Health PsychologyPsychology 46.339 (01)Summer 2007Instructor: Dr. Fuschia SiroisWednesday August 8: LAST CLASS!Lecture 9, Prep. Guides 9, 10Chapter 13: Heart Disease, Hypertension, Stroke, and DiabetesChapter 14: Psychoneuroimmunology, AIDS, Cancer, and Arthritis

Coronary Heart Disease: What Is CHD?

A general term referring to illnesses caused by atherosclerosis Narrowing of coronary arteries, the vessels that

supply the heart with blood Angina pectoris

Pain that radiates across the chest and armsCaused by temporary shortage of oxygen

Myocardial infarction – heart attack

Coronary Heart Disease (CHD):

Role of Stress Development of CHD is associated with

Hostility Depression Cardiovascular reactivity to stress Acute stress can precipitate sudden clinical events

Balance of control and demand in daily life is associated with CHD

Heart disease is more common in low SES individuals –WHY?

Coronary Heart Disease: Women and CHD

Cardiovascular disease Leading killer of women in Canada Women have 50% chance of dying from 1st

heart attack (30% for men) Recall that symptoms of a female heart

attack are different from those for men Women seem to be protected at younger

ages relative to men Higher levels of HDL premenopausal Estrogen diminishes sympathetic nervous

system arousal

Coronary Heart Disease: Cardiovascular Reactivity and Hostility

Type A Behavior Pattern Behavioral and emotional style

marked by an aggressive, unceasing struggle to achieve more and more in less time

Often in hostile competition with other individuals or forces

Risk factor for coronary artery disease

Anger and Hostility

appear to be

especially implicated

as risk factors

Coronary Heart Disease: Cardiovascular Reactivity and Hostility

Cynical Hostility Particularly lethal type of hostility Characterized by suspiciousness, resentment,

frequent anger, antagonism, distrust of others Have difficulty extracting social support from

others Fail to make effective use of available social

support Hostility combined with defensiveness is particular

problematic

Research suggests that social support decreases recovery time after heart surgery, heart attacks

depressed cardiac patients have higher mortality rate than non-depressed patients (7.5% vs 2.5%, in 1 study)

Coronary Heart Disease: Recovery

Quality of Social Support is important by-pass surgery patients feel highly supported if

partners express low fatigue, low displeasure, & low sadness - i.e. if partners are well adjusted to the situation (Schroeder & Swartzer, 1998)

CHD: Negative Emotions and Risk Factors

Strong Associations betweenDepression and heart attackHopelessness and heart attackAnxiety and sudden cardiac death

Recent research Social dominance may be related to all-

cause mortality Vital exhaustion predicts the likelihood of a

heart attack

Management of Heart Disease – Cardiac Rehabilitation

Cardiac invalidismpsychological state that can result after a

myocardial infarction or diagnosis of coronary heart disease

the perception that a patient’s abilities and capacities are lower than they actually are

both patients and their spouses are vulnerable to these misperceptions.

Behavioral Interventions can help reduce the risk of CD and also aid in the treatment of CD

relaxation techniques can significantly reduce BP & the need for medications

Diet changes can help reduce serum cholesterol levels

Exercise can also help to reduce BP weight loss is the most frequently prescribed

behavioral change - reduces BP

Coronary Heart Disease: Interventions - Interventions

Anger management training, stress coping strategies can help to reduce reactivity of Type A behavior

Stroke: Overview

Condition that results from a disturbance in blood flow to the brain Often marked by resulting physical or cognitive

impairments and, in the extreme, death. Deaths

Stroke is the fourth leading cause of death in Canada. Each year, about 16,000 Canadians die from stroke. Each year, more women than men die from stroke.

A chief risk of stroke That more strokes will follow in its wake Aspirin reduces the risk of recurrent strokes

Stroke: Overview

Prevalence There are between 40,000 to 50,000 strokes in Canada

each year. After age 55, the risk of stroke doubles every 10 years. A stroke survivor has a 20% chance of having another

stroke within 2 years. Effects

Of every 100 people who are hospitalized for stroke: 20 die before leaving the hospital 50 return home 10 go to an inpatient rehabilitation program 15 require long-term care

Stroke: Warning Signs

Learn to recognize the warning signs of a stroke. Weakness - Sudden weakness, numbness or tingling in the face,

arm or leg. Trouble Speaking - Sudden temporary loss of speech or trouble

understanding speech. Vision Problems - Sudden loss of vision, particularly in one eye,

or double vision. Headache - Sudden severe and unusual headache. Dizziness - Sudden loss of balance, especially with any of the

above signs.

Stroke: Risk Factors

Modifiable risk factors includeHigh blood pressureHeart diseaseCigarette smokingHigh red blood cell countTransient ischemic attacksPsychological distressAnger expression

Stroke: Consequences

Stroke affects all aspects of lifePersonalSocialVocationalPhysical

Motor, Cognitive, Emotional, and Relationship problems Symptoms and problems differ depending on

which side of the brain was damaged

insulin is a hormone produced by the pancreas that regulates blood sugar

Diabetics have defective insulin production/use when blood sugar levels are out of balance

hyperglycemia and hypoglycemia can result Approximately 2 million Canadians have diabetes. The rate is three to five times higher among Aboriginal

people.

Chronic Illness - Diabetes

Diabetes is a chronic blood sugar regulation disorder in which the body is not able to manufacture or utilize insulin properly.

Prevalence of Diabetes in Canada by age group

Diabetes: Overview

Cells of the body need energy to functionGlucose is the primary source of energyInsulin is a hormone produced by pancreasInsulin acts as a “key” to permit glucose to

enter cellsWithout insulin, cells don’t get the glucose they

needGlucose stays in the blood: Hyperglycemia

Diabetes: Types

Type I Diabetes (10% of all diabetes) Abrupt onset of symptoms Immune system falsely identifies cells in the pancreas as

invaders and destroys them Pancreas doesn’t produce insulin Develops relatively early in life most prevalent type of diabetes in children and adolescents

Diabetes mellitus can be Type I or Type II Type I = Insulin dependent (IDDM) Type II = Non-insulin dependent (NIDDM)Also gestational diabetes

Types of Diabetes

Type II Diabetes Cells lose ability to respond fully to insulin (known as

insulin resistance) Pancreas temporarily increases insulin production Insulin-producing cells may give out Most common in adults Increasingly common in children

Gestational diabetesA temporary condition that occurs during pregnancy. It affects two to four percent of all pregnancies with an increased risk of developing diabetes for both mother and child.

Risk factors you cannot change Increasing age Family history of

disease Race or ethnicity Gestational diabetes or

having a baby weighing 9+ lbs at birth

Risk factors you can change

Inactive lifestyle Overweight

Diabetes: Health Implications

Diabetes is associated with Thickening of the arteries due to buildup of wastes

in the blood High rates of CHD

Diabetes is a risk factor for cardiovascular disease Cardiovascular disease is the main cause of death

in diabetics (55%), particularly in Type 2 diabetics Diabetics are 2 to 4 times more likely to have, and

to die from, cardiovascular disease than non-diabetics

Complications of diabetes Heart and blood vessel

disease Kidney disease Eye damage

Foot damage

Infections, slow to heal

Gum disease

Constant Juggling:

Insulin/medication

with:

Exercise

Food intake

Diabetes Management 24/7

BGBG

BGBG

BGBG &

Diabetes Management

Proactive

a response is indicated corrective actions for

highs or low emergency intervention

keep juggling the balls

Reactive

Chronic Illness - Diabetes

Psychoneuroimmunology (PNI)

The study of the inter-relationships between psychosocial factors, and the immune, nervous, and endocrine systems

Immunocompetence: The extent to which the immune system is able to fight off invading microorganisms

The Immune System is comprised of tissues, organs, and processes that protect the body from invasion by foreign material

Psychoneuroimmunology: The Immune System - Review

The surveillance system of the body:Primary functionDistinguish between what is “self” and

what is foreignAttack and rid the body of foreign invaders

Distinction betweenNatural immunitySpecific immunity

Figure 14.1: Interaction between Lymphocytes and Phagocytes

PNI: Assessing Immunocompetence & Effects of Stress

Two general indicators of ImmunocompetenceMeasuring the amount of various components of

the immune system in the blood• Example: counting T, B, NK cells in the blood

Assessing the functioning of immune cells• Example: ability of certain white blood cells to ingest

foreign particles

Activation of the HPAC Axis affects immune functioning Corticosteroids have an immunosuppressive effect

Sympathetic activation can enhance or suppress immune functions under different conditions

Psychoneuroimmunology: Assessing Immunocompetence

Immunocompromise Indicators suggest that immune functioning

• Has been disrupted or reduced Wound-healing

Psychological distress impairs inflammatory responses that initiate wound repair

Immunocompromise relates to health outcomes Those under stress have lower levels of

antibody titres after vaccination

PNI: Stress and Interpersonal Relationships

Adverse changes in immunity are associated withBereavement (especially those who have

become depressed)LonelinessMartial disruption and conflict (including

short-term conflicts)Providing care for a friend or family member

with a long-term illness

Mood and the Immune System

Kiecolt-Glaser, et al. (1993) looked at effects of marital conflict on immune system functioning

Those who were more hostile or negative showed more negative immune system responses over 24 hrs than did those who were low on negativity/hostility; avoidant, positive or problems solving behaviors were not sig. related to these changes

Newlyweds isolated for 24 hours --> 4 immune assays, observation of behaviors during discussion of marital problems, social support & mood questionnaires

Women showed more negative changes than men, even though both groups were high on marital satisfaction

Chronic Illness - Cancer

Cancer - uncontrolled growth of abnormal cells tumors can be benign or malignant, localized or

metastasized (spread to other parts) Most types of cancer cells form a lump or mass

called a tumor. Tumor cells can break away and travel to other

parts of the body where they can continue to grow. This process is called metastasis.

What is Cancer?

All cancers have neoplastic growth, altered cells with nearly unlimited growth. Benign localizedMalignant spread much

more threateningMetastatic cancer cells

move to other parts of the body

Cancer:Canadian Cancer Society

A set of >100 diseases All cancers result from DNA dysfunction

Rapid cell growth and proliferation Cancerous cells provide no benefits to body Cancerous cells sap the body’s resources

An estimated 149,000  new cases of cancer and 69,500  deaths occured in Canada in 2005.

On average, 2,865 Canadians will be diagnosed with cancer every week.

On average, 1,337 Canadians will die of cancer every week.

Chronic Illness - Cancer

Often called a lifestyle disease~ 2/3 of Cancer deaths associated with lifestyle factors

Psychosocial factors implicated in the onset of Cancer include personality, stress, coping style, smoking habits (~30% of cancer deaths), diet, occupation (~4% of cancer), & UV exposure (~90% of skin cancers)

Smoking and diet are the 2 leading behavioral risk factors for cancer

Adjusting to Cancer

Coping with physical limitations Pain and discomfort Downregulation of immune system,

vulnerability to other disorders Fatigue

Treatment-related problems Cosmetic problems:

Surgical removal of organs Body image concerns Use of prosthesis Conditioned nausea and immune

suppression

More than one-third of

cancer victimslive at least

5 yearsafter their diagnosis

Social Support & Cancer

Research suggests that cancer patients who are married survive longer than unmarried patients (Goodwin et al., 1987)

WHY?

Support groups also give SS opportunity for downward comparisons (w/worse off patients) & upward comparisons (w/patients successfully coping)

Speigel et al. (1993) randomly assigned breast cancer patients to reg. Tx or Tx + support group

Arthritis: Overview

Autoimmunity: A condition in which the body produces an immune response against its own tissue constituents Most prevalent autoimmune disorder:

ARTHRITISArthritis means “inflammation of a joint”

Over 200 forms of arthritis. About 30% of adults have arthritis. Three major forms of arthritis

Rheumatoid, osteoarthritis, gout

Arthritis

Risk Factors - Arthritis

GENDER

AGE

OBESITY

WORK FACTORS

Arthritis occurs more frequently in women than in men.

Anybody can be at risk of developing arthritis, but in children is called Juvenile Rheumatoid arthritis

Obesity increases the chances of getting arthritis particularly in women

If you have a strenuous job that requires repetitive bending, kneeing, or squatting,you are at higher risk of getting arthritis.

Serious types of arthritis

Lupus (systemic lupus erythematosus) Rheumatoid arthritis Scleroderma Sjogren’s syndome Lyme disease Ankylosing spondylitis Psoriatic arthritis Reactive arthritis –aka Reiter’s Syndrome

Chronic Illness - Arthritis

Major symptom of Arthritis is pain - can lead to activity, depression, psychosocial costs

Coping & management of arthritis are affected by: behavioral pain coping stressful events social support culture specific coping strategies severity of pain level of functional impairment

Rheumatoid Arthritis

Crippling form of arthritis believed to result from an autoimmune process Usually attacking small joints of hands, feet, wrists,

knees, ankles, and neck Primarily affects

40-60 age group Women

Main complications Pain, limitations in activities, need to be dependent on

others

Rheumatoid Arthritis

Treatment includesAnti-inflammatories to reduce inflammation

and painRestSupervised exercise

Cognitive-behavioral interventionsEnhancement of perceived self-efficacyOptimismRelearning meaning of pain

Osteoarthritis

Form of arthritis that results when the articular cartilage (smooth lining of a joint) begins to crack or wear away because of overuse of a particular joint May also result from injury or other causes Usually affects weight-bearing joints Common among athletes and the elderly

Treatment Keeping weight down, exercise, aspirin,

joint replacement, prescription medications, joint injections

Inflammatory Bowel Disease (IBD)

170,000 Canadian men and women suffer from IBD 10,000 new cases of IBD diagnosed each year in Canada Canada has the highest rates of IBD in the worldfrequently diagnosed between the ages of 15-25, or 45-55. Crohn’s disease and ulcerative colitis

Inflammation of the intestinesDifference is which part of the intestines are affected

Inflammatory Bowel Disease (IBD)

Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus. Ulcerative colitis affects only the inner layer of the colon, or large bowel. Symptoms: diarrhea, abdominal pain, blood loss, diminished appetite, weight loss, weakness, fatigue, nausea and vomiting, fever, and anemia

Symptoms are often unpredictable and uncontrollableKnown to be triggered/exacerbated by stress

How Is It Treated? anti-inflammatory drugs immunosuppressive agents surgically removing the colon (UC) –”ostomy”

Inflammatory Bowel Disease (IBD)

Psychosocial impactpatients who suffer from IBD have described the disorder as “painful and embarrassing”, restricting freedom, and affecting all aspects of daily life

Embarrassment, stigma, social isolation

Bowel sounds, smelly stools

Need to be close to the bathroom at all timesaffects a person's self-concept, body image, sexuality, and lifestyle

particularly difficult for children and young adults WHY?

Coping with IBD and Arthritis

Internet and mail survey of individuals with arthritis and Inflammatory bowel disease (IBD)Arthritis N = 336; 81.3% female; mean age = 43.45IBD N = 290; 75.2% female; mean age = 36.20

Influence of disease on daily activity (1 - 4)Arthritis: 3.43 (.78) IBD: 3.13 (.93)

Different people have different things that they do to cope with their IBD/Arthritis when it is most bothersome. What do you do to cope with it?

Coping with ArthritisArthritis

“I take a weekend off. I sit on my butt all weekend. I read. I take bubble baths. I take naps. “

“I try my best not to ask for help. Hide that I'm experiencing pain. Try to keep an optimistic view, But I get into a depression”

“ignore it as much as possible and focus on something else”“Slow down and pace myself.”“I have not really learned to cope very well yet. I have only had it for about 9

months. ““Lay down; take medicine; cry; vent to my partner; Pray. ““I just try to accept what I can and can't do. I'm learning to accept my

limitations.”“I use visualization. I picture myself on a warm beach swimming in the water

and take myself there mentally ““I retreat into a shell - I hurt and I know that I treat people like crap (and I don't

want to do that) when I feel that”“I talk about it to family and friends. Or I just get real quiet and need to be left

alone…”

Coping with IBD

IBD“Talk to my friend whose husband has Crohn's disease. Read up on the

disease to find ways to cope. ““Pamper myself, read a good book, use a heating pad or soak in a hot tub.” “Watch a movie, have a nap, take various narcotics”“Try to keep a positive attitude, there are people far worse off…”“I haven't figured out how to cope with it yet. Mostly it just depresses me.”“Talk to my husband, friends. Use the internet for support.”“I use drugs ! Cannabis.”“I write my thoughts and feelings down in different forms. I keep a journal

and also write poetry and songs ….”“I try very hard to ignore it, living as far as possible into the center of

denial.”“I always try to have a sense of humour, and to stay positive. If I didn't do

that I would be depressed and crusty all the time.”“I pray and meditate a good bit”