Behavioral ScienceFaculty:William Greenough: Course DirectorBrian Ross, PsychologyMichael Wilson, College of MedicineDonna Korol, Psychology, MedicineKarl Rosengren, Psychology, KinesiologyRobert Rich, College of LawAaron Grossman, Teaching Assistant

Bill Greenough, Professor of

Psychology, Psychiatry and Cell and

Structural Biology

Wgreenou@uiuc.eduOffice Hour: 11-12 Tu or

by appt.Phone: 333-4472 (for

appts.)

Course Objectives: Bases

•Many of the greatest health risk factors today are behavioral, the realm of Behavioral Science•Self-injurious behaviors such as smoking, alcohol and drug abuse, poor dietary and exercise habits, now constitute the largest controllable risk factors for mortality•Psychiatric disorders: major cause of disability•Behavior can put others at risk (e.g., ARND)•Physician’s responsibility to inform and advise patients at risk or putting others at risk

Course Objectives: Bases

•Other behavioral issues important in Medicine•Stress is a serious medical issue (CardioVascD)• Compliance (taking medicine, following medical advice, regular preventative medicine)• Sexual function (taking a sexual history)• Is my child “normal”? Development and Aging• Stress-related or affected disorders• Lifestyle (Tobacco, Diet, Exercise, Alcohol, Sleep)

Source: U. S. Senate Sub-Committee on Aging, OASDI, 2003

Dramatic changes have occurred across the past century in causes and ages of death. Infectious disease has become largely controlled, and hence people are living longer and dying from different causes

Life Expectancy, 1900 = 54.3; 1996 = 81.5 (Sweden)Source: S. E. Taylor, Health Psychology (5th Edition), Mc Graw-Hill, 2003

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*Infectious Disease

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*Lifestyle

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Current Smokers* NationwideYear: Median %

1990 23.01991 23.11992 22.21993 22.61994 22.71995 22.41996 23.41997 23.21998 22.91999 22.62000 23.22001 22.8

States include District of Columbia and Puerto Rico in applicable years*All respondents 18 and older who have ever smoked 100 cigarettesin their lifetime and reported smoking every day or some days.

Is Smoking on the Decline? Not over the last decade (Source CDC, 2003; Behavioral Risk Factor Surveillance System)

Alcohol Use: Chronic Drinking* Nationwide (CDC, 2003)

Year: Median %1990 3.21991 3.41992 3.01993 3.01994** No Data1995 2.81996** No Data1997 3.01998** No Data1999 3.62000** No Data2001 5.1

States include District of Columbia and Puerto Rico in applicable years*All respondents 18 and older who report an average of twoor more drinks per day i.e., 60 or more alcoholic drinks a month.Denominator includes all survey respondents except those withmissing, don't know, and refused answers.

Obesity: By Body Mass Index* Nationwide

Year: Median %1990 11.61991 12.61992 12.61993 13.71994 14.41995 15.81996 16.81997 16.61998 18.31999 19.72000 20.12001 21.0States includes District of Columbia and Puerto Rico in applicable years*All respondents 18 and older who report that their Body MassIndex (BMI) is 30.0 or more. BMI is defined as weight in kilogramsdivided by height in meters squared (w/h**2).Denominator includes all survey respondents except those withmissing, don't know, and refused answers. (Source CDC, 2003)

Source: S. E. Taylor, Health Psychology (5th Edition), Mc Graw-Hill, 2003

Look again at the diseases that are increasing:

Risk Factors for Leading Causes of

Death in US• Heart Disease: Tobacco, Obesity, Blood Pressure, Cholesterol (Diet), Exercise • Cancer: Tobacco, Improper Diet, Alcohol, Environmental Exposure• Stroke: Tobacco, Blood Pressure, Cholesterol, Exercise• Accidents: Seat Belts, Alcohol, Home Hazards• Chronic Lung Disease: Tobacco, Environment

Source: M. McGinnis (1994). The role of behavioral research in National Health Policy, in S. Blumenthal et al.New Frontiers in Behavioral Medicine: Proceedings of the National Conference. NIH Publications.

Cost of Treatment for Selected Preventable

Conditions• Heart Disease: Coronary Bypass surgery, $30,000 • Cancer: Lung Cancer Treatment, $29,000• Injuries: Quadriplegia (lifetime), $600,000• Total Annual US Cost of Alcohol Abuse: $148,021,000,000*

Source: M. McGinnis (1994). The role of behavioral research in National Health Policy, in S. Blumenthal et al.New Frontiers in Behavioral Medicine: Proceedings of the National Conference. NIH Publications.*Source:THE ECONOMIC COSTS OF ALCOHOL AND DRUG ABUSE IN THE UNITED STATES,

1992. H. Harwood, D. Fountain, and G. Livermore. Analysis by the Lewin Group. Rockville, MD: DHHS, NIH, NIDA, OSPC, NIAAA, OPA.

Biomedical Model

• Illnesses arise from somatic causes

• Biochemical-Physiological bases• Psychiatric: Neurophysiological bases

• Psychological and social processes largely independent of disease processes

Biopsychosocial Model

• Emphasizes health maintenance over disease

• Biological, Psychological and Social Factors are all important determinants of health

• Health maintenance requires addressing issues at all of these levels

As a Physician, your Job is to Optimize

Health

Go Where the Problems Are

Arguably, if saving (or extending) lives is your principal goal, Behavioral

Science is the most important pre-clinical course you will take

Course Objectives: Basis

• Knowledge of human behavior is a critical tool of the physician.

• Behavior is a product of the biology of the individual--physician or patient

• Behavior is not only your primary source of information about your patients, it is also a primary tool for restoring or improving their health

Course Objectives

• To understand behavior and its origins in the brain

• To understand relationships of behavior to health and disease

• To begin to understand psychiatric disorders and their treatment

• To understand basic issues of human behavior

• To know about development across the lifespan: Adulthood and aging are part of the development process

Course Objectives• To appreciate the differences between human and veterinary medicine.

• Mammalian physiology is very similar in animals and humans (but not the same in all cases).

• What differs most is the capacity of the brain, which makes humans human. Physicians have to recognize this.

• To prepare for the Behavioral Science component of Step I of the Boards!

Why is there so much to learn in medical

school?The number of hours in

the basic sciences curriculum has not

changed appreciably since 1953.

The amount of relevant basic science has changed

Sociobehavioral Aspects of

Cardiovascular Disease (CVD): A Case Study

• Long history of interest in relationships of behavior, stress and susceptibility to CVD, Coronary Heart Disease (CHD)

• CHD: Myocardical Infarction (MI) [heart attack], pre-clinical signs (arterial plaque, angina [chest pain])

• “ Type A” coronary prone behavior pattern (Friedman & Rosenman)

Source: KA Matthews, Psychological perspectives on the development of coronary heart disease, American Psychologist, 60: 783-796, 2005

Coronary Heart Disease• Atherosclerosis: Dynamic and progressive disease

• Arterial endothelial dysfunction and inflammation

• Initial endothelial damage by oxidized low-density lipoprotein cholesterol, smoking, high blood pressure

• Inflammatory response: Intimal layer thickening: monocytes => macrophages

• Plaque (lipid and tissue accumulation) closes off artery; rupture => thrombosis

Atherosclerosis• Progressive disorder• Non-invasive assessment: Ultrasound scanning (corotid artery intima media thickness), electron beam tomography to assess aortic and coronory calcification

Source: KA Matthews, Psychological perspectives on the development of coronary heart disease, American Psychologist, 60: 783-796, 2005

Risk Factors for CHD: Most

Involve Behavioral Management• High blood pressure

• High cholesterol• Central adiposity (distribution: waist circumference)

• Obesity• Smoking• Sedentary• Diabetic• Low Socioeconomic background

Psychosocial Predictors of Coronary

Events• Stressful Environments

– Jobs•High effort; low reward•Low decision-making latitude

– Primary relationships•Marital distress, dissatisfaction (divorce during study)

•Poor communication

• Personal Characteristics

Psychosocial Predictors of Coronary or

Atherosclerotic Events• Stressful Environments• Personal Characteristics

– Hostility•Angry affect, mistrustful attitudes towards others, and antagonistic behavior

– Depression and anxiety– Major depression and anxiety disorders

Who Gets CHD?

• These are not just idle speculations but collective findings of many (>20) large scale prospective studies with data collection “blind” to subject characteristics during the study

• Criteria included both incidence of CHD and subclinical atherosclerosis measures

• Direction of associations can be uncertain, e.g., does stress lead or contribute to hostility and/or anxiety and depression?

Speculations on Mechanisms

• Stress-associated hormones (e.g., glucocorticoids) (McEwen, Sapolsky)

• Cytokines (signaling compounds released by inflamed or damaged tissue acting via receptors)

• Irritative effects of risk behavior elements (e.g., tobacco compounds, excess alcohol)

Take home points

• Behavior and lifestyle characteristics clearly affect susceptibility to cardiovascular disease

• There is evidence for mechanisms mediating these phenomena at system, cellular and molecular levels

• Psychosocial variables can have critical physiological and medical consequences beyond the realm of mental health