I. OVERVIEW: Relation of psychological and social factors to health.
A. Psychological and behavioral factors are important determinants of illness.
1) History: dominance germ theory/infectious disease/reductionisti model of health and illness
2) Recent research indicates that stress and other behavioral/lifestyle factors play a role in the onset and exacerbation of most physical illnesses
3) Influence of psychological factors on health can be direct or indirect.
a) stress can directly affect biological processes by altering neuroendocrine and immune function
b) stress can indirectly affect biological processes by affecting health behaviors (increase smoking, drinking, inactivity, unprotected sex, etc.)
B. Psychosocial treatments may be effective in preventing lifestyle-related illness and disease
C. DSM-IV Psychogical factors affecting medical condition. Different from somatoform disorders
D. Behavioral Medicine and Health Psychology
E. How do psychological and social factors influence health/disease?
I. What is stress? Demands exceed capacity. Selye - "a nonspecific result of any demand on the body". A state which arises from an actual or perceived demand-capability imbalance in the organism's vital adjustment and which is partially manifested by a nonspecific response. A negative emotional experience associated with predictable biochemical, physiological, cognitive, and behavioral changes that help the organism to alter the event or adapt to it.
The integrative model of stress discussed in class views stress as
a process that includes: (a) exposure to stressful events/hassles,
(b) a transaction --appraisal of demands and coping resourses, (c)
perception of stress, (d) psychological distress and physical stress
responses, and (e) physical and mental health outcomes
II. Theories of Stress:
1) Cannon's fight-or flight response
2) Seyle's General Adaptation Syndrome - Hans Selye- effects of chronic stress on the body, strain, and tried to explain them with his GAS model.
3 Stages of the GAS:
a) Alarm - fight-or-flight response when the bodies resources are mobilized, hypothalamus signals sympathetic NS and pituitary glands. The sympathetic NS stimulates the adrenal medulla that responds by releasing catecholamines -epinephrine and norepinephrine. The pituitary gland releases adrenocorticotrophic hormone (ACTH) which stimulates the adrenal cortex that responds by releasing corticosteroids to increase metabolism and access to energy reserves, and decrease inflammation
b) Resistance - resistance begins when the body starts to benefit from the increased access to the energy reserves provided by the alarm reaction. If the threat is brief, there is usually sufficient reserves to adapt. But continued arousal and high hormone release during a prolonged resistance phase upset the homeostasis and harms internal organs.... leaving the organism vulnerable to disease.
c) Exhaustion- after prolonged resistance, the energy reserves are depleted and breakdown occurs. The body does not return to normal, but abnormally low arousal by heightening the parasympathetic NS... resulting in depression, disease and even death.
Nonspecific-a variety of physical and psychological stressors produce the same physiological response. This notion has been challenged because cognitive processes can influence whether or not an event is experienced as stressful and different stressors elicit different emotions: anger= NE, fear= E, comfort = low E, suggesting their are diff patterns of hormone secretion to diff stressors.
Circular definition - cortisol and NE = stress, does not specify necessary and sufficient conditions for the induction of a stress response. What psychological, social, and environmental conditions result in a stress response?
McEwen's concept of allostatic load - chronic stress alters HPA axis functioning causing either hyperreactivity or hyporeactivity of the stress response thereby altering one's risk for "mental" and "physical" diseases. Sapolsky- evidence for degeneration of hippocampus.
3) Lazarus & Folkman's Cognitive Appraisal -stress is viewed as a consequence of the ongoing interaction of the individual and environment. Emphasis is on the meaning of the event, rather than its consequent strain. Cognitive appraisal is a two-part mental process which involves deciding whether stimuli are potentially stressful.
1) Primary appraisal -determines whether the event is stressful. Is there a threat?
a) irrelevant -an event is neutral
b) beneficial- an event is positive
c) stressful - an event appraised as follows:
i) potentially harmful or creating loss
ii) potentially threatening - expectation of future harm
iii) potentially challenging - provide opportunity for change/growth
2) Secondary appraisal - Can I cope with the threat? Deals with one's ability and resources to cope with an event judged to be stressful. Here the focus is on self-efficacy
III. What Makes Events Stressful?
A. Negative events are more likely to produce stress than are positive events.
B. Uncontrollable or unpredictable events are more stressful than controllable or predictable ones.
C. Ambiguous events are often perceived as more stressful than clear-cut events.
D. Overloaded people are more stressed than people with fewer tasks to perform
E. Individuals are more vulnerable to stress in central life domains than in peripheral ones.
IV. Theories of Stress- why are events perceived as stressful?
A. Cognitive-Costs Hypothesis (Glass & Singer, 1972) - stress overburdens our perceptual and cognitive resources, coping depletes these resources. Cohen (1978) attentional overload occurs because the person must constantly monitor the environment.
B. Helplessness & Stress (Maier & Seligman, 1976) Uncontrollable and unpredictable stress produces feelings of helplessness. 3 deficits: 1) motivational decrement - no longer try to change outcome; 2) cognitive- fail to learn new responses that could help them avoid and aversive outcome; and 3) emotional - mild or severe depression.
Health Effects of Helplessness & Hopelessness:
1) Carl Richter -restrain wild rats -sudden death, gave up their will to live
Held wild rats in his hand until the stopped struggling then put them in a vat of water with water pouring down upon their heads, the rats would only swim for 3-5 minutes and then drown. Nonrestrained wild rats swam 60-80 hours trying to survive.
Reinstated hope - rescued restrained rats, then swam 60 hours.
2) Survival from cancer may also be influenced by pessimistic style. Levy et al. (1989) pessimists died sooner even when matched for physical severity of the disease.
3) Langer & Rodin 1976 control over the environment in nursing home patients. 18 mo follow up = 15% of exp. group died vs. 30% of control group
4) Explanatory Style - susceptibility to helplessness is determined by one's explanatory style. Pessimistic people are more likely to become helpless and become ill.
Peterson & Seligman (1987) pessimists experienced twice as many infectious illnesses and made twice as many doctors visits compared to optimists.
V. Integrative Model: Different definitions of stress are not competing but represent different aspects of the stress process: stimulus/events-->transactional (appraisal)----> response (negative affect , coping, and physiological responses)---> immunity
VI. Measurement of Stressors (stimulus/events):
A. Stressful Life Events (stimulus/events) Social Readjustment Rating Scale (SRRS) developed by Holmes & Rahe (1967) 43 item SRRS lists these items from most to least stressful. Sick people had much higher numbers of life events than healthy people during the year before they fell ill.
a) Retrospective Studies: accounts could be biased by being ill.
b) Prospective Studies: future health could be predicted from life events. Rahe (1968) 2,500 healthy naval officers and enlisted men dividing them into high and low risk groups based on their SRRS scores (top and bottom 30%). Twice as many high risk subjects developed illnesses during their first months at sea and continued to develop more illness each month following.
c) Modest correlation between the SRRS and illness. It is not the number of life events themselves, but a variety of other variables which are important. Sudden, negative, unexpected and uncontrollable events are more likely to predict illness than are positive, expected, gradual, or controllable events.
B. Daily Hassles- Lazarus & Folkman (1989) developed an alternative to the SRRS: the Hassles and Uplifts Scales. Access life's relatively minor irritations and pleasures, rather than major stressors. Hassles=experiences and conditions of daily living that are appraised as salient and harmful or threatening. Uplifts= experiences appraised as salient and positive and favorable. Hassles and life events are uncorrelated for men and weakly correlated for women (.36). Suggests that a large proportion of hassles are independent of life events.Hassles, but not life events, are correlated with persistent sxs of poor psychological adjustment in college students. Some evidence that hassles are also related to physical health, correlations =.3 to .4, slightly better than for SRRS. There is a problem in determining the causal pathways. It is unclear how daily hassles interact with major life events and chronic stressors.
C. Other stressful events - chronic strains, e.g., economic, marital, work
VII. Measuring Transactional/Appraisal Process
A. Global Perceived Stress
B. Stressor-specific perceived stress
C. Hassles - accumulated events
VIII. Response Measures
A. Behavior (e.g., performance)
B. Emotion (negative affect)
C. Edocrine (cortisol, NE, EPI)
I. PERSONALITY - may influence the response to life events.
A. NEGATIVITY AFFECT & STRESS = experience more stress because of a pervasive negative outlook, negative affectivity characterized by anxiety, depression, and hostility. Related to poor health:
1. Disease prone personality- Friedman-weak but reliable evidence of a contribution of negative affect to asthma, arthritis, ulcers, headaches, and coronary artery disease.
2. Somatization - Negativity leads to increased somatization and physician visits, even when not sick.
3. Pessimistic explanatory style- Seligman - susceptibility to helplessness is determined by one's explanatory or attributional style (i.e., internal, stable, & global attributions for negative events = pessimism). Pessimistic people are more likely to become helpless and become ill. Peterson & Seligman (1987) twice as many infectious illnesses and twice as many doctors visit, reduced immunocompetence Levy et al. (1989) pessimists with breast cancer died sooner.
B. HARDINESS: enhances one's ability to cope with stress (Suzanne Kobasa, 1979). Characterized by:
1. Commitment - when one approaches life with a sense of meaning
2. Control - a feeling of being able to influence events
3. Challenge - a view of change as an opportunity for growth rather than threat.
Less likely to become ill when stressed because they are less likely to perceive or appraise events as stressful and harmful and they are better equipt to cope with it if they do. Hardiness does appear to be a direct mediator of illness and psychological health in many studies. Also, evidence that it may reduce cardiovascular reactivity to stress. Criticisms of construct: not unitary, only commitment and control are related to health outcomes,.not clear whether hardiness directly influences stress, may indirectly through altering health practices.
C. OPTIMISM - optimists (Life Orientation Test )
less likely to be bothered by physical sxs, more likely to cope (Ways
of Coping Inventory) using problem-focused strategies, social
support, and a positive focus on situations than pessimists.
Pessimists are more likely to use denial, distancing from the event,
focus on stressful feelings, and disengagement from the goal.
Optimistis = faster recovery from heart attack & other
conditions/procedures. Due to their effective coping strategies.
D. PSYCHOLOGICAL CONTROL - belief that one can determine one's internal states and behavior, influences the environment and produce desired outcomes. Important in medical patients who have very limited control.
E. OTHERS: Self-Esteem, Conscientiousness, Self-confidence and Easy-going individuals cope more actively with stressful events. Cheerful die earlier, introverts, social isolates, poor social skill = increased risk of illness and psychological distress.
II. COPING STYLES AND STRATEGIES
A. Coping Style: More specific than personality traits, refers to behaviors used when coping with stressors.
1) Avoidance vs. Confrontation: minimizing -avoidance vs. vigilant-confrontive, each style has its advantages and disadvantages, depends on the problem, its duration, Avoidant - cope well in the short-term, but do not engage in enough cognitive and emotional activity to manage the long-term problem outcome. Confrontational style - anxious in the short-term as they cognitively and emotionally deal with long-term issues. Avoidant = related long-term distress and poorer personal/environmental resources.
2) Catharsis - venting your feelings about stressful events has positive long-term effects. Pennebaker studies effects of emotional expression regarding a trauma on health. Foa - sexual assault victims - who develops PTSD?- Victims that relied heavily on dissociation during and shortly after the trauma were more likely to develop PTSD. Dissociation prevents emotional processing of the trauma. In order for spontaneous decline of post-trauma emotional disturbance to occur, the trauma memory, including it emotional elements, must be repeatedly activated and modified by new information. Dissociative strategies interferes with the emotional reliving of the trauma and impedes the natural course of recovery.
3) Humor - related to psychological and physical health (Anderson & Arnoult, 1989). Humor affects physiological measure of immune system functioning (Dillon et al 1985) viewing humorous videos increase salivary immunoglobin A
4) Spiritual Support - perceived support from God. Relationship between spiritual support and health status. Yates et al., 1981, 71 cancer pts, perceived spiritual support related to less reported pain. Lower rate of mortality in the elderly in poor health (Zuckerman et al., 1984). Predictive of later psychological well-being n college students. Orthodox religious = lower cancer mortality rates
5) Social Support- strong social support networks buffer the negative effects of stressful life events. May come in several forms: a) emotional support- verbal and nonverbal expressions of encouragement, reassurance, comfort, and caring; b) esteem support- verbal and nonverbal expressions that specifically build one's sense of self-worth, value, and competence; c) informational support- advice, guidance, and even directions from others; d) tangible support- direct material assistance in the form of services or resources; e) network support- membership in groups that share common interests and concerns
Social support reduces combat distress, decreases risk among Type A, reduces mortality; lower rates of heart attacks, reduces pregnancy and child birth complications. Animal studies affiliation buffers the pathogenic effects of stress on immune functioning. Alameda County Study - people w/ less social support die earlier, 2.8 years less in women and 2.3 years less in men. Mixed results in terms of its ability to reduce specific illness and disease, with the exception of coronary artery disease. Nevertheless, social support acts as a buffer for distress resulting from physical illness itself. Improves adjustment to chronic conditions and rate of recovery from illness, surgery. Affects health habits directly- more compliant with meds, use health care services. Direct effects hypothesis -social support provides health benefits during nonstressful and stressful periods. Buffering hypothesis- health and mental health benefits revealed at times of high stress
Matching Hypothesis: Some types of support are better suited to particular needs...uncontrollable stressors require more emotional support, while controllable stressor require more problem solving activity.
III. MANAGING STRESS
A. RELAXATION TRAINING - goal to decrease sympathetic arousal. Effective for anxiety, stress-related problems and pain management. Reduces arousal, increases immune function, and enhances perceived control. Jacobsonian Progressive Relaxation Training-Biofeedback - effective, but no advantage over relaxation training which is simpler and cost effective.
B. EXERCISE- stress-buffering role of exercise, prescribed as a stress-management technique (Zakowski et al., 1992). Alters mood, reduces stress, anxiety, tension and depression. Greater immediate than long-term effects.
C. TRANSACTION MANAGEMENT - one way to manage stress is to change or remove the stimulus perceived as the stressor.
1) Problem-Focused Coping- interventions that target the environment are considered problem-focused coping. Confrontive problem-solving (efforts to change the situation), seeking social support (emotional comfort and info from others), planful problem solving (cognitive efforts to solve the problem).
2) Emotion-focused Coping - efforts to regulate the emotional consequences of a stressful event. Recall that in Lazarus's theory of stress, a stimulus provokes arousal only when a mismatch occurs between one's perceived coping resources and a perceived stressor. Thus, successful coping does not require that the stressful situation be eliminated or changed, instead the cognitive aspects and emotional reaction of the stressful transaction can be modified: a) Self-control - regulate one's feelings; b) Distancing-efforts to detach the self from the stressful situation, distraction; c) Positive reappraisal - find positive meaning in the situation by focusing on personal growth; d) Accepting responsibility - acknowledging one's role in the situation and accepting it; e)Escape/avoidance - wishful thinking, distraction -read/movie,fantasy, substance use/abuse
D. STRESS INOCULATION THERAPY- 1) Conceptualization -examine stress transaction, interview, role play, behavioral observation, & imagery to ID stimuli, cognitions, & responses; 2) Skills Acquisition Rehearsal -new coping skills are learned and practiced. Cognitive redefinition takes place by monitoring self-statements, then redefine, replace or counteract pre-existing self-statements which influence the cognitive appraisal of stresors: a) preparing for a stressor, b) confronting and handling a stressor, c) coping with feeling of being overwhelmed, and d) reinforcing self-statements; and 3) Application and Follow-through - behavioral therapy in this otherwise cognitive approach. Client applies new skills to simulated and actual situations.