapy approach is comparable to other established treatments for depression, although less research exists to make firm conclusions.

Reminiscence therapy is a treatment that has been developed for older adults with depression. It involves teaching people to remember times when the individual was younger and functioned at a higher level than as a depressed older adult.

Self-control therapy and Problem-solving therapy are treatments which combine some elements of cognitive and behaviour therapy for depression and teach better self-control and problem-solving behaviours in problem situations.

Scheduled exercise can also be used to treat depression.  Consistent evidence reveals that a regular routine (about 3 or more times a week, at about 30 minutes each time) of at least moderate aerobic exercise is associated with reductions in depression.

Biological treatments also exist for the treatment of clinical depression. These treatments are not offered by psychologists, but are typically provided by a family physician, psychiatrist or nurse practitioner. These treatments include drug therapies, electroconvulsive therapy and light therapy (the latter for people who suffer Winter-time Seasonal Depression, also called Seasonal Affective Disorder; SAD).

Psychological treatments are effective and safe alternatives to drug therapy for depression when provided by a qualified professional psychologist.

The established psychological treatments for clinical depression are roughly as successful as pharmacotherapy for depression.  In fact, psychological treatments often have significantly lower drop-out rates than pharmacotherapy (approximately 10% in psychological therapies versus 25-30% in drug therapy) which may be related to the fact that drug therapies for depression often have unpleasant side-effects.  There is also evidence that cognitive therapy in particular reduces the risk of relapse relative to those individuals who are treated with drug therapy.

Although the evidence is somewhat inconsistent at present, it does not appear that combining drug and psychological treatments significantly enhances the success of either of these treatments alone. However, some of the drug therapies may be effectively combined with psychological treatments which provide for longer term change. Further research on the costs and benefits of combined treatments is needed.

It is also worth noting that psychological treatments that focus on relapse prevention have been developed and tested. One model in particular, called Mindfulness Based Cognitive Therapy, has demonstrated the ability to reduce the risk of relapse, relative to treatment as usual or medications alone, especially for individuals who experience recurrent depression.

In summary, depression is a disabling and potentially chronic disorder. There are a number of successful treatments, which include psychological and biological treatments. Unfortunately, there is no clear way to know in advance to which treatment any one person with depression will respond.

It is important to identify and treat depression as soon as possible, to prevent its development into a chronic problem. Further, long-term and more severe depression is associated with increased risk of suicide, so timely intervention from a qualified and professional health care provider is recommended.

Where do I go for more information?

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Registered psychologists are regulated health professionals across Canada, and are required to meet educational, ethical and legal standards.  You can find a list of colleges and regulatory organizations at https://acpro-aocrp.ca.  Provincial and territorial associations of psychology also often maintain referral services; for this information go to https://cpa.ca/public/whatisapsychologist/ptassociations/. The Canadian Register of Health Service Providers in Psychology also has a list of providers and can be reached at http://www.crhspp.ca.

Other organizations in Canada also provide information abut depression.  Two notable sources include: Health Canada, at https://www.canada.ca/en/public-health/services/chronic-diseases/mental-illness/what-depression.html and The Canadian Network for Mood and Anxiety Treatments, at https://www.canmat.org/

This fact sheet was prepared for the Canadian Psychological Association by Dr. Keith Dobson, Department of Psychology, University of Calgary.

Revised: January 2021

Your opinion matters! Please contact us with any questions or comments about this or any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

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Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

(Anxiety during pregnancy and baby’s first year)

What is perinatal anxiety?

Having a baby is typically a wonderful time in our lives. It is also a time of great change and uncertainty.  No wonder nearly all of us have an increase in worry and anxiety. Anxiety is a natural response we experience when we feel unsafe or threatened. We do not have to be in danger to experience anxiety. Even the idea of harm coming to ourselves or our loved ones —especially our baby— can make us feel anxious. During pregnancy, we may worry about the baby’s health and childbirth.  After birth, we may worry about the baby’s eating, sleeping, and safety.  Sometimes we don’t have specific worries.  Instead, we have a vague feeling of dread that something bad will happen. We may start avoiding situations, tasks, or even our own baby. We can also become extra careful and do more than is necessary (e.g., spend lots of time searching for information related to our worries). Although everyone experiences anxiety differently, changes in how we think, feel, and act are common.

Anxiety can affect our:

• thoughts(e.g., worrying too much, imagining the worst, trouble concentrating and focusing)
• actions or behaviours(e.g., avoiding, excessive planning, checking over and over again)
• feelings (e.g., scared, on edge, irritable, numb, frozen)
• bodies(e.g., upset stomach, racing heart, tense muscles, jumpy, not hungry, sleep trouble)

When is anxiety a problem?

Although anxiety can seem very scary, it is normal. It can even be helpful. Anxiety can help our body become stronger to deal with danger.  However, sometimes we have a lot of false alarms (we react as if there is danger when there is no real danger). When anxiety becomes upsetting and affects how we live our lives, it can become a problem or disorder. Approximately 20 percent of pregnant and new moms experience anxiety and related disorders. But perinatal anxiety does not only affect moms. Expecting and new parents of all genders, ages, and backgrounds can experience perinatal anxiety.

It is time to seek help when we…

• feel anxious, on edge, or worried a lot, most days
• notice anxiety is really upsetting us or getting in the way of daily life such as
  •  avoiding places, activities, people or situations that may bring anxiety
  •  doing too much of certain things (e.g., asking for a lot of reassurance)
  •  trouble carrying out routine activities
  •  difficulty enjoying the pregnancy or new baby
  •  more tension in close relationships

What helps people with perinatal anxiety get better?

People with perinatal anxiety may benefit from the following options (alone or in combination):

• psychological therapy
• pharmacological treatment
• psychosocial support

The best ways to get better will depend on the severity of the symptoms of perinatal anxiety and personal preference. Decisions are best made with the support of a trained health professional.

What psychological approaches are proven to treat perinatal anxiety?

The primary psychological treatment that helps people with perinatal anxiety is Cognitive Behaviour Therapy (CBT). CBT involves learning new ways of thinking and behaving that can help reduce anxiety.

Scientific research shows that many people who receive CBT will experience improvements in anxiety.  CBT works for many anxiety problems including excessive worry, obsessions, panic, and post-traumatic stress. CBT can also help us feel more confident about our ability to cope with anxiety related to becoming a parent and caring for our baby.

What can psychologists do to help people with perinatal anxiety?

Psychologists help people take an active role in positive change. They can help us feel better and reduce how much anxiety is getting in the way of living our lives to the fullest.

A psychologist can help us to learn and practice skills to manage anxiety. Some examples are:

• PSYCHOEDUCATION: Learning about anxiety is an important first step. It is often very comforting to know that we are not alone and it is not our fault.
• SELF-CARE: If we are going to have the energy to take care of a new life, we need to take care of ourselves. This includes eating well, exercising, getting as much rest as we can, and taking time for ourselves (even if it is only a few minutes).
• FLEXIBLE THINKING: When we are anxious, our thinking is sometimes unhelpful. The first step is to learn to recognize these unhelpful thoughts.  Next, we develop more helpful ways of looking at our situation and ourselves. This will often include learning to be kinder to ourselves.
• FACING FEARS: Anxiety tends to change our behaviour in unhelpful ways (e.g., avoiding situations that trigger our anxiety). This makes us feel better in the short term but increases anxiety over time. Facing fears helps us learn that the things we fear are not as dangerous as we think.
• RELAXATION & MINDFULNESS:. Learning skills such as calm breathing, muscle relaxation or mindfulness can help us reduce or better manage the bodily symptoms that are part of anxiety. Mindfulness techniques can also help us look at our thoughts differently. Mindfulness can help us notice and get untangled from our anxious thoughts so our thoughts have less power over us.

What is postpartum OCD?

Obsessive Compulsive Disorder (OCD) is an anxiety-related mental health problem. People with OCD experience thoughts that they don’t want to have and engage in behaviours they feel compelled to do.

The unwanted thoughts in postpartum OCD are often about harm to one’s baby. These thoughts can be frightening to ourselves and others. However, OCD thoughts are not associated with an increased risk of violence or harm to the baby. CBT can help improve the lives of mothers experiencing postpartum OCD.

Becoming a parent is a big change in our lives. Experiencing anxiety is often part of it. Fortunately, we can learn psychological strategies to help us manage our anxiety.

Psychology Works for Perinatal Anxiety!

Where can I go for more information?

You can consult with a registered psychologist to find out if psychological interventions may be helpful to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

A CBT expert can help us learn new skills to use in our daily life leading up to the birth and after the baby arrives. For the names of certified CBT Therapists in Canada, go to: https://cacbt.ca.

If you can’t find a trained CBT therapist in your community, you can use CBT self-management guides to help you learn these skills.  You can find free resources on anxiety for expecting and new parents at:

• https://www.anxietycanada.com/
• https://reproductivementalhealth.ca/resources
• http://postpartum.org

This fact sheet has been prepared for the Canadian Psychological Association, in cooperation with AnxietyBC, by Registered Psychologists Drs. Melanie Badali¹², Martha Capreol³, Nichole Fairbrother⁴, Michelle Haring², Sarah Newth², and Adrienne Wang³.
¹AnxietyBC, ²North Shore Stress and Anxiety Clinic. ³Changeways Clinic, ⁴University of British Columbia.

Date: March 23, 2018

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Cannabis is the most commonly used drug in Canada (Canadian Centre of Substance Use and Addiction). and was legalized in 2018. 27% of people reported using cannabis in the past 12 months in 2020 compared to 25% in the previous cycle. In 2020 the % of those who felt daily cannabis use can increase the risk of mental health problems dropped to 66% from 75% in 2019. Usage of cannabis with people aged 16-24 was approximately double that of those 25 years and older.

How does Cannabis affect young people?

Research suggests that regular or heavy use of cannabis in adolescence (ages 10-20 according to the World Health Organization) is related to difficulty in school, lower income, suicidality, greater welfare dependence and unemployment, as well as lower life satisfaction.

Our brains continue to develop up to the age of 24 years. Cannabis can change the way the brain develops, and medical imaging tests have shown differences between brains of cannabis users and non- cannabis users. Specifically, verbal learning, memory, and attention are negatively affected by acute and chronic use of cannabis. This effect can last even after someone stops using cannabis.

How does Cannabis affect mental health?

Cannabis use is related to mental health and mental illness. For example, research suggests that cannabis use is associated with psychosis, especially for those who use at an earlier age, who frequently use high potency cannabis, and who have a genetic predisposition for psychosis. There is also some research suggesting that cannabis use is associated with depression, bipolar disorder, and anxiety, though causality has not yet been clearly established for all such outcomes.

How does Cannabis affect judgement and decision making?

Executive functioning, which is our ability to plan, prioritize, and problem solve, is negatively affected by heavy or chronic cannabis use. This can lead to poor decision-making, planning, and organizing. Acute cannabis use is associated with an increased risk of motor vehicle collisions, especially fatal collisions.

What are the prevention and treatment options for dependence and abuse of Cannabis?

Research suggests that structured, school-based programs focused on making wise decisions about cannabis use, healthy coping, and substance use resistance skills offered in early adolescence can have strong effects on reducing cannabis use. Motivational Enhancement Therapy (MET) helps individuals resolve their ambivalence to get treatment and stop their drug use, and it has shown positive effects on reducing cannabis use in youth. Cognitive-behavioural therapy, motivational interviewing, and multi- dimensional family therapy are also shown to be helpful.

Where can I get more information?

Recommendations for the Legalization of Cannabis in Canada – provides further information regarding the research and recommendations for the legalization of cannabis in Canada: http://cpa.ca/docs/File/Position/Position_Paper_Recommendations_for_the_Legalization_of_Cannabis_i n_Canada-September_2017.pdf

The Centre for Addiction and Mental Health – provides information about use and abuse of cannabis:

http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/m arijuana/Pages/about_marijuana.aspx

Government of Canada – general information about cannabis: https://www.canada.ca/en/health- canada/services/substance-abuse/controlled-illegal-drugs/about-marijuana.html

Here to Help – Cannabis Use and Youth: A parents’ guide:  http://www.heretohelp.bc.ca/workbook/cannabis-use-and-youth-a-parents-guide

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to  https://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association (CPA) with information from the Recommendations for the Legalization Cannabis in Canada, a position paper prepared for the CPA by its Task Force on the Legalization of Cannabis.

Date: Updated by CPA October 2021.

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is an intellectual disability?

According to the American Association on Intellectual and Developmental Disabilities, an intellectual disability:

1. begins before age 18
2. presents itself within different settings (e.g., at school, at home) through observable limitations in both
   • adaptive behaviour (e.g., personal hygiene, social skills), and
   • level of intellectual functioning (i.e., a child’s thinking ability).

These limitations cannot be explained by differences in one’s culture. Children may have these limitations but also have strengths in other areas. Children with intellectual disabilities are usually able to learn and improve in specific areas of functioning when their challenges are well-identified, and personalized supports are put into place.

There are a number of conditions and developmental periods in which a child is at risk for developing intellectual disabilities. First, chromosomal and genetic errors can lead to a number of syndromes associated with intellectual disabilities (e.g., Down Syndrome). Intellectual disabilities can also be caused by other factors during the pre, peri, and postnatal period (e.g., extremely low birth weight, infection, physical trauma). The degree of impairment can be determined, and classified into different categories:

• Mild Intellectual Disability:
  • these children may experience difficulties in school, and can generally live independently
• Moderate Intellectual Disability:
  • these children often remain at or below the level of a grade three student, and may be consistently dependent on others in some areas
• Severe/Profound Intellectual Disability:
  • these children usually require support for the majority of daily activities, and many of these children do not have fully developed language skills.

What does it mean to be nonverbal?

In relation to this information sheet, nonverbal refers to children who have been diagnosed with an intellectual disability and do not communicate using spoken language. In other words, these children do not communicate with others using words or with a universally recognized form of sign language (e.g., American Sign Language). Children may occasionally be considered as nonverbal if they have a few words, but do not use them consistently or meaningfully.

What is pain?

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. Pain experience (how a person perceives what they are feeling) is different from pain expression (how a person shows that they are in pain). Pain is subjective: both pain experience and pain expression vary from person to person.

As individuals may experience pain differently, self-report is a very common method of pain measurement. However, many children who have intellectual disabilities and are nonverbal may not be capable of providing accurate self-reports about their pain. For this reason, caregivers are often asked to estimate the severity of pain a child is experiencing through observing their behaviour/pain expression. In this way, social factors may also come into play and be particularly important in a context where caregivers are relied on more heavily.

How does having an intellectual disability and being nonverbal impact pain experience and expression?

In the past, it was thought that children with intellectual disabilities did not experience pain in the same way that those without intellectual disabilities do. The belief that children with intellectual disabilities do not feel pain, are less sensitive to pain or are indifferent to pain still exists among some individuals. These beliefs are contrary to the findings of more recent research studies. The reason some individuals with intellectual disabilities, particularly those who are nonverbal, may appear to be insensitive to pain could be because they may express pain differently than other children. There are many potential explanations for this difference in expression, one being due to difficulty communicating effectively.

In what ways do children with intellectual disabilities communicate their pain to others?

As noted above, caregivers are often asked to report on these children’s pain. In some instances, caregivers may be able to see the source of pain (e.g., an open wound), however, in other cases, this may not be possible. Lack of a visible source of pain should not be interpreted as an absence of pain. Despite this, assessing the presence and severity of pain may be difficult for caregivers because children who have intellectual disabilities and are nonverbal do not always express pain very clearly. In some cases, even those caregivers who know the children very well still have difficulty assessing pain severity and location. Research suggests that parents are capable of identifying common behaviours expressed by their children who have intellectual disabilities and are nonverbal when they are in pain (see section below).

Studies seeking to create a list of common ways to express pain in this population have identified some general behaviours that may indicate a child is in pain. For example, the Non-Communicating Children’s Pain Checklist[1] [2] is a scale that has been used successfully by a variety of caregivers (e.g., health care providers, teachers, parents). A list of the behaviours on the NCCPC appears below. It is important to note that each individual may express pain differently and their baseline behaviour should be taken into consideration. Likewise, some of these behaviours may not always communicate pain; they may also express distress or frustration. Further, a child will not necessarily express all of these signals at once while in pain.

• Vocal Behaviour: moaning/whining/whimpering (fairly soft), screaming (very loud), crying (moderately loud)
• Social Behaviour: not cooperative/cranky/irritable/unhappy; less interaction with others/withdrawn, seeks comfort or physical closeness; difficult to distract/unable to satisfy
• Facial Expression: furrowed brow; changes in eyes; not smiling; lips pucker up/tighten/pout/quiver; clenches or grinds teeth/thrusts tongue out
• Activity: not moving/less active/quiet; jumping around/agitated/fidgety
• Body and Limbs: stiff/spastic/tense/rigid; gesturing or touching part of body that hurts; protects/favours/guards what is hurting; sensitive to touch
• Physical Signs: sweating; change in colour; tears; gasping

How can we ensure accurate pain assessment and management for children with intellectual disabilities who are nonverbal?

Effective pain assessment is critical for effective pain management.  These processes are challenging, due to many factors including differences in pain expression and cognitive limitations. Research has demonstrated that primary and secondary caregivers have varying pain-related beliefs, some of which may not be accurate. These beliefs may also influence care decisions. First, training programs may be an effective way to improve pain-related knowledge of those who care for children with intellectual disabilities. Second, further development and implementation of effective pain assessment tools for these caregivers could help to improve pain management in this population. Some medical settings have adopted the use of ‘tool kits’ for managing pain in children with disabilities, such as Holland Bloorview’s Chronic Pain Assessment Toolbox[3] for children with disabilities. Finally, ensuring that child-specific pain information is shared between a child’s various caregivers across settings is likely important. The Caregiver Pain Information Guide[4] is one example of a resource under development which aims to serve this purpose.

Where can I get more information?

To Access the Non-Communicating Children’s Pain Checklist^[1],[2]:

• https://pediatric-pain.ca/resources/our-measures/
• http://www.aboutkidshealth.ca/En/ResourceCentres/Pain/PainAssessment/MeasurementofPain/Pages/Tools-For-Measuring-Pain.aspx

To Access the Chronic Pain Toolbox^[3]:

• https://hollandbloorview.ca/research-education/knowledge-translation-products/chronic-pain-assessment-toolbox-children

To Access the Caregiver Pain Information Guide^[4] to be available at:

• https://www.uoguelph.ca/pphc/resources/Caregiver-Pain-Information-Guide

Additional Online Resources:

OUCH! How Understanding Pain can Lead to Gain when it Comes to Supporting Those with Developmental Disabilities *Not solely directed to children*:  https://www.porticonetwork.ca/documents/38160/99698/sss%2520vol%25206%2520issue%25205%2520-%2520ENGLISH.pdf/bf828358-15c9-48f6-a7d7-70812c0df146

Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations (MedScape) *Not solely directed to children with intellectual disabilities*: http://www.medscape.com/viewarticle/533939

Understanding Pain in Patients with Intellectual Disabilities (MedScape)*Not solely directed to children*:  http://www.medscape.com/viewarticle/752725

Cited References:

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services.

For the names and coordinates of provincial and territorial associations of psychology go to: https://cpa.ca/public/whatisapsychologist/ptassociations/

This fact sheet was originally prepared for the Canadian Psychological Association by Lara M. Genik (University of Guelph), Dr. C. Meghan McMurtry (University of Guelph) and Dr. Lynn Breau (Glenrose Rehabilitation Hospital). The current version was updated by Lara M. Genik (University of Guelph and Dr. C. Meghan McMurtry (University of Guelph).

May 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What are Neurocognitive Disorders (NCD)?

Neurocognitive Disorders are characterised by a cognitive decline which affect one or more cognitive domains such as memory and learning, executive functions, perceptivomotor activities, attention, language and social cognition. The decline must be significant in comparison with the person’s prior functioning, can be reported by the person or a family member, and objectified by a clinical assessment (e.g. neuropsychological evaluation). When cognitive decline does not affect the functional autonomy, about it is considered as a mild cognitive disorder. However, when deficits have more impact on functional autonomy, a diagnosis of major cognitive disorder can be made Neurocognitive disorders have many etiologies such as Alzheimer disease, Vascular disease, Lewy Body disease, Frontotemporal Disorders, etc.

What are the behavioural and psychological symptoms of dementia (BPSD)?

People who suffer from a neurocognitive disorder, such as Alzheimer’s disease, can have a number of difficulties related to:

• thinking (e.g., paranoid beliefs, delusions, , hallucinations);
• mood (e.g., anxiety, depression, apathy); and
• behaviour (e.g., aggressiveness, yelling, wandering, manipulating objects and inappropriate sexual conduct).

80 to 97% of older people with Alzheimer disorders may present BPSD during their disease (Gauthier S, Cummings J, Ballard C, Brodaty H, Grossberg G, Robert P, et al. Management of behavioral problems in Alzheimer’s disease. Int Psychogeriatr. 2010;22(3):346-72.)

What causes BPSD?

BPSD can be caused by a number of factors. These include:

• brain changes associated with the neurocognitive disorder;
• environmental factors such as , excessive demands, sensory overstimulation (e.g. too much noise or agitation in the environment), the absence of visual cues to help the person remain oriented (e.g., the green tagged door is the kitchen, the door with the picture of trees is the person’s bedroom), too few activities or pastimes;
• social factors such as challenging interpersonal or social relationships or situations (e.g., non adaptative communication);
• individual factors related to the person’s physical or emotional state such as pain, fatigue, stress, fear, boredom, or other unmet basic needs.

What are the effects of BPSD?

The distressing nature of BPSD can affect the quality of life of the person. He/she can feel left aside, can be frustrated or angry, feel lonely or hurt. The presence of BPSD also increases the risk of physical and chemical contention. But BPSD also affect relationships with family and caregivers, as well as treatment. Family caregivers may see a decrease of their quality of life and feel more psychological distress as anxiety and depression symptoms, culpability, hopelessness as well as difficulties to cope with BPSD. This context may precipitate the decision by the family to place the patient in residential care. The staff of residential care center can also find it difficult to care for a person with BPSD (e.g. resistance and physical agitation can make hygiene care more challenging).  They may report stress, anxiety, fear, helplessness, distress, burnout and they are more at risk of work-related accident.

What can psychologists do to help people with BPSD?

Studies have shown that psychological approaches are effective for reducing disruptive BPSD in individuals with neurocognitive disorder.

It is generally recommended that BPSD be treated first with nonpharmacological approaches, which are effective for many psychological and behavioral symptoms in individuals with neurocognitive disorders. However, when the situation is urgent or severe (i.e., there is a risk for the safety of the person or to others), pharmacological intervention might be added to non pharmacological approaches. Although some medications may help in treating BPSD, the risks and side-effects of the medication need to be carefully considered against their usefulness.

The implication of the psychologist in BPSD management is important. The psychologist’s mandate is quite diverse, and he/she can play an important part both with the person with BPSD and with the caregivers (family and staff members).

ASSESSMENT

The psychologist does a thorough assessment of symptoms – what they are and what makes them better or worse. Some psychosocial models have been developed for BPSD. One of the most popular is the Cohen Mansfield unmeet needs models (Cohen-Mansfield, 2000) who address BPSD as the result of unmeet needs. Another interesting model is the Newcastle Model developed by James (2011).  This model integrated elements of the experience of the person with neurocognitive disorder, the Cohen-Mansfield need model and cognitive behavioural model. With this model, clinicians work with caregivers to develop a hypothesis about the BPSD and take into account many contextual factors as personality traits, mental health, life story, social environment, etc. Second, the psychologist uses the findings from the assessment to develop a plan for intervention in collaboration with the caregiver and, in specific case, with the nursing team.

PSYCHOLOGICAL INTERVENTION

Psychological intervention as psychotherapy with patient with mild cognitive disorder may help decrease anxiety and depression symptoms (e.g. adaptation of CBT). The psychologist can also be involved to provide psychological support to the person and/or the family after a diagnosis of major neurocognitive disorder (e.g. understanding the illness, acceptance), or during life transitions associated with the illness (e.g. placement in a long-term care facility). Throughout the illness, psychological interventions can help reduce the person’s distress (e.g. reminiscence therapy, validation techniques).

BEHAVIOURAL INTERVENTION

Behavioural interventions can help by structuring routines and the environment in order to eliminate the factors that trigger or maintain symptoms.

For example, some patients manifest aggressive behaviour during personal hygiene activities, such as bathing. In this situation, the discomfort associated with bathing may be the trigger and avoiding the activity is the reinforcer. Rather than reducing the time devoted to bathing, it may be more useful to divert the patient’s attention away from the activity using conversation, music, etc. At the same time, it is necessary to reinforce appropriate behaviour that occurs during bathing. Similarly, lack of activity during the day may contribute to apathy and depressive symptoms. Scheduling pleasant activities may be a useful approach in this case.

Structuring activities in such a way to reduce stress is another approach. For example, a patient may present symptoms that are worse at a period of the day when he is very much involved in an activity. For this individual, it may be useful to provide rest and relaxation rather than activation during this specific time of day.

For another patient, symptoms may be worse during a period of the day when he is by himself and not doing anything. If the assessment reveals that symptoms are not usually present when the patient is engaged in activity, this might be the time to schedule visitors or arts and crafts.

Interventions such as sensory stimulation can also be of help. These include giving the patient fabric or a foam ball to handle, pictures in a book or magazine to look at, music to listen to, scents to smell, etc. Sometimes, if a particular person cannot be present to provide social interaction, listening to him or her on tape or watching him or her on video can be a good alternative.

It is not always necessary to stop patients from wandering. Organizing the environment to allow the patient to be physically active can be very helpful. For example, create specific areas in the residence where the patient can move about safely. Concealing outside doors and emergency exits can deter patients from exiting unsafely.

CAREGIVERS and NURSING TEAMS

Psychologists can have an important role to address distress and resistance of caregivers and nursing teams who work with people with BPSD. As a member (or partner) of the treating team, they can help identify the team’s difficulties, provide a space to vent their frustrations or express their concerns (debriefing), and help maintain motivation and bell-being within the team. They can also help the team in reaching a better understanding of the illness and the BPSD and help implement nonpharmacological interventions through formal teaching or coaching, in order to increase the team’s ability to manage BPSD.

At last, the psychologist can work with the family members in individual or group setting. The intervention could focus on increasing the caregiver’s knowledge of neurocognitive disorders and BPSD or coaching the caregiver on BPSD management techniques. The psychologist also plays a key role in assessing and addressing caregivers’ burnout and psychological distress. Psychotherapy can be necessary to address issues such as guilt and acceptance.

Where do I go for more information?

For more information visit the Alzheimer Society of Canada at http://www.alzheimer.ca.

https://alzheimer.ca/fr (in French)

https://www.baycrest.org/Baycrest/Education-Training/Educational-Resources/Responsive-Behaviours

https://www.msss.gouv.qc.ca/professionnels/maladies-chroniques/alzheimer-et-autres-troubles-neurocognitifs-majeurs/processus-cliniques-et-outils/ (in French)

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Philippe Landreville, Université Laval.

Revised: September 2020 by Caroline Ménard and Laurence Villeneuve, psychologists at the Institut Universitaire de Gériatrie de Montréal (IUGM)

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Sexual activity is an important part of quality of life and is often a great concern for both patients and their partners after a cardiac event. Fears and concerns may temporarily interfere with sexual spontaneity and response.

A few factors may interfere with your sexual health after your discharge from the hospital. You might temporarily suffer from mild depression, which will affect your sexual desire. Some medications may also impact sexual function. You might fear that sexual activity will cause another heart attack or your spouse might silently think the same. For the majority of patients, this will last a short period of time and life will pick up where it left off before you had a cardiac event.

There are also some unique difficulties that men and women may face. For example, erectile dysfunction (ED) is often associated with heart disease in men. The same factors that contributed to blocking the arteries of your heart can block arteries elsewhere in your body. Some medications may also contribute to ED. A healthy lifestyle that incorporates a heart healthy diet, exercise and reaching a healthy weight has been shown to correct ED in 30% of obese patients.

Women may face difficulties with several aspects of the sexual response cycle, including desire, arousal, and orgasm. Women may avoid intercourse due to pain caused by decreased blood flow or friction resulting from not enough lubrication. Over-the-counter lubricants can often address this concern and prevent further problems in the sexual and interpersonal relationship from developing.

Many of the sexual difficulties that people face after a heart attack, however, stem from just not knowing enough about whether they can safely have sex again.

When is it safe to engage in sexual activity after a heart attack?

If you have recently had a heart attack, your doctor will likely recommend that you wait one week or more (several months if you experienced complications) before resuming sexual activity. After this healing period, the risk of having a heart attack during sex is actually quite low. The risk is comparable to that of getting angry and is reduced if you exercise regularly and take your medication.

From a cardiac standpoint, sexual intercourse is like any other physical activity; your heart rate and your blood pressure increase. The effort on your heart is about the same regardless of your position. The activity is often compared to walking at three to six kilometers per hour on a level surface, or climbing 20 stairs in 10 seconds. However, each individual may have different physical factors to consider. It is important to always talk to your cardiologist/family physician before resuming sexual activity.

How can psychological strategies help to maintain my sex life after a heart attack?

• Start slowly and have realistic expectations. The first few weeks after a heart attack can be very stressful on your partner and yourself. Both of you might still be tired. Plan sexual activity for the time of day when you have the most energy and are least bothered by other health issues. You might also want to avoid having sex after a large meal. Give yourself a few hours to digest. Similarly, limit the amount of alcohol you drink and avoid using tobacco as both of these may affect sexual function. If you have chest pain or shortness of breath, speak to your doctor.
• Physical affection without sex is just as important. Explore your senses: hold hands, hug, and touch your partner. Create a bit of romance with music, candles, and special scents. You can also maintain emotional closeness by doing things like having regular date nights.
• For anyone,communication is key to an enjoyable sex life, and this is especially true after a heart attack. Agree to have honest discussions. Tell each other what you like and don’t like. If you are experiencing some communication difficulties in your relationship, meeting with a psychologist can help to improve communication skills.
• There aremany factors that can affect desire, including fatigue, fear/anxiety, depression, pain/physical discomfort, and drug-related sexual side effects. If you are experiencing any of these additional issues, it can be helpful to meet with a psychologist to specifically address these difficulties.

Where can I get more information?

Thriving with Heart Disease: A Unique Program for You and Your Family. Live Happier, Healthier, Longer – by Sotile & Cantor-Cooke (includes a chapter specifically on sexual functioning)

Heart and Stroke Foundation of Canada:  www.heartandstroke.com

Canadian Association of Cardiovascular Prevention and Rehabilitation:  www.cacpr.ca

Sex Information and Education Council of Canada (SIECCAN):  www.sieccan.org

The Society of Obstetricians & Gynaecologists of Canada:  www.sexualityandu.ca

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit: https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Heather Tulloch, University of Ottawa Heart Institute, Dr. Hannah Marchand, Kingston Orthopaedic and Pain Institute, and Dr. Michele de Margerie (physician), University of Ottawa Heart Institute.

Revised: September 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is heart disease?

Heart disease, also known as cardiovascular disease, is a general term for a variety of conditions that affect the heart and blood vessels. It is a chronic disease that can lead to serious events including heart attack and death. Heart disease is one of the leading causes of death in Canada and worldwide.

What are the risk factors for heart disease?

There are many risk factors for heart disease. There are “uncontrollable risk factors” including age, sex, heredity, and ethnicity. There are also “modifiable risk factors” that can be controlled or impacted by changes that you make in your lifestyle. These risk factors include smoking, excessive alcohol intake, excess body weight, high blood pressure, abnormal blood cholesterol levels, sedentary behaviour or limited exercise, diabetes, and excessive stress, anxiety, and depression.

Stress and anxiety and heart disease

Everyone experiences stress at some point in life. In these situations, your body reacts by releasing stress hormones, which in turn increases sweating, breathing, heart rate and blood pressure, as your body revs up into high gear to deal with the perceived stress. In the short term, these reactions may be helpful. However, in the long-term stress can be damaging. When individuals experience constant stress over a long period of time, fat cells may be converted into cholesterol, platelets can become more “sticky,” and patterns of daily life may change (decreased amount of healthy eating, regular exercise, and rest).

It is common for cardiac patients to experience varying degrees of fear or nervousness related to their health condition. About one in five (20%) cardiac patients experience significant anxiety symptoms that interfere with daily functioning including: uncontrollable worry, restlessness, irritability, muscle tension, headaches, sleep disturbances, increased fatigue, sweating, and/or gastrointestinal/stomach problems.

Depression and heart disease

Depression is also common in people with heart problems. Similar to anxiety, about one in five patients experience clinical (or major) depression that significantly interferes with daily functioning. Symptoms include feelings of sadness, loss of interest in pleasurable activities, changes in weight and/or appetite, sleep disturbances, decreased energy, difficulties with concentration/memory, feelings of worthlessness, helplessness, or hopelessness, and/or thoughts about suicide/death. Depression can contribute to both the onset of heart disease, and to poorer outcomes following a diagnosis of heart disease.

How can psychological treatments help to manage heart disease?

Psychologists play an important role in helping people to prevent and manage chronic diseases like heart disease. In addition to general training in the treatment of depression and anxiety, many psychologists are also specifically trained to help people cope with chronic diseases. In fact, some cardiac rehabilitation programs have a psychologist on their team.

Here are some ways that psychological approaches can help to prevent and manage heart disease:

• Stress and anxiety management – How you perceive stress in your life affects the level of stress or anxiety that you experience. It is important to learn how to recognize and identify your own “stress triggers” and how stress impacts you on a daily basis. To begin managing anxiety, it is important to develop healthy coping strategies including becoming aware of emotions which can trigger anxiety, learning relaxation and deep breathing techniques, distracting yourself from thoughts or physical symptoms, doing something pleasurable, sharing fears and worries with someone you trust, and focusing on what you can control rather than on the things you cannot. Additionally, positive social support networks (e.g., friends and family) and daily physical activity help reduce the effects of stress and anxiety.
• Depression management – Negative thinking, low activity levels, and difficulty handling strong emotions are often involved in depression. Many people with heart disease may also have unresolved issues of loss, grief, and anger, which may be weighing them down and draining their energy. Getting help to learn new ways of thinking and learning to better manage negative thoughts and strong emotions can be beneficial. Additionally, it is important to set realistic goals and engage in self-care activities such as regular exercise and doing pleasurable activities, even if you do not feel like doing so.
• Making and maintaining lifestyle changes – Psychologists and psychological strategies can also help people to make and maintain changes in their diet and exercise routines, which are important parts of managing heart disease. Psychologists can assist with issues such as identifying and enhancing your motivation for change, setting realistic and achievable goals, and building on success in making lifestyle changes.

Where can I get more information?

Thriving with Heart Disease: A Unique Program for You and Your Family. Live Happier, Healthier, Longer – by Sotile & Cantor-Cooke

Mind Over Mood: Change How You Feel by Changing the Way You Think – by Greenberger & Padesky

It’s Not All in Your Head: How Worrying about Your Health Could Be Making You Sick – and What You Can Do About It – by Asmundson & Taylor

Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness – by J. Kabat-Zinn

Heart and Stroke Foundation of Canada: http://www.heartandstroke.com

Canadian Association of Cardiovascular Prevention and Rehabilitation: http://www.cacpr.ca

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit: https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Hannah Marchand, Kingston Orthopaedic and Pain Institute, and Dr. Heather Tulloch, University of Ottawa Heart Institute.

Revised: September 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Imagine yourself relaxing by the pool. Suddenly, for no apparent reason, you feel faint, your chest hurts, you can’t breathe, your legs tremble, you think you’re having a heart attack and you’re dying. You may be having a heart attack or you could be one of several thousand Canadians suffering from panic disorder.

What is panic disorder?

Panic Disorder (PD) is marked by repeated attacks of panic that occur unexpectedly in the absence of any situational threat (i.e., they occur “out of the blue” and without any warning). These attacks begin quickly and build to a peak rapidly (usually in 10 minutes or less). They are often accompanied by a sense of imminent danger or impending death and an urge to escape. Panic attacks are often described as “the most terrifying experience I’ve ever had”. They leave the individual emotionally drained, frightened, feeling vulnerable and anxious about their health.

PD sufferers often live in fear of having another panic attack. Some fear that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g., cardiac disease). Others fear that the attacks are an indication that they are “going crazy” or losing control. Some individuals significantly change their behaviour (e.g., quit a job) in response to the attacks.

Individuals with PD often develop agoraphobia. The essential feature of PD with agoraphobia is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack. Agoraphobic fears typically involve situations such as being alone outside the home or being home alone; being in a crowd or standing in line; being on a bridge or in an elevator; and travelling in a bus, train or car. The situations are avoided or endured with considerable dread, or confronted only when accompanied by a trusted companion.

Untreated, PD may lead to both chronic debilitating anxiety and excessive visits to health care facilities. PD often is compounded by other problems. Depression occurs in 50%-65% of individuals with PD. It is also common for them to develop other anxiety disorders. It is estimated that 36% of people with PD have substance abuse problems (drugs and/or alcohol).

Who gets panic disorder?

PD is found more often in women than men. PD can appear at any age but it begins most often in young adults. The onset of PD is often preceded by a period of considerable stress (e.g., from an overload of work, the loss of a loved one, a move to a new city, a serious accident, a surgery, a divorce) or the anticipation of a stressful life event. It can also start right out of the blue. Studies throughout the world indicate that three out of every 100 individuals will suffer from PD at some point in their lives. It rarely goes away by itself.

What causes panic disorder?

Many individuals attribute PD to a lack of “strength” or “character”. Nothing could be further from the truth. Although no one knows the exact causes of PD, most experts believe that PD is caused by a combination of biological and psychological factors. For example, PD appears to run in families. This suggests that a genetic predisposition toward PD may exist. Another line of research shows that people with PD may have abnormalities in brain activity and biochemistry. Still another line of evidence suggests that there is a strong psychological component to PD. For example, scientists have found that people prone to panic attacks are much less likely to panic when they are told in advance about the sensations that some situations (e.g., hyperventilation) or substances (e.g., caffeine) will cause.

Can panic disorder be treated?

The vast majority of people with PD can be helped with the right professional care. Furthermore, they can almost always be treated without being admitted to a hospital. Recovery may occur in a matter of months but can take longer depending on individual circumstances. People with PD often have more than one disorder, which can complicate treatment. A successful treatment program must address all of an individual’s related problems including any depression or substance abuse that might accompany the underlying PD.

Can psychology help?

The most successful treatment approaches to PD include behavioural and cognitive therapies as well as medication. Results from numerous studies suggest that the best psychological approaches are as effective as the best pharmacological approaches in the short term and more durable over the long term.

However, there is no single correct approach: there are individuals who do not respond to cognitive-behavioural treatments and who may respond positively to medication; conversely, there are individuals who are resistant to pharmacotherapy and who may benefit from cognitive-behavioural therapy; finally, there are patients who may benefit more from a combination of both treatment approaches.

Behaviour therapy helps individuals reduce their fears and gain more control over difficult situations. It focuses on exposure to the actual physical sensations that someone experiences during a panic attack, as well as the situations that the individual fears and avoids.

Cognitive therapy attempts to change people’s thought patterns by helping them identify and criticize their unrealistic thoughts and helping them replace those thoughts with more realistic, positive ways of viewing the attacks. Psychologists developed behavioural and cognitive therapies and most often use a combination of both to treat PD. Patients have fewer and less severe panic attacks, actively participate in their own recovery and learn skills they will continue to use in many situations after the therapy ends.

Antidepressant and anti-anxiety medications can ease symptoms. Anti-anxiety medications (e.g., benzodiazepines) are fast-acting and may be used as a short-term solution to decrease acute anxiety. Antidepressants may be used in the longer term treatment of PD, but can take weeks to produce noticeable therapeutic benefits.

Both online and in-person support groups may be useful. Many people learn from others, use the support offered by group members and need the reassurance that they are not the only ones with PD.

Well-conceived smartphone applications (apps) using behavioural and cognitive strategies for the management of anxiety and panic attacks may be helpful. They can provide valuable support in daily life.

Effective treatment can bring significant relief to 70 to 90 percent of people with PD.

Where do I go for more information?

More information can be found on the following websites:

• Anxiety Disorders Association of Canada at http://www.anxietycanada.ca.
• Anxiety Disorders Association of British Columbia at http://www.anxietybc.com.
• Anxiety Disorders Association of Manitoba at http://www.adam.mb.ca.
• Anxiety Disorders Association of Ontario at http://www.anxietydisordersontario.ca.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Janel Gauthier, Université Laval, Québec.

Revised: May 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is obsessive-compulsive disorder?

Have you ever had a strange or unusual thought just pop into your mind that is entirely out of character for you? Maybe you’ve had the thought of suddenly blurting out an embarrassing or rude comment, or of causing harm or injury to another person, or of doubting whether you acted correctly in a particular situation.

Have you had an irresistible urge to do something that you know is entirely senseless, like checking the door even though you know it is locked, or washing your hands even though they are clean?

Most people experience unwanted, even somewhat bizarre or disgusting thoughts, images and impulses from time to time. We don’t feel upset by these thoughts and urges, even though they seem pretty unusual for our personality and our experience.

Some individuals, however, suffer with a special type of unwanted thought intrusion called obsessions. Obsessions are recurrent and persistent intrusive thoughts, images or impulses that are unwanted, personally unacceptable and cause significant distress.

Even though a person tries very hard to suppress the obsession or cancel out its negative effects, it continues to reoccur in an uncontrollable fashion.

Obsessions usually involve upsetting themes that are not simply excessive worries about real-life problems but instead are irrational concerns that the person often recognizes as highly unlikely, even nonsensical.

The most common obsessive content involve (a) contamination by dirt or germs, (b) losing control and harming oneself or other people, (c) doubts about one’s verbal or behavioural responses, (d) repugnant thoughts of sex or blasphemy, (e) or deviations from orderliness or symmetry.

Compulsions are repetitive, somewhat stereotypic behaviours or mental acts that the person performs in order to prevent or reduce the distress or negative consequences represented by the obsession. Individuals may feel driven to perform the compulsive ritual even though they try to resist it.

Typical compulsions include repetitive and prolonged washing in response to fears of contamination, repeated checking to ensure a correct response, counting to a certain number or repeating a certain phrase in order to cancel out the disturbing effects of the obsession.

People with clinical OCD typically have both obsessions and compulsions (although some may be more aware of struggling mainly with either obsessions or compulsions), with the majority (81%) experiencing more than just one kind of obsession or compulsion.

Approximately 1% of the Canadian population will have an episode of OCD, with the possibility that slightly more women experience the disorder than men. The majority of individuals report onset in late adolescence or early adulthood, with very few individuals experiencing a first onset after 40 years of age.

OCD is also seen in childhood and adolescence where it is a similar symptom pattern to that seen in adults. OCD tends to be a chronic condition with symptoms waxing and waning in response to life stresses and other critical experiences. It is uncommon for individuals to spontaneously recover from OCD without some form of treatment.

Depending on the severity of the symptoms, OCD can have a profound negative impact on functioning. In severe cases, obsessive thoughts and repetitive, compulsive rituals can consume one’s entire day. Like other chronic anxiety disorders, OCD often interferes with jobs and schooling. Social functioning may be impaired and relationships can be strained as family and close friends get drawn into the individual’s OCD concerns.

The actual cause of this disorder is not well known. Genetic factors may play a role but to date there is little evidence of a specific inheritance of OCD.

Studies have suggested there may be some abnormalities in specific regions or pathways of the brain. Other research indicates that critical experiences or personality predispositions might be related to increased susceptibility for OCD.

However, there is no known single cause to OCD. Instead, most of the genetic, biological and psychological causes probably increase susceptibility to anxiety in general rather than to OCD in particular.

What psychological approaches are used to treat OCD?

Since the early 1970s research has shown that behaviour therapy is the most effective treatment for most types of OCD. It involves experiencing the fearful situations that trigger the obsession (exposure) and taking steps to prevent the compulsive behaviours or rituals (response prevention).

These studies have shown that 76% of individuals who complete treatment (13-20 sessions) will show significant and lasting reductions in their obsessive and compulsive symptoms.

When measured against other treatment approaches such as medication, behaviour therapy most often produces stronger and more lasting improvement. In fact, there may be little advantage to combining behaviour therapy and medication given the strong effects of the psychological treatment.

However, up to 20% of people with OCD will refuse behaviour therapy or drop out of treatment prematurely. One of the main reasons for this is a reluctance to endure some discomfort that is involved in exposure to fearful situations.

More recently, psychologists have been adding cognitive interventions to the behaviour therapy treatments involving exposure and response prevention. Referred to as cognitive behaviour therapy (CBT), this approach helps people change their thoughts and beliefs that may be reinforcing obsessive and compulsive symptoms and can help individuals feel less fearful of exposure and response prevention exercises. Also, the cognitive interventions can be particularly helpful if you are mainly struggling with obsessions, rather than compulsions.

Together with exposure and response prevention, the CBT approach has been shown to be effective in offering hope to individuals suffering from OCD.

What are the symptoms of OCD¹?

• presence of obsessions and/or compulsions;
• obsessions and compulsions cause marked distress, are time consuming, or significantly interfere in daily activities;
• the content of the obsessions and compulsions is not restricted to concerns associated with another psychological disturbance such as the preoccupation with food in an eating disorder or guilty ruminations in major depression, nor are the symptoms directly caused by the effects of a substance or general medical conditions.

¹ Based on the diagnostic criteria of OCD as found in the Diagnostic and Statistical Manual of Mental Disorders (5^th ed.) of the American Psychiatric Association (2013).

Where do I go for more information?

The following websites provide useful information on OCD:

• Anxiety Canada at http://www.anxietycanada.ca.
• The International Obsessive Compulsive Foundation at http://www.ocfoundation.org.
• OCD-UK at https://www.ocduk.org/.

Other helpful resources include:

• Purdon, C., & Clark, D.A. (2005). Overcoming Obsessive Thoughts: How to Gain Control of your OCD. New Harbinger Publications.
• Baer, L. (2012). Getting control: Overcoming your obsessions and compulsions (3rd ed.). Plume.De Silva, P. & Rachman, S. (1992). Obsessive-Compulsive Disorder: The Facts. Oxford University Press.
• Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder: Therapist Guide (2^nd).Oxford University Press
• Steketee, G., & White, K. (1990). When Once is not Enough: Help for Obsessive Compulsives. New Harbinger Publications.
• Munford, P.R. (2004). Overcoming compulsive checking: Free your mind from OCD. New Harbinger Publications.
• Munford, P.R. (2005). Overcoming compulsive washing: Free your mind from OCD. New Harbinger Publications.
• Abramowitz, J.S. (2009). Getting over OCD: A 10-step workbook for taking back your life. Guilford Press.
• Challacombe, F., Oldfield, V.B., & Salkovskis, P. (2011). Break free from OCD: Overcoming obsessive compulsive disorder with CBT.
• Grayson, J. (2014). Freedom from obsessive-compulsive disorder:  A personalized recovery program for living with uncertainty (updated edition).  Berkley Publishing Group.
• Winston, S. M., & Seif, M. N. (2017). Overcoming Unwanted Intrusive Thoughts: A CBT-Based Guide to Getting Over Frightening, Obsessive, or Disturbing Thoughts. New Harbinger Publications.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, click https://cpa.ca/public/whatisapsychologist/ptassociations/.

 This fact sheet has been prepared for the Canadian Psychological Association by Dr. David A. Clark, University of New Brunswick. It was revised most recently in 2020 by Dr. Gillian Alcolado, University of Manitoba.

Revised: July 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:   factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is generalized anxiety disorder (GAD)?

If you have Generalized Anxiety Disorder you will experience chronic, excessive, and uncontrollable worry. You may also be on edge, be easily fatigued, have difficulty concentrating, feel irritable, experience muscle tension, and have problems sleeping.

GAD is one of the most common anxiety disorders. Canadian data suggest that one out of every 12 individuals will suffer from GAD at some time in their life. It can be mild or it can contribute to unemployment and serious family and social problems.

GAD can lead to other problems such as fear of meeting people (social anxiety disorder), severe panic attacks (panic disorder), and depression. If left untreated, those with GAD are at greater risk of developing medical problems such as heart disease, diabetes, and cancer.

Proven psychological approaches to treat GAD

There are a number of proven psychological therapies for GAD. They will help you gain control over your worries, decrease your anxiety, and improve your quality of life. The therapies that have been shown to be most helpful are:

• cognitive re-evaluation to help you correct thinking patterns that increase worry;
• behavioural experiments to help you cope with uncertainty;
• imaginal exposure to help you confront rather than avoid your fears;
• problem-solving training to help you learn better ways to solve everyday problems; and
• progressive relaxation to decrease your physical symptoms of anxiety such as rapid breathing and sore muscles.

Research shows that psychological treatments are effective in treating GAD

Psychological therapy is very effective in the treatment of GAD. In a Canadian study, 77% of those receiving short-term psychotherapy (16 sessions of cognitive re-evaluation, problem-solving training, and exposure) remained GAD-free one year after treatment.

The fact that you get better and stay better after psychological therapy is certainly an important consideration for those seeking help for anxiety-related problems.

Where do I go for more information?

For more information visit the following website:

• Anxiety Canada at http://www.anxietycanada.ca

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Michel J. Dugas, Université du Québec en Outaouais.

Revised: October 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What are gambling and gambling problems?

Most Canadians play games of chance for money or other prizes. Popular gambling activities include lottery and raffle tickets, scratch tickets, casino games, slot machines, video lottery terminals (VLTs), bingo, sports betting and informal card games. In Canada and around the world, people have had more and more opportunities to gamble over the past 30 years.

Although most Canadians are recreational gamblers, about 5% of the adult population develops gambling-related problems. These problems can range from the person who over spends on one occasion to the person who has a longer-term problem controlling his or her gambling activity.

At the extreme end of the scale is Gambling Disorder which is continued and extreme gambling that is maladaptive because of its negative effects on family, personal and work life (APA, 2013). About 1% of adults experience this severe form of the disorder.

Indicators[1] may include: repeated unsuccessful attempts to control, cutback or stop gambling, restlessness or irritability when making these attempts, needing to gamble with increasing amounts of money to achieve the desired excitement, preoccupation with gambling, gambling to escape from problems or emotions such as depression or anxiety, lying to family members or others about the extent of gambling,  jeopardizing relationships, jobs or career opportunities because of gambling, and relying on others to provide money to relieve the financial consequences of gambling. Chasing losses (returning to gamble on another day to win back lost money) is considered a key feature.

There is no one cause of gambling problems and it is clear that biological, psychological and social factors all play a role. Gambling problems tend to run in families and people who have or have had problems with other addictions such as alcohol are at an increased risk of developing a gambling problem.

Gambling problems can also be related to clinical depression but we do not yet fully understand whether gambling problems lead to depression, whether depression contributes to gambling problems, or both. People who are impulsive (for example, people who make decisions without thinking about consequences) are also more likely to have gambling problems. Most gambling also occurs in a social context. People gamble because their friends and family are gambling.

What can psychologists do to help people who have gambling problems?

Researchers have been active in examining k how successful we are at treating people with gambling problems. In most areas of the country, programs and counsellors use treatment approaches that are similar to those used for drug and alcohol problems. These approaches can be provided individually or in groups and for inpatients and outpatients. Most cities have chapters of Gamblers Anonymous which offer mutual support groups that operate on a twelve-step, spiritual model.

Research supports psychologists’ use of cognitive and behavioural treatments with problems gamblers. Cognitive treatments help people understand and change thinking that maintains maladaptive gambling.

For example, problem gamblers try to predict the outcome of their next bet by considering the outcomes of earlier bets.

This kind of thinking is false and risky. A certain outcome is not more likely because it has or has not occurred on earlier bets – the chance of a certain outcome remains the same for each bet. With behavioural treatments, people change their behaviours and environment in order to make it harder for them to gamble. For example, people will often limit their access to cash.

Research also highlights the importance of motivation in overcoming gambling problems. Motivational enhancement techniques help people to understand how gambling effects their lives and the mixed feelings they might have about stopping gambling.

To date, there are no medications which have been proven to be effective in treating problem gambling.

Where do I go for more information?

The website for the Responsible Gambling Council, http://www.responsiblegambling.org has a comprehensive list of links to Canadian treatment programs, Gamblers Anonymous and provincial help lines.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, click https://cpa.ca/public/whatisapsychologist/ptassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. David Hodgins, a faculty member in the Clinical Psychology Program at the University of Calgary, Calgary, Alberta. He is affiliated with the Alberta Gaming Research Institute http://www.addiction.ucalgary.ca.

Revised: October 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

[1] Based on the diagnostic criteria of gambling disorder as found in the Diagnostic and Statistical Manual of Mental Disorders (5^th Ed.) of the American Psychiatric Association (2013).

Why does pain from needle procedures matter?

Needle procedures are used to prevent, diagnose, monitor, and treat various health conditions. For example, insulin injections and finger pokes are a common experience for people with diabetes while bone marrow aspirations and lumbar punctures are experienced by people with cancer. Immunizations/vaccinations are the most common source of needle pain in childhood. For example, the Canadian Immunization Schedule recommends over 20 needles, not including yearly flu vaccinations, before a child reaches the age of 18. While vaccinations are a critical part of health care that have made a major difference in the prevention of infectious diseases, pain can be a consequence of these procedures. If the pain from needle procedures is not properly managed, there are short and long term consequences including longer procedure times, increased risk of fainting and injuries, negative memories, fear and avoidance of future procedures.

Why does pain from needle procedures matter?

The good news is that there are many ways that pain and distress during needle procedures can be managed. Types of strategies include:

• procedural – how the clinician performs the procedure (e.g., no aspiration for immunizations)
• physical – across ages, sitting upright is usually helpful unless the person has a history of fainting. If there is a history of fainting, a technique called muscle tension can be helpful.
• pharmacological – topical anesthetics or other medications for more invasive procedures.
• psychological strategies. More on these below for preschoolers and older.

The recommended strategies can change depending on the age of the person getting the needle. For example, infants benefit from kangaroo care (<1 month) or being closely held by the caregiver, breastfeeding, and/or sugar water for more minor procedures such as immunizations or venipunctures.

Research shows that the psychological techniques listed below help to reduce immunization pain, and can help for other needle pain in children as well as adults. They are all relatively easy to use and low in cost, if not free. Each technique can be adjusted as needed, depending on a person’s age and the specific procedure they are having.

• Education and Preparation – everyone deserves to know what procedure they are getting, why, and what will be done to make it comfortable (what they can do and what others will do). Provide choice when possible: for example, do they want to look at or away from the needle? What coping strategies will they use? Do they want a caregiver or other trusted individual to be present?

  Before a needle procedure:

• • Answer any questions people have in a way that is honest but appropriate for their age
  • Tell very young children about the needle only a little while before the procedure
  • Tell older children, adolescents, and adults about their procedure before the day in question so they can prepare coping strategies

• Communication to the individual immediately before and during the procedure. For all ages:
  • Speak calmly, clearly, with simple wording.
  • Signal the start of the procedure in a neutral way (e.g., “1, 2, 3, here we go”).
  • Do not say “it won’t hurt”. That does not help and it is not necessarily true so could led to mistrust.
  • Do not reassure (e.g., say “it’s okay” or “almost done”) over and over again. It does not help.

• Distraction – these are strategies that involve taking a person’s attention away from the procedure. Use age-appropriate distraction techniques such as:
  • Talking about things other than the procedure (e.g., holidays, favourite movie)
  • Toys
  • Videos (with adult coaching to engage for younger children)
  • Singing
  • Video games
  • Books

• Deep breathing or blowing – this strategy involves the person taking slow, deep, regular breaths, which can help with feeling relaxed. Using a toy is recommended for school-aged children and adolescents (e.g., pinwheel or bubble wand) which then also includes distraction. Children (and adults) can be instructed to take a calm and slow breath from their diaphragm (e.g., “take a deep breath in from your tummy. When you breathe in, your tummy should fill up like a balloon. Then breathe out pushing out all the air.”). Adults may also find coughing or taking a deep breath in and holding it (for brief injections such as immunizations) helpful.

What if a high level of needle fear is present?

Needle fear is present in about 2/3 of children and 1/4 of adults and can range from mild to severe levels. The strategies listed above are helpful for people with low to moderate needle fear. Across the lifespan, about 10% of individuals have high levels of needle fear that can interfere with their willingness to undergo needed medical procedures. At the most severe end of the spectrum, ~4-5% of individuals have a phobia related to needles which is characterized by extreme fear and anxiety and called blood injection injury phobia. People who have high levels of needle fear require different strategies than are listed above – they need to undergo exposure-based therapy in which they face their fear in a controlled, hierarchical manner. After their fear reduces, they can then benefit from the traditional pain and distress management strategies.

Where do I go for more information?

• Recently, the HELPinKids&Adults Team, a group of many different types of health professionals, including psychologists, published a pain management guideline for childhood immunizations. https://helpkidspain.ca/
  • The full HELPinKids&Adults team Clinical Practice Guideline can be found at: https://www.cmaj.ca/content/cmaj/187/13/975.full.pdf
    • The appendices contain age based algorithms and other tools
  • The CARD^TM system for school based immunizations is also based on this work: https://www.aboutkidshealth.ca/card
• Solutions for Kids in Pain: https://www.kidsinpain.ca/
• Itdoesnthavetohurt social media campaign and resources (e.g., videos) are available here https://itdoesnthavetohurt.ca/
• For needle fear:
  • CANVax Podcast on needle fear (see episode 3): https://canvax.ca/emerging-topics-podcast
  • Clinical Practice Guideline on treating high levels of needle fear (extra info in the supplementary material): https://www.tandfonline.com/doi/full/10.1080/16506073.2016.1157204
• Resources and videos on helping infants specifically:
  • Be Sweet to Babies: https://www.cheo.on.ca/en/clinics-services-programs/be-sweet-to-babies.aspx
  • Reducing pain from vaccinations in babies: https://www.youtube.com/watch?v=5Oqa1Fag5eQ&feature=youtu.be

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit:   https://cpa.ca/public/whatisapsychologist/ptassociations/

This fact sheet has been prepared for the Canadian Psychological Association by Dr. C. Meghan McMurtry, University of Guelph. The current version is based on the 2011 version written by Dr. C. Meghan McMurtry, Dr. Christine T. Chambers, Dalhousie University, and Dr. Anna Taddio, University of Toronto.  

Updated: May 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:   factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657