INTRODUCTION AND INTRODUCTION AND HISTORY OF HEALTH HISTORY OF HEALTH

PSYCHOLOGYPSYCHOLOGY

Lecture 39Lecture 39

Our lifestyle affects our health and sense of well-Our lifestyle affects our health and sense of well-being.being.

Most health problems are related to chronic diseases Most health problems are related to chronic diseases and these diseases are often associated with behavior and these diseases are often associated with behavior or lifestyle choices. or lifestyle choices.

The costs of medical care in the U.S. : more than $898 The costs of medical care in the U.S. : more than $898 billion annually. billion annually.

The potential financial burden associated with health The potential financial burden associated with health problems has led many to reevaluate their lifestyles problems has led many to reevaluate their lifestyles and behavior.and behavior.

Health has become associated with positive well-being Health has become associated with positive well-being rather than simply the absence of disease.rather than simply the absence of disease.

Psychology, as a science of behavior, has much to Psychology, as a science of behavior, has much to contribute to the field of health, and contribute to the field of health, and health health psychologypsychology has become a fast-growing specialty in has become a fast-growing specialty in clinical psychology. clinical psychology.

One clue that an emerging field has indeed been One clue that an emerging field has indeed been recognized is the appearance of textbooks and recognized is the appearance of textbooks and handbooks detailing that field. handbooks detailing that field.

Several specialty journals (Several specialty journals (including Health including Health Psychology and Journal of Behavioral Medicine)Psychology and Journal of Behavioral Medicine) report on research in these fields. report on research in these fields.

Finally, a separate division of the American Finally, a separate division of the American Psychological Association (Division 38) has been Psychological Association (Division 38) has been established as a way to publicize and advance the established as a way to publicize and advance the contributions of health psychologists.contributions of health psychologists.

PERSPECTIVEPERSPECTIVE Although a variety of overlapping sub Although a variety of overlapping sub

disciplines focus on Health related issues, we disciplines focus on Health related issues, we will focus primarily on two areas of psychology:will focus primarily on two areas of psychology:

Behavioral medicine and and health psychology.health psychology.

Recognition that mind and body are inextricably Recognition that mind and body are inextricably linked has been around since at least early linked has been around since at least early Greek civilization. Greek civilization.

However, it was not until the late 1970s that However, it was not until the late 1970s that definitions of behavioral medicine and health definitions of behavioral medicine and health psychology began to crystallize.psychology began to crystallize.

DEFINITIONS:DEFINITIONS:

The aggregate of the specific educational, The aggregate of the specific educational, scientific, and professional contributions of scientific, and professional contributions of the discipline of psychology to the the discipline of psychology to the promotion and maintenance of health, the promotion and maintenance of health, the prevention and treatment of illness, and the prevention and treatment of illness, and the identification of etiologic and diagnostic identification of etiologic and diagnostic correlates of health, illness and related correlates of health, illness and related dysfunction. (Matarazzo, 1980)dysfunction. (Matarazzo, 1980)

Brannon and Feist (2000), state that:Brannon and Feist (2000), state that:

‘’‘’Health psychology "includes psychology's Health psychology "includes psychology's contributions to the enhancement of health. contributions to the enhancement of health. the prevention and treatment of illness, the the prevention and treatment of illness, the identification of health risk factors, the identification of health risk factors, the improvement of the health care system, and improvement of the health care system, and shaping of public opinion with regard to shaping of public opinion with regard to health"health"

HISTORYHISTORY Two major perspectives have influenced our views of Two major perspectives have influenced our views of

health and illness.health and illness. First is the biomedical tradition, which developed over First is the biomedical tradition, which developed over

time as people sought to gain knowledge through time as people sought to gain knowledge through experience and observation. experience and observation.

Early attempts were rather crude but later biomedical Early attempts were rather crude but later biomedical scientists focused on anatomy, "germ theory," and scientists focused on anatomy, "germ theory," and ultimately genetics in their attempt ultimately genetics in their attempt

This Western tendency to focus solely on biological This Western tendency to focus solely on biological factors and to adopt a reductionistic approach is not factors and to adopt a reductionistic approach is not without its limitations, without its limitations,

For example, critics argue that we still do not know For example, critics argue that we still do not know what causes disease; rather, we have simply what causes disease; rather, we have simply discovered another malfunction at a smaller level of discovered another malfunction at a smaller level of analysis.analysis.

Bio medical research may be so enamored with Bio medical research may be so enamored with somatic correlates (such as abnormal physical somatic correlates (such as abnormal physical processes and biochemical imbalances) that processes and biochemical imbalances) that psychosocial variables are often ignored.psychosocial variables are often ignored.

Finally this tradition reinforces the mind-body dualism Finally this tradition reinforces the mind-body dualism perspective, one that is both outdated and limed in its perspective, one that is both outdated and limed in its utility. This is not to say that the biomedical tradition utility. This is not to say that the biomedical tradition has been unimportant or irrelevant to medicine, has been unimportant or irrelevant to medicine, science, and psychology.science, and psychology.

Rather, a strict biomedical viewpoint is at times too Rather, a strict biomedical viewpoint is at times too narrow because it cannot adequately account for narrow because it cannot adequately account for widely encountered forms of illness and disease.widely encountered forms of illness and disease.

A second major influence is the psychosocial A second major influence is the psychosocial perspective .perspective .

For centuries, medical literature has recognized that For centuries, medical literature has recognized that psychological and social processes may either cause psychological and social processes may either cause or influence illness and disease. or influence illness and disease.

By the 1940s, this broad generalization and coalesced By the 1940s, this broad generalization and coalesced into the field of into the field of psychosomatic medicine.psychosomatic medicine.

Psychosomatic medicine is based on he assumption Psychosomatic medicine is based on he assumption that certain illnesses and disease states are caused that certain illnesses and disease states are caused by psychological factors. by psychological factors.

Some who adopted this perspective believed that Some who adopted this perspective believed that each psychosomatic illness had a different, specific each psychosomatic illness had a different, specific underlying unconscious conflict predisposing the underlying unconscious conflict predisposing the person to that disorder.person to that disorder.

For example, repressed hostility was believed to result For example, repressed hostility was believed to result in rheumatoid arthritis. in rheumatoid arthritis.

Although initially appealing, these ideas and Although initially appealing, these ideas and psychosomatic medicine in general) began to founder psychosomatic medicine in general) began to founder as it became apparent that such specific psychogenic as it became apparent that such specific psychogenic factors were not very predictive; most empirical factors were not very predictive; most empirical studies did not support the theories. studies did not support the theories.

In fact, psychosocial factors are involved in all In fact, psychosocial factors are involved in all diseases, but these factors may not necessarily have diseases, but these factors may not necessarily have a primary causal role.a primary causal role.

Psychosomatic medicine was largely the province of Psychosomatic medicine was largely the province of psychiatrists and physicians. psychiatrists and physicians.

However, behavioral psychologists began to extend However, behavioral psychologists began to extend the range of their therapy methods to the so called the range of their therapy methods to the so called medical disorders. medical disorders.

Problems such as obesity and smoking came under Problems such as obesity and smoking came under the scrutiny of psychologists as well. the scrutiny of psychologists as well.

Then came a rapid increase in the use of biofeedback Then came a rapid increase in the use of biofeedback to help patients control or modify certain physiological to help patients control or modify certain physiological responses.responses.

Another set of factors was slow to develop but Another set of factors was slow to develop but ultimately had a strong impact. ultimately had a strong impact.

By the 1960s, many major infectious diseases had By the 1960s, many major infectious diseases had been conquered. been conquered.

The helping professions began to turn their attention The helping professions began to turn their attention to two of the biggest killers: to two of the biggest killers: cardiovascular diseasescardiovascular diseases and and cancer.cancer.

Behaviors such as overeating, smoking, and drinking Behaviors such as overeating, smoking, and drinking were increasingly identified as major correlates of were increasingly identified as major correlates of these diseases. these diseases.

The spotlight began to shine not just on the disease The spotlight began to shine not just on the disease process itself, but also on the associated behaviors process itself, but also on the associated behaviors whose reduction or elimination might reduce whose reduction or elimination might reduce individuals' vulnerability to disease.individuals' vulnerability to disease.

During the 1960s, stressful life events began to During the 1960s, stressful life events began to be implicated as specific risk factors for illness be implicated as specific risk factors for illness

The examination of how stressful major life The examination of how stressful major life events affect health led to an examination of the events affect health led to an examination of the health consequences of daily hassles, which health consequences of daily hassles, which can also prove stressful.can also prove stressful.

A related line of research demonstrated how A related line of research demonstrated how personality and behavioral style can influence personality and behavioral style can influence health. health.

The impetus came from two cardiologists who The impetus came from two cardiologists who were impressed with a common constellation of were impressed with a common constellation of traits and behaviors shared by many who traits and behaviors shared by many who suffered from coronary heart disease. suffered from coronary heart disease.

The so-called The so-called Type Type A personality is A personality is characterized by hostility, competitiveness, and characterized by hostility, competitiveness, and being time driven. being time driven.

Although subsequent research has failed to Although subsequent research has failed to support a direct link between Type A support a direct link between Type A personality and heart disease, the hypothesis personality and heart disease, the hypothesis stimulated research in health psychology and stimulated research in health psychology and served to focus attention on other behavioral served to focus attention on other behavioral risk factors for coronary heart disease, as well risk factors for coronary heart disease, as well as on prevention efforts.as on prevention efforts.

The recognition that both psychological and The recognition that both psychological and social factors influence illness and health is the social factors influence illness and health is the basis of an influential perspective known as the basis of an influential perspective known as the biopsychosocial model.biopsychosocial model.

In many ways, this model can be viewed as an In many ways, this model can be viewed as an integration of the biomedical and psychosocial integration of the biomedical and psychosocial perspectives. perspectives.

As the name implies, the biopsychosocial model holds As the name implies, the biopsychosocial model holds that illness and health are a function of biological, that illness and health are a function of biological, psychological, and social influences. psychological, and social influences.

Biological influences can include genetic Biological influences can include genetic predispositions, nutritional deficiencies, and bio predispositions, nutritional deficiencies, and bio chemical imbalances. chemical imbalances.

Psychological influences can include the individual's Psychological influences can include the individual's behaviors, emotions, and cognitions. behaviors, emotions, and cognitions.

Finally, social influences can include friends, family Finally, social influences can include friends, family members, home environment, and life events.members, home environment, and life events.

Many other factors were important in the development Many other factors were important in the development of the field of health psychology.of the field of health psychology.

The tremendous cost of health care has already The tremendous cost of health care has already been noted, along with the fact that infectious been noted, along with the fact that infectious diseases were no longer the principal culprits. diseases were no longer the principal culprits.

A large portion of health care costs are directly A large portion of health care costs are directly traceable to human behaviors and lifestyles that traceable to human behaviors and lifestyles that result in injuries, accidents, poisonings, or result in injuries, accidents, poisonings, or violence. violence.

Lifestyle choices such as alcohol and drug Lifestyle choices such as alcohol and drug abuse, smoking, and dietary patterns contribute abuse, smoking, and dietary patterns contribute to a variety of illnesses and diseases.to a variety of illnesses and diseases.

Linking Health with Lifestyle, Behavior, Linking Health with Lifestyle, Behavior, Personality, Social Support, and StressPersonality, Social Support, and Stress

STRESS AND HEALTHSTRESS AND HEALTH Although the term stress is frequently used, it is not Although the term stress is frequently used, it is not

often precisely defined often precisely defined Some use the term to refer to a quality of an external Some use the term to refer to a quality of an external

stimulus , others to refer to a response to a stimulus, stimulus , others to refer to a response to a stimulus, and still others believe stress results from an and still others believe stress results from an interaction between stimulus and response. interaction between stimulus and response.

Most contemporary health psychologists adopt this Most contemporary health psychologists adopt this third, interactionist viewpoint, seeing stress as a third, interactionist viewpoint, seeing stress as a process that involves an environmental event (a process that involves an environmental event (a stressor), its appraisal by the individual (is it stressor), its appraisal by the individual (is it challenging or threatening?), the various responses of challenging or threatening?), the various responses of the organism (physiological, emotional, cognitive, the organism (physiological, emotional, cognitive, behavioral), and the reevaluations that occur as a behavioral), and the reevaluations that occur as a result of these responses and changes in the stressor.result of these responses and changes in the stressor.

The physiological effect of stress on the body involves The physiological effect of stress on the body involves a complex chain of events.a complex chain of events.

Stress causes the sympathetic nervous system, to Stress causes the sympathetic nervous system, to stimulate the adrenal medulla of the adrenal gland. stimulate the adrenal medulla of the adrenal gland.

This results in the production of the catecholamines This results in the production of the catecholamines epinephrine and nor epinephrine, whose effects on the epinephrine and nor epinephrine, whose effects on the body include increased heart rate, respiration, blood body include increased heart rate, respiration, blood flow, and muscle strength. flow, and muscle strength.

Stress also causes the pituitary gland (a structure Stress also causes the pituitary gland (a structure connected to the hypothalamus in the forebrain) to connected to the hypothalamus in the forebrain) to release adrenocorticotropic hormone (ACTH), and release adrenocorticotropic hormone (ACTH), and ACTH stimulates the adrenal' cortex of the adrenal ACTH stimulates the adrenal' cortex of the adrenal gland to secrete glucocorticoids. gland to secrete glucocorticoids.

The most important glucocorticoids where stress is The most important glucocorticoids where stress is concerned is cortisol. concerned is cortisol.

Cortisol is a hormone that, like epinephrine and nor Cortisol is a hormone that, like epinephrine and nor epinephrine, mobilizes the body's resources. epinephrine, mobilizes the body's resources.

Cortisol serves primarily to increase energy level and Cortisol serves primarily to increase energy level and decrease inflammation. decrease inflammation.

The latter function is particularly useful if injuries are The latter function is particularly useful if injuries are sustained in an urgent situation.sustained in an urgent situation.

Although responses of the body to stress can be Although responses of the body to stress can be helpful, severe stress and prolonged activation of helpful, severe stress and prolonged activation of these systems can have adverse effects on body these systems can have adverse effects on body organs, mental functions, and the immune system.organs, mental functions, and the immune system.

For example, stress can affect the immune system so For example, stress can affect the immune system so that it cannot effectively destroy viruses, bacteria, that it cannot effectively destroy viruses, bacteria, tumors, and irregular cells. tumors, and irregular cells.

More than two decades ago, Ader and Cohen (1975) More than two decades ago, Ader and Cohen (1975) presented evidence suggesting that the nervous presented evidence suggesting that the nervous system and the immune system interact and are system and the immune system interact and are interdependent by demonstrating that immune system interdependent by demonstrating that immune system responses in rats could be classically conditioned.responses in rats could be classically conditioned.

This initial report eventually, led to a number of studies This initial report eventually, led to a number of studies investigating the relationship between physiological investigating the relationship between physiological factors and immune system response. factors and immune system response.

Currently it remains unclear whether Currently it remains unclear whether immunosuppression is a direct effect of stress or immunosuppression is a direct effect of stress or whether it is simply part of the body's response to whether it is simply part of the body's response to stressful events. stressful events.

In any case, stress does appear to be an important In any case, stress does appear to be an important (though not the only) influence on health and illness.(though not the only) influence on health and illness.

BEHAVIOR AND HEALTHBEHAVIOR AND HEALTH Behaviors, habits, and lifestyles can affect both health Behaviors, habits, and lifestyles can affect both health

and disease. and disease. Everything from smoking, excessive drinking, or poor Everything from smoking, excessive drinking, or poor

diet to deficient hygiene practices have been diet to deficient hygiene practices have been implicated. implicated.

Such behaviors are often deeply rooted in cultural Such behaviors are often deeply rooted in cultural values or personal needs and expectations. In any values or personal needs and expectations. In any event, they are not easily changed. event, they are not easily changed.

These include cigarette smoking, alcohol abuse and These include cigarette smoking, alcohol abuse and dependence, and weight control.dependence, and weight control.

Cognitive variables may influence our decisions about Cognitive variables may influence our decisions about adopting healthy or unhealthy behaviors. adopting healthy or unhealthy behaviors.

To cite one example, many health psychologists have To cite one example, many health psychologists have focused on the variable self efficacy.focused on the variable self efficacy.

Self-efficacy is relevant to a number of topics Self-efficacy is relevant to a number of topics addressed by health psychologists, including major addressed by health psychologists, including major theories of health-related behavior change. theories of health-related behavior change.

This construct plays a major role in the most This construct plays a major role in the most prominent social cognitive models of health behavior, prominent social cognitive models of health behavior, including the health belief model, protection motivation including the health belief model, protection motivation theory , and the theory of planned behavior.theory , and the theory of planned behavior.

Protection motivation theory (PMT),Protection motivation theory (PMT), for example, for example, posits that behavior is a function of threat appraisal posits that behavior is a function of threat appraisal (an evaluation of factors that will affect the likelihood (an evaluation of factors that will affect the likelihood of engaging in the behavior, such as perceived of engaging in the behavior, such as perceived vulnerability and perceived potential for harm) and vulnerability and perceived potential for harm) and coping appraisal (an evaluation of one's ability to coping appraisal (an evaluation of one's ability to avoid or cope with negative outcome). avoid or cope with negative outcome).

Coping appraisal is influenced by one's self-efficacy or Coping appraisal is influenced by one's self-efficacy or belief that one can implement the appropriate coping belief that one can implement the appropriate coping behavior or strategy. behavior or strategy.

An example that applies PMT to a real-life health An example that applies PMT to a real-life health decision may be instructive. decision may be instructive.

Janey, an adolescent girl faced with a decision about Janey, an adolescent girl faced with a decision about whether or not to start smoking cigarettes, according whether or not to start smoking cigarettes, according to PMT, would engage in threat appraisal and coping to PMT, would engage in threat appraisal and coping appraisal. appraisal.

Threat appraisal might involve evaluating the dangers Threat appraisal might involve evaluating the dangers of smoking (such as lung cancer) as well as the of smoking (such as lung cancer) as well as the likelihood of her own vulnerability to this outcome. likelihood of her own vulnerability to this outcome.

To the extent that she does not perceive the danger to To the extent that she does not perceive the danger to be severe or immediate to herself. Janey night be be severe or immediate to herself. Janey night be more likely to start smoking. more likely to start smoking.

Coping appraisal is also relevant. Coping appraisal is also relevant.

This process might involve Janey’s evaluation of how This process might involve Janey’s evaluation of how likely it is that she could refrain from smoking (the likely it is that she could refrain from smoking (the recommended coping strategy). recommended coping strategy).

To the extent that Janey’s believes she will not be able To the extent that Janey’s believes she will not be able to refrain from smoking (for example, because all her to refrain from smoking (for example, because all her friends smokes, it becomes more likely that she will friends smokes, it becomes more likely that she will engage in this behavior. engage in this behavior.

Thus, the cognitive variable self-efficacy can play a Thus, the cognitive variable self-efficacy can play a prominent role in behavior and lifestyle choices that prominent role in behavior and lifestyle choices that ultimately influence health.ultimately influence health.

Problems can also arise from the ways in which Problems can also arise from the ways in which people respond to illness. people respond to illness.

Some people may be unable or unwilling to appreciate Some people may be unable or unwilling to appreciate the severity of their illness and fail to seek timely the severity of their illness and fail to seek timely medical help. medical help.

When they do get medical advice, they may fail to When they do get medical advice, they may fail to heed it. All of these behaviors can indirectly foster heed it. All of these behaviors can indirectly foster adverse outcomes. adverse outcomes.

PERSONALITY FACTORSPERSONALITY FACTORS::

Both directly and indirectly, personality characteristics Both directly and indirectly, personality characteristics can affect health and illness in many ways (Friedman can affect health and illness in many ways (Friedman & Booth-Kewlev, 1987): & Booth-Kewlev, 1987):

(1) personality features may result from disease (1) personality features may result from disease processes; processes;

(2) personality features may lead to unhealthy (2) personality features may lead to unhealthy behaviors; behaviors;

(3) personality may directly affect disease through (3) personality may directly affect disease through physiological mechanisms: physiological mechanisms:

(4) a third, underlying biological variable may relate to (4) a third, underlying biological variable may relate to both personality and disease; and both personality and disease; and

(5) several causes and feedback loops (5) several causes and feedback loops may may affect the affect the relationship between personality and disease.relationship between personality and disease.

Perhaps the most widely studied association between Perhaps the most widely studied association between a personality trait and illness is that between Type A a personality trait and illness is that between Type A behavior and coronary heart disease. behavior and coronary heart disease.

As mentioned previously, the notion of a possible link As mentioned previously, the notion of a possible link between personality or coping style and adverse between personality or coping style and adverse health consequences, specifically coronary heart health consequences, specifically coronary heart disease, was proposed by two cardiologists (Friedman disease, was proposed by two cardiologists (Friedman & Rosenman, 1974). & Rosenman, 1974).

They identified a set of discriminating personality They identified a set of discriminating personality characteristics and behaviors and proposed that these characteristics and behaviors and proposed that these constitute a constitute a Type A behavior pattern. Type A behavior pattern. Glass (1977) Glass (1977) describes Type A individuals as those who tend to:describes Type A individuals as those who tend to:

Perceive time passing quicklyPerceive time passing quickly Show a deteriorating performance on tasks that Show a deteriorating performance on tasks that

require delayed respondingrequire delayed responding Work near maximum capacity even when there Work near maximum capacity even when there

is no time deadlineis no time deadline Arrive early for appointmentsArrive early for appointments Become aggressive and hostile when frustratedBecome aggressive and hostile when frustrated Report less fatigue and fewer physical Report less fatigue and fewer physical

symptomssymptoms Are intensely motivated to master their physical Are intensely motivated to master their physical

and social environments and to maintain controland social environments and to maintain control

A number of early studies suggested a relationship A number of early studies suggested a relationship between Type A behavior and coronary heart diseasebetween Type A behavior and coronary heart disease

However, these findings were often misinterpreted as However, these findings were often misinterpreted as indicating that Type A individuals are likely to develop indicating that Type A individuals are likely to develop coronary heart disease. coronary heart disease.

More recent studies do not show as strong a More recent studies do not show as strong a relationship between Type A behavior and heart relationship between Type A behavior and heart disease as was once thought, and it is clear that the disease as was once thought, and it is clear that the vast majority of Type A individuals do not develop vast majority of Type A individuals do not develop coronary heart disease (CHD). coronary heart disease (CHD).

However, Type A individuals are at relatively greater However, Type A individuals are at relatively greater risk for CHD. risk for CHD.

More recent studies suggest that the anger-hostility More recent studies suggest that the anger-hostility component of the Type A pattern does a better job of component of the Type A pattern does a better job of predicting coronary heart disease than the more global predicting coronary heart disease than the more global Type A categorization.Type A categorization.

SOCIAL SUPPORT AND HEALTHSOCIAL SUPPORT AND HEALTH Social support Social support refers not only to the number of refers not only to the number of

social relationships, but also to the quality of social relationships, but also to the quality of those relationships. those relationships.

The basic idea is that interpersonal ties can The basic idea is that interpersonal ties can actually promote health. actually promote health.

They insulate people from harm when they They insulate people from harm when they encounter stress, decrease susceptibility to encounter stress, decrease susceptibility to illness, and help people comply with and illness, and help people comply with and maintain treatment regimens. maintain treatment regimens.

Social support is, in many ways, a kind of Social support is, in many ways, a kind of coping assistance. A number of studies have coping assistance. A number of studies have indicated that better health outcomes are indicated that better health outcomes are positively related to social support. positively related to social support.

The relationships among social support stress, The relationships among social support stress, and health may depend on a number o factors, and health may depend on a number o factors, including race, gender, and culture. including race, gender, and culture.

For example, women (on average) seem to For example, women (on average) seem to benefit more from social support than do men; benefit more from social support than do men; this may be because women tend to have more this may be because women tend to have more emotionally intimate relationships. emotionally intimate relationships.

Preliminary data also suggest that white may Preliminary data also suggest that white may benefit from social support more than non benefit from social support more than non white. white.

However, the reason for this is not clear, and However, the reason for this is not clear, and the possibility of race and ethnic differences the possibility of race and ethnic differences needs further study Clearly, the relationship needs further study Clearly, the relationship between social support and health is complex.between social support and health is complex.

RANGE OF APPLICATIONSRANGE OF APPLICATIONS A full description of all the problems is hard to A full description of all the problems is hard to

describe but a partial list culled from recent accounts describe but a partial list culled from recent accounts would include the following: would include the following:

SmokingSmoking **UlcersUlcers

Alcohol abuse Alcohol abuse **ObesityObesity Type A personality Type A personality

Hypertension Hypertension ** Asthma Asthma Chronic Heart DiseaseChronic Heart Disease Alzheimer's diseaseAlzheimer's disease Acquired immune deficiency syndrome (AIDS)Acquired immune deficiency syndrome (AIDS) Anorexia nervosa etc.Anorexia nervosa etc.