PSYC706 - Health Psychology

Attachment and Health Behaviour

An emerging topic in health psychology is the role that attachment plays in health behaviours and healthcare-seeking behaviours. Attachment: the emotional bond a child develops with caregiver (established by John Bowlby and applied by Mary Ainsworth) The attachment patterns established within the first few years of life serve an internal working model for attachment relationships later in life (i.e., boyfriends/girlfriends, spouse) Scharfe & Elderidge (2001) studied attachment and health behaviours in late adolescence (university students) Health promotion behaviour examples: brush teeth, take vitamins, read books/magazines about health (??), routinely eat breakfast Health risk behaviour examples: using tranquilisers, consuming 6 or more ounces of alcohol per week, not using seatbelt Securely attached individuals were more likely to report health-promoting behaviours, quality sleep, and less likely to report risk behaviours Dismissive individuals were more likely to report sleep problems

BIO INDIVIDUAL NUTRITION

Bio Individual Nutrition is the science & clinical application of nutrition intervention (food & nutrient choices) based on individual biochemical needs of a unique person. Bio -individuality, meaning that a "one size fits all" approach to nutrition does not exist. Joshua Rosenthal is responsible for coining and trademarking "Bio -Individuality" as a term. Critique: When born healthy, humans anatomically similar, warranting a natural diet [lifetime food, not a weight -loss plan] intended for human anatomy & physiology. Elephants in India don't need totally different food than elephants in Africa

Mammography and over-diagnosis

COCHRANE REVIEW "Screening for breast cancer with mammography" (Gotzsche & Jorgensen, 2013) 7 trials, 6,000,000 women, 39 to 74 years, randomly assigned screening mammograms or not. If 2000 women are screened regularly for 10 years: ◼ 1 woman will avoid dying from breast cancer ◼ 10 healthy women, who would not have been diagnosed without screening, will have breast cancer diagnosed and be treated unnecessarily; 4 of these women will have a breast removed, 6 will receive breast conserving surgery, and most will receive radiotherapy. ◼ 1800 will be alive after 10 years; without screening 1799 will be alive. ◼ 200+ women will experience severe psychological distress including anxiety for years due to false positive findings. All women invited to screening should be fully informed of both the benefits & harms. https://www.cochrane.org/

What do we want in a doctor?

Competence Expertise Concern, warmth, sensitivity, empathy etc How do "good" doctors benefit? ⚫ Patients seem to adhere to treatment ⚫ Obtain more extensive (biopsychosocial?) diagnostic information

Terminology - compliance & adherence

Compliance ⚫ "extent to which the patient's behaviour matches the prescriber's recommendations" ⚫ Implies lack of patient involvement Adherence ⚫ "extent to which patient's behaviour matches agreed recommendations from the provider" ⚫ The extent to which the patient's behaviour coincides with medical advice in terms of taking medications, lifestyle changes, and future appointments ⚫ Emphasises need for agreement ⚫ Emphasises freedom of patient

Infertility and prevalence

Defined: The inability to conceive a pregnancy after one year of unprotected coitus or the inability to carry a pregnancy to a live birth Experienced in 1 in 6 couples of reproductive age (Fertility Society of Australian, 2013).

Obedience in Health Care?

Drug administration Nurses asked, by Dr on phone, to give patient a nonprescribed and incorrectly dosed drug Result: 21 / 22 administered the drug Interpretation: Perceived legitimate authority facilitates obedience as per Milgram - lots of demonstrations of this (Hofling et al., 1966)

Beliefs about medicines

Dual nature of medicines - healing and harm Judging efficacy - symptom control and side effects Negative concerns ⚫ Dependence ⚫ Continual use ⚫ Chemical vs natural ⚫ Overuse

Psychological Effects of Infertility

Elevated psychological distress in both men and women. Women's sense of self more affected than men Due to socialised pressure Default motherhood Stigma of childlessness Effects for women related to narrative of 'challenge' vs 'loss' Can lead to strain on the relationship, not usually break-up. Very dependent on culture: prenatal, women's roles, acceptability of childlessness, availability of other options e.g. adoption.

Women's health psychology

Emerged in courses and texts in the 1990s. Some areas converge with research & theories of general health psychology - in common with men Also, areas where women have unique/different issues. Recognises women are a diverse group. Holds women's health impacted by economics, social practices, cultural, political & relational contexts, at different life stages. About how behaviours, attitudes, lifestyles, & interactions between psychological & physical health influence women's wellbeing within diverse sociocultural contexts.

TO CONCLUDE

Exercise can take many forms Exercise has physical & psychological benefits Exercise is predicted by social & individual factors Exercise relapse also relates to social & individual factors

The Patient's Behaviour that Upsets the Doctor

Expressing anger or criticism Ignoring or not listening Insisting on procedures the physician thinks are not necessary Requesting the doctor certify something he/she does not think is true (e.g., disability) Sexually suggestive remarks

Methods for Promoting Health

Fear-arousing warnings - gain vs. loss-framed messages Providing information e.g. mass media http://www.youtube.com/watch?v=8EHBA5JHd0E&list= PL3B17AED777180AC7&index=8&feature=plpp_video Motivational interviewing - a counselling style designed to help individuals explore & resolve their ambivalence in changing a behaviour Behavioural methods manipulate the consequences, or reinforcements, teach new skills Behaviour-dependent Material rewards can be helpful when interest is low, but may reduce motivation if interest is high Community Approaches School-based Workplace-based

TYPES OF VEGETARIANISM

Forestell et al (2012) Semi-vegetarians and flexitarians -more restrained than omnivores Semi-vegetarians and flexitarians - motivated by weight control Vegetarians and pesco-vegetarians - motivated by ethical concerns Eating Pathology Restrained eating patterns associated with vegetarianism, food intolerances and allergies. - some people use these excuses for there eating disorders -- not all people who are vegetarian have ed BUT vegetarianism may be a smokescreen for ed. Eg- at a party: they will say they can't eat the cake bc they are vegan or have celiac Bardone-Cone et al. (2012) Compared vegetarianism behaviours among females with an eating disorder (n = 93) compared to controls (n = 67) Females with ED → more likely to be vegetarian, and to do so for weight control reasons

Some topics of relevance to women's health psychology

Heart disease - biology or bias? Breast cancer - anxiety, over-diagnosis & young women Violence against women - health impacts and cultural scaffolding Chronic pain & gender bias - fibromyalgia Body image, weight stigma & health impacts Infertility impacts, coping & culture. Lesbian health - minority stress.

EVOLUTIONARY PSYCHOLOGY AND EATING

Human body evolved to be highly efficient at storing excess energy from food in-take. Originally humans were solitary eaters. Social settings increase food intake Taste preferences foods high in sugar, salt and fat were on short supply in ancestral times - therefore humans evolved a predisposition to eat such foods Seasonal variation in food consumption people tend to eat more in Autumn

Improving patient recall

Important information first Stress importance ⚫ "It's very important that you remember what I am going to say next..." Simplification Categorisation ⚫ "Now I'm going to tell you what's wrong with you/what the treatment will be/how to take your medication..." Repetition Specific, concrete statements ⚫ "Go for an hour's walk, 3 times a week" vs "Exercise regularly" Written information Check for understanding

The Health Belief Model

In weighing the pros and cons, in order to perform the behaviour, people must feel that the perceived benefits outweigh the perceived barriers. Barriers can be: Financial eg- (can I pay for all organic food?) Psychosocial consequences (the doctor may find something serious, my doctor already thinks I'm a hypochondriac) Physical considerations eg- (doctor's office is too far away) Demographic, sociopsychological model, structural variables --- perceived benefits versus barriers of preventative action --- perceived threat or susceptibility/seriousness of an illness --- cues to action eg- mass media, illness of family or friend, newspaper etc. --- LEADS TO likelihood of preventative action

Infertility Treatments and Stress

Intervention options include: hormones, artificial insemination, range of variations in in-vitro fertilisation, ovum donation These options may produce considerable stress, challenge couple's coping resources, overall QOL Strain and pressure to continue on with treatment Financial hardships Women report experiencing considerable the relief when they stop IVF & explore alternatives (e.g., adoption, surrogate motherhood, remaining childless) - childless has a connotation of blame, some choose to use the term "child-free" adoption has a difficult process But each have their own challenges as well

CHD Treatment

Less aggressive in women than in men (Steingart et al., 1991). Women are half as likely to be recommended cardiac catheterization (a test that determines heart disease severity). Women are less likely to receive angioplasty and coronary bypass than men A recent study of emergency patients with similar presenting symptoms: Paramedics gave morphine to men who report pain but not women. Gender bias exists even when there are really clear diagnostic & treatment protocols - likely to be worse when there aren't e.g. chronic pain.

Loneliness and Health Behaviour

Loneliness Defined as perceived social isolation the discrepancy between the individual's desired & actual social relationships Lonely people tend to report poorer health... But, why? Cacipoppo & Hawkley (2003) propose mechanisms for the impact of loneliness on health behaviours: 1. Lonely individuals have less'normative pressures' to engage in healthy behaviours 2. Multiple social ties provide multiple sources of information about health behaviours (e.g., where to seek appropriate treatment) However, research among university students found that lonely student and non-lonely students engaged in similar health behaviours in terms of exercise, tobacco use, caffeine & soda consumption... But lonely students... also drank less alcohol!

Research into health impacts of violence against women

Mainly focusses on intimate partner violence (IPV) Fanslow & Robinson (2004): Random sample of women aged 18-64 in Auckland & Waikato (n=2,855). Lifetime non-partner physical violence: 15% A, 17% W. Lifetime physical or sexual intimate partner violence (IPV): 33% A, 39% W. Victims of IPV twice as likely to have visited a healthcare provider in the previous month. IPV significantly associated with current health: self-perceived poor health, physical health problems (eg, pain), mental health & suicide attempts. https://www.anrows.org.au/ ANROWS (2016): Burden of disease (impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators) Impacts of intimate partner violence (IPV) in Australian women 18-44. IPV adds 5.1% to burden of disease Higher contribution than any other risk factor in the study (including tobacco use, high cholesterol or use of illicit drugs).

Factors influencing patient recall

Medical jargon Importance ⚫ Statements perceived as important recalled better Primacy effect ⚫ Material presented first is better recalled ⚫ Diagnostic advice remembered better than treatment advice Unclear instructions Low levels of information

Breast cancer anxiety

Medically reclassified as chronic disease, not acute. Acute - come on abruptly & run a short, severe course Chronic - last prolonged time & come & go Yet one of the diseases most feared by women. Most common response to diagnosis (own or another's) is anxiety/dread. Societal discourses feed women's anxiety: high prevalence, death rates, & risk reduction 'the lump', the 'hidden disease' requires constant vigilance (Lupton, 1994). BC anxiety is associated with reluctance to be examined (by GP or self), present for mammography & BC treatment.

Heart disease - Biology or bias?

More women than men die from coronary heart disease (CHD) yearly No 1 killer of women in NZ- 50 a week Many risk factors in common with men Additional factors for women: smoking when young, diabetes, poverty, depression, anxiety. Under-researched. 50% of cardiovascular disease trials conducted between 2006 & 2010 did not include gender analysis

Coherence

Need for 'common-sense coherence' between representations of illness and treatment e.g., asthma The medical model of asthma as a chronic condition requiring daily maintenance treatment vs Patient experience of asthma as an episodic condition - symptoms come and go No symptoms = no asthma (Halm et al., 2006) Patients with this model had stronger doubts about the personal need for inhaled corticosteroids and lower adherence (Horne & Weinman, 2002)

Non-adherence

Not following advice given by (agreement with) healthcare professionals Variable behaviour, not a trait characteristic ⚫ Most people are non-adherent some of the time Unintentional non-adherence ⚫ Passive non-adherence ⚫ Caused by barriers such as forgetting, inability to follow instructions, lack of understanding, or physical problems e.g., poor eyesight Intentional non-adherence ⚫ Active non-adherence ⚫ The patient decides not to take treatment as instructed ⚫ Arises from beliefs, attitudes and expectations

Medical benefits, psychological impacts

Obviously - but some questions over the approach to treatment (medication vs lifestyle change), issues with invasive treatments that might not confer benefits relative to personal costs Screening info - raise anxiety? Negative results - generally relieve anxiety, but some want further reassurance Positive results - anxiety, shock, fear, etc Unclear results...anxiety, concern etc

HEALTHY EATING GONE AWRY

Orthorexia - obsession with the perfect diet "orthos" = straight/proper "orexia" = appetite Possibly a new mental illness - related to OCD However, not in the DSM. Avoidance of foods with any: artificial flavours or preservatives, pesticides, genetic modification, unhealthy fat, sugar or added salt - calorie counting can be triggering for some people to become obsessive

Fibromyalgia

Pain without a cause is the pain we can't trust... we assume it's been chosen or fabricated (Jamison, 2014) "I use the word 'suffer' not for pity, or attention, and have been disappointed to see people online suggest that I'm being dramatic, making this up, or playing the victim to get out of touring." Gaga

Psychological Processes in Who?

People who receive health care: - Patients: anyone interacting with a health care professional or service Users: perceived presence of symptoms driving health care use Consumers: active, and proactive, care seeking by the asymptomatic People who provide health care: - Providers: professional responsibility to provide care directly to patient Carers: as above, but without professional responsibility People who organise health care:- Purchasers / managers: who fund & evaluate local service against benchmark quality indicator, e.g. treatment targets Policy- / Decision-makers: set national-level quality indicators, provide clinical guidance & allocate financial resources

The Practitioner's Behaviour

Physicians tend to use a consistent style. Two general styles: Doctor-centred ⚫ Asks closed-ended questions and focuses on the first problem mentioned. ⚫ Ignores attempts to discuss other problems ⚫ Paternalistic Patient-centred (less common) ⚫ Asks open-ended questions and allows discussion ⚫ Avoids jargon and encourages participation in decisions

Sociological perspectives on infertility

Prior to 2000, infertility as a medical issue, with psychological consequences. Now - recognised infertility experiences as shaped by social context. *Must see parenthood as desirable to become 'infertile'* Generally not located in individual bodies - couples are infertile Generally no pathology - absence of the desired state Variety of viable alternatives to 'cure' Drawing on the cultural resources that are available to them: define their ability to have children as a problem, define the nature of the problem, construct an appropriate course of action.

Perceptions & Practicalities Approach for facilitating informed adherence to medication

Provide a rationale for personal NECESSITY: consistent with patients' 'common-sense' model of the illness - initiation and maintenance Elicit and address individual CONCERNS Tailor a convenient regimen that fits the patient's lifestyle and preferences, and addresses practical barriers Horne (2003)

Improving adherence

Relationship - satisfaction Discussion, time, understanding Reduce the number of medications where possible Use longer-acting medications to reduce the number of times taken during the day Use calendar dispensers where possible Co-ordinate timing of doses

Cartwright Inquiry in New Zealand 1987-1988

Responded to unethical experimentation on women at National Women's Hospital. 1966 - women with major cervical abnormalities were studied without definitively treating them and without their knowledge or consent. By 1987 many had developed cervical cancer & some had died. Exposed a core dynamic of twentieth-century medical practice: Arrogance: Doctors know best, are supremely objective, rational and scientific. Patients, particularly women, considered irrational, hysterical & incapable of understanding & making health choices for themselves.

stroop effect

Result: Fewer errors & faster time to name colour alone than in presence of word written in conflicting colour Explanation: Presence of conflicting colour word interferes with processing ability / task performance Conclusion: The meaning of a word is *processed automatically*, without intention We miss errors or scrambles letters with first and last letters correct, our brain automatically processes the word

Attachment and Cervical Screening

Secure attachment was associated with lowered cervical screening barriers, Fearful and preoccupied attachment patterns were associated with elevated barriers. However... When studying the big 5 with attachment theory, conscientiousness consistently emerged as the strongest predictor of screening behaviours/barriers

WHAT FACTORS PREDICT EXERCISE?

Social/political climate Availability of facilities Cultural attitudes Local funding for sports centres GP referral schemes Supervised exercise schemes INDIVIDUAL PREDICTORS Non-modifiable factors: Younger in age Better educated Low body weight Access to facilities Being male Having money Modifiable factors - beliefs: Perceived social benefits of exercise Value on health Beliefs about the benefits of exercise Exercise self-efficacy Social norms

Screening

Some have argued screening is a mechanism of social control (Illich, 1974; Zola, 1973) - medicine taking over people's lives, everyone at risk (healthy perceived as potentially ill), intrusion into people's lives, absolves personal responsibility for health More likely to attend a screening if: ⚫ Higher SES ⚫ Older ⚫ Healthy...

Personality

The Big Five personality theory has had a significant impact on the field of health psychology. Friedman and Booth-Kewley (1987) reviewed and meta-analysed personality (plus anxiety and depression) and chronic diseases (5 + heart disease) The similar pattern across diseases - the same personality predictors O C E A N Of the five personality factors, conscientiousness, neuroticism, and extraversion are most relevant to health. Conscientiousness: a key variable in health behaviour models and longevity

3. Stages of Change Model

The focus of this model is readiness Transtheoretical model - because it incorporates factors from other models 1.Precontemplation - no consideration of behaviour change 2.Contemplation - considering a change but have not taken any action 3.Preparation - making small changes 4.Action - actively engaging in new behaviour 5.Maintenance - sustaining change over time

Are more young women being diagnosed with breast cancer in NZ?

The public perception that breast cancer now has a younger face. Young women are no more likely to be diagnosed with breast cancer than they were 20 years ago. More women are being diagnosed overall, fewer are dying. Why the perception that more young women are affected? 'Going public' & shock value - media influence High profile diagnoses - Kylie Minogue, Sheryl Crow, Christina Applegate Over-diagnosis & public health messaging contribute to BC anxiety.

Family Violence Death Review Committee in NZ

The unnatural death of a person (adult or child) where the suspected perpetrator(s) is a family or extended family member, caregiver, intimate partner, previous partner of the victim, or previous partner of the victim's current partner, & where the death was an episode of family violence and/or there is an identifiable history of family violence Does not include: suicides; assisted suicides; & deaths from chronic illness associated with family violence.

Delay...

Time between first detection of symptom and first contact with a health professional. ⚫ Symptom perception • Distraction, overall QoL good ⚫ Illness cognitions • "It'll go away", " just ate/drank too much" ⚫ Social triggers • Social network suggests 'normal', others not noticing, family has history of xx, that'll be what it is ⚫ Costs and benefits of visit to GP • Problem minor, don't want to bother Dr, time/money and inconvenience, not happy with my (any) Dr

Less-Rational Processes

We're not rational people, as evidenced by behavioural economist Dan Ariely... and it affects our health. Life or Death Decision Making (Ralph Keeny - public risk expert) 44.5% of all premature deaths in the US are caused by personal decisions smoking, exercise, crime, drugs, unsafe sex (2008) Using the same method, only 10% of premature deaths were caused by personal decisions in 1900 Motivated Reasoning - the process by which people's desires and preferences influence the judgments they make about the validity and utility of new information Searching for information to support their reasoning e.g., my friend smokes and she ran a half marathon - it can't be that bad for your health -- or red wine is good for you - having in excess = bad ---cherry-picking False Hope - believing that you will succeed at a health behaviour without a rational basis eg- if you only cut down junk food a little bit, don't make enough changes to diet or exercise

6. The health psychology approach

Who is responsible for treatment? Individuals are *also*, (not soley) responsible for their treatment. What is the relationship between health & illness? Illness & health are not qualitatively different: There are different degrees of each, & they are both ends of a continuum. Or probably a multi-dimensional continuum. Holistic approach, showing that someone can be completly healthy in one area but not another What is the role of psychology in illness? There are not only psychological consequences, but psychological factors can be contributing to health at all stages: illness onset, help-seeking, illness adaptation, illness progression, & health outcomes. A study showed that those who had an optimistic view going to heart surgery had better health outcomes.

The Girl Who Cried Pain: Bias Against Women in the Treatment of Pain

Women report pain more frequently to health care providers, More likely to be discounted as "emotional", "psychogenic" or "not real", and less likely to be treated (Institute of Medicine, 2011). Men get pain relief, women get sedatives. Some paradoxical reasons suggested: Women report more coping mechanisms for pain, & therefore regarded as needing less treatment - resistance to being a 'suffering woman' Women look less 'in pain' as they are socialised to pay more attention to their appearance Men with chronic pain tend to delay treatment therefore more aggressively treated when they show up Medical bias towards discounting the emotional or psychological components of the experience of pain (Hoffman & Tarzian, 2001). ◼ "Pain that gets performed is still pain" (Jamison, 2014). ◼https://www.theatlantic.com/entertainment/archive/2017/09/lady-gagas-illnessis-not-a-metaphor/540369/

Development & Health-Behaviour: Childhood & Adolescence

accidental injury is the leading cause of death Cognitive development passes through stages of explanations of illness: Phenomenaism - illness - single symptom Contagion - a bit more knowledge about cause (e.g., proximity) Contamination - dirt or germs cause illness Internalisation - illness - problem inside body Physiological - knowledge about internal function (e.g., cancer cells grow too fast) Psycho-physiological - illness can result from psychological and physical problems

Unsaturated fats

can help lower your LDL cholesterol. Most vegetable oils that are liquid at room temperature have unsaturated fats: Mono-unsaturated fats, which include olive & canola oil - although some research says canola oil is not healthy Polyunsaturated fats, which include safflower, sunflower, corn, & soy oil Another unsaturated fat that is unhealthy: trans-unsaturated fatty acids - unhealthy fats form, when vegetable oil hardens in a process, called hydrogenation. limit foods made with hydrogenated and partially hydrogenated oils (e.g. hard butter & margarine). They contain high levels of trans-fatty acids --- some say butter is not unhealthy - good in moderation

Carbohydrates

carbs are pretty much sugars - 2 main forms - simple & complex. Also referred to as simple sugars & starches. Differences in how quickly carbs digested & absorbed. 1. Simple carbohydrates: Found in refined sugars, like white sugar (absorbed quicker). Also in nutritious foods - fruit & milk (absorbed slower). Healthier to get simple sugars from foods like these. Simple sugar raises blood glucose levels quickly. --- NOT always unhealthy 2. Complex carbohydrates: Include grain products, e.g. bread, crackers, pasta, & rice. As with simple sugars, some complex carbohydrates better choices. Strictly speaking, complex carbohydrate refers to any starches, including highly refined starches e.g. white flour, white rice, cakes & pastries that have been processed, removing nutrients & fibre. When dietitians & nutritionists advise having complex carbohydrates, referring to whole-grain foods & starchy vegetables - more slowly absorbed than refined carbohydrates. Rich in fibre helps digestive system work well - helps you feel full, less likely to overeat. eg- a bowl of oatmeal fills you up better than sugary candy. *There are both poor and healthy choices in both types of carbs*

Saturated fats

raise LDL (bad) cholesterol levels. High LDL (low-density lipoprotein) cholesterol - risk for heart attack, stroke, other major health problems. Best to avoid/limit foods high in saturated fats. E.g. butter, cheese, whole milk, ice cream, cream, & fatty meats. Some vegetable oils, such as coconut, palm, and palm kernel oil, also contains saturated fats. These fats are solid at room temperature. Coconut oil? - 92% saturated fat https://www.pritikin.com/your-health/healthy-living/eatingright/1790-is-coconut-oil-bad-for-you.html --- diets that advocate high fats refer to good fats (unsaturated)

Gender, SES and Health

women's biology protect from certain health problems Blood pressure increase and catecholamine (e.g. adrenaline) release during stress is greater in men males have shorter life expectancies than females males have a higher rate of accidents males engage in more exercise females have a higher rate of acute illnesses health correlates with socioeconomic status from birth (from conception?) lower SES have poorer health habits, behaviours and knowledge

Emotion-focused coping

"(or palliative) refers to thoughts or actions whose goal is to relieve the emotional impact of stress. These are apt to be mainly palliative in the sense that such strategies of coping do not actually alter the threatening or damaging conditions but make the person feel better." - Monat and Lazarus (1991, p. 6) "Stress and coping: An anthology" "hot" emotional systems - Metcalfe & Mischel (1999) - cool = "know", emotionally neutral, strategic, slow, cognitive hot - "go", emotion-driven, passion, impulsive https://www.researchgate.net/profile/Janet_Metcalfe/publication/13101564_A_HotCool-System_Analysis_of_Delay_of_Gratification_Dynamics_of_Willpower/links/54e731fe0cf2cd2e029188e6.pdf E.g., Cancer - avoid issue, focus on reducing emotional responses... Make decision (prob focused) then distance emotionally

Noticing BC symptoms

"I felt very alone. I felt a great weight of loneliness, And I became extremely anxious. This anxiety stayed with me throughout the whole process. My heart started to pound, and almost instantaneously I had flash-backs to my aunt on her death-bed, dying not an easy death, from breast cancer some years ago" (Anne, in Stephenson 2014).

Do the obese exercise less?

Research has also examined the relationship between activity and o using a cross-sectional design to examine differences between the o and non-o. In particular, several studies in the 1960s and 1970s examined whether the o exercised less than the non-o. Using timelapse photography, Bullen et al. (1964) observed girls considered o and those of normal weight on a summer camp. They reported that during swimming the o girls spent less time swimming and more time floating, and while playing tennis the o girls were inactive for 77 per cent of the time compared with the girls of normal weight, who were inactive for only 56 per cent of the time. In addition, research indicates that the o walk less on a daily basis than the non-o and are less likely to use stairs or walk up escalators. For example, to assess the impact of stair climbing Shenassa et al. (2008) explored the relationship between BMI and floor of residence in nearly 3,000 normal weight adults across eight European cities. The results showed that for men, higher floor was associated with lower BMI. This association was not, however, found for women. The authors concluded that daily stair climbing may reduce weight and therefore should be encouraged. Why the association was not there for women is unclear. Further cross-sectional data in 2008 from the UK explored the relationship between body weight and being sedentary in the week and at the weekend. The results are shown in Figure 15.8 for men and women. The results from this data indicate that the o are more sedentary at both the weekend and in the week than either those who are overweight or those of normal weight. These studies are cross-sectional and whether reduced exercise is a cause or a consequence of o is unclear. It is possible that the obese take less exercise due to factors such as embarrassment and stigma and that exercise plays a part in the maintenance of o but not in its cause.

Characteristics of the Health Professional (Non-interactive theories)

Research has also looked at the c of the hp, suggesting that the kind of hp administering the placebo treatment may determine the degree of the placebo effect. For example, higher hp status and higher concern have been shown to increase the placebo effect.

Does control affect the stress response?

Research has examined the extent to which the controllability of the s influences the stress response to this stressor, both in terms of the subjective experience of stress and the accompanying physiological changes. 1. Subjective experience. Corah and Boffa (1970) examined the relationship between the controllability of the s and the subjective experience of stress. Subjects were exposed to a loud noise (the experimental s) and were either told about the noise (the s was predictable) or not (an unpredictable s). The results indicated that if the noise was predictable, there was a decrease in subjective experience of s. The authors argued that predictability enables the subject to feel that they have control over the stressor, and that this perceived control reduces the s response. Baum et al. (1981) further suggested that if a s is predicted, there is a decrease in the s response, and reported that predictability or an expectation of the stress enables the individual to prepare their coping strategies. 2. Physiological changes. Research has also examined the effect of control on the physiological response to s. For example, Meyer et al. (1985) reported that if a s is regarded as uncontrollable, the release of corticosteroids is increased.

Stress, illness onset and progression

Research indicates that s causes physiological changes that have implications for promoting this s has also been linked with wound healing. Sympathetic Activation - The prolonged production of adrenalin and noradrenalin can result in the following: • blood clot formation • increased blood pressure • increased heart rate • irregular heart beats • fat deposits • plaque formation • immunosuppression. These changes may increase the chances of heart disease and kidney disease and leave the body open to infection. HPA Activation - The prolonged production of cortisol can result in the following: • decreased immune function • damage to neurons in the hippocampus. These changes may increase the chances of infection, psychiatric problems and losses in memory and concentration.

Profile characteristics weight loss and maintenance

Research suggests that baseline BMI predicts w l and m; however, while some studies indicate that lower baseline weight is predictive of greater success (Ogden 2000), others show the reverse effect (Wadden et al. 1992). Research also suggests that employment outside the home, higher income and being older are predictive of w l and m (Wong et al. 1997; Ogden 2000). Some research has also looked at gender although the data remain contradictory (e.g. Colvin and Olson 1983).

Self-report measures for stress

Researchers use a range of s r measures to assess both chronic and acute stress. Some of these focus on life events and include the original Social Readjustment Rating Scale (SRRS) (Holmes and Rahe 1967) which asks about events such as 'death of a spouse', 'changing to a different line of work' and 'change of residence'. Other measures focus more on an individual's own perception of stress. The Perceived s Scale (PSS) (Cohen et al. 1983) is the most commonly used scale to assess self-perceived s and asks questions such as 'In the last month how often have you been upset because of something that happened unexpectedly?', and 'In the last month how often have you felt nervous or stressed?' Some researchers also assess minor stressors in the form of 'daily hassles'. Kanner et al. (1981) developed the Hassles Scale which asks participants to rate how severe a range of hassles have been over the past month including 'misplacing or losing things', 'health of a family member' and 'concerns about owing money'. Johnston et al. (2006) used a small hand-held computer called a personal digital assistant (PDA) which participants carry around with them and which prompts them at pre-set intervals to complete a diary entry describing their level of stress. S r measures have been used to describe the impact of environmental factors on stress whereby stress is seen as the outcome variable (i.e. 'a poor working environment causes high stress'). They have also been used to explore the impact of stress on the individual's health status whereby stress in seen as the input variable (i.e. 'high stress causes poor health').

Respondent methods

Respondent methods are designed to modify the physiological system directly by reducing muscular tension. Examples are relaxation methods which aim to decrease anxiety and stress and consequently to decrease pain and biofeedback which is used to enable the individual to exert voluntary control over their bodily functions. Biofeedback aims to decrease anxiety and tension and therefore to decrease pain. However, some research indicates that it adds nothing to relaxation methods. Hypnosis is also used as a means to relax the individual. It seems to be of most use for acute pain and for repeated painful procedures such as burn dressing.

cognitive appraisal stress antecedents

Richard Lazarus (1922-2002) and colleagues notably Susan Folkman Highly recommend reading some of his books E.g., Stress, Appraisal and Coping; Stress and Emotion Environmental Variables Demands - implicit and explicit pressures from the social environment (can be internalised) Constraints - define what you should not do Culture - Lazarus not convinced that this isn't the above Opportunities - timing and choices Personal Variables Goals - no goal, no stress... Beliefs about self and world - our conception of ourselves in our environment - shapes expectations (behaviour?) Personal resources - influences what we can and cannot do to attain goals/gratification

Psychological factors (obesity success)

Rodin et al. (1977) reported the results from a study designed to assess the baseline p predictors of successful weight loss. The results indicated a role for the individual's beliefs about the causes of obesity and their motivations for weight loss. Kiernan et al. (1998) indicated that individuals who were more dissatisfied with their body shape at baseline were more successful, suggesting that motivations for weight loss guided by a high value placed on attractiveness may also be important. Ogden (2000) examined differences in psychological factors between weight loss regainers, stable obese and weight loss maintainers who were classified as those individuals who had been obese (BMI > 29.9), lost sufficient weight to be considered non-obese (BMI < 29.9) and maintained this weight loss for a minimum of three years. The results showed that the weight loss maintainers were more likely to endorse a p model of obesity in terms of its consequences such as depression and low self-esteem and to have been motivated to lose weight for p reasons such as wanting to increase their self-esteem and feel better about themselves. Further, they showed less endorsement of a medical model of causality including genetics and hormone imbalance. These results suggest that it is not only what an individual does that is predictive of success, but also what they believe. Accordingly, for an obese person to lose weight and keep this weight off it would seem that they need both to change their behaviour and believe that their own behaviour is important. Further, they need to perceive the consequences of their behaviour change as valuable. This supports the research exploring the p effects of taking obesity medication (Ogden and Sidhu 2006) and reflects the role of coherent models described in Chapter 9.

Patient Expectations

Ross and Olson (1981) examined the effects of p's e on recovery following a placebo. They suggested that most p experience spontaneous recovery following illness as most illnesses go through periods of spontaneous change and patients attribute these changes to the treatment. Therefore, even if the treatment is a placebo, any change will be understood in terms of the effectiveness of this treatment. This suggests that because p's want to get better and expect to get better, any changes that they experience are attributed to the drugs they have taken. However, Park and Covi (1965) gave sugar pills to a group of neurotic patients and actually told the patients that the pills were sugar pills and would therefore have no effect. The results showed that the p's still showed some reduction in their neuroticism. It could be argued that in this case, even though the p's did not expect the treatment to work, they still responded to the placebo. However, it could also be argued that these p's would still have some e that they would get better otherwise they would not have bothered to take the pills.

Self-reports (Measuring Pain)

SR scales of pain rely on the individual's own subjective view of their pain level. They take the form of visual analogue scales (e.g. 'How severe is your pain?' Rated from 'not at all' (0) to 'extremely' (100)), verbal scales (e.g. 'Describe your pain: no pain, mild pain, moderate pain, severe pain, worst pain') and descriptive questionnaires (e.g. the McGill Pain Questionnaire (MPQ); Melzack 1975). The MPQ attempts to access the more complex nature of pain and asks individuals to rate their pain in terms of three dimensions: sensory (e.g. flickering, pulsing, beating), affective (e.g. punishing, cruel, killing) and evaluative (e.g. annoying, miserable, intense). Some self-report measures also attempt to access the impact that the pain is having upon the individual's level of functioning and ask whether the pain influences their ability to do daily tasks such as walking, sitting and climbing stairs. Similarly, pain is often assessed within the context of quality of life scales which include a pain component. (Chap 18 for more).

Sex in later life (men)

Schiavi (1990) - significant age related decreases in desire, arousal, and erectile capacity. But, older men are adaptable, and their levels of sexual and marital satisfaction remain consistent. And now Viagra et al Older people in long-term relationships generally have relationships rated more positive and successful than younger people, and for most older men sexual activity ends only with their death, major disability, or the death of their spouse... Health status and partner's interest in sex best predictors of behaviour Beyond the hydraulics of sex, little attention to intimate relationships. On average men are older than their spouses and don't live as long less likely to be widowed. But, more likely than older widowed women to remarry - possibly just a reflection of availability?

Sex and sexuality

Sex sells, and like it or not, society is highly sexualised. Are gender differences in sexual attitudes and behaviours biologically or socially/culturally driven? Is this even a sensible question to ask?? In general, there seems to be a double standard across many cultures, with a greater degree of sexual freedom afforded to males. Many societies have allowed, and continue to allow men to have >1 wife (Murdock, 1967 - 83%), while few allow women to have >1 husband (0.5%).

social capital

Since the 1990s researchers have also explored the notion of 's c' which has been shown to have an impact on health (e.g. Putnam 1993; Veenstra 2000; Almedon 2005). is a broad construct that incorporates trust, social networks, social participation, successful cooperation and reciprocity. Therefore, rather than a person having sc, it could be argued that a town or village is high on sc if there is a strong sense of community and mutual support. Sc is hard to measure as it contains components at both the individual (i.e. trust) and group (i.e. social networks) levels. Within psychology, therefore, the focus has tended to be upon social support from a more individualistic perspective, although Abbott and Freeth (2008) argued that sc, particularly the elements of trust and reciprocity, could be useful in understanding ways to reduce stress.

Genetic theories of obesity

Size appears to run in families and the probability that a child will be o w is related to the parents' w. For example, having one o parent results in a 40 per cent chance of producing an obese child, and having two obese parents results in an 80 per cent chance. In contrast, the probability that thin parents will produce o w children is very small, about 7 per cent (Garn et al. 1981). This observation has been repeated in studies exploring populations from different parts of the world living in different environments (Maes et al. 1997). However, parents and children share both environment and g constitution, so this likeness could be due to either factor. To address this problem, research has examined twins and adoptees. • Twin studies. Twin studies have examined the weight of identical twins reared apart, who have identical g but different environments. Studies have also examined the w of non-identical twins reared together, who have different genes but similar environments. The results show that the identical twins reared apart are more similar in w than non-identical twins reared together. For example, Stunkard et al. (1990) examined the BMI in 93 pairs of identical twins reared apart and reported that g factors accounted for 66-70 per cent in the variance in their body weight, suggesting a strong g component in determining o. However, the role of g appears to be greater in lighter twin pairs than in heavier pairs. • Adoptee studies. Research has also examined the role of g in o using adoptees. Such studies compare the adoptees' weight with both their adoptive parents and their biological parents. Stunkard et al. (1986) gathered information about 540 adult adoptees in Denmark, their adopted parents and their biological parents. The results showed a strong relationship between the w class of the adoptee (thin, median w, o w , o) and their biological parents' w class but no relationship with their adoptee parents' w class. This suggests a major role for g and was also found across the whole range of body w. Interestingly, the relationship to the biological mother's weight was greater than the relationship with the biological father's w. Research therefore suggests a strong role for g in predicting o. It also suggests that the primary distribution of this w (upper versus lower body) is also inherited (Bouchard et al. 1990). However, how this g predisposition expresses itself is unclear. Metabolic rate and appetite regulation may be two factors influenced by g.

Compassion and self compassion

So-called sc intervention have become very popular recently • Sc scores are often highly correlated with mindfulness (although might also be due to the fact that development of these scales used mindfulness as discriminant validity criterion) • Useful for people who tend to exhibit a lot of guilt and shame • Cebolla et al. (2017) included compassion meditation in their typology, which was associated with unique aspects in the FFMQ

Socioeconomic Status

Social class can be defined in terms of economic situation (income or deprivation) or educational status, or even as subjective social class whereby people identify themselves as being working class, middle class or upper class. A consistent relationship emerges between SES, health, illness and mortality. For example, the WHO has classified the countries of the world into three income groups: low income, middle income and high income, and has explored the relationship with premature mortality (i.e. < 75). This data are shown in Figure 2.6 and demonstrate a clear gradient by income group, with deaths by communicable disease, perinatal conditions and nutritional deficiencies decreasing as income increases and non-communicable conditions (e.g. cancer, coronary heart disease − CHD, diabetes) increasing as income increases. Interestingly, death by injury is highest in the middle income group. The prevalence of individual illnesses also varies by SES. For example, variation of obesity in the UK is shown in Figure 2.7. These data indicate that for women there is a clear relationship between income and both overweight and obesity, with body weight increasing as income decreases.

Implementation intention intervention

Some experimental research has shown that encouraging individuals to make implementation intentions can actually increase the correlation between intentions and behaviour for a range of behaviours such as adolescent smoking

Men's health: What do we know?

Some male-specific conditions - prostate and testicular cancer, over-representation in injuries - accidental and otherwise Males are biologically less robust? Higher neonatal death rates 3.4 per ,000 vs 2.5 in Aust - pain tolerance, no evidence But sociocultural reasons must be important in other deaths CHD is 2nd to cancer in developed countries, but men still die of CHD younger than women Men lack oestrogen which has a protective effect - improves lipid profiles and reduces CHD risk in pre-menopausal women Cultural institutions/assumptions about masculinity encourage attitudes and behaviours that increase the risk of CHD in men - eating, drinking etc Often put down as natural and due to testosterone - not the case, the link between testosterone and behaviour is variable, and situation-dependent Men tend to believe that life expectancy difference due to hard work and higher stress levels Women tend to believe that men don't take good care of their health Evidence suggests women are probably correct Evidence generally suggests women have higher workloads, work longer hours, and have higher self-reported stress men don't take much responsibility for their health compared to women, except they do more exercise

The experience of pain

Some of the measures of pain capture these experiences by asking people whether their pain can be described by words such as 'flickering', 'punishing', 'cruel', 'killing' or 'annoying' (see p. 355 for a discussion of pain measures). Qualitative research has further explored the pain experience. For example, Osborn and Smith (1998) interviewed nine women who experienced chronic back pain and analysed the transcripts using interpretative phenomenological analysis (IPA) (Smith and Osborn 2003). The results showed that the patients experienced their pain in a range of ways which were conceptualized into four main themes. First, they showed a strong motivation to understand and explain their situation and to know why they had developed chronic pain. They also described how they could not believe that nothing else could be done for their condition, how they felt poorly informed about their pain and often described their pain as acting of its own volition. Their need to make sense of their pain was therefore frustrated, leaving them with feelings of uncertainty and ambiguity about their experience. Second, they showed a process of social comparison and compared themselves with others and with themselves in the past and future. In general they saw their pain as denying them the chance to be who they once were and who they wanted to be in the future and attempts to boost their self-esteem by making comparisons with those more unfortunate seemed to fail as they only acted as reminders of their gloomy prognosis. Third, they described how they were often not believed by others as they had no visible signs to support their suffering or disability. Finally, they described how their pain had resulted in them withdrawing from public view as they felt a burden to others and felt that when in public they had to hide their pain and appear healthy and mobile. For these sufferers, chronic back pain seemed to have a profound effect on their lives, impacting on how they felt about themselves and how they interacted with others. In a further qualitative study, McGowan et al. (2007) asked 32 women with chronic pelvic pain to write stories about their illness trajectories. The data were analysed using a narrative approach to explore why women disengaged from their treatment and often become dissatisfied with the care they received. The results showed that the women wanted validation and recognition of their experiences and therefore engaged with the process of finding a diagnosis. But they often felt that they weren't listened to and opted out of this process, leaving them with a sense of disempowerment and being in limbo. Much of this failure was attributed to the medical consultation and its dualistic model of the mind and body being separate.

Anxiety and pain

Some research has explored how patients worry about their ... For example, Eccleston et al. (2001) asked 34 male and female chronic ... patients to describe their experience of pain over a seven-day period. The results showed that the patients reported both ...-related and non-... related worry and that these two forms of worry were qualitatively different. In particular, worry about chronic ... was seen as more difficult to dismiss, more distracting, more attention grabbing, more intrusive, more distressing and less pleasant than non-...-related worry. Other research has explored how worry and ... relate to ... perception. Fordyce and Steger (1979) examined the relationship between ... and acute and chronic ... They reported that ... has a different relationship to these two types of .... In terms of acute ..., ... increases ...; the successful treatment for the p then decreases the p which subsequently decreases the a. This can then cause a further decrease in the p. Therefore, because of the relative ease with which acute ... can be treated, ... relates to this p perception in terms of a cycle of p reduction. However, the pattern is different for chronic .... Because treatment has very little effect on chronic ..., this increases a, which can further increase p. Therefore, in terms of the relationship between a and chronic p, there is a cycle of pain increase. Research has also shown a direct correlation between high a levels and increased p perception in children with migraines and sufferers of back and pelvic p (Feuerstein et al. 1987; McGowan et al. 1998). In an experimental study, participants took part in the cold pressor test which involves placing the hand and arm in icy water as a means to induce pain. Their trait anxiety was assessed and some were actively distracted from thinking about their pain (James and Hardardottir 2002). The results showed that both distraction and low a reduced the p experience.

Ways of coping

Some researchers differentiate between approach and avoidance c, while others describe emotion-focused and problem-focused c. Approach versus Avoidance Roth and Cohen (1986) defined two basic modes of c: approach and avoidance. approach c allow for appropriate action and/or the possibility for noticing and taking advantage of changes in a situation that might make it more controllable. In contrast, avoidant c involves minimizing the importance of the event. People tend to show one form of c or the other, although it is possible for someone to manage one type of problem by denying it and another by making specific plans. Some researchers have argued that approach c is consistently more adaptive than avoidant c. However, research indicates that the effectiveness of the c style depends upon the nature of the stressor. For example, avoidant c might be more effective for short-term stressors (Wong and Kaloupek 1986), but less effective for longer-term stressors (Holahan and Moos 1986). Therefore it might be best to avoid thinking about a one-off stressor such as going to the dentist but make plans and attend to a longer-term stressor such as marital conflict. Some researchers have also explored repressive c (Myers 2000) and emotional (non-) expression (Solano et al. 2001) which are similar to avoidance coping. Problem-Focused versus Emotion-Focused c (Instrumentality-Emotionality) In contrast to the dichotomy between approach and avoidant c, the problem- and emotion focused dimensions reflect types of c strategies rather than opposing styles. People can show both problem-focused coping and emotion-focused c when facing a stressful event. For example, Tennen et al. (2000) examined daily c in people with rheumatoid arthritis and showed that problem-focused and emotion-focused coping usually occurred together and that emotion-focused c was 4.4 times more likely to occur on a day when problem-focused c had occurred than when it had not. Problem-Focused c: This involves attempts to take action to either reduce the demands of the stressor or to increase the resources available to manage it. Examples include devising a revision plan and sticking to it, setting an agenda for a busy day, studying for extra qualifications to enable a career change and organizing counselling for a failing relationship. Emotion-Focused c: This involves attempts to manage the emotions evoked by the stressful event. People use both behavioural and cognitive strategies to regulate their emotions. Examples include talking to friends about a problem, turning to drink or smoking more, or getting distracted by shopping or watching a film. Examples of cognitive strategies include denying the importance of the problem and trying to think about the problem in a positive way.

Behavioural methods

Some treatment approaches draw upon the basic principles of operant conditioning and use reinforcement to encourage the individual to change their behaviour. For example, if a chronic pain patient has stopped activities that they believe may exacerbate their pain, the therapist will incrementally encourage them to become increasingly more active. Each change in behaviour will be rewarded by the therapist and new exercises will be developed and agreed to encourage the patient to move towards their pre-set goal.

A stimulus approach to stress

Something happens in the environment (s...or) to provoke a s reaction -Intuitive, useful, we have a shared general idea of what stress is: I lost my job, she insulted me etc -Daily Hassles -Life Events Theory: unweighted s life events is part of the reason people get ill. While sful circumstances may predispose to depression, the presence of supportive resources and adaptive appraisal and coping responses may moderate the adverse effects of s, and thus prevent a serious depressive outcome. -Social Readjustment Rating Scale Weighted: a technique in survey research where the tabulation of results becomes more than a simple counting process. It can involve re-balancing the data in order to more accurately reflect the population and/or include a multiplier which projects the results to a larger universe. scale for identifying major sful life events. 1967 - https://www.sciencedirect.com/science/article/pii/0022399967900104?via%3Dihub Updated weightings Scully et al., (2000) - https://journals.sagepub.com/doi/pdf/10.1177/00131640021970952 stress and health are related

Partner loss - men's health

Spousal loss is devastating at any stage - within a year though some sense of progress. Recently bereaved men are more likely than women to die from all causes, including suicide. Overall mixed results on who struggles to cope more - very individual thing Support/relationships Resources

Stage Model

Strategies to change behaviour based upon both learning theory and social cognition theory conceptualize behaviour as a continuum and change behaviour by encouraging people to move along the continuum from unhealthy to healthy ways of acting. In contrast, sm of behaviour such as the SOC and the health action process approach (HAPA) emphasize differences between people who are at different stages (see Chapter 3). Sm have influenced behaviour change interventions in two ways: the use of stage-matched interventions and the development of motivational interviewing.

Immunosuppression model

Stress can downregulate i function via: Activation of autonomic nervous system fibres that descend from the brain to lymphoid organs (e.g., thymus, spleen) Triggering of hormone secretion that bind to white blood cells and alter their function More complex - induction of i...modulatory coping behaviours (e.g., cigarette smoking, heavy alcohol consumption, etc.) Psychological stress is known to suppress immune function and increase susceptibility to infections and cancer. Paradoxically, stress is also known to exacerbate some allergic, autoimmune, and inflammatory diseases, which suggests that stress may enhance immune function under certain conditions. Although the exact pathways responsible for this effect have not yet been elucidated, stress is assumed to downregulate immunity by (a) activating autonomic nervous system fibers that descend from the brain to lymphoid organs (Felten & Felten, 1994), (b) triggering the secretion of hormones and neuropeptides that bind to white blood cells and alter their function (Blalock, 1994), and (c) inducing immunomodulatory coping behaviors, such as cigarette smoking and alcohol consumption (Kiecolt-Glaser & Glaser, 1988). Under these conditions, the immune system's capacity to mount an effective response to challenge is diminished (Andersen, KiecoltGlaser, & Glaser, 1994; Cohen & Williamson, 1991). Strengths: good at explaining the relationship between stress, and infectious diseases, some cancers (tumours), wound healing. Good at explaining how stress might increase susceptibility to negative health outcomes that arise because of compromised host resistance. Infectious disease, some forms of cancer, and wound healing all fall into this category Weaknesses: does not explain how stress influences diseases where inflammation is a key feature and is already there. it does not offer a parsimonious explanation for how stress might influence diseases whose central feature is excessive inflammation. This is the case in many disease contexts: Inflammation plays a role in the pathogenesis of allergic, autoimmune, rheumatologic, and cardiovascular diseases and contributes to the formation of illness symptoms in many infectious diseases. These conditions seem to be exacerbated by stressful experience. However, it is difficult to see how the immunosuppression model could account for these findings. In fact, the most straightforward prediction that could be derived from it is that stress should improve disease course by suppressing the inflammatory response/ immunity function. Because these diseases cause immunity systems to overreact, thinking that there is something that needs to be fought off when there is nothing, causing increase in white blood cells. The available data in humans generally do not bear out this prediction. *memorize for test*

Interaction between the behavioural and physiological pathways

Stress can therefore influence health and illness by changing b or by directly impacting upon an individual's p. So far the b and p pathways have been presented as separate and discrete. However, this is very much an oversimplification. Stress may cause changes in b such as smoking and diet which impact upon health by changing the individual's p. Likewise, stress may cause p changes such as raised blood pressure but this is often most apparent in those who also exhibit particularly unhealthy behaviours (Johnston 1989). Therefore, in reality, stress is linked to illness via a complex interaction between b and p factors. Further, Johnston (1989) argued that these factors are multiplicative, indicating that the more factors that are changed by stress, the greater the chance that stress will lead to illness

Physiological versus self-report measures of stress

Stress is considered to reflect both the experience of 'I feel stress' and the underlying p changes in factors such as heart rate and cortisol levels. But do these two sets of measures relate to each other? This question is central not only to stress research but also to an understanding of mind-body interactions. Research has addressed this association and has consistently found no or only poor relationships between p and perceived measures of stress (see Focus on Research 11.1, p. 301). This is surprising given the central place that perception is given in the stress response. It is possible, however, that this lack of congruence between these two types of measure reflects a role for other mediating variables. For example, it might be that p measures only reflect self-report measures when the stressor is controllable by the individual, when it is considered a threat rather than a challenge or when the individual draws upon particular coping strategies.

The Interaction between Psychological and Physiological Aspects of Stress

Stress is generally considered to illustrate the interaction between psychological and physiological factors. The psychological appraisal of a stressor is central to the s response and without appraisal, physiological changes are absent or minimal. Further, the degree of appraisal also influences the extent of the physiological response. However, there is little research illustrating a link between how s'd people say they are feeling (perceived s) and how their body is reacting (physiological s). It is likely that the mind-body interactions illustrated by s are dynamic and ongoing. Therefore, rather than appraisal causing a change in physiology which constitutes the response, appraisal probably triggers a change in physiology which is then detected and appraised causing a further response and so on. In addition, psychological factors such as control, personality, coping and social support will impact upon this ongoing process. This psychophysiological model of the stress response is described in Figure 11.4.

Allostatic load

Stress recovery is linked with this which was described by McEwan and Stellar (1993). They argued that the body's physiological systems constantly fluctuate as the individual responds and recovers from stress - a state of ... - and that, as time progresses, recovery is less and less complete and the body is left increasingly depleted. "the wear and tear on the body" which accumulates as an individual is exposed to repeated or chronic stress.

Emotional Expression

Strong, silent and self contained - do not express emotions openly, do not share with others, and do not ask for help. Men express negative internally focussed emotions (e.g., grief) and positive externally focussed emotions (e.g., tenderness) considerably less than women (Brody, 1999) NOT experience of emotion Cultural not biological, and it seems generally detrimental to physical and emotional well-being Men who express emotions are stigmatised as weak, effeminate, etc... Women who do not, are stigmatised as hard, unsympathetic, unwomanly etc

How do people cope with dying?

Task work approach (Corr, 1992) - four distinct types of tasks Satisfy physical needs minimize physical stress Maximize psychological security live life to fullest Sustain/enhance interpersonal commitments Develop/reaffirm spiritual energy; fosters hope.

mass media

Television, the internet, magazines and outdoor advertising all constantly bombard us with information about what to buy, what to see and what to do. This has a major impact upon our health behaviours in both negative and positive ways. For example, after Eyton's The F Plan Diet (1982), which recommended a high fibre diet, was featured in a number of magazine articles and on numerous television programmes, sales of bran-based cereals rose by 30 per cent, whole-wheat bread sales rose by 10 per cent, wholewheat pasta by 70 per cent, and baked beans by 8 per cent. Similarly, when Edwina Curry, then junior health minister in the UK, said on television in December 1988 that 'most of the egg production in this country, sadly, is now infected with salmonella' egg sales fell by 50 per cent and by 1989 were still only at 75 percent of their previous levels (Mintel, 1990). Similarly, massive publicity about the health risks of beef in the UK between May and August 1990 resulted in a 20 per cent reduction in beef sales. The mass media can be used either as a means to make us more unhealthy or as a resource to help improve the health of the population.

The impact of chronic stress

The Impact of cs Most research described to date has explored the impact of acute stress induced in the laboratory or individual stressors such as life events. However, many people exist in a life of ongoing cs including poverty, unemployment, job stress and marital conflict. There is much research linking these social factors to health inequalities, with results consistently showing that psychological distress, CHD and most cancers are more prevalent among lower-class individuals who have more cs in their lives (e.g. Adler et al. 1993; Marmot 1998). However, untangling this relationship is difficult: although cs such as poverty may cause heart disease, they are also linked to a range of other factors such as nutrition, hygiene, smoking and social support which are also linked to health status. Furthermore, whereas a lower socioeconomic position is linked to cs such as poverty, the higher socioeconomic position is linked to higher perceived stress (Heslop et al. 2001). As a result of these methodological problems, many researchers have focused on specific areas of cs including job stress and relationship stress.

Are Changes in Food Intake Associated with Changes in Obesity?

The UK National Food Survey collects data on food intake in the home, which can be analysed to assess changes in food intake over the past 50 years. The results from this database illustrate that, although overall calorie consumption increased between 1950 and 1970, since 1970 there has been a distinct decrease in the amount we eat (see Figure 15.9). However, this data relates only to f i in the home and does not take into account meals and snacking in cafés and restaurants or on the move. Prentice and Jebb (1995) examined the association between changes in f i in terms of energy intake and fat intake and changes in o. Their results indicated no obvious association between the increase in o and the changes in f i (see Figure 15.10). Therefore, using population data, there appears to be no relationship between changes in f i and changes in o

Psychological problems with obesity

The contemporary cultural obsession with thinness, the aversion to fat found in both adults and children and the attribution of blame to the o may promote low self-esteem and poor self-image in those individuals who do not conform to the stereotypically attractive thin image. Some studies have explored levels of depression in those waiting for surgical treatment for their obesity and consistently show that such patients report more depressive symptoms than average-w individuals (e.g. Wadden et al. 1986). In addition, Rand and MacGregor (1991) concluded that individuals who had lost w following gastric bypass surgery stated that they would rather be deaf, dyslexic, diabetic or have heart disease or acne than return to their former w. More recently, Simon et al. (2006) carried out a large survey on over 9,000 adults in the USA and concluded that o was associated with increased lifetime diagnosis of major depression, bipolar disorder, panic disorder or agoraphobia. In line with this, Ogden and Clementi (2011) carried out a qualitative study of the experience of being o and reported that the o describe a multitude of negative ways in which their w impacts upon their self-identity and that this is exacerbated by living in a society that stigmatizes their condition. However, it is possible that depressed obese individuals are more likely to seek treatment for their o than those who are not depressed and that there may be many o individuals who are quite happy and therefore do not come into contact with health professionals. Ross (1994) addressed this possibility and interviewed a random sample of more than 2,000 adults by telephone. These were individuals who varied in w and were not necessarily in the process of seeking help for any w-related issues. The results from this large-scale study showed that o w was unrelated to depression. There was a small subgroup in Ross's study who were both o w and depressed, and these tended to be the most educated. Ross argued that these individuals were also dieting to lose w and that it was the attempt to lose w rather than the w per se that was distressing. Therefore, although many o people may experience their o in negative ways, there is no consistent support for a simple relationship between body size and p problems.

Psychosomatic medicine

The earliest challenge to the biomedical model was psychosomatic medicine. This was developed at the beginning of the twentieth century in response to Freud's analysis of the relationship between the mind and physical illness. At the turn of the century, Freud described a condition called 'hysterical paralysis', whereby patients presented with paralysed limbs with no obvious physical cause and in a pattern that did not reflect the organization of nerves. Freud argued that this condition was an indication of the individual's state of mind and that repressed experiences and feelings were expressed in terms of a physical problem. This explanation indicated an interaction between mind and body and suggested that psychological factors may not only be consequences of illness but may contribute to its cause.

Obesity Summary

The evidence for the causes of obesity is therefore complex and can be summarized as follows: • There is good evidence for a genetic basis to o. The evidence for how this is expressed is weak. • The prevalence of o has increased at a similar rate to decreases in physical activity. • There is some evidence that the o exercise less than the non-o. • The prevalence of o has increased at a rate unrelated to the overall decrease in calorie consumption (but measured in the home). • There is inconsistent evidence as to whether the o eat more calories than the non-o. • The o may eat differently and for different reasons than the non-o. • The relative increase in fat is parallel to the increase in o. • The o may eat proportionally more fat than the non-obese. Therefore the following points would seem likely: • Some individuals have a genetic tendency to be o. • o is related to lack of exercise. • o is related to consuming relatively more fat and relatively less carbohydrates. The causes of o remain complex and unclear. Perhaps an integration of all theories is needed before proper conclusions can be drawn.

Multidimensional behavioural programs for obesity

The failure of traditional treatment packages for o resulted in longer periods of treatment, an emphasis on follow-up and the introduction of a m perspective to o treatment. Recent comprehensive, m cognitive behavioural packages aim to broaden the perspective for o treatment and combine traditional self-monitoring methods with information, exercise, cognitive restructuring, attitude change and relapse prevention (e.g. see Chapter 8 for a discussion of behaviour change strategies). Brownell and Wadden (1991) emphasized the need for a m approach, the importance of screening patients for entry onto a treatment programme and the need to match the individual with the most appropriate package. State-of-the-art behavioural treatment programmes aim to encourage the o to eat less than they do usually rather than encouraging them to eat less than the non-o. Analysis of the effectiveness of this treatment approach suggests that average weight loss during the treatment programme is 0.5kg per week, that approximately 60-70 per cent of the weight loss is maintained during the first year but that follow-up at three and five years tends to show weight gains back to baseline weight (Brownell and Wadden 1992). In a comprehensive review of the treatment interventions for o, Wilson (1994) suggested that although there has been an improvement in the effectiveness of o treatment since the 1970s, success rates are still poor. Wadden (1993) examined both the short- and long-term effectiveness of both moderate and severe caloric restriction on weight loss. He reviewed all the studies involving randomized controlled trials in four behavioural journals and compared his findings with those of Stunkard (1958). Wadden concluded that 'Investigators have made significant progress in inducing weight loss in the 35 years since Stunkard's review.' Wadden stated that 80 per cent of patients stayed in treatment for 20 weeks and that 50 per cent achieved a weight loss of 20lb or more. Therefore modern methods of weight loss produced improved results in the short term. However, Wadden also concluded that 'most obese patients treated in research trials still regain their lost weight'. This conclusion has been further supported by a systematic review of interventions for the treatment and prevention of o, which identified 92 studies that fitted the authors' inclusion criteria (NHS Centre for Reviews and Dissemination 1997). The review examined the effectiveness of dietary, exercise, behavioural, pharmacological and surgical interventions for o and concluded that 'the majority of the studies included in the present review demonstrate weight regain either during treatment or post intervention'. Further, Fabricatore and Wadden in 2006 argued that the weight losses achieved with non-surgical approaches 'have remained virtually unchanged over the past 20 years'. Accordingly, the picture for long-term weight loss is still fairly pessimistic.

Costs and benefits of Physiological and self-report measures

The former reflect a more p emphasis and the latter a more psychological perspective. A researcher who has a greater interest in physiology might argue that p measures are more central to stress research, while another researcher who believes that experience is more important might favour s. Most stress researchers measure both p and psychological aspects of stress and study how these two components interact. However, in general the different types of measures have the following costs and benefits: 1. p measures are more objective and less affected by the participant's wish to give a desirable response or the researcher's wish to see a particular result. 2. S measures reflect the individual's experience of stress rather than just what their body is doing. 3. S measures can be influenced by problems with recall, social desirability, and different participants interpreting the questions in different ways. 4. S measures are based upon the life events or hassles that have been chosen by the author of the questionnaire. One person's hassle, such as 'troublesome neighbours' which appears on the Hassles Scale, may not be a hassle for another, whereas worries about a child's school might be, which doesn't appear on this scale.

Problems with the GCT

The g represented an important advancement on previous simple stimulus-response theories of pain. It introduced a role for psychology and described a multidimensional process rather than a simple linear one. However, there are several problems with the theory: • Although there is plenty of evidence illustrating the mechanisms to increase and decrease pain perception, no one has yet actually located the 'gate' itself. • Although the input from the site of physical injury is mediated and moderated by experience and other psychological factors, the model still assumes an organic basis for pain. This integration of physiological and psychological factors can explain individual variability and phantom limb pain to an extent, but because the model still assumes some organic basis it is still based on a simple stimulus-response process. • The g attempted to depart from traditional dualistic models of health by its integration of the mind and the body. However, although the g suggests some integration or interaction between mind and body, it still sees them as separate processes. The model suggests that physical processes are influenced by the psychological processes, but that these two sets of processes are distinct.

The treatment alternatives for obesity

The implications of restraint theory suggest that the o should avoid restrained eating. Dieting offers a small chance of weight loss and a high chance of both negative physical and psychological consequences. Taking dieting out of the treatment equation leaves us primarily with drug treatments and surgery.

The physiological effects of social support

The main theory used to explore this mechanism is the s s reactivity hypothesis (Lepore 1998) which argues that s s reduces p responses to stress, particularly cardiovascular reactivity. This is important as prolonged cardiovascular reactivity has been linked with hypertension and CHD (Treiber et al. 2003; see p. 315 for a discussion of reactivity). Using this approach research has explored the impact of different types of s s on reactivity in the laboratory. For example, separate studies indicate that enacted s (i.e. getting actual s, e.g. Lepore et al. 1993) and the availability of functional support (i.e. potential access to s, e.g. Uchino and Garvey 1997) are associated with reduced reactivity to stressors in the laboratory setting. In a detailed analysis of the relative impact of different types of social support, O'Donovan and Hughes (2008) explored the role of both perceived network s and the availability of functional s on reactivity (measured as heart rate and blood pressure) in response to an acute stressor (a video-recorded and assessed reading out loud). Female participants rated their network s and those scoring in the top or bottom tertiles (n = 152) were included in the study (i.e. those with the most and least people who could help them). They were then randomly allocated to one of three conditions: (1) functional s, available (i.e. they were told by the researcher 'My job is to be available to you with help if you need it during your task'); (2) functional s, not available (i.e. they were told by the researcher 'My job is to supervise the experiment. If there are any words in any of the passages that are unfamiliar . . . I will not help you in any way'); (3) control (i.e. s not mentioned). The results showed a complex relationship between network s and the availability (or not) of functional s for heart rate (not blood pressure). In particular, when functional s was available (i.e. from the researcher), those with low network support (i.e. not many friends and family) showed lower heart rate reactivity than those with high network s. However, when functional s was not available (i.e. not from the researcher), those with low network s had higher heart rate reactivity. This indicates that network s moderates the effect of functional s and that available functional s can compensate for lower network s.

The media as a resource for positive change

The media has also been used by government and health promotion campaigns as a means to reach a wide audience and promote health behaviour. To date there is very little evidence as to whether these campaigns have been effective and it has been argued that perhaps such initiatives should be about raising awareness rather than changing behaviour (Steadet al. 2002). It is also possible that whereas individual campaigns may only raise awareness, repeated ongoing campaigns over many years may cause change through a 'drip drip effect' as successive generations gradually become accustomed to a new way of thinking or behaving. This is particularly apparent in the reduction in drink driving over the past decade. No one campaign may have made this happen but negative attitudes towards drink driving in the new generation of drivers may be a response to always having been aware that this was not an acceptable thing to do (Shinar et al. 1999). One way to understand the impact of mass media campaigns is to identify those which are memorable and explore why this might be. Memorable campaigns over recent years include: • 'Five a day: just eat more': this is a simple message using simple words and imagery and aims to promote healthy eating. Interestingly it encourages doing more rather than less of something which minimizes the chance of a rebound effect which is a common response to many other forms of dietary advice (see Chapter 5). It also offers clear rules of what to eat which are set slightly higher than the average intake but are also realistic. • 'Most people are killed by someone they know': this was the basis of an advert to promote seat-belt wearing in the back of cars to prevent those in the back seat from being thrown into the front during an accident. One advert involved a group of young men buying pizzas and setting off in the car without doing up their seat belts. They crashed and the ones in the back were flung forward and killed the ones in the front. The message was very simple. The imagery was powerful and the solution it offered required very little effort. Also the target audience was clearly represented in the advert.

Measuring coping

The most commonly used are the Ways of c Checklist (Folkman and Lazarus 1988) and c (Carver et al. 1989). The strategies described by these m's include the following: • Active c (e.g. 'I've been taking action to try to make the situation better'). • Planning (e.g. 'I've been trying to come up with a strategy about what to do'). • Positive reframing (e.g. 'I've been looking for something good in what is happening'). • Self-distraction (e.g. 'I've been turning to work or other activities to take my mind off things'). • Using emotional support (e.g. 'I've been getting emotional support from others'). • Substance use (e.g. 'I've been using alcohol or other drugs to help me get through it'). • Behavioural disengagement (e.g. 'I've given up trying to deal with it'). • Denial (e.g. 'I've been saying to myself, "this isn't real"'). • Self-control (e.g. 'I've tried to keep my feelings to myself'). • Distancing (e.g. 'I didn't let it get to me. I refused to think about it too much'). • Escape/avoidance (e.g. 'I wished that the situation would go away'). Some of these strategies are clearly problem-focused such as active c and planning. Others are more emotion-focused such as self-c and distancing. Some strategies, however, are a mix of both problem- and emotion-focused c. For example, positive reframing involves thinking about the problem in a different way as a means to alter the emotional response to it. Some strategies can also be considered approach c such as using emotional support and planning, whereas others reflect a more avoidance c style such as denial and substance use.

Stress and Changes in Physiology

The physiological consequences of stress have been studied extensively, mostly in the laboratory using the acute stress paradigm which involves bringing individuals into a controlled environment, putting them into a stressful situation such as counting backwards, completing an intelligence task or giving an unprepared speech, and then recording any changes. This research has highlighted two main groups of physiological changes (see Figure 11.3): 1. Sympathetic activation: when an event has been appraised as stressful it triggers responses in the sympathetic nervous system. This results in the production of catecholamines (adrenalin and noradrenalin, also known as epinephrine and norepinephrine) which cause changes in factors such as blood pressure, heart rate, sweating and pupil dilation and is experienced as a feeling of arousal. This process is similar to the fight-or-flight response described by Cannon (1932). Catecholamines also have an effect on a range of the body's tissues and can lead to changes in immune function. 2. Hypothalamic-pituitary-adrenocortical (HPA) activation: in addition to the aforementioned sympathetic activation, stress also triggers changes in the HPA system. This results in the production of increased levels of corticosteroids, the most important of which is cortisol, which results in more diffuse changes such as the management of carbohydrate stores and inflammation. These changes constitute the background effect of stress and cannot be detected by the individual. They are similar to the alarm, resistance and exhaustion stages of stress described by Selye (1956). In addition, raised levels of the brain opioids beta endorphin and enkephalin have been found following stress which are involved in immune-related problems. The physiological aspects of the stress response are linked to stress reactivity, stress recovery, the allostatic load and stress resistance.

Behaviour and longevity

The role of behaviour has also been highlighted by the work of Belloc and Breslow and their colleagues (Belloc and Breslow 1972; Breslow and Enstrom 1980) who examined the relationship between mortality rates and behaviour among 7,000 people as part of the Alameda County study in the USA, which began in 1965. They concluded from their original correlational analysis that seven behaviours were related to positive health status. These behaviours were: 1 Sleeping 7-8 hours a day. 2 Having breakfast every day. 3 Not smoking. 4 Rarely eating between meals 5 Being near or at prescribed weight. 6 Having moderate or no use of alcohol. 7 Taking regular exercise. Their large sample was followed up over 5.5 and 10 years in a prospective study and the authors reported that these seven behaviours were related to mortality. In addition, they suggested for people aged over 75 who carried out all of these health behaviours, health was comparable to those aged 35-44 who followed less than three.

The immune system

The role of the i system is to distinguish between the body and its invaders and to attack and protect the body from anything that is considered foreign. These invaders are called 'antigens'. When the i system works well, the body is protected and infections and illnesses are kept at bay. If the immune system overreacts, then this can lead to allergies. If the i system mistakes the body itself for an invader, then this can form the basis of autoimmune disorders. The main organs of the i system are the lymphoid organs which are distributed throughout the body and include the bone marrow, lymph nodes and vessels, the spleen and thymus. These organs produce a range of 'soldiers' which are involved in identifying foreign bodies and disabling them. There are three levels of immune system activity. The first two are called specific i processes and are 'cell mediated i' and 'humoral mediated i'. Cell mediated i involves a set of lymphocytes called T cells (killer T cells, memory T cells, delayed hypersensitivity T cells, helper T cells and suppressor T cells). These operate within the cells of the body and are made within the thymus (hence 'T'). Humoral mediated i involves B cells and antibodies and takes place in the body's fluids before the antigens have entered any cells. Third, there is non-specific i which involves phagocytes which non-specifically attack any kind of antigen. Immunocompetence is when the immune system is working well. Immunocompromise is when the immune system is failing in some way

Visualization

The saying 'a picture paints a thousand words' reflects the belief that visual images may be more effective at conveying information or changing beliefs compared to language-based messages. This forms the basis of most advertising, marketing and health education campaigns and is central to the use of diagrams and illustrations throughout education. Some research has explored the impact of visual images in health research (see Chapter 9 for a discussion of imagery and changes in illness cognitions). For example, Hammond et al. (2003) examined the effectiveness of the cigarette warning labels and reported an association between reading and discussing the labels with a higher intention to stop smoking, more quit attempts and a reduction in smoking (see chap 3 for further egs). In a similar vein, Lee et al. (2011) used a web-based intervention to show participants images of heart disease (with or without text) and concluded that imagery caused more changes than text alone but that a combination of the two forms of information was the most effective. Images therefore seem to change cognitions and behaviour but to date little is known about the mechanisms behind this process. However, researchers have begun to theorize about this process and have suggested that images may be processed more rapidly than text and may be more memorable over time. In addition, images may also have a greater impact upon affect than text which in turn influences behaviour (Cameron 2008, 2009; Cameron and Chan 2008).

2. Social Psychology (processes in health psych)

The scientific study of the way in which people's thoughts, feelings, & actions influenced by the social environment Empirical approach: Vary aspects of social environment & see how this affects thoughts, feelings, &/or behaviour Posits psychological processes as explanations for observed effects Classic examples: Obedience (legitimate authority) schemas - representation of scenarios scripts - the way we expect a situation to happen

What is stress?

The term means many things to many different people. A layperson may define it in terms of pressure, tension, unpleasant external forces or an emotional response. Psychologists have defined it in a variety of different ways. Contemporary definitions regard stress from the external environment as (e.g. problems at work), the response to the stress as stress or distresss (e.g. the feeling of tension), and the concept of stress as something that involves biochemical, physiological, behavioural and psychological changes. Researchers have also differentiated between stress that is harmful and damaging (ds) and stress that is positive and beneficial (eus). In addition, researchers differentiate between acute stress, such as an exam or having to give a public talk, and chronic stress, such as job s and poverty. The most commonly used definition was developed by Lazarus and Launier (1978), who regarded stress as a transaction between people and the environment and described stress in terms of 'person-environment fit'. If a person is faced with a potentially difficult s such as an exam or having to give a public talk, the degree of s they experience is determined first by their appraisal of the event ('Is it s?') and second by their appraisal of their own personal resources ('Will I cope?). A good person-environment fit results in no or low s and a poor fit results in higher s.

The interaction between these different processes

The three-process model describes the separate components that influence pain perception. However, these three processes are not discrete but interact and are at times interchangeable. For example, emotional factors may influence an individual's physiology and cognitive factors may influence an individual's behaviour. Further, the different components within each process also interact. For example, association may increase pain in terms of learning. However, it is likely that this process can be explained by changes in anxiety and focus, with places and experiences that have previously been associated with pain resulting in increased anxiety and increased attention to pain, therefore increasing the pain experience. Likewise, pain behaviours may exacerbate pain by limiting physical movement. But it is also likely that they operate by increasing focus and anxiety - staying in bed leaves the individual with nothing to do other than think and worry about their pain. Research also indicates that fear influences attention, that fear interacts with catastrophizing and that catastrophizing influences attentional interference (Crombez et al. 1998a, 1998b, 1999; Van Damme et al. 2002). The three-process model offers a framework for mapping out the different factors that influence pain. However, this categorization is probably best seen as a framework only, with the different components being interrelated rather than discrete categories of discrete factors.

What is the relationship between the mind and the body? Health psychology

The twentieth century saw a challenge to the traditional separation of mind and body suggested by a dualistic model of health and illness, with an increasing focus on an interaction between the mind and the body. This shift in perspective is reflected in the development of a holistic or a whole-person approach to health. Health psychology therefore maintains that the mind and body interact.

Pain Behaviour and Secondary Gains

The way in which an individual responds to pain can itself increase or decrease the pain perception. In particular, research has looked at pain behaviours which have been defined by Turk et al. (1985) as facial or audible expression (e.g. clenched teeth and moaning), distorted posture or movement (e.g. limping, protecting the pain area), negative affect (e.g. irritability, depression) or avoidance of activity (e.g. not going to work, lying down). It has been suggested that pain behaviours are reinforced through attention, the acknowledgement they receive, and through secondary gains, such as not having to go to work. Positively reinforcing pain behaviour may increase pain perception. Pain behaviour can also cause a lack of activity and muscle wastage, no social contact and no distraction leading to a sick role, which can also increase pain perception. Williams (2002) provides an evolutionary analysis of facial expressions of pain and argues that if the function of pain is to prioritize escape, recovery and healing, facial expressions are a means to communicate pain and to elicit help from others to achieve these goals. Further, she argues that people often assume that individuals have more control over the extent of their pain-induced facial expressions than they actually do and are more likely to offer help or sympathy when expressions are mild. Stronger forms of expression are interpreted as amplified and as indications of malingering.

Help seeking behaviours obesity

There appear to be several hs factors which are predictive of success for o Primarily research highlights a role for the types and intensity of weight loss methods used. For example, many studies have emphasized the importance of dietary changes (e.g. McGuire et al. 1999) although Ogden (2000) reported that calorie-controlled diets were associated with weight loss and regain rather than maintenance. Many studies have also highlighted the role of exercise and general increases in physical activity (Hoiberg et al. 1994; French and Jeffrey 1997; Klem et al. 1997; Wong et al. 1997). Furthermore, research has highlighted the relative effectiveness of different interventions involving contact with a range of health professionals. These include psychological interventions such as CBT, counselling, self-h groups and medical interventions involving drug therapy and surgery (see NHS Centre for Reviews and Dissemination 1997 for review). The general conclusion from this research is that the more intense the intervention, the longer the follow-up period and the greater the professional contact, the higher the probability of successful weight loss and maintenance.

Attention and pain

There has also been research exploring the impact of A on p and much work shows that attention to the p can exacerbate it whereas distraction can reduce the p experience. For example, Chapman and Martin (2010) reported that patients with irritable bowel syndrome paid more attention to p words compared to controls when exposed to an exogenous cuing task. The results also showed that those who paid more a to the p words also reported more symptoms and took more time off work. However, this study was cross-sectional in design and only shows associations rather than causal relationships. Further, it addresses attention to p words rather than p itself. In the experimental study described earlier, however, James and Hardardottir (2002) illustrated that increasing a to p increased the p experience using the cold pressor task. Eccleston and Crombez have carried out much work in this area which they reviewed in the Psychological Bulletin in 1999. They illustrated how patients who attend to their p experience more p than those who are distracted. This association explains why patients suffering from back pain who take to their beds and therefore focus on their p take longer to recover than those who carry on working and engaging with their lives. This association is also reflected in relatively recent changes in the general management approach to back p problems − bed rest is no longer the main treatment option. In addition, Eccleston and Crombez provide a model of how p and a are related (Eccleston 1994; Eccleston and Crombez 1999). They argue that pain interrupts and demands a and that this interruption depends upon p-related characteristics such as the threat value of the p and environmental demands such as emotional arousal. They argue that p causes a shift in a towards the pain as a way to encourage escape and action. The result of this shift in a is a reduced ability to focus on other tasks, resulting in attentional interference and disruption. This disruption has been shown in a series of experimental studies indicating that patients with high p perform less well on difficult tasks that involve the greatest demand of their limited resources (e.g. Eccleston 1994; Crombez et al. 1998a, 1999).

Men's health Inequality...

There is a 4-year difference in life expectancy 70 vs 66 worldwide - men live shorter lives than women In 'more developed' countries 80 vs 73 In less developed countries 67 vs 64 In New Zealand 82 vs 78 Māori approximately 7 years less than non-Māori Australia 83 and 79 But Aboriginals approx 20 years less than others In some countries, e.g., Afghanistan, Zimbabwe no difference -- when everyone dies young In 1920 the difference was 1 year... Mostly due to social factors

Relationship stress

There is much evidence indicating an association between r status, psychological dis and health status. For example, separated and divorced people have the highest rates of both acute and chronic medical problems even when many demographic factors are controlled for (Verbrugge 1979). In addition, these people also have higher rates of mortality from infectious diseases such as pneumonia and are also over-represented in both inpatient and outpatient psychiatric populations (Crago 1972; Bachrach 1975). However, it is not just the presence or absence or a relationship that is important. The quality is also linked to health. For example, whereas marital happiness is one of the best predictors of global happiness, those in troubled marriages show more distress than those who are unmarried (Glenn and Weaver 1981). These links between relationship status and quality have been understood using a range of literatures including attachment theory, life events theory and self-identity theory. Kiecolt-Glaser et al. (1987, 2003) have explored these links within the context of stress and the role of immune function. In one study, they assessed the associations between marital status and marital quality and markers of immune function. Their results showed that poor marital quality was associated with both depression and a poorer immune response. In addition, they reported that women who had been recently separated showed poorer immune response than matched married women. Time since separation and attachment to the ex-husband predicted variability in this response (Kiecolt-Glaser et al. 1987). In another study they explored the relationship between measures of s hormones during the first year of marriage and marital status and satisfaction 10 years later. The results showed that those who were divorced at follow-up had shown higher levels of s hormones during conflict, throughout the day and during the night than those who were still married. Further, those whose marriages were troubled at follow-up also showed higher levels of s hormones at baseline than those whose marriages were untroubled. This suggests that s responses during the first year of marriage are predictive of marital dissatisfaction and divorce 10 years later (Kiecolt-Glaser et al. 2003). Research therefore shows a link between s and illness. For many, this s takes the form of discrete events. However, many people also experience chronic s caused by factors such as poverty, unemployment or work load. Much research has focused on two aspects of chronic s (J and R) This research indicates an association between chronic s and i, with a role for changes in immune function. However, there exists much variability in the s-i link. In part this can be explained by factors such as s reactivity and s recovery which have already been described. However, research also highlights a role for other moderating variables which will now be considered.

Are diagnoses biased?

Think about ADHD for example Argument is that with objectively identical behaviour, women are more likely to be given anorexia/bulimia diagnosis - men more likely to be diagnosed depressed with weight loss as a symptom... Also, cultural expectations, seen as a female issue, male likely to be reluctant to seek help Underreporting and under detection? Studies of both suggest everything very similar (age of onset, comorbidities, body dissatisfaction, attitudes to the eating disorder etc) except the likelihood of seeking or having sought help -- weight loss in men is seen as depression rather than an eating disorder The notion that the body is infinitely perfectible might be responsible for much-disordered behaviour in both genders None of exercise, diet and physiology are related in a linear way to muscularity Use of anabolic steroids - both among professional and 'wannabee' professional athletes, and among ordinary males desiring more musculature Many risks - liver disorders, changes in lipid metabolism, increased cardiovascular disease, development of breast tissue in men, aggressive behaviour etc some suggestion that the extent of risk is overstated, but certainly enough to suggest that they're not a good idea In some sports might be endemic - approx 80% of competitive bodybuilders 20% of recreational ones, relatively recent ructions in American baseball, about 3% of 16-19 male students in Sweden..., 4% of American males Everyone a bit NIMBY Psychological and body image issues significant predictor or steroid use in bodybuilders, similar to attitudes among eating disorder patients drive for bulk to parallel drive for thinness?

The need for theory-based intervention

This has been based upon two observations. First, it was observed that many interventions designed to change behaviour were only minimally effective. For example, reviews of early interventions to change sexual behaviour concluded that these interventions had only small effects (e.g. Oakley et al. 1995) and dietary interventions for weight loss may result in weight loss in the short term but the majority show a return to baseline by follow-up (e.g. NHS Centre for Reviews and Dissemination 1997). Second, it was observed that many interventions were not based upon any theoretical framework, nor were they drawing upon research that had identified which factors were correlated with the particular behaviour (e.g. Fisher and Fisher 1992). see chap 3 for illustation - content analysis of health promotion leaflets to assess their theoretical basis std leaflets - The results showed very little association between theory and this form of behavioural intervention. Specifically, only 25 per cent of the leaflets referred to 10 or more of the correlates and two-thirds of the leaflets failed to frequently target more than two of the correlates.

What is control?

This has been studied within a variety of different psychological theories. 1. Attributions. Kelley's (1967) attributional theory examines c in terms of attributions for causality (see Chapter 3 for a discussion of attribution theory). If applied to a stressor, the cause of a stressful event would be understood in terms of whether the cause was controllable by the individual or not. For example, failure to get a job could be understood in terms of a c cause (e.g. 'I didn't perform as well as I could in the interview', 'I should have prepared better') or an uncontrollable cause (e.g. 'I am stupid', 'The interviewer was biased'). 2. Self-efficacy. C has also been discussed by Bandura (1977) in his self efficacy theory. Self-efficacy refers to an individual's confidence to carry out a particular behaviour. Control is implicit in this concept. 3. Categories of c. Five different types have been defined by Thompson (1986): - behavioural (e.g. avoidance); - cognitive (e.g. reappraisal of c strategies); - decisional (e.g. choice over possible outcome); - informational (e.g. the ability to access information about the stressor); - retrospective (e.g. 'Could I have prevented that event from happening?'). 4. The reality. C has also been subdivided into perceived c (e.g. 'I believe that I can c the outcome of a job interview') and actual c (e.g. 'I can c the outcome of a job interview'). The discrepancy between these two factors has been referred to as illusory c (e.g. 'I c whether the plane crashes by counting throughout the journey'). However, within psychological theory perceived c is important

Are changes in obesity related to changes in activity?

This question can be answered in two ways, first using *epidemiological (experimental) data on a population and second using prospective (longitudinal) data on individuals.* In 1995, Prentice and Jebb presented epidemiological data on changes in physical a from 1950 to 1990, as measured by car ownership and TV viewing, and compared these with changes in the prevalence of o. The results from this study suggested a strong association between an increase in both car ownership and TV viewing and an increase in o (see Figure 15.7). They commented that 'it seems reasonable to conclude that the low levels of physical a now prevalent in Britain must play an important, perhaps dominant role in the development of o by greatly reducing energy needs'. However, their data were only correlational. Therefore it remains unclear whether the two factors are related (the third factor problem - some other variable may be determining both o and a), and whether decreases in a cause increases in o or whether, in fact, increases in o actually cause decreases in activity. In addition, the data are at the population level and therefore could miss important individual differences (i.e. some people who become o could be active and those who are thin could be inactive). In an alternative approach to assessing the relationship between a and o a large Finnish study of 12,000 adults examined the association between levels of physical a and excess weight gain over a five-year follow-up period (Rissanen et al. 1991). The results showed that lower levels of a were a greater risk factor for w gain than any other baseline measures. In a recent study the authors analysed data from 146 twin pairs as a means to assess the relative contribution of genetics and physical a over a 30-year period (Waller et al. 2008). The results showed that persistent physical a across the 30 years of the study was related to smaller waist circumference and a decreased w gain as the active twin showed less weight gain than the inactive twin even though they shared the same genetic make-up and childhood environment. However, although these data were prospective, it is still possible that a third factor may explain the relationship (i.e. those with lower levels of activity at baseline were women, the women had children and therefore put on more weight). Unless experimental data are collected, conclusions about causality remain problematic.

Does control affect health?

This question has been examined by looking at both animal and human models. *Animal Research* Seligman and Visintainer (1985) reported the results of a study whereby rats were injected with live tumour cells and exposed to either c or unc shocks. The results indicated that the unc shocks resulted in promotion of the tumour growth. This suggests that c may influence the stress response, which may then promote i. In a further study, the relationship between control and CHD was studied in monkeys (Manuck et al. 1986). Some breeds of monkey exist in social hierarchies with clearly delineated roles. The monkeys are categorized as either dominant or submissive and this hierarchy is usually stable. However, the authors introduced new members to the groups to create an unstable environment. They argued that the dominant monkeys showed higher rates of CHD in the unstable condition than the dominant monkeys in the stable condition, or the submissive monkeys in the stable condition. It was suggested that the dominant monkeys had high expectations of control, and were used to experiencing high levels of control. However, in the unstable condition, there was a conflict between their expectations of control and the reality which, the authors argued, resulted in an increase in CHD. These animal models are obviously problematic in that many assumptions are made about the similarities between the animals' experience of control and that of humans. However, the results indicate an association in the predicted direction. *Human Research* Human models have also been used to examine the effect For example, the job strain model was developed to examine the effects of c on CHD (e.g. Karasek and Theorell 1990). The three factors involved in the model are: (1) psychological demands of the job in terms of workload; (2) the autonomy of the job, reflecting control; (3) the satisfaction with the job. This model has been used to predict CHD in the USA (Karasek et al. 1988), and in Sweden (Karasek et al. 1981). The results of these studies suggest that a combination of high workload (i.e. high demand), low satisfaction and low c are the best predictors of CHD.

Hardiness

This shift towards emphasizing self-control is also illustrated by Kobasa's concept of 'h' (e.g. Maddi and Kobasa 1984). Hardiness was described as reflecting: (1) personal feelings of control; (2) a desire to accept challenges; and (3) commitment. It has been argued that the degree of hardiness influence an individual's appraisal of potential stressors and the resulting stress response. Accordingly, a feeling of being in control may contribute to the process of primary appraisal.

Glucocorticoid resistance model reading

This study examined whether chronic stress impairs the immune system's capacity to respond to hormonal signals that terminate inflammation. In this article, we describe a study examining the basic principles of this model. It explores whether chronic psychological stress alters the capacity of a synthetic g (dexamethasone) to inhibit the in vitro production of the pro-inflammatory cytokines interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor- (TNF-). These cytokines are soluble molecules, released by white blood cells, that orchestrate inflammation. They have wide-ranging biological effects that include directing white blood cells toward sites of injury or infection, stimulating the production of other molecules involved in the inflammatory response, and enhancing the killing capacity of certain classes of white blood cells. Fifty healthy adults were studied; half were parents of cancer patients, and half were parents of healthy children. Parents of cancer patients reported more psychological distress than parents of healthy children. They also had flatter diurnal (during the day) slopes of cortisol secretion, primarily because of reduced output during the morning hours. There was also evidence that chronic stress impaired the immune system's response to anti-inflammatory signals: The capacity of a synthetic g hormone to suppress in vitro production of the pro-inflammatory cytokine interleukin-6 was diminished among parents of cancer patients. Findings suggest a novel pathway by which chronic stress might alter the course of inflammatory disease. This study had a number of limitations. Perhaps the most important was its cross-sectional design, which precludes us from making any causal inferences regarding the relationship between chronic psychological stress and IL-6 glucocorticoid sensitivity. Although reverse causality is an unlikely explanation for our findings, it is conceivable that some unmeasured third variable was responsible, such as exposure to an environmental toxin that increases offspring cancer risk and disrupts immune function. Another important limitation of the study was that it relied on an assay system that does not closely resemble the in vivo environment in which white blood cells operate.

Do the Obese Eat for Different Reasons than the Non-Obese?

Throughout the 1960s and 1970s theories of eating behaviour emphasized the role of food intake in predicting weight. Original studies of o were based on the assumption that the obese ate for different reasons than people of normal weight (Ferster et al. 1962). Schachter's externality theory suggested that, although all people were responsive to environmental stimuli such as the sight, taste and smell of food, and that such stimuli might cause overeating, the o were highly and sometimes uncontrollably responsive to external cues. It was argued that normal-weight individuals mainly ate as a response to internal cues (e.g. hunger, satiety) and o individuals tended to be under-responsive to their internal cues and over-responsive to external cues. Within this perspective, research examined the eating behaviour and eating style of the o and non-o in response to external cues such as the time of day, the sight of food, the taste of food and the number and salience of food cues (e.g. Schachter and Gross 1968; Schachter and Rodin 1974). The results from these studies were fairly inconsistent. Research has also addressed the emotionality theory of eating behaviour. For example, Bruch (e.g. 1974) developed a psychosomatic theory of eating behaviour and eating disorders which argued that some people interpret the sensations of such emotions as emptiness as similar to hunger and that food is used as a substitute for other forms of emotional comfort. Van Strien et al. (2009) explored the relationship between dietary restraint, emotional and external eating, overeating and BMI to assess how people resist (or not) the opportunity to become overweight offered by the obesogenic environment. The results showed that although overeating was associated with being overweight, this association was moderated by both restraint and emotional eating (not external eating). They drew two conclusions from their data. First, they argued that the impact of overeating is limited by dietary restraint; second, they argued that emotional eating is a better predictor of body weight than external eating.

Principles of a good death? (BMJ)

To know when death is coming, and to understand what to expect To be able to retain control of what happens To be afforded dignity and privacy To have control over pain relief and symptom control To have choice and control over where death occurs To have access to information and expertise of whatever kind is necessary To have access to any spiritual or emotional support required To have access to hospice care in any location, not just the hospital To have control over who is present, and who shares the end To be able to issue advance directives which ensure wishes are respected To have time to say goodbye, and control over other aspects of timing To be able to leave when it is time to go, and not to have life prolonged pointlessly

The effect of investment

Totman (1987) suggested that i results in the individual having to go through two processes: (1) the individual needs to justify their behaviour; and (2) the individual needs to see themselves as rational and in control. If these two factors are in line with each other (e.g. 'I spent money on a treatment and it worked'), then the individual experiences low dissonance. If, however, there is a conflict between these two factors (e.g. 'I spent money on a treatment and I do not feel any better'), the individual experiences a state of high dissonance. Totman argued that high justification (it worked) results in low guilt and low dissonance (e.g. 'I can justify my behaviour, I am rational and in control'). However, low justification (e.g. 'it didn't work') results in high guilt and high dissonance (e.g. 'I cannot justify my behaviour, I am not rational or in control'). The best way to resolve this dissonance, according to Totman, is for there to be an outcome that enables the individual to be able to justify their behaviour and to see themselves as rational and in control. Accordingly, Totman argued that when in a state of high dissonance, unconscious regulating mechanisms are activated which may cause physical changes that improve the health of the individual, which in turn enables the individual to justify their behaviour, and this resolves the dissonance. Totman therefore suggested that for a placebo effect to occur, the individual does not require an expectation that they will get better, but a need to find justification for their behaviour and a state of cognitive dissonance to set this up.

Conditioning Effects

Traditional c theories have also been used to explain placebo effects (Wickramasekera 1980). It is suggested that patients associate certain factors with recovery and an improvement in their symptoms. For example, the presence of doctors, white coats, pills, injections and surgery are associated with improvement, recovery and effective treatment. According to c theory, the uc stimulus (treatment) would usually be associated with an uc response (recovery). However, if this uc stimulus (treatment) is paired with a c stimulus (e.g. hospital, a white coat), the c stimulus can itself elicit a c response (recovery, the placebo effect). The c stimulus might be comprised of a number of factors, including the appearance of the doctor, the environment, the actual site of the treatment or simply taking a pill. This stimulus may then elicit placebo recovery. For example, people often comment that they feel better as soon as they get into a doctor's waiting room, that their headache gets better before they have had time to digest a pill and that symptoms disappear when a doctor appears. According to this theory, these changes would be examples of placebo recovery. Several reports provide support for c theory. For example, research suggests that taking a placebo drug is more effective in a hospital setting when given by a doctor than if taken at home and given by someone who is not associated with the medical profession. This suggests that placebo effects require an interaction between the patient and their environment. In addition, placebo pain reduction is more effective with clinical and real pain than with experimentally created pain. This suggests that experimentally created pain does not elicit the association with the treatment environment, whereas the real pain has the effect of eliciting memories of previous experiences of treatment, making it more responsive to placebo intervention.

Psychology as a secular discipline

Traditionally has been s Early theorists occasionally made very negative remarks about the role of religion, or largely Christianity. has generally been describing the role and function of religious behaviors, without much direct engagement with the philosophies underlying these religious traditions. With the recent rise in popularity of mindfulness-based interventions (in parallel with wider developments, such as the field of positive p), the discipline of p will from now on be required to investigate in more detail the role of religious p

Ecological momentary interventions (EMIs)

Traditionally interventions occurred in the clinical setting with patients attending individual or group-based therapy sessions. It has long been recognized that interventions are more effective if contact between therapist and patient can be extended beyond these interactions and until recently this has taken the form of homework to ensure that the patient takes the ideas discussed back into their day-to-day lives, or telephone helplines so that people can ring up whenever they need extra support when their resilience is weakened and addiction motivation is needed. The development of new technologies such as mobile phones and palmtop computers provides a simple and cost-effective way to extend therapy beyond the consultation and patients become accessible at all times. The term EMI refers to treatments provided to people during their everyday lives (i.e. in real time) and in natural settings (i.e. in the real world). Such treatments/interventions have been used for a wide range of behaviours such as smoking cessation, weight loss, anxiety, alcohol use, dietary change and exercise promotion. They have also been used across a number of different chronic illnesses including diabetes, coronary heart disease (CHD), eating disorders and obesity (see Heron and Smyth 2010 for a comprehensive review). They are particularly useful for hard-to-reach groups such as adolescents who would usually avoid contact with health professionals. For example, Sirriyeh et al. (2010) explored the impact of affective text messages and instrumental texts for promoting physical activity in adolescents, with those in the intervention groups receiving one text per day over a two week period. The results showed that all participants increased their activity levels over the course of the study. In addition, affective texts such as 'exercise is enjoyable' were particularly effective at changing behaviour in those who were most inactive at baseline. For their review of the evidence, Heron and Smyth (2010) identified 27 interventions using EMIs to change behaviour and drew three conclusions. First, at the most practical level EMIs can be easily and successfully delivered to the target group. Second, this new approach is acceptable to patients, even those who are hard to reach such as adolescents, and third, EMIs are effective at changing a wide range of behaviours including smoking (Rodgers et al. 2005), physical activity (King et al. 2008), a reduction in calorie intake (Joo and Kim 2007), and diabetes self-management (Kwon et al. 2004), although most changes seem to be in the shorter rather than longer term. EMIs are a relatively new approach but offer a simple and cost-effective means to change behaviour for a wide section of the population.

Placebos and pain reduction

Traditionally, p's were used in randomized control trials to compare an active drug with the effects of simply taking 'something'. However, p's have been shown to have an effect on pain relief. Beecher (1955) suggested that 30 per cent of chronic pain sufferers experience pain relief after taking placebos. In the 1960s Diamond et al. (1960) carried out several sham operations to examine the effect of p on pain relief. A sham heart bypass operation involved the individual believing that they were going to have a proper operation, being prepared for surgery, being given a general anaesthetic, cut open and then sewed up again without any actual bypass being carried out. The individual therefore believed that they had had an operation and had the scars to prove it. This procedure obviously has serious ethical problems. However, the results suggested that angina pain can actually be reduced by a sham operation by comparable levels to an actual operation for angina. This suggests that the expectations of the individual change their perception of pain, again providing evidence for the role of psychology in pain perception. P will now be explored in more details in terms of definitions of a p, a brief history of inert treatments, how p work and their implications for health psychology in terms of pain and other key areas.

Hippocampus

Two main roles: 1. Spatial learning and memory Supports the amygdala in determining context in which emotionally-laden events take place, as well as other aspects of episodic and declarative memory Also plays an important role in consolidation of information from short-term memory to long-term memory 2. Negative feedback regulation of HPA Axis cortisol returns to hypothalamus and inhibits stress response the structure of the h is sensitive to environmental demands Taxi Driver study (Maguire et al., 2000) Licensed London taxi drivers were compared to control subjects not found in route bus drivers result: The posterior h of taxi drivers were significantly larger relative to those of control subjects. A more anterior hippocampal region was larger in control subjects than in taxi drivers. H volume correlated with time spent as a taxi driver - reflects spatial memory

How does social support influence health?

Two theories have been developed to explain the role of s s in h status and its mechanisms: 1. The *main effect hypothesis* suggests that s s itself is beneficial and that the absence of s s is itself stressful. This suggests that s s mediates the stress-illness link, with its very presence reducing the effect of the stressor and its absence acting as a stressor. 2. The *stress buffering hypothesis* suggests that s s helps individuals to cope with stress, therefore mediating the stress-illness link by buffering the individual from the stressor; s s influences the individual's appraisal of the potential stressor. This process, which has been described using s comparison theory, suggests that the existence of other people enables individuals exposed to a stressor to select an appropriate coping strategy by comparing themselves with others. For example, if an individual was going through a stressful life event, such as divorce, and existed in a s group where other people had dealt with divorces, the experiences of others would help them to choose a suitable coping strategy. The stress buffering hypothesis has also been described using role theory. This suggests that s s enables individuals to change their role or identity according to the demands of the stressor. Role theory emphasizes an individual's role and suggests that the existence of other people offers choices as to which role or identity to adopt as a result of the stressful event.

Views on deliberate shortening of life

Unsurprisingly some fairly strongly held opinions, not always based on evidence: New Zealand study1 suggested age 50+ most liberal, GPs least, students in between Often opposed by disadvantaged groups (e.g. those with disability), presumably seen as some form of threat Ethnic and religious variations widely noted.

Medical Interventions (health inequalities)

Variations in health and illness are explained with a focus on the success or failure of medical interventions and the availability of health care. Research indicates wide variations in health care provision and access, particularly by geographical area in terms of the types and costs of medicines, the training and expertise of health care professionals, the distances needed to travel to access health care and the availability of free health care versus the need for health insurance. A good example of the impact of medical interventions is that of HIV/AIDS. In the western world HIV/AIDS is now considered a chronic illness with many people living with the HIV virus having a normal life expectancy. This change has been attributed to the antiretroviral medication HAART (see Chapter 14). In Sub-Saharan Africa, however, where HAART is far less available, HIV/AIDS still shows the pattern of an acute terminal illness. other egs in chapter 2

social support and illness limitations

Virtually all research is correlational! Possible explanations A) i leads to disruption in ss After initial increase, perhaps? B) third variable causes the association Alternative Explanations Unlikely longitudinal studies still show an association between ss and rates of mortality studies still show link when taking other variables into account such as socioeconomic status and personality

Psychological Problems and obesity treatment of dieting

Wadden et al. (1986) reported that d resulted in increased depression in a group of o patients and Loro and Orleans (1981) indicated that o d'ers report episodes of bingeing precipitated by 'anxiety, frustration, depression and other unpleasant emotions'. This suggests that the o respond to d in the same way as the non-o, with lowered mood and episodes of overeating, both of which are detrimental to attempts at weight loss. The o are encouraged to impose a cognitive limit on their food intake, which introduces a sense of denial, guilt and the inevitable response of overeating. Consequently any weight loss is precluded by episodes of overeating, which are a response to the many cognitive and emotional changes that occur during d (see Chapter 5 for a discussion of the consequences of d).

stress reading: social support and recovery from surgery

We found that faced with the imminent threat of major (coronary-bypass) surgery, patients engaged in more cognitive clarity affiliation with a roommate who had a similar rather than dissimilar surgical problem and, independently, with a roommate who was postoperative rather than preoperative. Affiliations concerned more directly with emotions, that is, emotional support and emotional comparison, also were greater when patients had a roommate who had a similar rather than dissimilar surgical problem. In contrast, we found no evidence that the total amount of time patients spent talking to their roommates differed as a function of roommate condition. This null result appears at odds with a previous study, which found that patients reported spending more total time talking to a roommate who was preoperative rather than postoperative (Kulik et al., 1993). There are several possible explanations for the divergence. First, the studies involved very different surgical populations. Another possibility is that there was more noise in the measurement of the total time spent talking in the current study, and therefore, actual differences were masked. This might have occurred as a result of much longer average exposure times in the current study (almost 13 hr) compared with the earlier study (about 2.5 hr). Third, and a bit more subtle, there may have been important differences in the opportunity for affiliation in the respective studies. That is, Kulik et al. (1993) proposed that patients might have talked less overall with postoperative than preoperative roommates in that postoperative roommates were more apt to be temporarily non-communicative because of their physical condition (e.g., pain, nausea, sleeping).

Research designs

We have a number of research designs all of which have their strengths and weaknesses. We need to ask: • How can the authors describe 'cause' or predict anything when a cross-sectional design was used? • How can the results be generalized when the data were collected in an artificial laboratory setting? • How can the results be trusted when they were collected in a natural setting with so many uncontrolled potentially confounding variables? Health psychology uses a range of methods, all of which have their problems. Being critical of methodology involves understanding these problems and making sure that the conclusions from any study are justified. Central to all research is the assumption that data can be collected about the world and that data we separate to the tool that is collecting it. This raises the problem of whether research collects or creates the very things it is trying to measure

percieved stress scale

We looked at this when discussing PNI - more 'subjective' approach Avoids specific events, and focuses on response... That's not a problem - psychometrics good, and relates to outcomes (health) showed aqaquate reliability and correlated with life event scores, depressive and physical symptomatology - cohen et al 1983. did as in-class excersize cohen

Corr (1993) 3 lessons to learn - 3

We need to learn from those who are dying and coping with dying in order to come to know ourselves better as limited, vulnerable, finite, and mortal; but also as resilient, adaptable, interdependent, and lovable. Here the advice is to draw on the experiences of those who are coping with dying for our own benefit and instruction. Kubler-Ross would have us regard dying persons and those coping with dying as our teachers.

stroop and race (Is racial categorization automatic?)

We used a modification of the Stroop (1935) color-naming task to investigate spontaneous, unintentional categorization based on race. Participants were presented with names of African American and Caucasian celebrities. The names were written either in black, white, green, or blue font against a background of a different color. The experimental task was to name the font color. We reasoned that because black and white are used in colloquial English as both colorlabels and race-labels, spontaneous categorization of African American and Caucasian experimental targets by race should result in Stroop-like effects on a color naming task. Specifically, we expected that identifying font color as black would be faster when a name of an African-American target is presented in that font than when a name of a Caucasian target is presented. Similarly, identifying white font color should be faster when a name of a Caucasian target is presented in that font. Our results supported these predictions. (Karylowski, et al., 2002) Result: Slower to read ink colour when colour & racial category mismatch than when they match What do these data actually mean? Racial categories come to mind automatically

sick role theory critiques

Weberian theorist Elliot Friedson (1970) found in his studies that when people become ill, they on average ask the opinion of a dozen friends and family members before approaching a doctor. Friedson called these 'lay-referrals' and claimed that gaining access to the sick role was not just legitimised by a doctor, but others around the patient needed to be convinced that the individual really was ill. Friedson also found that depending on the type of illness, patients had differing levels of access to the sick role. Firstly, the 'conditional sick role' as set out by Parsons that applies to short-term illnesses that people can recover from. Secondly, the 'unconditional sick role' which refers to the long-term ill and disabled who have no hope of recovery and lastly, the 'illegitimate sick role' where patients are blamed for their illness due to their own choices, where people are not always offered the rights of the sick role. Friedson highlights one of the biggest problems with Parsons' theory, which is that it only takes into account acute illnesses and not long-term chronic illnesses and disabilities. Another Weberian theorist Bryan S. Turner (1973) argued that doctors are not always professional in their conduct (e.g. Harold Shipman!) and patients are not always passive, trusting and prepared to wait for medical help.

Anger death stage

When denial can not be maintained any longer, KR argues it is replaced by feelings of anger, rage, envy and resentment. One patient "I suppose most anybody in my position would look at somebody else and say, 'Well, why couldn't it have been him?' and this has crossed my mind several times... An old man whom I have known ever since I was a little kid came down the street. He was 82 years old, and he is of no earthly use as far as we mortals can tell. He's rheumatic, he's a cripple, he's dirty, just not the type of person you would like to be. And the thought hit me strongly, now why couldn't it have been old George instead of me?" A much more difficult stage for families and carers - anger displaced in many directions, and at random times. Put yourself in their shoes though, why wouldn't you be annoyed? Life is being interrupted prematurely, and sadly most of us don't achieve our goals etc anyway... They are often in pain, and/or constantly explicitly and/or implicitly being reminded of what they cannot do, or are missing out on doing... Respect, understanding, attention and time are all often helpful. Hard, but empathy will lead to an understanding of why the person is angry, important not to take it personally.

The role of dieting for obesity

With the exception of the surgical interventions now available (see p. 412), all o treatment programmes involve recommending d in one form or another. Traditional treatment programmes aimed to correct the o individual's abnormal behaviour, and recent packages suggest that the obese need to readjust their energy balance by eating less than they usually do. But both styles of treatment suggest that to lose weight the individual must impose cognitive restraint upon their eating behaviour. They recommend that the o deny food and set cognitive limits to override physiological limits of satiety. And this brings with it all the problematic consequences of restrained eating (see Chapter 5).

Aspects of the Task (variabilty of emotional exp and immunity)

Writing versus Talking: Some research has compared the effectiveness of writing versus talking either into a tape recorder or to a therapist (e.g. Donnelly and Murray 1991; Esterling et al. 1994). The results showed that both writing and talking about emotional topics were more effective than writing about superficial topics. Type of Topic: Some research has shown that changes in outcome only occur after writing about particularly traumatic experiences (e.g. Greenberg and Stone 1992). Others have found that it is the relevance of the topic to the outcome variable that is important. For example, Pennebaker and Beall (1986) found that writing about the experience of coming to college had a greater impact upon college grades than writing about 'irrelevant' traumatic experiences. Amount of Writing: Research using the writing paradigm has varied the stipulated time of writing both in terms of the length of sessions (from 15 to 30 minutes) and the spread of sessions (over a few days to over a month). Smyth (1998) carried out a meta-analysis and concluded that writing over a longer period might be the most effective approach.

Observational assessment (Measuring Pain)

attempt to make a more objective assessment of pain and are used when the patient's own self-reports are considered unreliable or when they are unable to provide them. For example, observational measures would be used for children, some stroke sufferers and some terminally ill patients. In addition, they can provide an objective validation of selfreport measures. Observational measures include an assessment of the pain relief requested and used, pain behaviours (such as limping, grimacing and muscle tension) and time spent sleeping and/or resting.

Wellness

by dictionary definition, is "the condition of good physical and mental health, especially when maintained by proper diet, exercise, and habits" (Dunn, 1961). As a health movement, it focuses on helping people become aware of the choices they can make to achieve good physical and mental health (Ralph and Corrigan, 2005). This focus is wholly consistent with our Positive Health initiative, and both share the goal of fostering interventions that target well-being (Garofalo, 1994). Positive Health, in contrast, is an empirical science that seeks to build a science around health assets in order to discover what assets truly matter for health, what are the relevant strategies for building or enhancing these assets, whether interventions to build/enhance assets are effective for maintaining good health and reducing the risk of illness, and how cost-effective these interventions are. Positive Health also targets disease prevention goals achieved by building these health assets. Wellness, on the other hand, often has a New Age flavour, which in itself is not objectionable but does run the risk of substituting ideology for science when alternative medicine interventions are not subjected to rigorous testing (Randi, 1987). In sum, Positive Health is compatible with disease prevention, health promotion, and wellness, but it is an empirical and systematic discipline that subsumes the goals and methods of these other approaches to good health in a more general framework and employs an explicitly interdisciplinary scientific approach to build an evidence base to support (or refute) key premises.

social cognition-based interventions

followed the steps outlined earlier to identify salient beliefs about safety helmet wearing for children. They then developed an intervention based upon persuasion to change these salient beliefs. The results showed that after the intervention the participants showed more positive beliefs about safety helmet wearing than the control group and were more likely to wear a helmet at five months' follow-up. There are some problems with using social cognition models for interventions, as follows. • How to change beliefs? As Hardeman et al. (2002) found from their systematic review, although many interventions are based upon theory, this is often used for the design of process and outcome measures and to predict intention and behaviour rather than to design the intervention itself. Using the TPB for behaviour change interventions describes which beliefs should be changed but not how to change them. • Does behaviour change? A TPB-based intervention assumes that changing salient beliefs will lead to changes in behaviour. However, studies indicate that there is an attenuation effect whereby any changes in beliefs are attenuated by the other variables in the model which reduce their impact upon behaviour (Armitage and Conner 2001; Sniehotta 2009). Further, although there is some evidence that theory-based interventions are successful, whether the use of theory relates to the success of the intervention remains unclear. • Do they miss other important factors? Sniehotta (2009) described the 'bottleneck' whereby interventions using the TPB assume that all changes in behaviour will be mediated through intentions. This, he argues, misses the opportunity to change other relevant factors which may influence behaviour directly such as changes in the environment and which do not need to pass through behavioural intentions. Sc models have therefore been used to develop behaviour change interventions. To date, however, although they provide a clear structure for evaluating an intervention, the actual intervention to change beliefs require further attention.

Who is hostile

h is higher in men than women (Matthews et al. 1992), higher in those of lower socioeconomic status (e.g. Siegman et al. 2000) and seems to run in families (Weidner et al. 2000). It seems to be more common in people whose parents were punitive, abusive or interfering and where there was a lot of conflict (Matthews et al. 1996), and Houston and Vavak (1991) have argued that it relates to feelings of insecurity and negative feelings about others.

Smoking and stress illness link

has been consistently linked to a range of illnesses including lung cancer and CHD (see Chapter 4). Research suggests a link between s and sm behaviour in terms of sm initiation, relapse and the amount smoked. Wills (1985) reported that sm initiation in adolescents was related to the amount of s in their lives. In addition, there has been some support for the prediction that children who experience the s of changing schools may be more likely to start sm than those who stay at the same school throughout their secondary education (Santi et al. 1991). In terms of relapse, Lichtenstein et al. (1986) and Carey et al. (1993) reported that people who experience high levels of s are more likely to start sm again after a period of abstinence than those who experience less s. Research also indicates that increased sm may be effective at reducing stress. In an experimental study, Perkins et al. (1992) exposed sm to either a stressful or a non-s computer task and asked the subjects to sm or sham sm an unlit ci. The results showed that, regardless of whether the sm's smd or not, all subjects reported an increased desire to smoke in the s condition. However, this desire was less in those sm who were actually allowed to sm. This suggests that s causes an increased urge for a ci, which can be modified by sm. In a more naturalistic study, sm were asked to attend a sful social situation and were instructed either to sm or not to sm. Those who could not sm reported the occasion as more socially sful than those who could sm (Gilbert and Spielberger 1987). Similarly, Metcalfe et al. (2003) used the Reeder s Inventory to relate s to health behaviours and concluded that higher levels of s were associated with sm more ci. This association was also found in one large-scale study of over 6,000 Scottish men and women which showed that higher levels of perceived s were linked to sm more (Heslop et al. 2001).

The clinical health psychologist

has been defined as someone who merges 'clinical psychology with its focus on the assessment and treatment of individuals in distress . . . and the content field of health psychology' (Belar and Deardorff 1995). In order to practice, it is generally accepted that someone would first gain training as a cp and then later acquire an expertise in health psychology, which would involve an understanding of the theories and methods of health psychology and their application to the health care setting. A trained chp would tend to work within the field of physical health, including stress and pain management, rehabilitation for patients with chronic illnesses (e.g. cancer, HIV or cardiovascular disease) or the development of interventions for problems such as spinal cord injury and disfiguring surgery.

Placebos

have been defined as follows: • Inert substances that cause symptom relief (e.g. 'My headache went away after having a sugar pill'). • Substances that cause changes in a symptom not directly attributable to specific or real pharmacological actions of a drug or operation (e.g. 'After I had my hip operation I stopped getting headaches'). • Any therapy that is deliberately used for its non-specific psychological or physiological effects (e.g. 'I had a bath and my headache went away').

Health promotion

helps people strive for "optimal health," which is said to be a balance of physical, emotional, social, spiritual, and intellectual fitness (Naidoo and Wills, 2000). Lifestyle change to achieve optimal health is brought about by enhanced awareness of the need for change, increasing motivation, building skills, and supporting environments that provide Positive Health practices (O'Donnell, 2002, 2009). The target of good health is a goal that Positive Health shares with health promotion. Positive lifestyle interventions, such as increasing exercise, improving nutrition, and encouraging responsibility for healthy choices, is a second common goal of both endeavours (Dines and Cribb, 1993; Leddy, 2006). Positive Health differs from health promotion in two ways. First, it is tied to the prevention of disease outcomes and prognosis once illness strikes as well as to achieving positive goals for their own sake. Second, Positive Health is agnostic about what health assets are real, so it is steadfastly empirical. It moves from the longitudinal studies that isolate causal health factors to interventions building those health assets to considering their comparative effectiveness and ultimately assessing the cost-effectiveness.

NZ MINISTRY OF HEALTH - ACTIVITY GUIDELINES

https://www.health.govt.nz/our-work/eating-and-activity-guidelines 1. Sit less, move more! Break up long periods of sitting. 2.Do at least 2 ½ hours of moderate or 1 ¼ hour of vigorous physical activity spread throughout the week. 3. For extra health benefits, aim for 5 hours of moderate or 2 ½ hours of vigorous physical activity spread throughout the week. 4.Do muscle-strengthening activities on at least 2 days each week. 5.Doing some physical activity is better than doing none.

distal causes

initial differences that lead to effects over long periods of time and often through indirect relations A cause that underlies or is remote from the more obvious direct cause of a departure from good health. For example, atmospheric contamination with ozone-destroying substances, such as chlorofluorocarbon compounds, is a distal cause of skin cancer due to increased ultraviolet radiation flux.

Summary: Obesity

is a disease • Genetic, environmental, and behavioural factors all contribute to its pathogenesis • Impairments in physical and physiologic functioning contribute to high rates of morbidity and mortality

Becoming critical

is about developing the confidence to question and scrutinize a paper to see whether it really makes sense and whether the conclusions are justified. At one level being critical may be quite simple in terms of exploring issues such as sample size (is it representative?), the measures used (are they valid?), the statistical tests employed (are they the right ones?) or the chosen research design (can they make causal conclusions from a qualitative study?). But at a more sophisticated level, being critical also means thinking about the theories being tested (do they make sense?), the constructs used (are they different from each other?) and whether the arguments are coherent (what are they really saying?). Furthermore, being critical may also highlight some fundamental flaws in a discipline if we start to ask about an author's underlying assumptions (do people really have a consistent personality?; is what people say they think what they really think?), or what a discipline chooses to focus on and chooses to ignore (why do psychologists focus on behaviour while sociologists focus on society-level variables such as social class, education, social capital, economic stability, etc.?). And finally, being critical involves learning to trust the feeling that something 'isn't quite right' or 'doesn't quite make sense' or 'is so obvious that it's not interesting'.

Some Evidence - relationship infidelity - (Treas & Giesen, 2000)

is accounted for by permissive sexual values, opportunities for sexual activity, and low levels of relationship satisfaction. Once these variables are accounted for, there are no gender differences in infidelity. Cubbins and Tanfer, 2000 - high-risk sexual behaviours - sex with multiple partners, unprotected sexual activities, casual sex etc were explained by social and cultural factors rather than gender

Retirement - men's health

is an important transition - mostly positive views, but if not a classic well-funded retirement, this can pose problems. Men with stable careers, retirement benefits etc likely to have better emotional and physical health in retirement

Positive Health

is an interdisciplinary effort from cardiology, psychiatry, psychology, epidemiology, exercise science, & public health to examine - • what it means to be healthy above-and-beyond the absence of symptoms & diseases. • The field of p h overlaps with other fields like disease prevention, health promotion, & wellness but has its own signature provided by its explicit focus on health assets. P h is the scientific study of health assets: - factors that produce longer life, lower morbidity, lower health care expenditure, better prognosis when illness strikes, and/or higher quality of physical health - - over and above the usual suspect risk factors like hypertension, obesity, and a sedentary lifestyle. • Research: - Watch clip http://positivehealthresearch.org/ - See About and Projects sections in website - Read: https://positivehealthresearch.org/content/positive-healthand-health-assets-re-analysis-longitudinal-datasets Martain Seilgman - optimism - 1/4 of cardiovascular health deaths, much less

chronic pain

lasts for longer than six months and can be either benign, in that it varies in severity, or progressive, in that it gets gradually worse. Chronic low back pain is often described as chronic benign pain whereas illnesses such as rheumatoid arthritis result in chronic progressive pain.

signs of a heart attack

lightheadesness, shortness of breath, loss of appitite, heart flutters etc. Often we do not picm up on the signs as they could be indicting somehing else

expression vs experience

males seem to have/exert greater control overexpression, but males tend to spend more time dwelling on negative emotions than women express emotions less often, less amplitude, with fewer people (often just a female partner), ongoing behaviour seems less affected by reported levels of emotion complex though, and history of inhibition and expectations of manliness make direct comparisons problematic Expressions of vulnerability and warmth might reduce ([self] perceived) ability to be provider and competition with other males Evidence that everyday situations elicit different emotions, men more likely to be in situations that might elicit frustration or anger, and have fewer opportunities for positive emotional experiences with family and children

Mechanism 1 of allostatic load: repeated hits

r stress with limited recovery time too much "stress" in the form of r, novel events that cause r elevations of stress mediators over long periods of time. For example, the amount and frequency of economic hardship predicts decline of physical and mental functioning as well as increased mortality or increased risk of cardiovascular disease from constant occupational noise exposure. McEwen & Giaronos (2011).

restrained eating obesity treatment

r theory (see Chapter 5) suggests that d has negative consequences, and yet the treatment of o recommends d as a solution. This paradox can be summarized as follows: • O is a physical health risk, but r eating may promote weight cycling, which is also detrimental to health. • O treatment aims to reduce food intake, but r eating can promote overeating. • The o may suffer psychologically from the social pressures to be thin (although evidence of psychological problems in the non-d o is scarce), but failed attempts to d may leave them depressed, feeling a failure and out of control. For those few who do succeed in their attempts at weight loss, Wooley and Wooley (1984: 187) suggest that they 'are in fact condemned to a life of weight obsession, semi-starvation and all the symptoms produced by chronic hunger . . . and seem precariously close to developing a frank eating disorder'. If r theory is applied to obesity, the o should not be encouraged to r their food intake. O may not be caused by overeating but overeating may be a consequence of o if r eating is recommended as a cure.

Inflammation

refers to your body's process of fighting against things that harm it, such as infections, injuries, and toxins, in an attempt to heal itself. When something damages your cells, your body releases chemicals that trigger a response from your immune system

Stress reactivity

the capacity or tendency to respond to a s. It is a disposition that underlies individual differences in responses to stressors and is assumed to be a vulnerability factor for the development of diseases. Some individuals show a stronger physiological response to stress than others which is known as their level of 'cardiovascular reactivity' or ... This means that when given the same level of s and regardless of their self-perceived s, some people show greater sympathetic activation than others (e.g. Vitaliano et al. 1993). Research suggests that greater s reactivity may make people more susceptible to s-related illnesses. For example, individuals with both hypertension and heart disease have higher levels of stress reactivity (e.g. Frederickson et al. 1991, 2000). However, these studies used a cross-sectional design which raises the problem of causality. Some research has therefore used a prospective design. For example, in an early study Keys et al. (1971) assessed baseline blood pressure reaction to a cold pressor test and found that higher reactivity predicted heart disease at follow-up 23 years later. Similarly, Boyce et al. (1995) measured baseline levels of s reactivity in children following a s task and then rated the number of family s and illness rates over the subsequent 12 weeks. The results showed that s and illness were not linked in the children with low reactivity but that those with higher reactivity showed more illness if they had experienced more s. Everson and colleagues (1997) also assessed baseline stress reactivity and explored cardiac health using echo cardiography at follow-up. The results showed that higher s reactivity at baseline was predictive of arterial deterioration after four years. In addition, s reactivity has been suggested as the physiological mechanism behind the impact of coronary-prone behaviours on the heart (Suarez et al. 1991). This doesn't mean that individuals who show greater responses to s are more likely to become ill. It means that they are more likely to become ill if subjected to s (see Figure 12.3). - indirect pathway- in the middle is psycholgical changes, .../ allostatic load (wear and tear on body from chronic s) and behaviour change.

Psychoimmunology (PNI)

the study of how psychological, neural, and endocrine processes together affect the immune system and resulting health is an in interdisciplinary field concerned with the relationships between the nervous system and immune system, and the impact of these relationships on disease. P = psychosocial processes N = nervous system processes I= immune system processes stress perception is more predective

Selye's general adaptation syndrome (GAS)

was developed in 1956 and described three stages in the stress process (Selye 1956). The initial stage was called the 'alarm' stage, which described an increase in activity, and occurred as soon as the individual was exposed to a stressful situation. The second stage was called 'resistance', which involved coping and attempts to reverse the effects of the alarm stage. The third stage was called 'exhaustion', which was reached when the individual had been repeatedly exposed to the stressful situation and was incapable of showing further resistance. This model is shown in Figure 11.1.

Cognitive treatment of pain

¨ (1) Distraction ¤ Focusing on a non p stimulus in the immediate environment ¤ Factors: Attention - greater attention, lower p ratings n Whether the distractor is interesting - e.g., watching a movie, being asked to reflect on what's going on in the movie (used when giving needles to children) ¨ (2) Imagery ¤ Guided imagery - alleviation through imaging mental scene unrelated to the p ¤ Useful in acute p ¤ Not clear in terms of its use in chronic p ¤ Difficult for some people ¨ (3) p redefinition: ¤ Replacing maladaptive thoughts about threat and harm with constructive and realistic thoughts ¤ Focus often on the internal dialogue ¤ Coping statements: emphasise person's ability to tolerate discomfort (e.g., "It hurts, but you're in control") ¤ Reinterpretative statements: designed to negate the unpleasant aspects of discomfort (e.g., "It's not the worst thing that could happen") -Useful for those undergoing medical procedures -But be careful not to create feelings of guilt 1. Medical procedure information - can be provided by a therapist -- reduces anxiety and discomfort 2. Coping with chronic p - therapist can promote active coping and p acceptance ¤ Have them perform activities to see they have enjoyment even with p present 3. Reducing illogical thoughts in chronic p patients ¤ Helping to reduce overall discomfort

What controls opening and closing of the gate?

¨ (1) The amount of activity in the pain fibres ¤ Activity of the large fibres due to injury ¤ The stronger the noxious stimulation - the more active the pain fibres ¨ (2) The amount of activity in other peripheral fibres ¤ A-beta fibres - carry information about harmless stimulation - touching, rubbing, light scratching Stimulation of the small fibres (e.g. gentle massage, TENS, medication) tends to close the g (inhibits pain neurons) ¨ (3) Messages that descend from the brain ¤ Efferent pathways (brain to spinal cord) can open or close the g ¤ E.g., emotional factors such as anxiety (open gate) or excitement (close) ¤ Behavioural factors, such as focusing on pain (open) or concentration on other things or distraction (close) This pathway explains why people who are distracted by environmental stimuli may not notice the pain.

Types of chronic pain

¨ C recurrent: ¤ Stems from benign causes ¤ Repeated episodes of p and episodes of no p ¤ e.g., myofascial p syndrome ¨ C intractable benign: ¤ Discomfort that is present all the time ¤ Not related to a malignant condition ¤ E.g.,l long term back p ¨ C progressive: ¤ Continuous discomfort ¤ Associated with a malignant condition ¤ Increases in intensity as condition worsens ¤ e.g., rheumatoid arthritis, cancer

Cognitions of pain

¨ Catastrophising ¤ Rumination ("I can feel my knee click"); focus on threatening information ¤ Magnification ("I will become paralysed"); overestimation of threat ¤ Helplessness ("Nobody can help me and I just can't bear the p anymore"); underestimating personal resources to cope Each predict p intensity ¨ Meaning ¤ Positive meaning (e.g., childbirth, muscle strength training) may reduce p ¤ Negative meaning (e.g., serious illness) may increase p

Pain and the role of learning

¨ Classical conditioning: past experience and association can exacerbate (e.g., going to the dentist after a bad experience) ¨ Jamner & Tursky (1987): migraine sufferers react with more anxiety to words associated with migraine ¨ Operant conditioning: Reinforcement can exacerbate (e.g., getting attention)

Managing pain

¨ Clinical - any p that requires professional care ¤ Acute and chronic Acute Why is this important to manage? - Occurs during surgical procedures - Following surgical procedures - Impacts patient adherence to treatment (e.g., returning to the dentist for another filling) Chronic Why is this type important to manage? - Important in chronic illness - e.g., arthritis, cancer - Needs to be managed properly in terminal cases - Important to the improvement of quality of life

Gate control theory of pain

¨ Developed in 1960s by Melzack and Wall ¤ Integrated physiology with psychology and improved preceding theories; complex pathway mediated by a network of interacting processes. ¨ The Basics ¤ There is a "g...ing mechanism" located in the spinal cord (substantia gelatinosa of the dorsal horn)

Behavioural and cognitive treatment of pain

¨ Goals: help patients cope more effectively, and reduce their reliance on drugs; moving client out of comfort zone back into activities that they had been avoiding. Operant Approach ¤ Especially used with children ¤ Reinforcement of desirable behaviour (e.g., if you do this exercise, then we can play a game) ¤ Give praise for desirable activities - sleeping through naptime, not complaining ¨ Relaxation and Biofeedback ¤ Helps reduce stress (which is linked to chronic pain, tension headaches, etc) ¤ E.g., progressive muscle relaxation -- usually does not work with acute physical p ¤ E.g., biofeedback - learning control over bodily functions such as heart rate (through electronic devices)

Assessing pain

¨ Interviews: ¤ History of p, emotional adjustment, lifestyle factors, impact on interpersonal relations and work ¨ p questionnaires (e.g. McGill p Questionnaire) ¨ Verbal description ¨ Rating Scales ¤ Box Scale (0 = no pain, 10 = worst possible p) ¤ Visual Analogue Scale: see scrn ¨ rating scales are simple, direct ways of assessing ¨ Excellent for assessing current functioning and change over time ¨ Also helps clients and helpers see patterns and take more control ¨ Observational assessment ¤ Generally considered unreliable, but sometimes required ¤ E.g. children, non-verbal adults, some terminally ill adults ¨ Physiological measures ¤ Assessment of inflammation ¤ Measure of sweating, heart rate, skin temperature ¤ Also often not reliable

Problems with early theories of pain

¨ Medical treatments (drugs and surgery) tend to work for acute p only. ¨ Degree of tissue damage and reports of pful sensations differ (e.g. soldiers requesting less p relief than civilians). ¨ Phantom limb phenomenon; p felt as coming from the place where the amputated limb used to be.

Pain without detectable damage

¨ Neuralgia ¤ Recurrent shooting/stabbing along course of nerve ¨ Causalgia ¤ Renamed "Complex regional p syndrome" ¤ Severe burning p triggered by minor stimuli (e.g., clothing, puff of air), can occur spontaneously ¤ Sometimes where body has healed - e.g., gunshot, stabbing ¨ Fibromyalgia ¤ Chronic widespread p with unknown (probably multiple) causes ¨ Phantom Limb p ¤ P in limb no longer there ¤ Can persist for months and even years

Problems with gate control theory

¨ No clear evidence yet for precise location of the supposed "g". ¨ Unclear how exactly the psychological factors interact with the organic basis of pain.

Pain signals

¨ Nociceptors - nerve endings that respond to p stimuli and signal injury to the brain ¤ Found in: skin, blood vessels, muscles, joints, etc. ¨ Types of Afferent Peripheral Fibres: ¤ A-delta fibres - coated with myelin, quick transmission ¤ C fibres - slower impulse - dull, burning, aching

Organic vs. Psychogenic Pain

¨ O pain - discomfort from tissue damage (e.g., stubbed toe, scraped knee) ¨ P pain - discomfort without clear organic basis (e.g., pain disorder - a somatoform disorder) - could be dangorous as it could be o pain just not pinpointed yet ¨ In the past: ¤ Physicians and researchers thought organic and p pain were completely separate. ¨ Today: ¤ Physicians acknowledge that both factors influence the pain experience.

Types of pain

¨ Referred p: ¤ originating from internal organs perceived as coming from other parts of the body ¤ E.g. heart attack - Internal organs and skin use same pathway in the spinal cord - Due to not being used to p originating from internal organs We may feel p in a different area than the actual cause or site

Early theories of pain

¨ Specificity theory: ¤ P receptors, nerves, brain region; direct and automatic link between cause of p and brain ¨ Pattern theory: ¤ Similar; level of p determined by nerve impulses from damaged tissue ¨ Commonalities of these theories: ¤ p caused by damaged tissue ¤ psychological consequences only ¤ p as an automatic response with a single cause ¤ psychogenic p acknowledged but only when no organic cause can be found

Inhibition of pain

¨ Stimulation-produced analgesia (SPA) ¤ Stimulation to the periaqueductal gray area of the midbrain produces an insensitivity (e.g. TENS, acupuncture); Kotzé & Simpson (2008) ¨ Serotonin activates inhibitory interneurons ¨ release endorphins at p fibres ¨ endorphins inhibit release of substance P (p message) from p fibres

Medical treatment for pain

¨ Surgical methods ¤ More likely to be effective for acute ... ¤ Other methods: Synovectomy - removing membranes of arthritic joints Spinal fusion - fusing vertebrae to treat severe back p; typically using donor bone material to join vertebrae

What is pain?

¨ The sensory and emotional experience of discomfort, which is usually associated with actual or threatened tissue damage or irritation. ¨ Plays an important protective feedback function ¨ Most common medical complaint ¨ More than 80% of all visits to physicians is needed otherwise we would be an extinct species

Gating example TENS machine

¨ Transcutaneous Electrical Nerve Stimulation ¤ Used for surgery, trauma, long term pain, or child birth ¨ How it works: ¤ The nerve cannot carry pain impulse and non-pain impulse (from TENS) simultaneously - therefore pain signal is overridden ¤ Also encourages body to produce endorphins

Chronic clinical pain

¨ e.g., lower back pain, arthritis, cancer ¨ Can lead to increased hopelessness and despair in the transition from acute c p ¤ While some studies found a relationship between the neurotic triad of personality of the MMPI (hypochondriasis, depression, hysteria) and c p (Armentrout et al., 1982; McGill et al., 1983), others found that the MMPI is not a reliable tool to predict p perception (Cox et al., 1978; Naliboff et al., 1982) ¨ Other major issues with ...: ¤ Interpersonal and emotional difficulties ¤ Excessive drug use ¤ Frequent sleep disturbance

Other definitions of mindfulness

• "[W]e see m as a *process of regulating attention* in order to bring a quality of *nonelaborative awareness* to current experience and a quality of relating to oneʼs experience within an orientation of *curiosity, experiential openness, and acceptance.* We further see m as a process of gaining insight into the nature of oneʼs mind and the adoption of a de-centered perspective...on thoughts and feelings so that they can be experienced in terms of their subjectivity (versus their necessary validity) and transient nature (versus their permanence)" (Bishop et al., 2004) • Some researchers argue that acceptance is redundant in the d of m, as it is implicit in focused attention. When one does not accept things, one re-directs attention to change, avoid or escape the event. So, acceptance is perhaps just a "side-effect" of being present in the moment.

definition of health

• "h is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." (WHO) • What does "complete" and "mental" mean? complete mental - not lacking • "Mental h is defined as a state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community." (WHO)

The role of leptin

• A hormone released by the fat cells → decreases food intake and increases energy expenditure • Plays a role in feeling full • The role of leptin was found during an experiment in mice: • Following a genetic mutation, leptin was not produced in some mice - these mice did not feel full and therefore ate excessively. • However, injections of leptin is not the answer, as obesity is associated with leptin resistance.

1. External eating

• According to externality theory, eating in people with obesity is triggered by external cues, not by internal ones. • People should learn to rely on internal physiological cues of hunger and satiety - determined by gastric contractions • Some people might not have learned to recognise these internal cues - may therefore be more inclined to follow external cues - e.g., presence of tasty foods, time of day, smell or taste Consequence: eating in absence of hunger, and consumption of larger amounts than necessary • Eating speed is correlated with the risk of obesity in children. • An experimental study by Hill and McCutcheon (1984) showed that overweight people are more likely to have higher eating rates and larger bite sizes. • Thus, fast eaters may eat too fast for satiation feedback.

Mindfulness practices in ACT

• Clients are instructed to be mindful in the present moment and to practice acceptance and awareness of negative thoughts even though they generally tried to avoid them before. • Clients also commit to clear goals. After having achieved a habit of acceptance and awareness of one's thoughts, these may now change: • A person with an anxiety disorder, for example, might learn to accept anxiety and reframe the therapeutic goal from recovery of anxiety to leading a meaningful life. They thus learn to live with anxiety but focus on what is important to their lives. • While this therapy uses stories, conversations, paradoxes and exercises to promote mindfulness in the client, these are not used to solve the behavior problem with logical reasoning but through the experience of mindfulness.

Obesity and psychological problems

• Cross-sectional surveys of health service users indicate people with obesity - higher rates of depression. • However, confounded by fact obese people with depression more likely to seek help. • Other studies (e.g. Ross, 1994, using random sampling via telephone), show lack of a relationship between obesity & psychological problems. • Stereotype obese as slow, lazy, and sloppy, less sincere, less friendly, meaner, & more obnoxious - Rychman et al. (1989) • African American women are less critical of large AA women than white women are of large white women (NZ??) • Negative social attitudes even in young children age 5 - Richardson et al. (1961) • Reasons for negative attitudes - it is under the person's control he/she could stop eating if he/she wanted to stop - Dejon (1980) study of likeability of normal weight & overweight pictures of girls

Mindfulness-Based Stress Reduction (MBSR)

• Developed by Jon Kabat-Zinn. • As the name implies, it was designed for s reduction, but also as a tool to cope with chronic pain. • Meditation is a central part of a course that is typically 8-10 weeks long. Around 10-30 participants gather for weekly 2- to 2.5-hour sessions, and one full-day workshop. • Outside the class, participants are requested to meditate daily for 45 min and to complete homework to apply mindfulness into their daily lives. • One of the major goals of the program is to foster a nonjudgmental attitude. People develop a habit of observing the content of their thoughts without judging them and to return their attention to the present moment.

Mindfulness-Based Cognitive Therapy (MBCT)

• Developed by the Segal, Williams, and Teasdale. • This therapy is directly based on the MBSR program, but was designed to be a program to prevent relapse from depression. • Traditional c therapy treats depression by teaching people to replace negative thoughts (e.g. self-talk such as "I am overweight and ugly") with rational ones ("I am not more overweight than most people my age"). While this might work, clients are still vulnerable to relapse. • MBCT teaches clients to stop identifying themselves with thoughts and in this way attempts to prevent depression from re-occurring. • They learn to notice, without judging, that thoughts come and go.

Acceptance and Commitment Therapy (ACT)

• Developed by the psychologist Stephen Hayes. • As the name implies, its goals are about mindful a of unwanted thoughts and feelings as well as c to act according to one's values. • People often place too much emphasis on the literal content of thoughts, which in conditions such as depression is perpetuated in a continuous vicious cycle. • Clients are taught to stop identifying themselves with the thoughts and instead focus back on the process of thinking. • For example, a person with low self-esteem might verbalize the following thought: "I am worthless". The client learns to reframe this thought into: "I am having the thought that I am worthless".

Implementation intention intervention critisms

• Do people make plans when asked to? Research indicates that between 20 and 40 per cent of people do not make implementation intentions when they are asked to (Skar et al. 2008). This must influence the effectiveness of any intervention. • The impact of existing plans. Implementation intention interventions ask people to make plans and then explore the impact of this on their behaviour. This assumes that people have not already made plans. Sniehotta et al. (2005) suggest that we need to differentiate between spontaneous plans and those made in response to the interventions. • Do people own their plans? If people have made their own spontaneous plans they may well feel more ownership of these plans, making them more motivated to carry them out. This is not usually assessed in intervention studies • Is all behaviour change volitional (their will)? Central to a social cognition model approach to behaviour and the use of implementation intentions is the assumption that behaviour is volitional and under the control of the individual. Much behaviour, however, may be either habitual or in response to environmental changes. These aspects are not addressed within this framework. • Not all plans are the same. Sniehotta (2009) argues that research often treats all types of plans as the same but that it is important to differentiate between action plans and coping plans. Action plans involve choosing the behaviour that will achieve the goal (the where, when and how of the behaviour) and are what have been called implementation intentions. In contrast, coping plans prepare an individual for successfully managing high-risk situations in which strong cues might encourage them to engage in unwanted habits (without intention) or new unhealthy behaviours (with intention). Sniehotta et al. (2006) explored the relative impact of action and coping plans in promoting physical activity post-heart attack and concluded that those in the combined planning group did more activity that those in either the action planning group or the usual care group.

Other treatments for obesity

• Drug Treatments • Fenfluramine and dexfenfluramine - both have been pulled from the market due to association with heart disease; should be used only when other options have failed • (1) Drugs targeting CNS and suppress appetite, e.g. Phentermine • Side effects: nausea, dry mouth, constipation • (2) Drugs targeting gastrointestinal system, e.g. Orlistat • Reduce fat absorption • Side effects: liquid stools, anal leakage (especially after a high-fat meal) • Surgical Treatments • 21 different surgical treatments for obesity • Two most popular: gastric bypass and gastric banding: • Gastric bypass - stomach into two pouches (one upper/one remaining lower) that connect to the small intestine • Gastric band - silicone device placed around the top of the stomach • Only recommended for people with BMI > 35 who have not shown substantial weight loss following dietary or drug treatment

Which Factors Moderate the Stress-Illness Link?

• Exercise. This can cause a reduction in s (see Chapter 6). • Coping styles. The individual's type of coping style may well mediate this and determine the extent of the effect of the s event on their health status (see Chapter 9 for a discussion of coping with i). • Social support. Increased social support has been related to a decreased s response and a subsequent reduction in i. • Personality. It has been suggested that personality may influence the individual's response to a s situation and the effect of this response on health. This has been studied with a focus on type A behaviour and personality and the role of hostility (see Chapter 15 for details in the context of CHD). • Actual or perceived control. Control over the s may decrease the effects of s on the individual's health status. Coping with s, social support, personality and control will now be examined in greater detail (see Figure 12.4).

Informal mindfulness

• Generalising formal m practices into everyday life • Attention on water while taking a shower • m engaging in household tasks • "Surfing the urge" - increased awareness of physical sensations as urges are noticed and observed; watching them rise and fall • What about m colouring?

Session 4 e therapy study

• Guided breathing meditation • Physical movement meditation exercise • Slideshow presentation on types of awareness, negative bias, and walking meditation • 45-min talk about foundations of mindfulness and emotions • "Urge surfing" • Final meditation exercise focusing on observing sound, body, and emotions • Home practice: Insight meditation

pain clinics have been set up that adopt a multidisciplinary approach to pain treatment

• Improving physical and lifestyle functioning. This involves improving muscle tone, self-esteem, self-efficacy and distraction, and decreasing boredom, pain behaviour and secondary gains. • Decreasing reliance on drugs and medical services. This involves improving personal control, decreasing the sick role and increasing self-efficacy. • Increasing social support and family life. This aims to increase optimism and distraction and decrease boredom, anxiety, sick role behaviour and secondary gains

Socio-economics differences

• In New Zealand, prevalence of obesity 2013/2014: • Quintile 5 (most disadvantaged neighbourhoods) - 44.5% • Quintile 4 - 30.8% • Quintile 3 - 27.9% • Quintile 2 - 22.1% • Quintile 1 - 18.4%

Are changes in food intake at home associated with changes in obesity?

• In-home calorie consumption increased between 1950 and 1970 • Since 1970 there has been a decrease in our food intake in households • At the population level, there does not seem to be a relationship between caloric intake and obesity. • However, a New Zealand study cautions us about accepting the reliability of dietary intake data from many studies and health surveys, as this kind of information may often be under-reported.

Eightfold Path (Buddhism)

• M in B is discussed in the context of this • right/correct/complete/wholesome view (wisdom/prajñā) • right intention (wisdom/śīla) • right speech (ethics/śīla) • right action (ethics/śīla) • right livelihood (ethics/śīla) • right effort (concentration/samādhi) • right mindfulness (sammasati) (concentration/samādhi) • right concentration (concentration/samādhi)

Mindfulness-informed approaches

• Meditation and related exercises are generally considered central to developing mindfulness. • This is what distinguishes so-called mindfulness-based approaches (where it is central) from mindfulness-informed approaches (where mindfulness may be part of some exercises and there isn't the same disciplined practice) • An example of the latter is ACT:

Kaplan's model

• Most m's in health psych have a biological measure on rightmost end - k argues *behavioural outcome is fundamental*, and of course can have effects to the left • Not to say an intervention at level of tissues or organs not valid - but interventions have importance because they have *effects on behavioural outcomes.* • He argues that the traditional approach leads to focus on risk factors not outcomes... • Example (dated now, but the pattern will be familiar) Many epidemiological studies have shown no relationship between coffee consumption & death due to CHD - in fact seems to be no effect on overall life expectancy • But, studies have shown coffee increases LDL cholesterol & blood pressure • So, recommendation to abstain from coffee... logical? If risk factors are your focus, yes, but are they? Most people focus on outcome • Two outcomes of importance • Life expectancy • Quality of Life or functioning along the way • Biological & physical events are mediators, & affect individuals very differently • Concern over cancer, blood pressure, cholesterol, etc might well in itself reduce life expectancy, or Quality of Life • As we'll see stress is bad, unquestionably. Impedes on qual of life • A balancing act... most cost effective and most beneficial looking at behavioural intervention death as a behavioural outcome - no observable behavioural activity = death outcome measures in studies often use mortality and quality of life but often do not include behavioral aspects helpful behaviours such as healthy eating are not shown immediate benefits but in future which should be considered in health not just the ability to function now treat the patient not the disease

Objective measures

• Most measures still involve the possibility of human error or bias through coding, choosing what to measure and when, and deciding how the data should be analysed. • An objective measure of a psychological construct may miss the important part of that construct (e.g. is cortisol really a reflection of stress or just one component of it?).

Terminology in positive health

• Much of "h care" is illness care. How can we fix someone bringing them to a neural state • Even the occasional forays made by professionals into disease prevention and h promotion focus on the reduction of risk factors for illness and • very rarely on the encouragement of "good health" in its own right. • If it ain't broke don't fix it?? • What does good h / bad h mean? - How do we decide? - Who decides? if someone is in good h, why do we need to do anything? --- example of what others can do to have good h, preventative measures

Measuring obesity

• Obesity can be measured in various ways. (1) Population Means • Getting the mean weight of a population (e.g., a country) • Then determining whether an individual is below average, average or above average • Mild obesity - 20-40% overweight • Moderate obesity - 41-100% overweight • Severe obesity - >100% overweight • (2) BMI (Body Mass Index) • Calculated using the equation: kg/m2 • Normal weight (20-24.9) • Overweight (grade 1: 25-29.9) • Clinical obesity (grade 2: 30-39.9) • Severe obesity (grade 3: 40+) • Problems: • Doesn't account for location of fat. • Doesn't allow for differences in weight of muscle and fat • (most strength-focused athletes are considered obese). • (3) Waist-to-Hip Ratio (W/H) • Lower ratio indicating less visceral fat (around organs), which is good. • (4) Waist circumference: • Waist reduction is recommended when: • >102 cm in men • > 88 cm in women • High waist circumference is associated with risk for: • Cardiovascular Disease • Insulin resistance & development of Type-2 diabetes • (5) Percentage body fat • Basic assessment: skinfold thickness using callipers - at upper arm, upper back, lower back • Advanced assessment - bioelectrical impedance analysis - measured using a bioelectrical current between a person's hand and foot • Water conducts electricity and fat is an insulator - therefore the current can be used to calculate the ratio between water and fat

Surge of interest in Buddhism and Eastern Philosophies

• Occurred after the Second World War. • There were many factors that started this in 1960s and 1970s (e.g., Beatles George Harrison and John Lennon and Hare Krishna). • Alan Watts was a particularly prolific writer of e philosophy. Relevant for psychology was his book Psychotherapy e and w.

3. Restrained eating

• Overeating as a consequence of unsuccessful dieting • Chronic diet is impossible → eventually leads to relapse • Ignoring of internal cues (e.g., hunger) leads to a heightened sensitivity to external cues (which can lead to overeating) • Emotional and external eating are thus consequences of dieting

2. Emotional eating: Psychosomatic Theory

• Overeating as a reaction to emotion • People learn to label negative feelings (e.g., depression, anxiety) as hunger • Develop the habit of overeating to react against emotional feelings

How does the GCT differ from earlier models of pain?

• P as a perception. According to the GCT, p is a perception and an experience rather than a sensation. This change in terminology reflects the role of the individual in the degree of p experienced. In the same way that psychologists regard vision as a perception, rather than a direct mirror image, p is described as involving an active interpretation of the pful stimuli. • The individual as active, not passive. According to the GCT, p is determined by central and peripheral fibres. P is seen as an active process as opposed to a passive one. The individual no longer just responds passively to painful stimuli, but actively interprets and appraises painful stimuli. • The role of individual variability. Individual variability is no longer a problem in understanding pain but central to the GCT. Variation in pain perception is understood in terms of the degree of opening or closing of the g • The role for multiple causes. The GCT suggests that many factors are involved in pain perception, not just a singular physical cause. • Is pain ever organic? The GCT describes most pain as a combination of physical and psychological. It could, therefore, be argued that within this model pain is never totally either organic or psychogenic. • Pain and dualism. The GCT attempts to depart from traditional dualistic models of the body and suggests an interaction between the mind and the body.

e therapy study observations

• Participant feedback indicated no major problems with delivery format • May have been slightly less willing to ask questions (facilitator noted fewer questions than usually expected) • One session had technical problems delaying start of session by 15 min • Therefore still requires presence of a researcher • But also shows that effectiveness might not be compromised if guest speaker or mentor is not in physical proximity

What is obesity?

• Population means. Population means involves exploring mean weights, given a specific population, and deciding whether someone is below average weight, average or above average in terms of percentage o w. Stunkard (1984) suggested that o should be categorized as either mild (20-40 per cent o w), moderate (41-100 per cent o w) or severe (100 per cent overweight). This approach is problematic as it depends on which population is being considered - someone could be o in India but not in the USA. • BMI. Body mass index (BMI) is calculated using the equation weight (kg)/height (m2). This produces a figure that has been categorized as normal weight (20-24.9); o w (grade 1, 25-29.9); clinical o (grade 2, 30-39.9); and severe o (grade 3, 40) (see Figure 15.2). This is the most frequently used definition of o. However, it does not allow for differences in weight between muscle and fat - a bodybuilder would be considered o. • Waist circumference. BMI is the most frequently used measure of o but it does not allow for an analysis of the location of fat. This is important as some problems such as diabetes are predicted by abdominal fat rather than lower body fat. Researchers originally used waist:hip ratios to assess o but recently waist circumference on its own has become the preferred approach. For men, low waist circumference is < 94cm; high is 94−102cm and very high is > 102cm. For women, low waist circumference is < 80cm; high is 80−88cm and very high is > 88cm. Weight reduction is recommended when waist circumference is greater than 102cm in men and 88cm in women (Lean et al. 1995). A reduction in waist circumference is associated with a reduction in cardiovascular risk factors and abdominal obesity is associated with insulin resistance and the development of type 2 diabetes (Chan et al. 1994; Han et al. 1997). Waist circumference has been suggested as the basis for routine screening in primary care (Despres et al. 2001) although Little and Byrne (2001) have argued that more evidence is needed before such a programme should be implemented. • Percentage body fat. As health is mostly associated with fat rather than weight per se, researchers and clinicians have also developed methods of measuring percentage body fat directly. At its most basic this involves assessing skinfold thickness using callipers, normally around the upper arm and upper and lower back. This is not suitable for those individuals who are severely obese and misses abdominal fat. At a more advanced level, body fat can be measured using bioelectrical impedence which involves passing an electrical current between a person's hand and foot. As water conducts electricity and fat is an insulator, the impedence of the current can be used to calculate the ratio between water and fat and therefore an overall estimate of percentage body fat can be made.

The past and present of positive health

• Psychology has done reasonably well with mental illness. - Somewhat treatable = Depression, anxiety etc. • Medicine or the biomedical model, has long focused on the prevention, diagnosis, treatment, & cure of disease & illness. - Very good job. Many cures. • Both psychology & medicine have done poorly with h & mental h. - Optimal functioning, positive emotion, engagement, purpose, positive relationships, etc.

'New' risk factor: lack of sleep

• Sleeping less than 6 hours per night has been found to be a risk factor for the development of obesity Possible Mechanisms: Short Sleep and Weight Gain

Kaplan (1990) an alternative to biological model

• Studies criticised if no examination of blood chemistry, cholesterol, blood pressure, immune response, or use of disease categories • Equated by many as a more 'scientific approach' • Biological measures viewed as pure, more reliable, more valid - which is not the case, biological measures are often not asessed for reliability • Just because we can measure something, doesn't mean the measure is useful • Reliability is about consistency of measure, A measure is said to have a high reliability if it produces similar results under consistent conditions. Validity is about accuracy of measure • reliability does not mean validity! "Biologicalisation" for example, studies have shown that blood pressure is increased in the presence of physicians called - white coat hypertension and measures of rhumetology have been difficult to evaluate such as arthritus measure have not been reliable

End states: the negative and positive health

• The absence of disease is often taken to be equivalent to health. • However: - When disorders or illness ends, health or mental health is not always evident. • Correlation between happiness & depression = -0.35 (rather than -1). - If one variable increases, the other variable decreases but not to the same magnitude. • Thus mental disorders impede mental health, but • Do not preclude mental health aspects like positive emotions, engagement, etc. flourishing vs languishing - living your best life vs not having good mental health but not having a mental disorder "Bringing about wellbeing might be one of the best weapons against mental disorder" happiness and depression don't correlate

Ross and Olson (1981) summarize the placebo effects

• The direction of placebo effects parallels the effects of the drug under study. • The strength of the placebo effect is proportional to that of the active drug. • The reported side-effects of the placebo drug and the active drug are often similar. • The time needed for both the placebo and the active drug to become active are often similar.

Effectiveness of MBSR

• The effectiveness has been studied much more than other therapies (with depression, chronic pain, coping with cancer, heart disease, and also general population with no specific problems). • In cancer patients, it leads to better mood, better sleep quality and reduced stress. • However, meditation is more than simply relaxation. • In patients with chronic pain, the goal is not to strive to reduce pain, but to observe sensations and emotions as they happen in the moment. • A famous saying goes: "Pain is inevitable, suffering is optional".

Nutritional Theories: What causes obesity?

• There is mixed evidence whether people with obesity eat more than those with healthy body weights. • It seems that the type of food consumed plays a more important role • (more fat consumed). • Calories from fat lead to more weight gain than calories from carbohydrates. The fat proportion theory of obesity (Blundell & Macdiarmid, 1997) - Possible Mechanisms 1. Benefits of Complex Carbohydrate Use - it takes more energy to burn carbohydrates than fat. Carbohydrates are burned, fat is stored. 2. Benefits of Complex Carbohydrates to Hunger - carbs reduce hunger due to their bulk/fibre content 3. Costs of Fat to Hunger - fat does not switch off the desire to eat, making it easier to eat more fat without feeling full

Session 1 e therapy study

• This occurred face to face • Classroom tables were moved to the side and chairs arranged in a circle • An ice breaker introduction game was played • The also facilitator introduced himself, his background, and experience • The purpose of the course was outlined • Researchers were introduced • Researchers participated in all exercises just like any other participants • The facilitator explained mindfulness in his own words • The facilitator explained the role of posture when sitting • The facilitator brought cushions and gave the option for participants to try them while explaining posture • The session finished with a 10-min meditation exercise • Home practice included: • www.youtube.com/watch?v=AfWK6hvUjEg • Also loving kindness

Reasons for the increase in prevalence of obesity?

• Thrifty Genotype Hypothesis (Neel, 1972). Natural selection favoured individuals with a highly efficient rate of fat storage during periods between famines. But: - Famines only become a regular occurrence with the introduction of agriculture (10,000 years ago) - Most people in famine die of disease rather than starvation - People who die in famines tend to be those of non-reproductive age (children and elderly) Thrifty Phenotype Hypothesis Hales and Barker (1992) Gene expression is triggered by environmental cues. The pathways of foetal development are determined by anticipated environmental conditions. In response to "hard times", the foetus makes a series of metabolic adaptations to increase chances of survival in postnatal life. Metabolism is then geared towards being small, hoarding calories, and avoiding exercise

Factors influencing which coping strategy is used

• Type of problem. Work problems seem to evoke more problem-focused coping whereas health and relationship problems tend to evoke emotion-focused coping (Vitaliano et al. 1990). • Age. Children tend to use more problem-focused coping strategies whereas emotion-focused strategies seem to develop in adolescence (Compas et al. 1991, 1996). Folkman et al. (1987) reported that middle-aged men and women tended to use problem-focused coping whereas the elderly used emotion-focused coping. • Gender. It is generally believed that women use more emotion-focused coping and that men are more problem-focused. Some research supports this belief. For example, Stone and Neale (1984) considered coping with daily events and reported that men were more likely to use direct action than women. However, Folkman and Lazarus (1980) found no gender differences. • Controllability. People tend to use problem-focused coping if they believe that the problem itself can be changed. In contrast they use more emotion-focused coping if the problem is perceived as being out of their control (Lazarus and Folkman 1987). • Available resources. c is influenced by external resources such as time, money, children, family and education (Terry 1994). Poor resources may make people feel that the stressor is less controllable by them, resulting in a tendency not to use problem-focused coping. • c training. Kaluza (2000) evaluated an intervention designed to change the coping profiles of 82 healthy working men and women. The intervention lasted for 12 weeks and focused on assertiveness, cognitive restructuring, time management, relaxation, physical activities and the scheduling of pleasant activities. Changes were compared to a control group who received no intervention. The results showed significant improvements in emotion focused coping and problem-focused c which were related to the individual's original c profiles. In particular, those who were originally more problem-focused became more emotion-focused and those who were more avoidant c became more problem-focused. The authors suggest that the intervention changed unbalanced c profiles. In addition, these changes were related to improvements in aspects of well-being.

Videoconferencing for e therapy

• Using the commercially available software GoToMeeting. • Allows real-time audiovisual interaction • The researcher received an invite, which allowed them to connect to the remote session. • View could be switched between two cameras and zoomed in and out • PowerPoint presentation could also be shared • After each session, one of the researchers forwarded additional material (such as links to videos) to the participants for additional exercises

How do we measure positive health?

• We measure what we value, we value what we measure. Wellbeing Compass https://mywellbeingcompass.com/ we need to measure what we value • Optimal wellbeing includes facets - body (physical), - heart (emotional), - mind (mental), and - spirit (spiritual). --- Holistic • State of distress, - facets out of balance result of perceived stressors. - biochemical, structural, electromagnetic, emotional, mental, and spiritual. - 1st three stressors impact physical facet. - last three stressors impact emotional, mental, & spiritual facets. some may say that they are not spiritual however, everyone can appriciate something bigger than them uch as a sunset. Studies show that those who incorperate spirituality, meditation etc are healthier. chronic stress can lead to chronic disease The Illness-Wellness Continuum was first proposed by Travis in 1972. Suggests wellbeing includes mental & emotional health, as well as the presence or absence of illness.

Benefits of weight loss

• Weight loss is linked to: • Elation, improved self-confidence, wellbeing • Improved blood pressure • Reduction in CHD risk • Improvements for diabetics • Even if weight loss is fairly small. • However, risk of weight regain & its negative consequences. • According to restraint theory, restrained eating should be avoided; different kinds of food and exercise instead (although more beneficial for weight loss maintenance)

Mindfulness attention and awareness scale (MAAS)

• has 15 statements, and the respondent ticks the appropriate answer on a Likert scale (1= "strongly disagree, 2= "disagree",...). •All answers are converted into one single score. •Example question: •"I find myself doing things without paying attention" critisized as measuring absentmindedness but is that the opposite of m? limited, does not measure judgment etc

The Freiburg Mindfulness Inventory (FMI)

• has 30 statements, and the respondent ticks the appropriate answer on a Likert scale (1= "strongly disagree, 2= "disagree", ...). •All answers are converted into one single score. •Example question: "I am open to the experience of the present moment" for experienced meditators

Giving mindfulness questionaires to monks

•Christopher et al. (2009) gave the MAAS and KIMS to Theravada m and American university students. •The m had higher scores on awareness, but lower scores on observing and accepting without judgment. The problem is that this kind of exercise is littered with biases related to language (e.g. translations, different connotations) and culture. •Feng et al. (2018) conducted a cognitive interviewing study with more questionnaires and senior Buddhist from a variety of traditions. They concluded that mindfulness in Buddhism differs in terms of characteristics they described as purposeful, skillful, ethical, and profound.

Social consequences of obesity

•Psychological correlates of obesity in children • Decreased quality of life • Depression (bi-directional?) • Self-worth negative associated with obesity • Low self-esteem: Franklin et al., 2006, although certainly not all. • But boys are less affected.

Women's indictment of the medical system in 1970s NZ...

"We have been treated like children, neurotics and idiots... We have been given prescriptions, drugs, injections, incisions and stitches. We have been told our pain is imaginary when we could feel it in our guts. We have been forced to bear children we did not want... We have had to beg and plead, and pretend we were mad to get sterilisations and abortions...We have not been listened to. We have had enough." (Broadsheet Collective, 1974, p. 4, Broadsheet)

Final Word From EKR

"is not meant to be a textbook on how to manage dying patients, nor is it intended as a complete study of the psychology of dying, It is simply an account of a new and challenging opportunity to refocus on the patient as a human being, to include him in dialogues, to learn from him the strengths and weaknesses of our hospital management of the patient. We have asked him to be our teacher so that we may learn more about the final stages of life with all its anxieties, fears, and hopes" (p. xi)

Neurophysiology of Mindfulness

"m is proposed to be a unique form of higher-order information processing in which subjective assessment of transient events is silenced in favour of maintaining objectivity and gaining insight" (Ives-Deliperi et al., 2011, p. 240). m may promote psychological health through disintegration of both self-concept and permanent sense of self (Martin, 1997). m may enhance unfocused and sustained attention capacity, memory and executive function. Limitations: methodology and lack of research on pure m.

Problem-focused coping

"refers to efforts to improve the troubled person-environment relationship by changing things, for example, by seeking information about what to do, by holding back from impulsive and premature actions, and by confronting the person or persons responsible for one's difficulty." Monat and Lazarus (1991, p. 6) "cool" cognitive systems - Metcalfe & Mischel (1999) E.g., Cancer - consult experts, determine best course of action.

What factors influence stress appraisals?

*Personal factors* include intellectual, motivational and personality characteristics Self-efficacy - the confidence in one's abilities to solve problems Motivation - perceived importance of a goal increases its s Belief system - attitudes to encountering s Hardiness - personal resilience to s *Environmental variables* Familiarity, predictability, controllability and clarity favour challenge Ambiguity, imminence, poor timing and long duration tend to favour threat Of course environmental and personal variables interact... E.g., ambiguity, controllability *Cognitive* s can distract attention from other tasks, but also enhance attention toward the s...or Tuning out, remembering emotional events s can inhibit cognitive functioning, including short- and long-term memory and motivation s about an event can maintain thoughts about s events But, remember Lazarus and Eriksen (1952): Students with high academic standing tended to improve performance under s, while those with low standing did more poorly and were more variable. *Emotional* Younger infants display s by d...s, older infants display anger Adults can also display anger in reaction to s Cognitive a's assigned to sful event determine emotional reaction Physiological rxn similar, use context Fear is a common response to s - can also manifest as phobias and anxiety s can lead to depression *Social behaviour* Emergency situations can foster cooperation s can lead to hostility, insensitivity and social withdrawal E.g., serious illness s accompanied by anger can increase negative social behaviours E.g., relationship between parental s and child abuse... s can decrease helping behaviours Difficult task -- opportunity to help study

Coping strategies

*Problem‑focused* used to reduce demands or expand resources when the situations are changeable. *Emotion‑focused* utilises behavioural and cognitive techniques to deal with unchangeable conditions. People more likely to use: Problem-focused for work-related Emotion-focused for health-related

Symptoms of stress

- Long-term state of reacting to complex environmental demands. - Physical symptoms can include: low energy, insomnia, lowered immune system (frequent colds), upset stomach and headaches - Long-term s leads to burnout: state of exhaustion, characterized by feelings of disillusionment and helplessness. Loss of interest and motivation, irritability, feeling overwhelmed and resentful.

Adjustment after stroke (Theadom et al., 2019)

- Longitudinal qualitative study: 55 stroke patients plus 27 significant others (6, 12, 24 & 36 months post-stroke) - Explored people's experiences over the first 3 years to identify what factors influence adjustment - Patients described an ongoing process of shock, disruption, fear, making sense of what had happened to them, evolving a new "normal", managing ups and downs. - Adjustment process continued over 3 years, even for those who recovered. - Implications: the importance of attending to psychological processes: - "Rehabilitation services need to support patients to make sense of their stroke, navigate the health system, address individual concerns and priorities and to know what, when and how much to challenge themselves."

Rehabilitation psychology interventions

- Making sense of illness and injury - Facilitating lifestyle change - Rebuilding sense of self - Identifying values and meaningful goals - Managing sleep and fatigue - Coping with cognitive and behavioural difficulties - Reducing emotional consequences - Building social relationships - Maximising independence and participation

individual differences and stress

- Many areas of psychology seem ambivalent (implicitly): General laws transcending context. With notable exceptions Noise, errors of measurement, variations around general laws... - Substantial i d in response to 's...ors': Do we simply passively respond? Lazarus & Eriksen (1952) - threat of failure increased variability Is it useful to suggest that some events are statistically more likely to result in a s reaction?

Attachment and Sick Behaviour

- secure: "trusting others" "feels worthy of other's attention" --- low anxiety, low avoidance - preoccupied: "emotionally dependent on others" low avoidance, high anxiety - healthcare overuse - dismissive: "compulsively self-reliant" low anxiety, high avoidance - mixed findings - fearful: "approach-avoidance behaviour" high anxiety, high avoidance - healthcare underuse

Problems with the Cannon and Selye Models

1. Both regarded the individual as automatically responding to an external stressor and described stress within a straightforward stimulus-response framework. They therefore did not address the issue of individual variability and psychological factors were given only a minimal role. For example, while an exam could be seen as stressful for one person, it might be seen as an opportunity to shine to another. 2. Both also described the physiological response to stress as consistent. This response is seen as non-specific in that the changes in physiology are the same regardless of the nature of the stressor. This is reflected in the use of the term 'arousal' which has been criticized by more recent researchers. Therefore these two models described individuals as passive and as responding automatically to their external world.

NZ MINISTRY OF HEALTH - EATING GUIDELINES

1. Enjoy a variety of nutritious foods every day including: • plenty of vegetables & fruit • grain foods, mostly whole grain & those naturally high in fibre • some milk & milk products, mostly low & reduced fat -- HOWEVER some nutritionists say that low fat is worse as it has added sugar • some legumes, nuts, seeds, fish & other seafood, eggs, poultry (e.g., chicken) and/or red meat* with fat removed. * If choosing red meat, eat less than 500 g of cooked red meat a week. 2. Choose and/or prepare foods & drinks: • with unsaturated fats instead of saturated fats • low in salt (sodium); if using salt, choose iodised salt • with little or no added sugar • mostly 'whole' & less processed. 3. Make plain water your first choice over other drinks. 4. If you drink alcohol, keep your intake low. • Stop drinking alcohol if could be pregnant, are pregnant or trying to get pregnant. 5. Buy or gather, prepare, cook & store food in ways that keep it safe to eat. https://www.health.govt.nz/our-work/eating-and-activity-guidelines https://www.health.govt.nz/system/files/documents/publications/eating-activityguidelines-for-new-zealand-adults-oct15_0.pdf

limitations of chronic model

1. Exercise protects against the wear and tear of stress with more active individuals being less likely to die from cardiovascular disease than more sedentary individuals (Kivimaki et al. 2002). However, exercise can also immediately come before a heart attack. 2. The wear and tear caused by stress can explain the accumulative damage to the cardiovascular system, but this c model does not explain why coronary events occur when they do. In the light of these problems, Johnston (2002) argues for an a model.

Physiological theories: What causes obesity?

1. Genetic Theories: •1 obese parent → 40% chance of having an obese child •2 obese parents → 80% chance of having an obese child Evidence from: •Twin Studies - Stunkard et al. (1990) found that 60-70% of variance in body weight was determined by genetics. BUT the role of genetic appears to be greater in lighter twins. •Adoptee Studies - strong relationship between adopted child & biological parents' weight class (especially mother). No relationship with adoptee parents' weight class. •Possibly is due to: metabolic rate, number of fat cells, appetite regulation. 2. Metabolic Rate Theory: •The rate of energy use for biological processes that keep us alive (e.g., respiration, heart rate, blood pressure) is called: resting metabolic rate (RMR) - which is highly heritable. •Relationship between metabolic weight gain: • Researchers studied RMR of Pima Native Americans (80% obesity rate) through breathing over a 40-min period - oxygen consumed and CO2 were measured • After 4 years, the participants who gained weight had the lowest metabolic rates. Similar results in other studies. • However - other research indicates that overweight people have a slightly higher metabolic rate, although they might have lower rates prior to their weight gain. 3. Fat Cell Theory • People of average weight - 25-35 billion fat cells • Mildly obese people have larger cell sizes • Severely obese: 100-125 billion fat cells • Cell number is mainly determined by genetics • Growth in the number of fat cells occurs during gestation & early childhood • Fat cells are typically stable - once made, they can never be lost (only emptied) 4. Set-Point Theory • There is an internal control for fat storage & weight which matches appetite & energy-expenditures • Genetic factors are the primary determinants of weight setpoints • Retention of weight lower than one's physiological set-point can trigger hunger & distress • Hunger, in turn, can lead to preoccupation with food, which can result in loss of control and binge eating • Problems with this theory is that it can't explain the "obesity epidemic" or psychological and social influences on hunger & eating.

Impact of Subjective Wellbeing on Health

1. Likelihood of contracting an illness. - Higher levels of positive emotions protect against various illness: • Heart disease. • Winter colds. 2. Length of life after contracting illness. - Longer, but: • A positive and optimistic viewpoint can hinder help seeking and adoption of medical advice. 3. Persons life span. - Happier people live longer

Problems with obesity and CHD research

1. Measuring and defining o is problematic as they rely upon assessments of body weight and body size, whereas the factor that is most linked to health status is probably body fat. Therefore research can show contradictory evidence for the consequences of obesity which probably illustrates the drawbacks of using proxy measures (i.e. BMI and waist circumference) for what the real measurement should be (i.e. body fat). 2. O is a product of biological factors (e.g. genetics), social factors (e.g. the food industry, town planning) and psychological factors (e.g. diet, exercise, beliefs). Research tends to focus on the contribution of one set of these factors. How they all interact remains unclear. This means that most research misses the complexity of the obesity problem. However, if research were to try to address all these factors, the studies would become unwieldy and the conclusions would be too complex to put into practice. 3. CHD illustrates the impact of stress and behaviour on illness. Research focuses on how these factors can predict CHD and how they can be changed to prevent the development of CHD or prevent the reoccurrence of a myocardial infarction in the future. Central to this is the measurement of stress and behaviour which is problematic due to the reliance upon self-report. This may be particularly biased if a person has been identified as having CHD and wishes to seem to be compliant with any recommendations they have been given by their health professional.

Some Problems with Illness Cognitions Research

1. Research often explores how people feel about their symptoms or i by using existing questionnaires. It is possible that such measures change beliefs rather than simply access them (i.e. do I really have a belief about what has caused my headache until I am asked about it?). This is the same as the mere measurement effect described in Chapter 3. 2. Models of i behaviour describe how the different constructs relate to each other (i.e. i representations are associated with coping). It is not always clear, however, whether these two constructs are really discrete (e.g. 'I believe my i is not going to last a long time' could either be an i cognition or a coping mechanism). 3. Many of the constructs measured as part of research on i behaviour are then used to predict health outcomes such as i beliefs and coping. It is not clear how stable these constructs are and whether they should be considered states or traits. As a self-regulatory model, the changing nature of these constructs is central. However, it presents a real methodological problem in terms of when to measure what and whether variables are causes or consequences of each other

++Models of Health Behaviour:

1. The Health Belief Model (HBM) The Health Belief Model states that preventive behaviours are determined by two factors: (1) The evaluation of the threat of a health problem, (2) The weighing of the pros & cons of performing the behaviour The perceived threat is composed of: 1. Perceived seriousness of the health problem 2. Perceived susceptibility 3. Cues to action (e.g., reminders, public service announcements)

Costs and benefits of lab and naturalistic settings

1. The degree of stressor delivered in the laboratory setting can be controlled so that differences in stress response can be attributed to aspects of the individual rather than to the stressor itself. 2. Researchers can artificially manipulate aspects of the stressor in the laboratory to examine corresponding changes in physiological and psychological measures. 3. Laboratory researchers can artificially manipulate mediating variables such as control and the presence or absence of social support to assess their impact on the stress response. 4. The laboratory is an artificial environment which may produce a stress response that does not reflect that triggered by a more natural environment. It may also produce associations between variables (i.e. control and stress) which might be an artefact of the laboratory. 5. Naturalistic settings allow researchers to study real stress and how people really cope with it. 6. However, there are many other uncontrolled variables which the researcher needs to measure in order to control for it in the analysis.

Evaluative conditioning

A form of associative learning whereby an attitude object is paired repeatedly with an object which is either viewed positively or negatively as a means to make the attitude object either more positive or negative. This method is frequently used in marketing as a means to make relatively neutral objects (e.g. perfume, cigarettes, pet food, air freshener) seem more positive by pairing them with something that is inherently attractive (e.g. attractive people, green fields, romantic music, etc.). Gibson (2008) tested this process experimentally and reported that evaluative conditioning could make participants predictably choose between Coca-Cola or Pepsi depending on which one had been paired with positive meaning. In terms of health, Hollands et al. (2011) used an evaluative conditioning procedure to increase the negative value attached to unhealthy snacks such as crisps and chocolate. Participants were shown images of unhealthy snacks interspersed with aversive unhealthy images of the body for the experimental condition (e.g. artery disease, obesity, heart surgery), or a blank screen for the control condition. The results showed that the intervention resulted in more positive implicit attitudes compared to the control condition. In addition, those in the experimental condition also chose fruit rather than high calorie snacks in a behavioural task.

Behavioural medicine

A further discipline that challenged the biomedical model of health was behavioural medicine, which has been described by Schwartz and Weiss (1977) as being an amalgam of elements from the behavioural science disciplines (psychology, sociology, health education) and which focuses on health care, treatment and illness prevention. Behavioural medicine was also described by Pomerleau and Brady (1979) as consisting of methods derived from the experimental analysis of behaviour, such as behaviour therapy and behaviour modification, and involved in the evaluation, treatment and prevention of physical disease or physiological dysfunction (e.g. essential hypertension, addictive behaviours and obesity). Behavioural medicine therefore included psychology in the study of health and departed from traditional biomedical views of health by not only focusing on treatment, but also focusing on prevention and intervention. In addition, behavioural medicine challenged the traditional separation of the mind and the body.

Appetite Regulation genetic obesity

A g predisposition may also be related to a control. Over recent years researchers have attempted to identify the g, or collection of g, responsible for o. Although some work using small animals has identified a single g that is associated with profound o, for humans the work is still unclear. Two children have, however, been identified with a defect in the 'ob g', which produces leptin, which is responsible for telling the brain to stop eating (Montague et al. 1997). It has been argued that the obese may not produce leptin and therefore overeat. To support this, researchers have given these two children daily injections of leptin, which has resulted in a decrease in food intake and weight loss at a rate of 1-2kg per month (Farooqi et al. 1999). Despite this, the research exploring the role of g on a control is still in the very early stages. In summary, there is strong evidence for a g basis to o, but how this g basis expresses itself remains unclear, as the research on lowered metabolic rate has mostly been refuted and the g of appetite control remains in its infancy. There are also some problems with g studies which need to be considered. For example, the sample size of studies is often small, zygosity needs to be confirmed, and there remains the problem of the environment. Twin studies assume that the environment for twins is constant and that only the genetic makeup of non-identical twins is different. It is possible, however, that identical twins are brought up more similarly because they are identical whereas parents of non-identical twins emphasize their children's differences. In addition, adopted children often go to the homes of parents who are similar to their biological parents. There also remains a substantial amount of variance in body fat which is unexplained by genetics, and the recent increased prevalence of o in the West within populations whose gene pool has remained relatively constant points to a role for additional factors. This has led to researchers examining the impact of our changing environment.

The biopsychosocial model

A model of illness that holds that physical illness is caused by a complex interaction of biological, psychological, and sociocultural factors. developed by Engel (1977) attempt to integrate the psychological (the 'psycho') and the environmental (the 'social') into the traditional biomedical (the 'bio') model of health as follows: (1) the bio contributing factors included genetics, viruses, bacteria and structural defects; (2) the psycho aspects of health and illness were described in terms of cognitions (e.g. expectations of health), emotions (e.g. fear of treatment) and behaviours (e.g. smoking, diet, exercise or alcohol consumption); (3) the social aspects of health were described in terms of social norms of behaviour (e.g. the social norm of smoking or not smoking), pressures to change behaviour (e.g. peer group expectations, parental pressure), social values on health (e.g. whether health was regarded as a good or a bad thing), social class and ethnicity

How does control mediate the stress-illness link?

A number of theories have been developed to explain this • c and preventive behaviour. It has been suggested that high c enables the individual to maintain a healthy lifestyle by believing that 'I can do something to prevent illness'. • c and behaviour following illness. It has also been suggested that high c enables the individual to change behaviour after illness. For example, even though the individual may have low health status following an illness, if they believe there is something they can do about their health, they will change their behaviour. • c and physiology. It has been suggested that c directly influences health via physiological changes. • C and personal responsibility. It is possible that high c can lead to a feeling of personal responsibility and consequently personal blame and learned helplessness. These feelings could lead either to no behaviour change or to unhealthy behaviours resulting in illness.

Environmental Factors (health inequalities)

According to McKeown (1979) much of the improvement seen in health and mortality in the developed world is due to environmental and social factors rather than medical interventions. Such environmental factors include food availability, food hygiene, sanitation and sewage facilities, and clean water. These basic requirements vary by country and may contribute to health inequalities. In terms of sanitation facilities, in 2008 the WHO reported that 2,600 million worldwide were not using 'improved sanitation facilities' and that 1,100 million were still defecating in the open, which raises the risk of worm infestation, hepatitis, cholera, trachoma and environmental contamination. The use of improved sanitation facilities by WHO region is shown in Figure 2.18, which indicates that the lowest rates of use of improved sanitation facilities were in the African and South-East Asian regions. The state of drinking water is also linked to health and poor water is associated with illnesses such as vomiting, sickness, diarrhoea and cholera. Data from the WHO show that the lowest levels of safe drinking water are in the Africa and South-East Asian regions (see Figure 2.19). All these data therefore shows variation in key environmental factors which are linked to health and may help to explain health inequalities. In the developed world, where these basic requirements tend to be met, our health may still be influenced by our environment in terms of the quality of food available, easy access to fast unhealthy food, working environments that encourage a sedentary lifestyle, town planning which makes walking hard and using the car the norm, the absence of walkways or cycle paths and poor street lighting (see Chapter 15 for a discussion of the obesogenic environment).

Two effects of coping

According to models of stress and illness First, it should reduce the intensity and duration of the stressor itself. Second, it should reduce the likelihood that stress will lead to illness. Therefore effective c can be classified as that which reduces the stressor and minimizes the negative outcomes. Some research has addressed these associations. In addition, recent research has shifted the emphasis away from just the absence of illness towards positive outcomes.

Glucocorticoid resistance model

According to the GRM, chronic stress diminishes the immune system's sensitivity to glucocorticoid hormones that normally terminate the inflammatory cascade (For acute stress, cortisol has anti-inflammatory properties) When there are chronically elevated levels of g (e.g., cortisol), lymphocytes downregulate receptors of g hormones (and cortisol can no longer do its anti-inflammatory job!) Inflammation results can be seen in addiction or too much cortisol -- body gets used to it and ignore signals, down regulates and shut down receptors leading to needing to upregulate intake -- cortisol anti inflamatory response stops eg- coffee, need more over time addiction explanation from reading: So, how might the impact of stress on inflammatory conditions be explained? To answer this question, we propose a grm. Its basic premise is that chronic stress diminishes the immune system's sensitivity to g hormones that normally terminate the inflammatory cascade. The model begins with the notion that chronic stress elicits secretion of the hormonal products of the hypothalamic-pituitary-adrenocortical (HPA) and sympathetic adrenal medullary (SAM) axes. With continued exposure to high concentrations of these hormones, white blood cells mount a counterregulatory response and downregulate the expression and/or function of receptors responsible for binding g hormones. This receptor downregulation subsequently diminishes the immune system's capacity to respond to cortisol's anti-inflammatory actions. To the extent that this process occurs, inflammatory processes flourish and the course of disease subsequently worsens.

What causes illness? Biomedical model

According to the biomedical model of medicine, diseases either come from outside the body, invade the body and cause physical changes within the body, or originate as internal involuntary physical changes. Such diseases may be caused by several factors such as chemical imbalances, bacteria, viruses and genetic predisposition.

Affective cognition

Affect is a difficult construct to measure as at its most pure it is probably a state that exists prior to language and description. It is therefore the feeling we have before that feeling is turned into words. This creates problems for researchers as most of our studies use language-based measures. One approach therefore has been to define affective cognitions which are measured using emotional words such as 'pleasant', 'enjoyable', 'exciting' and 'boring'. Affective attitudes have been shown to be good predictors of behaviour (e.g. Lawton et al. 2009; see Chapter 3) and some studies have therefore developed interventions to change behaviour through the modification of affective attitudes. Sirriyeh et al. (2010) explored the impact of affective cognitions of physical activity and whether these variables could be changed by a brief text-based intervention. Adolescents were therefore randomized to one of four groups: (1) affective texts (focusing on affective beliefs such as 'physical activity can make you feel cheerful' and 'physical activity can make you feel more enthusiastic'); (2) instrumental texts (e.g. 'physical activity can help maintain a healthy weight' and 'physical activity can keep your heart healthy'); (3) both types of text; (4) neutral texts. The results showed that affective texts significantly increased physical activity but only for those who had been inactive at baseline.

What is the link between social support and health

Alameda County, California Study - Berkman and Syme (1979) 7000 men and women studied in 1965 Index based on four types of s ties: marital status, number contacts with friends and relatives, and church and group membership Persons with low scores (lack of s ties) had 9-year mortality rates 1.9 to 3 times greater than those with high scores (more s ties) Results have been replicated in U.S. and Europe Assoc with mortality independent of self-reported physical health, year of death, socioeconomic status, smoking, alcohol use, obesity, physical activity, utilisation of preventative health services, and cumulative index of h practices.

Value of working in the community

Allows direct observation of how the client is in their own environment Fosters ability to practice skills in the environment in which they will be needed Potential to offer higher impact of interventions - meeting the specific needs of the client Enhanced knowledge and links to a range of services available to the client

Legal euthanasia

Almost always involves detailed constraints and restrictions That the act should be at individual's request is universal requirement Other aspects vary considerably, usually include: Requirement that individual be terminally ill Requirement of second opinion Requirement to investigate and suggest other options Formal reporting Constraints on method used for killing

Developmental Origins of Human Adult Disease (DOHAD) Hypothesis

Also known as foetal programming. This is the notion that impaired fetal growth causes adult disease. In response to "hard times", foetus makes a series of metabolic adaptations to survive. These adaptations, or their effects, persist into adult life & can lead to insulin resistance, hypertension etc. Many metabolic, endocrine & cardiovascular disorders are thus the result of a mismatch between predicted & actual environment.

media as a negative influence

Although cigarette and alcohol adverts have now been banned across the USA and most of Europe, food adverts are still considered acceptable. For example, Radnitz et al. (2009) analysed the nutritional content of food on TV aimed at children under 5 and showed that unhealthy foods were given almost twice as much air time and were shown to be valued significantly more compared to healthy foods. Some research has explored the potential impact of TV adverts on eating behaviour. For example, Halford et al (2004) used an experimental design to evaluate the impact of exposure to food-related adverts. Lean, overweight and obese children were shown a series of food and non-food-related adverts and their snack food intake was then measured in a controlled environment. The results showed that overall the obese children recognized more of the food adverts than the other children and that the degree of recognition correlated with the amount of food consumed. Furthermore, all children ate more after exposure to the food adverts than the non-food adverts.

The benefits of obesity treatment

Although failed o t may be related to negative mood, actual weight loss has been found to be associated with positive changes such as elation, self-confidence and increased feelings of well-being (Stunkard 1984). This suggests that, whereas failed dieting attempts are detrimental, successful t may bring with it psychological rewards. The physical effects of o t also show a similar pattern of results. Yo-yo dieting and weight fluctuation may increase the chances of CHD and death, but actual weight loss of only 10 per cent may result in improved blood pressure and benefits for type 2 diabetes (Wing et al. 1987; Aucott 2008). These results again suggest that actual weight loss can be beneficial. Halmi et al. (1980) reported significant psychological and physical benefits of weight loss in the severely o. They compared a group of severely o subjects who received surgery with a comparison group who received a behavioural diet programme. The results indicated that the surgery group showed higher rates of both weight loss and weight maintenance. In addition, the diet group reported significantly higher changes in psychological characteristics, such as preoccupation with food and depression, than the surgery group. Thus permanent weight loss through surgery brought both physical and psychological benefits. Weight loss can therefore be beneficial in the o, but only if treatment is successful and the results are permanent. Therefore dieting may be rejected as a treatment but weight loss may still be seen as beneficial. An argument for treating severe o can be made, but only if a positive outcome can be guaranteed, as failed treatment may be more detrimental than no treatment attempts at all

Limits to disclosure

Although in many societies the tendency has moved away from concealment to disclosure as the default position, there are still some groups where the picture is less clear, including: Children Those with developmental delay The mentally ill Dementia sufferers

(Measuring illness beliefs/ cognition) illness perception questionairre

Although it has been argued that the preferred method to access i c is through interview, interviews are time-consuming and can only involve a limited number of subjects. In order to research further into individuals' beliefs about illness, researchers in New Zealand and the UK have developed the IPQ (Weinman et al. 1996). This q asks subjects to rate a series of statements about their i. These statements reflect the dimensions of identity (e.g. a set of symptoms such as pain, tiredness), consequences (e.g. 'My illness has had major consequences on my life'), time line (e.g. 'My i will last a short time'), cause (e.g. 'Stress was a major factor in causing my illness') and cure/control (e.g. 'There is a lot I can do to control my symptoms'). This questionnaire has been used to examine beliefs about i's such as chronic fatigue syndrome, diabetes and arthritis and has been translated in a number of different languages. A revised version of the IPQ has now been published (the IPQR; MossMorris et al. 2002) which has better psychometric properties than the original IPQ and includes three additional subscales: cyclical time line perceptions, i coherence and emotional representations. A brief IPQ has also been developed which uses single items and is useful when participants don't have much time or when they are completing a large battery of different measures (the B-IPQ; Broadbent et al. 2006). In addition, researchers have created a version of the IPQ-R for use with healthy people (Figueiras and Alves 2007).

Measuring immune changes

Although it is accepted that the i system can be changed, m such changes has proved to be problematic. The four main markers of i function used to date have been as follows: (1) tumour growth, which is mainly used in animal research; (2) wound healing, which can be used in human research by way of the removal of a small section of the skin and can be monitored to follow the healing process; (3) secretory immunoglobulin A (sIgA), which is found in saliva and can be accessed easily and without pain or discomfort to the subject; and (4) natural killer cell cytoxicity (NKCC), T lymphocytes and T helper lymphocytes, which are found in the blood. All these markers have been shown to be useful in the study of immune functioning (see Chapter 14 for a discussion of immunity and longevity in the context of HIV/AIDs). However, each approach to m has its problems. For example, both wound healing and tumour growth present problems of researcher accuracy. But both these m's are actual rather than only proxy measures of outcome (i.e. a healed wound is healthier than an open one). In contrast, whereas m's of sIgA, NKCC, T lymphocytes and T helper cells are more accurate, their link to actual health status is more problematic. In addition, the m of i function raises questions such as 'How long after an event should the i system marker be assessed?' (i.e. is the effect immediate or delayed?), 'How can baseline measures of the i system be taken?' (i.e. does actually taking blood/saliva, etc. cause changes in immune functioning?) and 'Are changes in i functioning predictive of changes in health?' (i.e. if we m changes in a marker, do we really know that this will impact on health in the long term?).

Is social support always a good thing?

Although most research points to the beneficial effects of s s, some studies suggest that at times s s may be detrimental to how an individual responds to stress. For example, laboratory results indicate that high perceived network support (i.e. a large number of people) sometimes relates to increased responses to stressors (Hughes and Curtis 2000; Hughes 2007). There have been several explanations for the negative impact of s s including the following: • A high number of s ties could increase the chances of vicarious distress if someone in one's social group is upset (Rook et al. 1991). • People with large s networks may prefer s forms of coping and therefore respond less well to stressors in isolated laboratory settings (Hughes 2007). • Large social networks provide the opportunity for upward s comparisons which may be detrimental to health (Hughes 2007). • The impact of s s may be mediated through other variables (O'Donovan and Hughes 2008). • Different types of s s may have either positive or negative effects. For example, de Ridder et al. (2005) identified 'overprotection' as a potentially harmful form of s. Research therefore indicates that stress can cause illness. Research also indicates that s s may mediate this relationship.

Measurement issues illness cognition

Although quantitative m of i and treatment beliefs are now commonly used, they are not without their limitations. Beliefs about i can be assessed using a range of m. Some research has used interviews (e.g. Leventhal et al. 1980, 2007a; Schmidt and Frohling 2000), some has used formal questionnaires (e.g. Horne and Weinman 2002; Llewellyn et al. 2003), some has used vignette studies (e.g. French et al. 2002) and other research has used a repertory grid method (e.g. Walton and Eves 2001). French and colleagues asked whether the form of method used to elicit beliefs about i influenced the types of beliefs reported. In one study French et al. (2002) compared the impact of eliciting beliefs using either a questionnaire or a vignette. Participants were asked either simply to rate a series of causes for heart attack (the questionnaire) or to read a vignette about a man and to estimate his chances of having a heart attack. The results showed that the two different methods resulted in different beliefs about the causes of heart attack and different importance placed upon these causes. Specifically, when using the questionnaire, smoking and stress came out as more important causes than family history, whereas when using the vignette, smoking and family history came out as more important causes than stress. In a similar vein French et al. (2001) carried out a systematic review of studies involving attributions for causes of heart attack and compared these causes according to method used. The results showed that stressors, fate or luck were more common beliefs about causes when using interval rating scales (i.e. 1-5) than when studies used dichotomous answers (i.e. yes/no). French et al. (2005) also asked whether causal beliefs should be subjected to a factor analysis as a means to combine different sets of beliefs into individual constructs (e.g. external causes, lifestyle causes, etc.) and concluded that although many researchers use this approach to combine their data, it is unlikely to result in very valid groups of causal beliefs. In addition, the IPQ measures have been criticized for having ambiguous subscales, for been too general and not specific to the beliefs of each individual, and for not being sufficiently relevant for the characteristics of each individual condition (French and Weinman, 2008). In summary, it appears that individuals may show consistent beliefs about i that can be used to make sense of their i and help their understanding of any developing symptoms. These i c's have been incorporated into a model of i behaviour to examine the relationship between an individual's c representation of their i and their subsequent coping behaviour. This model is known as the 'self-regulatory model of i behaviour'.

The professional health psychologist

Although still being considered by a range of committees, it is now generally agreed that a professional hp should have competence in three areas: research, teaching and consultancy. In addition, they should be able to show a suitable knowledge base of academic health psychology, normally by completing a higher degree in health psychology. Having demonstrated that they meet the required standards, a professional hp could work as an academic within the higher education system, within the health promotion setting, within schools or industry, and/or within the health service. The work could include research, teaching and the development and evaluation of interventions to reduce risk-related behaviour.

The academic health psychologist

An academic hp usually has a first degree in psychology and then completes a masters in health psychology and a PhD in a health psychology-related area. For example, they may focus their PhD on obesity, stress, coronary heart disease or behaviour change. They will then enter the pathway for an academic hp by getting a post-doctoral position or a lectureship at a university. The pathway in the UK involves the progression from lecturer, to senior lecturer, to reader and then professor (although in many countries the terms 'assistant professor', 'associate professor' and 'full professor' are used). The career of an academic involves teaching at all levels (undergraduate and postgraduate), project supervision for students, carrying out research, writing books and research articles in peer review journals and presenting work at conferences. Most academics also have an administrative role such as managing the examination process or directing the teaching programmes for undergraduate or postgraduate students

Cortisol Awakening Response (CAR)

An allostatic biomarker, CAR is defined as the brisk increase of c levels within 30 min of awakening in the morning Considered a sensitive indicator of the function of the HPA axis Increased CAR is associated with: Chronic stress and worrying Social stress and lack of social recognition Function of CAR - unknown, perhaps associated with daily need to get things done, enhanced need for energy

Stage 1 of SRM: interpretation

An individual may be confronted with the problem of a potential illness through two channels: symptom perception ('I have a pain in my chest') or social messages ('the doctor has diagnosed this pain as angina'). Once the individual has received information about the possibility of illness through these channels, according to theories of problem-solving, the individual is then motivated to return to a state of 'problem-free' normality. This involves assigning meaning to the problem. According to Leventhal, the problem can be given meaning by accessing the individual's illness cognitions. Therefore the symptoms and social messages will contribute towards the development of illness cognitions, which will be constructed according to the following dimensions: identity, cause, consequences, timeline, cure/control. These cognitive representations of the 'problem' will give the problem meaning and will enable the individual to develop and consider suitable coping strategies. However, a cognitive representation is not the only consequence of symptom perception and social messages. The identification of the problem of illness will also result in changes in emotional state. For example, perceiving the symptom of pain and receiving the social message that this pain may be related to coronary heart disease (CHD) may result in anxiety. Therefore, any coping strategies have to relate to both the illness cognitions and the emotional state of the individual

Stress management interventions

Antoni et al. (2006) randomized 130 gay men who were HIV positive to receive either a cognitive behavioural s m i (CBSM) and anti-retroviral medication adherence training (MAT) - training for taking meds regularly, or to receive MAT alone. The men were then followed up after 9 and 15 months in terms of viral load. The results showed no differences overall between the two groups. When only those men who already showed detectable viral loads at baseline were included (i.e. those with a lot of virus in the blood already), differences were found. In particular, for these men, those who received the stress management showed a reduction in their viral load over the 15-month period even when medication adherence was controlled for. The authors conclude that for HIV-positive men who already show a detectable viral load, stress management may enhance the beneficial effects of their anti-retroviral treatment. In a similar study, the mechanisms behind the impact of stress management were explored (Antoni et al. 2005). For this study 25 HIV-positive men were randomized to receive s m or a waiting list control. Urine samples were taken before and after the i period. The results again showed that s m was effective and that this effect was related to reduction in cortisol and depressed mood. The authors conclude that s m works by reducing the s induced by being ill with a disease such as HIV. Therefore, whereas s can exacerbate illness, s m can aid the effectiveness of treatment and reduce the consequences of the s resulting from being ill.

Psychological support for postcancer rehabilitation

Appropriate information resources and delivery Psychological support Self‐management strategies Connections to support groups Return to education or work support (vocational rehabilitation) Access to appropriate spiritual care and cultural support that assesses and addresses needs - Post-treatment - common questions for patients - Now what? - When will I get back to normal? - Is what I'm feeling normal? - Fears of recurrence - very common! - Aims of the psychological group‐based programme: - Processing loss and change - Cope with associated fear - Encourage post‐traumatic growth - "Your rehabilitation is just as important as your treatment" - Content of programme: - ACT‐based focus - Processing experiences/emotions and exploring change - Coping with uncertainty and post‐ treatment anxiety - Mindfulness: engaging in the present - Finding a new normal and exploring values - Goal setting - Outcomes: - Reduced distress/emotional impact - More confidence managing anxiety/worry/stress - Increased psychological flexibility (AAQ‐II) - Feeling empowered to move forward as a cancer survivor

Work

Are men still defined by "what they do"? A 'real man' will have a full-time permanent job, and support his family financially Men who are underemployed or unemployed, in role reversal homes, same-sex relationships or otherwise do not conform can be stigmatised. Some argue that the patriarchal society mitigates against women's freedom to make optimal life choices... does the opposite not apply, in what sense are the choices available to, or made by, males "optimal"? Better, worse, or just constrained differently?

Classical Conditioning and pain

As described by theories of associative learning, an individual may associate a particular environment with the experience of p. For example, if an individual associates the dentist with p due to past experience, the p perception may be enhanced when attending the dentist due to this expectation. In addition, because of the association between these two factors, the individual may experience increased anxiety when attending the dentist, which may also increase p. Jamner and Tursky (1987) examined the effect of presenting migraine sufferers with words associated with p. They found that this presentation increased both anxiety and pain perception and concluded that the words caused a change in mood, which caused a change in the subject's perception of p. This is further discussed in terms of the impact of anxiety

How does hostility link to stress

As described earlier, individuals vary in their physiological reactions to s, with some showing greater s reactivity than others. Researchers have argued that h may be the social manifestation of this heightened reactivity. To assess this, Guyll and Contrada (1998) explored the relationship between h and s reactivity and reported that chronically h people showed greater reactivity to s involving interpersonal interactions than non-h people. In addition, Fredrickson et al. (2000) indicated that h people show larger and longer-lasting changes in blood pressure when made to feel angry. Therefore h and s reactivity seem to be closely linked. What are the implications of this for the s i link

physical well being and social support (ss)

Associated with lower coronary heart risks - study of 3809 Japanese-American males - Berkman (1985) Associated with lower levels of PSA (a marker of prostate cancer) - Stone et al. (1999) Impact on health of having low levels of SS is similar in magnitude to the effects of smoking - House et al. (1988) With women, higher SS associated with fewer pregnancy complications, heavier and healthier babies, and lower rates of postpartum depression Shorter period of labour - experimental study - "s..ive lay women" - High SS: 8.7 hrs. Low SS 19.3 hrs. - Sosa et al. (1980)

ABCDE system

Awareness: because much of our self-talk is automatic, the first step is to become aware of the cognitions we hold and the ways in which these impact upon emotional and physical responses. This awareness process can involve diary-keeping, reflection and talking to a therapist. Beliefs: clients are then asked to rate their beliefs about each of the self-talk processes they hold to identify how strong their cognitions are. They should ask themselves 'How much do I believe that each of these cognitions is true?'. Challenge: clients challenge their thoughts through questions which ask for evidence or encourage the client to think through what other people would think or do in the same situation. Delete: Antoni and colleagues then argue that clients need to delete these self-statements and replace them with constructive cognitions. This can involve thinking through alternative explanations and different ways of making sense of what happens to them. Evaluate: the final stage is for the client to evaluate how they feel after the cognitions have been deleted and whether they feel the process has been successful.

transition from lapse to relapse (Marlatt and Gordon)

Baseline State Abstinence. If an individual sets total abstinence as the goal, then this stage represents the target behaviour and indicates a state of behavioural control. Pre-Lapse State High-risk situation. A high-risk situation is any situation that may motivate the individual to carry out the behaviour. Such situations may be either external cues, such as someone else smoking or the availability of alcohol, or internal cues, such as anxiety. Research indicates that the most commonly reported high-risk situations are negative emotions, interpersonal conflict and social pressure. This is in line with social learning theories, which predict that internal cues are more problematic than external cues. Coping behaviour. Once exposed to a high-risk situation the individual engages the coping strategies. Such strategies may be behavioural, such as avoiding the situation or using a substitute behaviour (e.g. eating), or cognitive, such as remembering why they are attempting to abstain. Positive outcome expectancies. According to previous experience the individual will either have positive outcome expectancies if the behaviour is carried out (e.g. 'smoking will make me feel less anxious') or negative outcome expectancies (e.g. 'getting drunk will make me feel sick'). No Lapse or Lapse? Marlatt and Gordon (1985) argue that when exposed to a high-risk situation, if an individual can engage good coping mechanisms and also develop negative outcome expectancies, the chances of a lapse will be reduced and the individual's self-efficacy will be increased. However, if the individual engages poor coping strategies and has positive outcome expectancies, the chances of a lapse will be high and the individual's self-efficacy will be reduced. • No lapse: good coping strategies and negative outcome expectancies will raise self-efficacy, causing the period of abstinence to be maintained. • Lapse: poor or no coping strategies and positive outcome expectancies will lower self-efficacy, causing an initial use of the substance (the cigarette, a drink). This lapse will either remain an isolated event and the individual will return to abstinence, or will become a full-blown relapse. Marlatt and Gordon describe this transition as the abstinence violation effect (AVE). Relapse prevention has been used in a multitude of different contexts as a means to change behaviour either on its own or as part of a complex intervention. For example, Roske et al. (2008) explored the impact of a smoking cessation intervention using relapse prevention techniques in women post-pregnancy. The results showed that the intervention predicted both non-smoking and improved self-efficacy by six months. But by one year the intervention group showed smoking levels similar to the control group. Learning theory (along with cognitive theory) therefore form the basis of many interventions to change behaviour. Some of these take the form of behavioural strategies with their emphasis on reinforcement, modelling and associative learning. Many incorporate both cognitive and behavioural strategies such as CBT (with its emphasis on behaviour change) and relapse prevention (with its emphasis on sustaining change and preventing relapse).

Who is responsible for illness? Biomedical model

Because illness is seen as arising from biological changes beyond their control, individuals are not seen as responsible for their illness. They are regarded as victims of some external force causing internal changes.

The amount eaten obesity

Because it was believed that the o ate for different reasons than the non-o, it was also believed that ... Research explored the food intake of the o in restaurants and at home, and examined what food they bought. For example, Coates et al. (1978) suggested that perhaps the o were overeating at home and went into the homes of 60 middle-class families to examine what was stored in their cupboards. They weighed all members of the families and found no relationship between body size and the mass and type of food they consumed at home. In an attempt to clarify the problem of whether the o eat more than the non-o, Spitzer and Rodin (1981) examined the research into eating behaviour and suggested that *'of twenty-nine studies* examining the effects of body weight on amount eaten in laboratory studies . . . *only nine* reported that overweight subjects ate significantly more than their lean counterparts'. Therefore the answer to the question 'Do the o eat more/differently to the non-o?' appears to be 'no'; the o do not necessarily overeat (compared with others). Over recent years, however, researchers have questioned this conclusion for the following reasons. First, much of the early research was based on self-report data, which are notoriously unreliable, with most people consistently under-reporting how much they eat (Prentice et al. 1986; Heitmann and Lissner 1995). Second, when the o and non-o are either over- or underfed in a controlled environment, these two groups gain or lose weight at the same rate, suggesting that the o must eat more in order to maintain their higher weight (Jebb et al. 1996). Finally, it has been argued that assessing food intake in terms of gross amount without analysing the types of food being eaten misses the complex nature of both eating behaviour and food metabolism (Prentice 1995). Further, if overeating is defined as 'compared with what the body needs', it could be argued that the o overeat because they have excess body fat.

Who is responsible for treatment? Health psychology

Because the whole person is treated, not just their physical illness, the patient is therefore in part responsible for their treatment. This may take the form of responsibility to take medication and/or responsibility to change their beliefs and behaviour. They are not seen as a victim.

Dividing up the soup

Beliefs (risk perception, outcome expectancies, costs and benefits, intentions, implementation (smoking, drinking, eating, screening) are conceptualized as separate and discrete. Health psychology then develops models and theories to examine how these variables interrelate. For example, it asks, 'What beliefs predict smoking?', 'What emotions relate to screening?' Therefore it separates out 'the soup' into discrete entities and then tries to put them back together again. However, perhaps these different beliefs, emotions and behaviours were not separate until psychology came along. Is there really a difference between all the different beliefs? Is the thought 'I am depressed' a cognition or an emotion? Health psychology assumes differences and then looks for associations. However, perhaps without the original separation there would be nothing to associate!

Obesity in childhood

Biggest risk factors: • Low birth weight (nutritionally deprived new-borns "programmed" to eat more because develop less neurons in a region of the brain that controls food intake) • Low SES • Parental obesity • Genetics vs. food preferences • Sleep duration • More sleep is protective against the development of obesity • Physically active children may be more likely to sleep throughout the night. • Television viewing • Decreased energy expenditure

Mechanism 3 of allostatic load: prolonged response

Body loses its effectiveness in turning off the stress response (e.g. after damage to hippocampal region). involves the failure to shut off either the hormonal stress response or to display the normal trough of the diurnal cortisol pattern. One example of this is blood pressure elevations in work-related stress which turn off slowly in some individuals with a family history of hypertension. Another example of perturbing the normal diurnal rhythm is that of sleep deprivation leading to elevated evening cortisol and hyperglycemia and depressive illness leading to chronically elevated cortisol and loss of bone mineral mass. After very p and severe stress, pyramidal neurons may actually die (Uno et al. 1989). Through some or all of these processes, the hippocampus undergoes an atrophy, and this can be picked up in the human brain by MRI in such conditions as recurrent depressive illness, Cushing's syndrome, post-traumatic stress disorder (PTSD), mild cognitive impairment in aging, and schizophrenia

Physiological measures for pain

Both self-report m and observational measures are sometimes regarded as unreliable if a supposedly 'objective' m of p is required. In particular, self-report m are open to the bias of the individual in p and observational m are open to errors made by the observer. Therefore ph measures are sometimes used as an index of p intensity. Such m include an assessment of inflammation and m of sweating, heart rate and skin temperature. However, the relationship between ph m and both observational and self-report m is often contradictory, raising the question, 'Are the individual and the rater mistaken or are the ph m's not m p?'

What is coping?

C has been defined by Lazarus and colleagues as the process of managing stressors that have been appraised as taxing or exceeding a person's resources and as the 'efforts to manage . . . environmental and internal demands' (Lazarus and Launier 1978). In the context of stress, c therefore reflects the ways in which individuals interact with stressors in an attempt to return to some sort of normal functioning. This might involve correcting or removing the problem, or it might involve changing the way a person thinks about the problem or learning to tolerate and accept it. For example, c with relationship conflict could involve leaving the relationship or developing strategies to make the relationship better. In contrast, it could involve lowering one's expectations of what a relationship should be like. Lazarus and Folkman (1987) emphasized the dynamic nature of c which involves appraisal and reappraisal, evaluation and re-evaluation. Lazarus's model of stress emphasized the interaction between the person and their environment. Likewise, c is also seen as a similar interaction between the person and the stressor. Further, in the same way that Lazarus and colleagues described responses to stress as involving primary appraisal of the external stressor and secondary appraisal of the person's internal resources, c is seen to involve regulation of the external stressor and regulation of the internal emotional response. Cohen and Lazarus (1979) defined the goals of c as: 1. To reduce stressful environmental conditions and maximize the chance of recovery. 2. To adjust or tolerate negative events. 3. To maintain a positive self-image. 4. To maintain emotional equilibrium. 5. To continue satisfying relationships with others.

stress-induced immune changes

Chronic s has been associated with a state of chronic low-grade inflammation, delayed wound healing, poor responses to vaccine, and increased susceptibility to infectious illnesses. Activation of neuroendocrine and sympathetic systems provides physiological pathways linking stress and these immune outcomes. Behavioral changes under conditions of chronic s also contribute to immune dysregulation. Behavioral and pharmacological interventions may attenuate s-induced i dysregulation.

Neurophysiology of Mindfulness: EEG

Davidson et al. (2003) compared cortical activity of 25 participants after 8 weeks MBSR to 16 wait-list controls. Significantly higher left-side anterior activation (C3/4) - linked to positive affective style was reported for mindfulness group compared to controls. This study also gave participants an influenza vaccine to test their immune system. Significant rise of antibody cells associated with mindfulness compared to control group. Also, decrease of negative affect & anxiety were reported.

Aspects of the individual (variability of emotional exp and immunity)

Demographics: Pennebaker (1997) concludes that the effectiveness of emotional expression does not seem to vary according to age, level of education, language or culture. However, a meta-analysis of writing studies by Smyth (1998) indicated that men may benefit more from writing than women and those who do not naturally talk openly about their emotion may benefit more than those who do. Personality and Mood: Pennebaker (1997) also concludes that anxiety, inhibition or constraint do not influence the effectiveness of writing. However, Christensen et al. (1996) concluded that individuals high on hostility scores benefited more from writing than those low on hostility. Use of Language: To explain the effectiveness of writing Pennebaker et al. (2001) developed a computer programme to analyse the content of what people were writing during the task. They coded the transcripts in terms of the types of words used: negative emotion words (sad, angry), positive emotion words (happy, laugh), causal words (because, reason) and insight words (understand, realize). The results from this analysis showed that greater improvement in health was associated with a high number of positive emotion words and a moderate number of negative emotion words. More interestingly, they also found that those who showed a shift towards more causal and insight words also showed greater improvement (Pennebaker et al. 1997). They concluded from this that this shift in language use reflected a shift from poorly organized descriptions towards a coherent story and that a coherent story was associated with better health status. However, in contrast to this Graybeal et al. (2002) directly assessed story-making and found no relationship with health outcomes.

Early Pain Theories: Pain as a Sensation

Described it within a biomedical framework as an automatic response to an external factor. Descartes, perhaps the earliest writer on pain, regarded it as a response to a painful stimulus. He described a direct pathway from the source of pain (e.g. a burnt finger) to an area of the brain that detected the painful sensation. Von Frey (1895) developed the specificity theory of pain, which again reflected this very simple stimulus-response model. He suggested that there were specific sensory receptors which transmit touch, warmth and pain, and that each receptor was sensitive to specific stimulation. This model was similar to that described by Descartes in that the link between the cause of pain and the brain was seen as direct and automatic. In a similar vein, Goldschneider (1920) developed a further model of pain called the pattern theory. He suggested that nerve impulse patterns determined the degree of pain and that messages from the damaged area were sent directly to the brain via these nerve impulses. Therefore these three models of pain describe the sensation in the following ways: • Tissue damage causes the sensation of pain. • Psychology is involved in these models of pain only as a consequence of pain (e.g. anxiety, fear, depression). Psychology has no causal influence. • Pain is an automatic response to an external stimulus. There is no place for interpretation or moderation. • The pain sensation has a single cause. • Pain was categorized into being either psychogenic pain or organic pain. Psychogenic pain was considered to be 'all in the patient's mind' and was a label given to pain when no organic basis could be found. Organic pain was regarded as being 'real pain' and was the label given to pain when some clear injury could be seen.

Cognitive Dissonance Theory

Developed by Totman (1987) attempted to remove patient expectations from the placebo equation and emphasized justification and dissonance. Totman placed his cd theory of placebos in the following context: 'Why did faith healing last for such a long time?' and 'Why are many of the homeopathic medicines, which have no medically active content, still used?' He argued that faith healing has lasted and homeopathic medicines are still used because they work. In answer to his question why this might be, Totman suggested that the one factor that all of these medically inert treatments have in common is that they require an investment by the individual in terms of money, dedication, pain, time or inconvenience. He argued that if medically inactive drugs were freely available, they would not be effective and that if an individual lived around the corner to Lourdes then a trip to Lourdes would have no effect on their health status.

Health inequalities

Due to the internet and the publication of online reports there is now a huge volume of data available from respected bodies such as the World Health Organization (WHO) and the Office for National Statistics (ONS), health charities such as British Heart Foundation (BHF), Cancer Research UK (CRUK), the British Diabetes Association (BDA) and the American Cancer Society (ACS) as well as academic groups such as the European Heart Network. These data provide insights into health inequalities across the world and within individual countries, and evidence generally indicates that the diseases people are diagnosed with and whether or not they die from them vary according to four key dimensions: geographical location; time; SES and gender. Time (i.e. changes throughout history) will not be explored independently as most available data includes this dimension in its analyses. Please read the following as a useful preliminary insight into the notion of variation and health inequalities, but do not expect it to be an exhaustive or systematic analysis of this vast database.

Social Cognition Theory

Emphasizes expectancies, incentives and sc (e.g. Bandura 1986). Expectancies include beliefs such as 'a poor diet can cause heart disease', 'if I changed my diet I could improve my health' and 'I could change my diet if I wanted to'. Incentives relate to the impact of the consequences of any behaviour and are closely aligned to reinforcements. For example, a healthy diet would be continued if an individual lost weight or had more energy but stopped if they became bored. Sc reflect an individual's representations of their social world in terms of what other people around think about any given behaviour. These constructs form the basis of sc models such as the theory of planned behaviour (TPB) and were described in Chapter 3 in the context of predicting how people behave. Recently this approach has been used to develop interventions to change behaviour with a focus on ways to change individual cognitions which in turn will result in changed behaviour. Further, as a development of this approach, research within the framework of sc theory has also explored the intention−behaviour gap and interventions that can be used to increase the likelihood that intentions will be translated into behaviour. These interventions consist of the use of planning, particularly implementation intentions. Finally, researchers have used knowledge- and information-based interventions as a means to change cognitions and therefore behaviour.

Health psychology aims to understand, explain, develop and test theory by:

Evaluating the role of behaviour in the aetiology of illness. For example: • Coronary heart disease is related to behaviours such as smoking, food intake and lack of exercise. • Many cancers are related to behaviours such as diet, smoking, alcohol and failure to attend for screening or health check-ups. • A stroke is related to smoking, cholesterol and high blood pressure. • An often overlooked cause of death is accidents. These may be related to alcohol consumption, drugs and careless driving. Predicting unhealthy behaviours. For example: • Smoking, alcohol consumption and high fat diets are related to beliefs. • Beliefs about health and illness can be used to predict behaviour. Evaluating the interaction between psychology and physiology. For example: • The experience of stress relates to appraisal, coping and social support. • Stress leads to physiological changes which can trigger or exacerbate illness. • Pain perception can be exacerbated by anxiety and reduced by distraction. Understanding the role of psychology in the experience of illness. For example: • Understanding the psychological consequences of illness could help to alleviate symptoms such as pain, nausea and vomiting. • Understanding the psychological consequences of illness could help alleviate psychological symptoms such as anxiety and depression. Evaluating the role of psychology in the treatment of illness. For example: • If psychological factors are important in the cause of illness, they may also have a role in its treatment. • Changing behaviour and reducing stress could reduce the chances of a further heart attack. • Treatment of the psychological consequences of illness may have an impact on longevity.

Understanding Sustained Behaviour Change

Even though there has been much research and a multitude of interventions, many people continue to behave in unhealthy ways. For example, although smoking in the UK has declined from 45 per cent in 1970 to 26 per cent in 2004, a substantial minority of the population still continue to smoke. Similarly, the prevalence of diet- and exercise-related problems, particularly obesity and overweight, is rising. Further, even though many people show initial changes in their healthrelated behaviours, rates of sustained behaviour change are poor, with many people reverting to their old habits. For example, although obesity treatments in the last 20 years have improved rates of initial weight loss, there has been very little success in weight loss maintenance in the longer term with up to 95 per cent of people returning to baseline weights by five years (NHS Centre for Reviews and Dissemination 1997; Jeffery et al. 2000; see Chapter 15). Similarly, nearly half of those smokers who make a quit attempt return to smoking within the year (see Chapter 4). If real changes are to be made to people's health status, then research needs to address the issue of behaviour change in the longer term. To date, however, most research has focused on the onset of new behaviours or changes in behaviour in the short term due to the use of quantitative methods, with prospective designs that have follow-ups varying from a few weeks only to a year, as longerterm follow-ups require greater investment of time and cost. Some research, however, has addressed the issue of longer-term behaviour change maintenance, particularly for weight loss, smoking cessation and exercise. • Weight loss maintenance: research indicates that although the majority of the obese regain the weight they lose, a small minority show weight loss maintenance. The factors that predict this are described in detail in Chapter 15 and illustrate a role for profile characteristics such as baseline body mass index (BMI), gender and employment status, historical factors such as previous attempts at weight loss, the type and amount of help received and psychological factors including motivations and individuals' beliefs about the causes of their weight problem. In particular, research suggests that longer-term weight loss maintenance is associated with a behavioural model of obesity whereby behaviour is seen as central to both its cause and solution see chap 3 for smoking and excersize egs In general it would seem that there is a role for a range of demographic, psychological and structural factors in understanding longer-term changes in behaviour and that, while some changes in behaviour may result from the 'drip drip' effect illustrated by stages and plans, other forms of change are the result of more sudden shifts in an individual's motivation. To date, however, there remains very little research on longer-term changes in behaviour. Further, the existing research tends to focus on behaviour-specific changes rather than factors that may generalize across behaviours.

Stereotypes vs actual behaviour?

Evidence that the stereotypes alone lead to male behaviours being interpreted differently by observers. Large studies suggest the differences in expression/inhibition are real. Kring and Gordon (1998) showed males and females watching films reported the same levels of emotions, by males were less expressive Doesn't generalise to all emotions while women are more open to expressing fear, sadness etc, men more open to expressing emotions around power and control - anger and jealousy... jealous rage if the exclusive sexual relationship is threatened can be viewed as quite appropriate/normal. But cultural differences - Spanish males and females were likely to view sexual jealousy an uncontrollable emotion and an adequate excuse for partner violence, a British sample was much less likely to take this view. Again, it seems that women experience anger and jealousy to the same degree, but are less likely to express these emotions - or perhaps express them in more passive/controlled ways? Contingencies - what are the reinforced behaviours? These are emotions that seem to run counter to men's unemotional facade, but also are counterproductive in terms of relationships and general wellbeing Emotional expression has a generally positive effect on emotional well-being, physical health and immune function (Smyth 1998, Brody, 1999) expression through writing has beneficial effects

Stress and immunity research

Example 1: Wound healing Dental Student Study two punch biopsies in 11 dental students - during examination s and while they were on vacation Measured healing with: (1) daily photographs, (2) foaming response to hydrogen peroxide (antiseptic) - it reacts with catalase from blood and damaged cells Results- Wounds took 3 days (40%) longer to heal on average - and no student healed as quickly as they did while they were on holiday. Interleukin cytokine production decreased 68% during exam time as well. NO variation Example 2: Cortisol and NK cell activity during bereavement (Irwin et al., 1988) results- Natural killer cell (NK) activity, which is important in the defense against tumors and viral infections, is reduced in women undergoing conjugal bereavement. Bereaved women showed reduced NK activity and increased plasma cortisol levels as compared to controls. Anticipatory bereaved women also showed significant reductions in NK activity, but had levels of plasma cortisol comparable to those of controls. The reduction of NK activity during anticipatory and actual bereavement cannot be explained solely on the basis of increased cortisol secretion. shows that its complicatated Example 3: Accelerated HIV progression in rejection-sensitive gay men (Cole, Kemeny, & Taylor, 1997) 9-year prospective study following 72 initially healthy HIV positive gay men Results- Rejection-sensitive individuals had: Acceleration in appearance of critically low T-lymphocyte level Acceleration to AIDS diagnosis and death

What effect does exercise have on energy expenditure?

Exercise burns up calories. For example, 10 minutes of sleeping uses up to 16kcals, standing uses 19kcals, running uses 142kcals, walking downstairs uses 88kcals and walking upstairs uses 229kcals (Brownell 1989). In addition, the amount of calories used increases with the individual's body weight. Therefore, exercise has long been recommended as a weight loss method. However, the number of calories that exercise burns up is relatively few compared with those in an average meal. In addition, exercise is recommended as a means to increase metabolic rate, however, only intense and prolonged exercise appears to have an effect on that rate. The role of exercise in o is still unclear. There appears to be an association between population decreases in activity and increases in obesity. In addition, prospective data support this association and highlight lower levels of activity as an important risk factor. Further, cross-sectional data indicate that the obese appear to exercise less than the non-o. However, whether inactivity is a cause or consequence of o is questionable. It is possible that an unidentified third factor may be creating this association, and it is also debatable whether exercise has a role in reducing food intake and promoting energy expenditure. However, exercise may have psychological and general health effects, which could benefit the o either in terms of promoting weight loss or simply by making them feel better about themselves (see Chapter 6 for the effects of exercise on mood and health).

Divorce

Fathers less likely to live in same home as children now, increase in divorce rates, and increase in parents that don't maintain a relationship Just under half of 1st marriages end in divorce, and rates higher for subsequent ones Divorces more often initiated by women, men often unprepared Negotiating satisfactory roles as non-custodial parents, single fathers, etc etc can be problematic - few templates Divorced men experience worse physical health and have less healthy lifestyles than married men - but much is explained by pre-existing variables such as alcohol and aggression, which of course increase relationship breakdown rates Divorced men more likely to suffer depression, ameliorated by close relationships with children

History of Inert/placebo Treatments

For centuries, individuals (including doctors and psychologists) from many different cultural backgrounds have used (and still use) apparently i treatments for various different conditions. For example, medicines such as wild animal faeces and the blood of a gladiator were supposed to increase strength, and part of a dolphin's penis was supposed to increase virility. These so-called 'medicines' have been used at different times in different cultures but have no apparent medical (active) properties. In addition, treatments such as bleeding by leeches to decrease fever or travelling to religious sites such as Lourdes in order to alleviate symptoms have also continued across the years without any obvious understanding of the processes involved. Faith healers are another example of i treatments, including Jesus Christ, Buddha and Krishna. The tradition of faith healers has persisted, although our understanding of the processes involved is very poor. Such apparently inert interventions, and the traditions involved with these practices, have lasted over thousands of years. In addition, the people involved in these practices have become famous and have gained a degree of credibility. Furthermore, many of the treatments are still believed in. Perhaps the maintenance of faith, both in these interventions and in the people carrying out the treatments, suggests that they were actually successful, giving the treatments themselves some validity. Why were they successful? It is possible that there are medically active substances in some of these traditional treatments that were not understood in the past and are still not understood now (e.g. gladiators' blood may actually contain some still unknown active chemical). It is also possible that the effectiveness of some of these treatments can be understood in terms of modernday placebo effects.

Coping and the Stress-Illness Link

For some studies the outcome variable has been more psychological in its emphasis and has taken the form of well-being, psychological distress or adjustment. For example, Kneebone and Martin (2003) critically reviewed the research exploring coping in carers of persons with dementia. They examined both cross-sectional and longitudinal studies and concluded that problem-solving and acceptance styles of coping seemed to be more effective at reducing stress and distress. In a similar vein, research exploring coping with rheumatoid arthritis suggests that active and problem solving coping are associated with better outcomes whereas passive avoidant coping is associated with poorer outcomes (e.g. Newman et al. 1996). For patients with chronic obstructive pulmonary disease (COPD), wishful thinking and emotion-focused coping were least effective (Buchi et al. 1997). Similarly, research exploring stress and psoriasis shows that avoidant coping is the least useful (e.g. Leary et al. 1998). Other studies have focused on more illness-associated variables. For example, Holahan and Moos (1986) examined the relationship between the use of avoidance coping, stress and symptoms such as stomach-ache and headaches. The results after one year showed that, of those who had experienced stress, those who used avoidance coping had more symptoms than those who used more approach coping strategies.

What does it mean to be healthy?

For the majority of people living in the western world, being h is the norm - most people are h for most of the time. Therefore, beliefs about being ill exist in the context of beliefs about being h (e.g. illness means not being h, illness means feeling different to usual, etc.). The World Health Organization (WHO) (1947) defined good h as 'a state of complete physical, mental and social well being'. This definition presents a broad multidimensional view of h that departs from the traditional medical emphasis on physical health only. Over recent years this multidimensional model has emerged throughout the results of several qualitative studies from medical sociology that have asked lay people this question For example, Blaxter (1990) asked 9,000 individuals to describe someone whom they thought was h and to consider, 'What makes you call them h?' and 'What is it like when you are h?' A qualitative analysis was then carried out on a sub-sample of these individuals. For some, h simply meant not being ill. However, for many, h was seen in terms of a reserve, a h life filled with h behaviours, physical fitness, having energy and vitality, social relationships with others, being able to function effectively and an expression of psychosocial well-being. Blaxter also examined how a concept of h varied over the life course and investigated any sex differences. Calnan (1987) also explored the h beliefs of women in England and argued that their models of h could be conceptualized in two sets of definitions: positive definitions including feeling energetic, plenty of exercise, feeling fit, eating the right things, being the correct weight, having a positive outlook and having a good life/marriage; and negative definitions including not getting coughs and colds, only in bed once, rarely go to the doctor and have check-ups - nothing wrong. The issue of h has also been explored from a psychological perspective with a particular focus on h and illness cognitions. For example, Lau (1995) found that when young h adults were asked to describe in their own words 'what being h means to you', their beliefs about health could be understood within the following dimensions: • Physiological/physical, for example, good condition, have energy. • Psychological, for example, happy, energetic, feel good psychologically. • Behavioural, for example, eat, sleep properly. • Future consequences, for example, live longer. • The absence of illness, for example, not sick, no disease, no symptoms. Lau argued that most people show a positive definition of h (not just the absence of illness), which also includes more than just physical and psychological factors but is multidimensional.

Mindfulness: Neuroimaging

Functional magnetic resonance imaging or functional MRI (fMRI) measures brain activity by detecting changes associated with blood flow. Relies on the fact that cerebral blood flow and neuronal activation are coupled. Volume of Grey matter (darker tissue of the brain) correlates negatively with attention task performance & age in normal, non m population but not in experienced Zen practitioners. ¤ Older we are the less grey matter we have and the poorer our ability for attention task performance These findings suggest that Zen m practice may prevent age-related cognitive deterioration by inhibiting reduction of grey matter volume (Pagnoni & Cekic, 2007) Recent study reported increased grey matter density in the brain regions involved in emotion regulation, learning, memory and selfrelated cognitions after MBSR training. (Hölzel et al., 2011)

Measuring social support

Given the definitions of s s above, the focus of m s s tends to be on the numbers of people available to provide support and the benefit of this to the individual. The most commonly used is the S s Questionnaire (SSQ; Sarason et al. 1987) which comes as a long and short version and asks people to list the number of those people they could turn to when in need (i.e. network s) and to rate how helpful they would find this s (i.e. functional s). Some researchers use the SSQ-N just to measure the number of people available to their participants. There are problems with this approach as it is possible that one person could have 20 available people whom they didn't really like, while someone else could have only 2 that they felt really close to. Therefore, if the researcher wants to network s and functional support they need to use the complete m.

Legalising of Euthanasia

Groundbreaking study that of the Dutch Remmelink Commission, 1990-1991 Practitioners granted immunity from prosecution if reporting honestly "Serious" MDELs involved in 38% of all deaths 1.8% of deaths involved painless killing at patient's request Estimated 0.8-1.6% involved killing without patient's explicit request 1995 follow-up found (as predicted) increase in voluntary euthanasia and decrease in MDELs without request Euthanasia eventually legalised formally in Netherlands.

Session 6 e therapy study

Guided breathing meditation • Physical movement meditation exercise • Slideshow presentation on four foundations of mindfulness and its purpose. • Also discussed loving-kindness meditation • Like all sessions, ended with Q&A (although longer here in this final session) and home learning meditation, happy activity etc

Historical foundations of stress

Hans Selye - Hungarian endocrinologist who stumbled upon the effects of s on the body in his experiments with rats Was studying the effects of a new ovarian hormone, when he discovered consistent physiological changes in the rats... - enlarged adrenal cortex: produces hormones that are vital to life, such as cortisol (which helps regulate metabolism and helps your body respond to s) and aldosterone (which helps control blood pressure). - shrinking thymus: T cells mature. T cells are critical to the adaptive immune system, where the body adapts specifically to foreign invaders. -ulceration of mucosa: The function of the membrane is to stop pathogens and dirt from entering the body and to prevent bodily tissues from becoming dehydrated.

Historical foundations of psychoneuroimmunology (lecture)

Hans Selye credited physiologist Walter Cannon for laying groundwork for his discovery we are more unnecessarily stressed than in the past Cannon described: Homeostasis -- keeping things balanced. you may need a coffee or 2 to feel normal and balanced Fight or Flight Response The emergence of the field of this is often credited to Robert Ader (psychologist) and Nicholas Cohen (immunologist) - who used behavioural models to understand disease progression (in rodents). Standard classical conditioning experiment Immunosuppressive drug (UCS) immune suppression (UCR) Immunosuppressive drug + saccharin (NS initially) immune suppression (UCR) Saccharin (CS) Immune Suppression (CR) Later others demonstrated that activating immune function was possible

Aging

Health does deteriorate, but at variable rates. Older people generally rate their health as good or better, despite mostly having been diagnosed with at least one chronic illness. Context! Self-rated health is an excellent predictor of survival - anecdotally, many older people seem very positive (in health domains), and resilient to substantial setbacks. Older adults accept some physical decline, and although they regard poor physical health as a major disadvantage, tend to take a broad holistic view of health - a focus on what one can do, rather than dwelling on what one cannot. Often a fear of losing cognitive abilities - dementia - 19% at >88-89, 32% 90 to 94, 41% 95+ meet criteria for dementia. Distinct from cognitive decline which does not affect day-to-day functioning. (2-3% 65-74, 7-8% if 75-84) - fear of losing intellectual abilities is perhaps not justified Depression? Usually related to poor physical health and/or poor social networks Social connectedness is an issue, and women better at it - better at developing and maintaining relationships. But, men cope better with smaller social networks, and the level of social support is not as strongly predictive of survival among older men as among women. Finances moreso for men

The mind-body split

Health psychology sets out to provide an integrated model of the individual by establishing a holistic approach to health. Therefore it challenges the traditional medical model of the mind-body split and provides theories and research to support the notion of a mind and body that are one. For example, it suggests that beliefs influence behaviour, which in turn influences health; that stress can cause illness and that pain is a perception rather than a sensation. In addition, it argues that illness cognitions relate to recovery from illness and coping relates to longevity. However, does this approach really represent an integrated individual? Although all these perspectives and the research that has been carried out in their support indicate that the mind and the body interact, they are still defined as separate. The mind reflects the individual's psychological states (i.e. their beliefs, cognitions, perceptions), which influence but are separate from their bodies (i.e. the illness, the body, the body's systems).

Stage models

Health psychology uses a number of stage models such as the SOC. We need to ask: • Are the different stages qualitatively separate from each other? • Are stages real or a products of statistics (i.e. if I ask if people across stages are different, will I then find that they are different, because I am imposing difference on the data?)? • Are stages an artefact of labelling them as such?

Qualitative studies

Health psychology uses a range of q methods such as focus groups and interviews and applies different data analysis approaches such as thematic analysis, interpretative phenomenological analysis (IPA) or narrative analysis. Q researchers are clear about the subjective nature of their data and argue that their findings are neither generalizable nor representative. But we need to ask the following questions: • If the data analysis is open to subjective interpretation by the researcher, how much of the analysis reflects only what the researcher wants to see and is any of the analysis reflective of what went on in the interview? Is q analysis just the fiction of the researcher? • Although qualitative findings are not supposed to be generalizable, are we in fact interested to see if they can tell us about people other than those few (just 10 perhaps?) who took part in the study?

Constructs

Health psychology uses a wide range of constructs such as coping, illness beliefs, perceived control, quality of life, depression and anxiety. We need to ask whether these constructs are meaningful and discrete. For example: • Is 'I feel depressed' an emotion or a cognition? • Can depression cause poor quality of life or is it part of quality of life? • Can poor health status lead to poor quality of life or is health status part of quality of life? • Is the illness belief 'my illness won't last a long time' an illness belief or a coping mechanism? • Are different personality types mutually exclusive to each other (can I be extrovert and introvert?)?

Schedule of Recent Experiences (SRE)

Holmes and Rahe (1967) developed the... , which provided respondents with an extensive list of possible life changes or life events. These ranged in supposed objective severity from events such as 'death of a spouse', 'death of a close family member' and 'jail term', to more moderate events such as 'son or daughter leaving home' and 'pregnancy', to minor events such as 'vacation', 'change in eating habits', 'change in sleeping habits' and 'change in number of family get-togethers'. Originally the SRE was scored by simply counting the number of actual recent experiences. For example, someone who had experienced both the death of a spouse and the death of a close family member would receive the same score as someone who had recently had two holidays. It was assumed that this score reflected an indication of their level of stress. Early research using the SRE in this way showed some links between individuals' SRE score and their health status. However, this obviously crude method of measurement was later replaced by a variety of others, including a weighting system whereby each potential life event was weighted by a panel, creating a degree of differentiation between the different life experiences. A recent longitudinal study explored the impact of life events on mortality at 17 years follow-up (Phillips et al. 2008). Participants were 968 Scottish men and women aged 56 years old who completed measures of stressful life events for the preceding 2 years at baseline, then after 8 or 9 years and then at 11/13 years. By 17 years 266 participants had died. The results showed that when sex, occupational status, smoking, body mass index (BMI) and systolic blood pressure were controlled for the number of health-related life events, the stress load they imposed (not health unrelated life events) was strongly predictive of mortality

Information-giving

If a person believes 'I smoke but I am not at risk of getting lung cancer' or 'I eat a high fat diet but my heart is healthy', then the obvious first starting point to change their behaviour would be to improve their knowledge about their health. This has been the perspective of health education and health promotion campaigns for decades and has resulted in information provision through leaflets, billboards, TV advertisements and group-based seminars and lectures. Some research has evaluated the impact of information-giving using a range of mediums. For example, O'Brien and Lee (1990) manipulated knowledge about pap tests for cervical cancer by showing subjects an informative video and reported that not only did the video improve knowledge but that the resulting increased knowledge was related to future healthy behaviour. Further, Hammond et al. (2003) examined the effectiveness of the warning labels on cigarette packets and showed that the intention to stop smoking in the next six months and the number of quit attempts was higher in those who reported reading, thinking about and discussing the labels with other people. The provision of information is often incorporated into more complex interventions such as CBT, relapse prevention and psychoeducational interventions with people in rehabilitation (e.g. Dusseldorp et al. 1999; Sebregts et al. 2000; Rees et al. 2004). Generally it is accepted that giving information is not sufficient to change behaviour but that it is a useful and necessary adjunct to any other form of behaviour change strategy

Motivational interviewing

If people are at a stage when they are unmotivated to change their behaviour, then there seems little point in offering them an intervention or including them in a study, particularly as motivation is a consistently good predictor of behavioural intentions and behaviour (e.g. Jacobs et al. 2011). Motivational interviewing (MI) was developed by Miller and Rollnick (2002) as a way to help people consider changing their behaviour and to increase their motivation to change. From a stages of change perspective it takes people from a pre-contemplation to a contemplation stage in the behaviour change process. MI therefore doesn't show people how to change but encourages them to think about their behaviour in ways that may make them realize that they should change. MI was originally used with people with addictions but is now used across all health care settings and has become a core part of the toolkit of any health professional. The process of MI is based upon the idea that cognitive dissonance is uncomfortable and that people are motivated to get out of a state of dissonance by changing their cognitions (Festinger, 1957). For health-related behaviours conflicting beliefs such as 'My drug addiction lost me my job' and 'I like taking drugs' or 'My weight makes it difficult for me to move' and 'I like eating a lot' cause cognitive dissonance and are uncomfortable. The aim of MI is to encourage people to focus on these conflicting beliefs and therefore feel the discomfort more strongly. Questions asked would include: 'What are some of the good things about smoking/eating a lot/taking drugs?' 'What are the not so good things about smoking/eating a lot/taking drugs?' The client is then encouraged to elaborate on the costs and benefits of their behaviour which are then fed back to them by the health professional to highlight the conflict between these two sets of cognitions: 'So your smoking makes you feel relaxed but you are finding it hard to climb stairs?' 'So taking drugs helps you cope but you have lost your job because of them?' Next, the client is asked to describe how this conflict makes them feel and to consider how things could be different if they changed their behaviour. It is hoped that by focusing on their cognitive dissonance they will be motivated to change both their cognitions and behaviour as a means to resolve this dissonance. Obviously it is hoped that they will change towards being healthier, although this may not always be the case as the process could encourage people to see the benefits Miller and Rollnick (2002) are very clear that their approach should be non-confrontational and should encourage people to think about the possibility of change rather than persuading them to change. Miller and Rollnick also emphasize that professionals using MI should be empathic and non-judgemental and should assume that the client is responsible for the decision to change. A systematic review shows that MI is an effective tool for use by non-specialists for drug abuse treatment (Dunn et al. 2001). Research also shows that MI is effective across a number of problems see chap 3 for egs

significance of health assets

If we can identify potential h a we can see if they may reveal - a variety of potent, low-cost approaches to enhance wellbeing (good in itself) - and help protect against physical and mental illness. • If h a can be scientifically linked to positive health outcomes, - we can design interventions that can help build and sustain these assets to help people increase their chances of living a healthier, longer, happier life. Wellbeing literacy - studies that can improve gratitude and improve affect person intervention fit - not everything works for everyone. Eg- the gratitude study, not everyone had improved health.

Social Triggers to asessing treatment

Illness cognitions (read Ch 9) - a mental representation of the problem ⚫ Self-regulatory model of illness (Leventhal) links to Lazarus' coping work ⚫ The SRMI theory suggests individuals search to understand illness or disease threat by developing an understanding of what illness is, what it means, its causes, its consequences, how long it will last, & whether it can be cured or controlled. ⚫ This understanding (or illness representation) is not necessarily scientifically or medically validated, but formulated from personal experience (physical symptoms and emotions), social influences, and/or interaction with healthcare providers. ⚫ Individuals thought to reduce health risk or change health behaviour in ways consistent with own illness representation. Zola (1973) - pathways to the doctor ⚫ Disturbance in daily life - help-seeking to restore equilibrium • Interference with work/physical activity • Interference with social relations • Interpersonal crisis • Sanctioning by other people - how we perceive an illness will impact how we behave

Explaining Variability in Health and Illness

In 1980 the Black Report was produced in the UK by the Department of Health (DH) working group on health inequalities to explore the possible explanations for variability by SES. Although focusing on the variability due to SES the explanations are also relevant to differences by geographical location and gender. The report described three possible explanations as follows: • Artefact. It was argued that the relationship between SES and health may simply be an artefact of how these two constructs are measured. However, it is generally now accepted that the relationship is too robust across measures and countries to be simply a matter of measurement error. • Social selection. The Black Report argued that social patterning by SES may be a product of social selection and that rather than SES determining health, health determines SES, because those with better health improve their social circumstances including income and education. Although there is some evidence for social mobility based upon health (i.e. people who are ill can't work and therefore earn less), the size of this effect is estimated to be quite moderate. • Social causation. The report argued that the social patterning of health is due to a number of key social conditions which can either promote good health or facilitate illness. This third explanation accounts for most of the variability in health and has received the most support.

Physiological Problems and obesity Treatment of dieting

In addition to the psychological consequences of imposing a d structure on the obese, there are physiological changes which accompany attempts at food restriction. Heatherton et al. (1991) reported that restraint in the non-obese predicts weight fluctuation, which parallels the process of weight cycling or 'yo-yo' d in the obese. Research on rats suggests that repeated attempts at weight loss followed by weight regain result in further weight loss becoming increasingly difficult due to a decreased metabolic rate and an increase in the percentage of body fat (Brownell et al. 1986a). Human research has found similar results in dieters and athletes who show yo-yo d (Brownell et al. 1989). Research has also found that weight fluctuation may have negative effects on health, with reports suggesting an association between weight fluctuation and mortality and morbidity from CHD (Hamm et al. 1989) and all-cause mortality (Lissner et al. 1991). Repeated failed attempts at d, therefore, may be more detrimental to physical health than remaining statically obese.

Does Appraisal Influence the Stress Response?

In an early study by Speisman et al. (1964), subjects were shown a film depicting an initiation ceremony involving unpleasant genital surgery. The film was shown with three different soundtracks. In condition 1, the trauma condition, the soundtrack emphasized the pain and the mutilation. In condition 2, the denial condition, the soundtrack showed the participants as being willing and happy. In condition 3, the intellectualization condition, the soundtrack gave an anthropological interpretation of the ceremony. The study therefore manipulated the subjects' a of the situation and evaluated the effect of the type of appraisal on their s response. The results showed that subjects reported that the trauma condition was most s. This suggests that it is not the events themselves that elicit stress, but the individuals' interpretation or a of those events. Similarly, Mason (1975) argued that the stress response needed a degree of awareness of the stressful situation and reported that dying patients who were unconscious showed less signs of physiological s than those who were conscious. He suggested that the conscious patients were able to a their situation whereas the unconscious ones were not. These studies therefore suggest that s is related to the s response. However, in contrast, some research indicates that a may not always be necessary. For example, Repetti (1993) assessed the objective s (e.g. weather conditions, congestion) and subjective s (e.g. perceived stress) experienced by air traffic controllers and reported that both objective and subjective s independently predicted both minor illnesses and psychological distress. This could indicate that either a is not always necessary or that at times individuals do not acknowledge their level of subjective s. In line with this possibility some researchers have identified 'repressors' as a group of individuals who use selective inattention and forgetting to avoid stressful information (Roth and Cohen 1986). Such people show incongruence between their physiological state and their level of reported anxiety. For example, when confronted with a s they say, 'I am fine' but their body is showing arousal. This suggests that although a may be central to the stress response there may be some people in some situations who deny or repress their emotional response to a stressor.

Conclusions - men's health

In general, do we focus to much on illness and not enough on health? The primary causes of death (heart disease and cancer), and the primary risk factors (smoking, obesity, sedentary lifestyle) are similar for men and women... Perhaps better to focus on the influences and determinants of these choices - which might not be the same for men and women. E.g., why are men more likely to exercise, but less likely to eat healthily? Take differences seriously, and understand them. Approaches have traditionally been 'male', but it seems not much has been learned from the more 'feminine' approaches Men's behaviours and health are affected in obvious ways by social and cultural systems - as obviously as women's are - not sensible to make the argument for one gender and not the other. Men's choices and behaviours constrained by social context, just as women's are... Focus on individual behaviours such as screening might be missing the forest for the trees. Health is not a series of isolated problems that can be understood one-by-one. Patterns of choices in a complex and dynamic environment - understood in in several contexts (e.g., individual, social, political, and cultural) Men's lives need to be examined in context, with an awareness of the diversity of men's experiences, and through a thoughtful combination of quantitative and qualitative approaches

Changing work and domestic patterns on women's health

In line with the emphasis on j strain some research has also explored the impact of ... Whereas 50 years ago women may have worked until they had children, and then given up work to be at home with their offspring, nowadays an increasing number of women take on multiple roles and balance working with being a parent and a partner. There are two contrasting models of the impact of such multiple roles. The first is the enhancement model which suggests that multiple roles have a positive effect on health as they bring benefits such as economic independence, social contact and self-esteem (Collijn et al. 1996; Moen 1998). In contrast the role strain model suggests that multiple roles can be detrimental to health as people only have limited resources and can experience role overload and role conflict (Weatherall et al. 1994). Steptoe et al. (2000) explored the effect of multiple roles on cardiovascular activity throughout the day. They monitored the blood pressure and heart rate throughout the working day and evening in 162 full-time teachers and explored the impact of whether the teacher was also married and/or a parent with a child at home. The results showed that marital status or parenthood had no effect on cardiovascular changes throughout the working day. However, these factors did affect the day-evening drop in blood pressure. In particular, parents who reported good social support showed the greatest drop in blood pressure between the end of the working day and evening. The authors conclude that this supports the enhancement model of job strain as those who worked and were parents with support (i.e. had multiple roles) showed a lower allostatic load. This may have been because they found it easier to switch off from their work stress at the end of the day. To explain the possible effects of multiple roles recent research has focused on the impact of rumination.

The role of appraisal in stress

In the 1970s, Lazarus's work on stress introduced psychology to understanding the stress response (Lazarus and Cohen 1973; Lazarus 1975; Lazarus and Folkman 1987). This role for psychology took the form of his concept of a. Lazarus argued that stress involved a transaction between the individual and their external world, and that a stress response was elicited if the individual appraised a potentially stressful event as actually being stressful. Lazarus's model therefore described individuals as psychological beings who a the outside world, rather than simply passively responding to it. Lazarus defined two forms of a: primary and secondary. According to Lazarus, the individual initially a's the event itself - defined as primary a. There are four possible ways that the event can be a: (1) irrelevant; (2) benign and positive; (3) harmful and a threat; (4) harmful and a challenge. Lazarus then described secondary a, which involves the individual evaluating the pros and cons of their different coping strategies. *Therefore primary a involves an a of the outside world and secondary a involves an 'a' of the individual themselves.* The form of the primary and secondary a's determines whether the individual shows a stress response or not. According to Lazarus's model this stress response can take different forms: (1) direct action; (2) seeking information; (3) doing nothing; or (4) developing a means of coping with the stress in terms of relaxation or defence mechanisms. Lazarus's model of a and the transaction between the individual and the environment indicated a novel way of looking at the stress response - the individual no longer passively responded to their external world, but interacted with it.

Incentives

In the context of health-related behaviours, incentivizing can take the form of centralized changes to the cost of products such as cigarettes, fatty foods and fizzy drinks or directly paying people to lose weight, stop smoking or be more physically active. Over the past few years research has addressed the effectiveness of these simple (and fairly crude) approaches and indicates that, in general, changes in cost and direct financial rewards can effectively change behaviour. For example, increased taxes on both alcohol and cigarettes over the past few decades have been linked with a reduction in drinking and alcohol (Sutherland et al. 2008) reviewed the evidence for incentivizing behaviour change and concluded the following: • The greater the incentive, the greater the likelihood of behaviour change. • Incentives are better at producing short-term rather than longer-term changes. • The impact of the incentive depends upon the financial state of the individual. • Incentives are more effective if the money is paid as close as possible to that target behaviour. • Incentives work better for discrete and infrequent behaviours such as having vaccinations rather than repeated habitual behaviours such as diet or smoking. Marteau et al. also concluded that there may be three unintended consequences of incentivizing behaviour. These are: • Incentives may undermine an individual's intrinsic motivation for carrying out a behaviour (e.g. 'I ate healthily but now I don't really like healthy foods'). • Incentives are a form of bribery which undermine an individual's informed consent and autonomy. • Incentives may change the doctor−patient relationship if the patient is paid by the doctor to behave in certain ways. Incentives therefore seem to change behaviour through a crude version of reinforcement. However, they may also have unintended consequences which may undermine changes in behaviour in the longer term.

Physical Activity obesity

Increases in the prevalence of o coincide with decreases in daily energy expenditure due to improvements in transport systems, and a shift from an agricultural society to an industrial and increasingly information-based one. As a simple example, a telephone company in the USA has suggested that in the course of one year an extension phone upstairs − which means the person no longer needs to run downstairs − saves an individual approximately one mile of walking, which could be the equivalent of 2-3lb of fat or up to 10,500 kcals (Stern 1984). Imagine how much energy a mobile phone saves! Further, at present only 20 per cent of men and 10 per cent of women are employed in active occupations and for many people leisure times are dominated by in a (see Chapter 6 for a discussion of physical activity). Although data on changes in activity levels are problematic, there exists a useful database on TV viewing which shows that, whereas the average viewer in the 1960s watched 13 hours of TV per week, in England this had doubled to 26 hours per week (OPCS 1994). Overall, data seem to indicate that the majority of people do not meet the recommended targets for activity, that generally people get more sedentary and less active as they get older and that men are more active than women particularly when young, but watch more TV than women as they get older. This is further exacerbated by the increased use of videos and computer games by both children and adults. It has therefore been suggested that o may be caused by in a. In a survey of adolescent boys in Glasgow in 1964 and 1971, whereas daily food diaries indicated a decrease in daily energy intake from 2,795kcals to 2,610kcals, the boys in 1971 showed an increase in body fat from 16.3 per cent to 18.4 per cent. This suggests that decreased physical activity was related to increased body fat (Durnin et al. 1974).

Cognitive behavioural therapy (CBT)

Increasingly used with chronic pain patients and is based upon the premise that pain is influenced by four sources of information: cognitive sources such as the meaning of the pain ('it will prevent me from working'); emotional sources such as the emotions associated with the pain ('I am anxious that it will never go away'); physiological sources such as the impulses sent from the site of physical damage; and behavioural sources such as pain behaviour that may either increase the pain (such as not doing any exercise) or decrease the pain (such as doing sufficient exercise). CBT focuses on these aspects of pain perception and uses a range of psychological strategies to enable people to unlearn unhelpful practices and learn new ways of thinking and behaviours. CBT draws upon the three treatment approaches described earlier, namely respondent methods such as relaxation and biofeedback, cognitive methods such as attention diversion and Socratic questioning, and behavioural methods involving graded exercises and reinforcement. Several individual studies have been carried out to explore the relative effectiveness of CBT compared to other forms of intervention and/or waiting list controls. Recently systematic reviews have been published which have synthesized these studies in terms of CBT for adults and for children and adolescents.

Problems with Promoting Wellness

Individual Factors Many health behaviours are less pleasurable than unhealthy alternatives Prevention requires a change in long-standing behaviours - making a sustainable habit - eg exercising every day only if sustainable, may be more suitable to workout 5 or 6 instead for sustainability. Self-efficacy and motivation are needed Factors influencing motivation: "person who" fallacy (a flaw in reasoning - won't happen to me) inconvenience, delayed gratification vs. instant gratification, procrastination - habitual, does not always need willpower, putting environmental triggers to do the target behaviour Interpersonal Factors Family, friends or work peers may hinder personal behavioural change Sharing meals with flatmates, smoke breaks at work, living away from home Community Factors Wide-spread behaviour change is often dependent on community-based promotion. Requires large amounts of money, and physicians are largely training in treating, not preventing illness, e.g. don't drink and drive commercials, healthy option advertising and in supermarkets having healthier options

OKAY, SO WE SHOULD EAT PLANTS...

Insufficient Fruit & Veggie Consumption attributable to 2.8% of deaths worldwide Estimated to cause 14% of gastrointestinal cancer deaths globally 11% of ischemic heart disease (reduced blood flow to heart muscle) globally 9% stroke deaths globally Challenges in Studying Fruit & Vegetable Consumption Food content depends on: Preparation method The variety of products Growing and storage conditions

prefrontal cortex

Involved in higher cognitive functioning: Working memory Executive control Threat-related responding and coping Orbital and dorsal medial f c communication directly with the hypothalamus in regulating stress response axes.

Mechanism 2 of allostatic load: lack of adaptation

Involves a failure to habituate or a to the same stressor. This leads to the over-exposure to stress mediators because of the failure of the body to dampen or eliminate the hormonal stress response to a repeated event. An example of this is the finding that repeated public speaking challenges, in which most individuals habituated their cortisol response, led a significant minority of individuals to fail to habituate and continue to show cortisol response First described in repeated public speaking challenge - subset of individuals failed to habituate their cortisol response.

Associative learning

Involves pairing two variables together so that one variable acquires the value or meaning of the other. For example, in the classic early studies Pavlov's dogs heard a bell ring whenever they were given food and after a while they started to salivate when they heard the bell (even without the food).

Behaviour and mortality

It has also been suggested that 50 per cent of mortality from the 10 leading causes of death is due to behaviour. Early research by Doll and Peto (1981) reported estimates of the role of different factors as causes for all cancer deaths. They estimated that tobacco consumption accounts for 30 per cent of all cancer deaths, alcohol for 3 per cent, diet for 35 per cent and reproductive and sexual behaviour for 7 per cent. Accordingly, approximately 75 per cent of all deaths due to cancer are related to behaviour. More specifically, lung cancer, which is the most common form, accounts for 36 per cent of all cancer deaths in men and 15 per cent in women in the UK. It has been calculated that 90 per cent of all lung cancer mortality is attributable to cigarette smoking, which is also linked to other illnesses such as cancers of the bladder, pancreas, mouth, larynx and oesophagus and CHD. The impact of smoking on mortality was shown by McKeown when he examined changes in life expectancies in males from 1838 to 1970. His data are shown in Figure 2.20 which indicates that the increase in life expectancy shown in non-smokers is much reduced in smokers. The relationship between mortality and behaviour is also illustrated by bowel cancer which is linked to behaviours such as a diet high in total fat, high in meat and low in fibre. In 2004, Mokdad et al. also explored the role of health behaviour in illness and mortality. Their analysis was based upon studies which had identified a link between risk behaviours such as smoking, diet, activity, alcohol consumption, car crashes and sexual behaviour and the deaths of 2.4 million people who had died in the year 2000 in the USA. They then developed an estimate of how many of the disease-related deaths could be accounted for by a particular behaviour and multiplied this by the data on actual causes of deaths in 2000. For example, from the literature they estimated what proportion of deaths by cancer could be accounted for by diet. They then multiplied this estimate by the number of people who actually died from cancer in the year 2000. Then, by collating these figures they arrived at the total number of deaths (regardless of disease) attributable to each behaviour.

Beliefs and immunity

It has also been suggested that b may themselves have a direct effect on the immune system. Kamen and Seligman (1987) reported that an internal, stable, global attributional style (i.e. a pessimist approach to life whereby the individual blames themselves when things go wrong) predicted poor health in later life. This was supported by Seligman et al. (1988) who argued that pessimism may be related to health through a decrease in T-cells and immunosuppression. The authors argued that this was not mediated through behavioural change but was indicative of a direct effect of attributional style and beliefs on physiology. In a further study, Greer et al. (1979) suggested that denial and a fighting spirit, not hopelessness, predicted survival for breast cancer, suggesting again that beliefs might have a direct effect on illness and recovery. Similarly, Gidron et al. (2001) measured hopelessness (defined as pessimism and helplessness) at baseline and assessed change in a serological marker for breast cancer in women with breast cancer after four months. The results showed that helplessness but not pessimism was related to poorer outcome (see Chapter 14 for a discussion of cancer)

Geographical Location health

It is clear that the prevalence of a range of diseases and their mortality rates vary both between and within countries. For example, worldwide death rates in 2006 are shown in Figure 2.1 per 1,000 population. The highest death rates being in Sub-Saharan Africa, Afghanistan, Russia and Eastern Europe. Childhood mortality rates also vary by geographical area. For example, data from the WHO shown in Figure 2.2 illustrate that the highest child mortality rates are in Africa, the Eastern Mediterranean region and South-East Asian region with the lowest rates being in Europe and the Americas. The graph also shows changes in child mortality between 1990 and 2008 and indicates that mortality has fallen universally. There are also geographical differences in specific diseases. For example, the global prevalence of HIV in 2009 is shown in Figure 2.3, which shows that the highest rates were in Sub-Saharan Africa and Russia. Health and illness also vary within continents. For example, Figure 2.4 illustrates incident rates of lung cancer across Europe in 2008. These data indicate that the highest rates were in Hungary, Poland, Estonia and Belgium and that the lowest rate was in Sweden. The graph also shows that lung cancer is consistently higher in men than in women. Finally, there is also g variation within countries. For example, Figure 2.5 illustrates how mortality rates in people aged under 75 vary across England. It can be seen that mortality rates from all causes are higher in northern England than southern England and even vary within London, with the highest rates being in East London. These illustrations are just a snapshot of the available data, but they illustrate how mortality and disease prevalence rates vary by g location in terms of broad WHO region, continent, country and even within a capital city.

What is Pain?

It provides constant feedback about the body, enabling us to make adjustments to how we sit or sleep. Pain is often a warning sign that something is wrong and results in protective behaviour such as avoiding moving in a particular way or lifting heavy objects. Pain also triggers help-seeking behaviour and is a common reason for patients visiting their doctor. Pain also has psychological consequences and can generate fear and anxiety. From an evolutionary perspective therefore, pain is a sign that action is needed. It functions to generate change either in the form of seeking help or avoiding activity. However, pain is not that simple. Some pain seems to have no underlying cause and functions to hinder rather than to help a person carry on with their lives. Such pain has a strong psychological component.

What is Health Psychology?

It was described by Matarazzo as 'the aggregate of the specific educational, scientific and professional contribution of the discipline of psychology to the promotion and maintenance of health, the promotion and treatment of illness and related dysfunction' (1980: 815). Health psychology again challenges the mind-body split by suggesting a role for the mind in both the cause and treatment of illness, but differs from psychosomatic medicine and behavioural medicine in that research within health psychology is more specific to the discipline of psychology. Health psychology emphasizes health and illness as being on a continuum and explores the ways in which psychological factors impact health at all stages. Therefore, psychology is involved in illness onset (e.g. beliefs and behaviours such as smoking, diet and stress), help-seeking (e.g. symptom perception, illness cognitions, doctor-patient communication), illness adaptation (e.g. coping, behaviour change, social support, pain perception), illness progression (e.g. stress, behaviour change) and health outcomes (e.g. quality of life, longevity) Health psychologists consider both a direct and indirect pathway between psychology and health. The direct pathway is reflected in the physiological literature and is illustrated by research exploring the impact of stress on illnesses such as coronary heart disease and cancer. From this perspective, the way a person experiences their life ('I am feeling stressed') has a direct impact upon their body which can change their health status. The indirect pathway is reflected more in the behavioural literature and is illustrated by research exploring smoking, diet, exercise and sexual behaviour. From this perspective, the way a person thinks ('I am feeling stressed') influences their behaviour ('I will have a cigarette') which in turn can impact upon their health. there is also variability between people and this is also the focus of health psychology. For example, two people might both know that smoking is bad for them but only one stops smoking.

Job stress

J stress has been studied primarily as a means to minimize w-related illness but also because it provides a forum to clarify the relationship between stress and illness. Early work on j stress highlighted the importance of a range of j-related factors including work overload, poor w relationships, poor control over w and role ambiguity. Karasek and colleagues integrated many of these factors into their j demand-j control model of stress, central to which is the notion of j strain (Karasek et al. 1981; Karasek and Theorell 1990). According to the model, there are two aspects of j strain: 1. j demands, which reflect conditions that affect performance, and 2. j autonomy, which reflects the control over the speed or the nature of decisions made within the j. Karasek's j demand−j control model suggests that high j demands and low j autonomy (control) predict CHD. Karasek and co-workers have since developed the j demand-control hypothesis to include social support. Within this context, social support is defined as either emotional support, involving trust between colleagues and social cohesion, or instrumental social support, involving the provision of extra resources and assistance. It is argued that high social support mediates and moderates the effects of low control and high demand. Karasek and Theorell (1990) reported a study in which subjects were divided into low social support and high social support groups, and their decisional control and the demands of their job were measured. The results indicated that subjects in the high social support group showed fewer symptoms of CHD than those subjects in the low social support group. In addition, within those groups high j control and low j demands predicted fewer CHD symptoms. A series of studies have tested and applied Karasek's model of j strain and associations have been reported between job strain and risk factors for heart disease and heart disease itself (Marmot 1998; Tsutsumi et al. 1998) as well as psychiatric morbidity (Cropley et al. 1999). For example, Kivimaki et al. (2002) used a prospective design to explore the links between j strain and subsequent death from cardiovascular disease. A total of 812 employees from a metal factory in Finland that manufactures paper machines, tractors and firearms along with other equipment completed a baseline assessment in 1973 including measures of their behavioural and biological risks and their work stress. Those with cardiovascular disease at baseline were excluded. Cardiovascular mortality was then recorded between 1973 and 2001 using the national mortality register. The results showed that 73 people had died from cardiovascular disease since the study onset, who were more likely to be older, male, have low j status, to smoke, have a sedentary lifestyle, high blood pressure, high cholesterol and higher BMI. Further, when age and sex were controlled for, death was predicted by high j strain and low j control. However, after occupational group was also controlled for (i.e. a measure of class), high j strain remained the best predictor.

Hope death stage

KR argues that the one constant throughout is hope. "In listening to our terminally ill patients we were always impressed that even the most accepting, the most realistic patients left the possibility open for some cure, the discovery of a new drug, or the last-minute success in a research project" p 123 Hope maintains them through days, weeks or months of suffering - if there is some meaning, there must be some pay off if you can only endure a little longer. Special drug etc, some argue that we're all searching for that one thing that makes us remarkable... conflict re the conveyance of hopelessness from physicians or family - when patients need hope. Second re the family's inability to accept the patient's final stage - i.e., they cling to hope, and the patient is accepting of imminent death. Communication, listening to ill person, alignment etc... "it might be helpful if more people would talk about death and dying as an intrinsic part of life, just as they do not hesitate to mention when someone is having a baby. If this were done more often, then we would not have to ask ourselves if we ought to bring this topic up with a patient" p125 We have seen several patients who were depressed and morbidly uncommunicative until we spoke with them about the terminal stage of their illness. Their spirits lightened, they began to eat again and a few of them were discharged... I am convinced that we do more harm by avoiding the issue than by using time and timing to sit, listen and share." p. 125 Timing - moments when we feel like talking about things, and moments when we don't... Important that we (and the patient) knows that someone will be available when the time is right. Be sensitive to cues, listen to watch and learn

Acceptance of Death

KR suggests that if a patient has sufficient time and gets the right support to negotiate through the four stages, they will reach a stage at which they are neither depressed nor angry about their fate. "he will have been able to express his previous feelings, his envy for the living and the healthy, his anger at those who do not have to face their end so soon. He will have mourned the impending loss of so many meaningful people and places and he will contemplate his coming end with a certain degree of quiet expectation. He will be tired, and in most cases quite weak. He will also have a need to doze off or to sleep often and in brief intervals... It is not a resigned and hopeless "giving up", though we hear such statements too... Acceptance should not be mistaken for a happy stage. It is almost void of feelings... This is also the time during which the family often needs more help, understanding and support than the patient himself (pp. 99-100) "while the dying patient has found some peace and acceptance, his circle of interest diminishes. He wishes to be left alone, or at least not stirred up by news and problems of the outside world. Visitors are often not desired, or if they come the patient is not in a particularly talkative mood... communication can become more non-verbal... the patient may just make a gesture of the hand to invite us to sit down for a while. He may just hold our hand and ask us to sit in silence. Such moments of silence may be the most meaningful communications for those who are not uncomfortable in the presence of a dying person... Our presence may just let him know that we are going to be around until the end..." "We have found that those patients who do best have been encouraged to express their rage, to cry in preparatory grief, and to express their fears and fantasies to someone who can sit quietly and listen" p105

Leventhal's Self-Regulatory Model of Illness Behaviour (SRM)

L incorporated his description of illness cognitions into his (SRM) of illness behaviour. This model is based on approaches to problem-solving and suggests that illness/symptoms are dealt with by individuals in the same way as other problems (see Chapter 10 for details of other models of problem solving). It is assumed that, given a problem or a change in the status quo, the individual will be motivated to solve the problem and re-establish their state of normality. Traditional models describe problem-solving in three stages: (1) interpretation (making sense of the problem); (2) coping (dealing with the problem in order to regain a state of equilibrium); and (3) appraisal (assessing how successful the coping stage has been). According to models of problem-solving, these three stages will continue until the coping strategies are deemed to be successful and a state of equilibrium has been attained. In terms of health and illness, if healthiness is an individual's normal state, then any onset of illness will be interpreted as a problem and the individual will be motivated to re-establish their state of health (i.e. illness is not the normal state). These stages have been applied to health using the SRM (see Figure 9.2) and are described briefly here and in more detail, later on, pp. 225-36.

Laboratory versus naturalistic research

L research is artificial whereas real-life research is uncontrolled. Some studies, however, illustrate high levels of congruence between physiological responses in the laboratory and those assessed using ambulatory machines in real life. For example, Matthews et al. (1986) reported similarity between reactivity following l tasks and public speaking and Turner and Carroll (1985) reported a correlation between the response to video games and real life stress identified from diaries. However, other studies have found no relationship or only some relationship with some measures (e.g. Johnston et al. 1990). Johnston and colleagues (Anastasiades et al. 1990; Johnston et al. 1990, 1994) designed a series of studies to try to explain this variability. Using a battery of tasks to elicit stress in the laboratory and ambulatory machines to assess stress reactivity in real life, they concluded that physiological measures taken in the l concord if the following conditions are met: the field measure is taken continuously; the analysis takes into account physical activity levels (as this produces a similar response to the stressor); and when the laboratory task involves active coping such as a video game rather than a passive coping task such as the cold pressor task (i.e. placing the hand in icy water). In addition, they argued that appraisal is central to the congruence between l and n measures and that higher congruence is particularly apparent when the stressors selected are appraised as stressful by the individual rather than identified as stressful by the researcher. This indicates that laboratory assessments may be artificial but do bear some resemblance to real-life stress.

Which events are appraised as stressful?

Lazarus has argued this. It could be concluded from this that the nature of the e itself is irrelevant - it is all down to the individual's own perception. However, research shows that some types of e are more likely to result in a s response than others. • Salient e's. People often function in many different domains such as work, family and friends. For one person, work might be more salient, while for another their family life might be more important. Swindle and Moos (1992) argued that stressors in salient domains of life are more stressful than those in more peripheral domains. • Overload. Multitasking seems to result in more stress than the chance to focus on fewer tasks at any one time. Therefore a single stressor which adds to a background of other stressors will be appraised as more stressful than when the same stressor occurs in isolation - commonly known as the 'straw that broke the camel's back'. • Ambiguous e's. If an event is clearly defined, then the person can efficiently develop a coping strategy. If, however, the event is ambiguous and unclear, then the person first has to spend time and energy considering which coping strategy is best. This is reflected in the work s literature which illustrates that poor job control and role ambiguity in the workplace often result in a s response. • Uncontrollable e's. If a stressor can be predicted and controlled, then it is usually appraised as less sful than a more random uncontrollable event. For example, experimental studies show that unpredictable loud bursts of noise are more stressful than predictable ones (Glass and Singer 1972). The issue of control is dealt with in more depth later on.

What are illness cognitions?

Leventhal and his colleagues (Leventhal et al. 1980, 2007a, 2007b; Leventhal and Nerenz 1985) defined ic as 'a patient's own implicit common-sense beliefs about their illness'. They proposed that these cognitions provide patients with a framework or a schema for coping with and understanding their i, and telling them what to look out for if they are becoming i. Using interviews with patients suffering from a variety of different illnesses, Leventhal and his colleagues identified five c dimensions of these beliefs (see Figure 9.1) --- Some of these dimensions are similar to those described by attribution theory in Chapter 3: 1. Identity: this refers to the label given to the i (the medical diagnosis) and the symptoms experienced (e.g. I have a cold - 'the diagnosis', with a runny nose - 'the symptoms'). 2. The perceived cause of the i: these causes may be biological, such as a virus or a lesion, or psychosocial, such as stress- or health-related behaviour. In addition, patients may hold representations of illness that reflect a variety of different causal models (e.g. 'My cold was caused by a virus', 'My cold was caused by being run down'). 3. Time line: this refers to the patient's beliefs about how long the i will last, whether it is acute (short term) or chronic (long term) (e.g. 'My cold will be over in a few days'). 4. Consequences: this refers to the patient's perceptions of the possible effects of the i on their life. Such consequences may be physical (e.g. pain, lack of mobility), emotional (e.g. loss of social contact, loneliness) or a combination of factors (e.g. 'My cold will prevent me from playing football, which will prevent me from seeing my friends'). 5. Curability and controllability: patients also represent i in terms of whether they believe that the i can be treated and cured and the extent to which the outcome of their i is controllable either by themselves or by powerful others (e.g. 'If I rest, my cold will go away', 'If I get medicine from my doctor, my cold will go away').

Physiological theories placebos

Levine et al. (1978) argued that p increase endorphin (opiate) release - the brain's natural painkiller - which therefore decreases pain. Evidence for this comes in several forms. P have been shown to create dependence, withdrawal and tolerance, all factors that are similar to those found in abstinent heroin addicts, suggesting that placebos may well increase opiate release. In addition, results suggest that p effects can be blocked by giving naloxone, which is an opiate antagonist. This indicates that p may increase the opiate release, but that this opiate release is blocked by naloxone, supporting the ph theory of p. However, the ph theories are limited as pain reduction is not the only consequence of p.

Fertility

Lifestyle factors such as smoking and drinking appear to have a greater effect on men's fertility than women's but still little research. Men generally don't undergo testing until their partner has been thoroughly checked - viewed as women's business, and/or lack of masculinity? - women are tested first most of the time Surrounding research on infertility almost exclusively looks at women, men's role seen as supportive of the woman - Webb and Daniluk (1999) did study men, and found consistent descriptions of grief, loss, shock that they could be infertile, and inadequacy/powerlessness that they let their partner down - isolation and confusion Miscarriages - 12-24% of pregnancies - not that much research on women's reactions, almost completely ignored in men - but profound distress, and confusion over exactly what the appropriate response should be - deny own feelings to be supportive of the partner, feeling that own feelings of grief are inappropriate. Men less likely to blame themselves

The importance of cortisol

Linked to a variety of health outcomes - cardiovascular disease, poor cognitive functioning, fractures, functional disability, obesity, type-II diabetes, autoimmune diseases, mortality Because most bodily cells have cortisol receptors, it affects many different functions in the body. C can help control blood sugar levels, regulate metabolism, help reduce inflammation, and assist with memory formulation. It has a controlling effect on salt and water balance and helps control blood pressure. The challenge of studying c - it follows a diurnal (fluctuation) pattern naturally - highest c production occurs in the second half of the night with peak c levels in the early morning hours

Questions - men's health

Little/no research on multiple roles in men's lives to parallel that for women. Researchers seem to implicitly and uncritically accept the notion that men have only one role that counts, that of a worker... Are the conflicts between paid work and family responsibilities faced by men really freely chosen, or are they legitimate social concerns? (and who decides?) To what extent do men experience guilt over continuing social inequity in both paid and unpaid work? What are the actual preferences of men in terms of childcare and unpaid domestic labour, and what do these correlate with? Has psychology ignored the internalised contradictory understandings of masculinity? (traditional with supportive, flexible, egalitarian) No doubt traditional division benefits men financially, but are we over concerned about 'financially', is that really what's important? Continued socialisation of men to have career, and take a limited role in domestic labour and childcare - there is a conflict between social and actual expectations stress and related problems

Depression death stage

Logical really - great sense of loss. Many facets - some specific to illness - e.g., breast cancer or uterine cancer, loss of figure and/or womanhood, facial surgery for many - appearance issues - and more generally, financial burdens and loss of ability to engage in a range of activities that were previously pleasurable, familial impacts etc Kubler-Ross proposed a second "depression" "preparatory grief that the terminally ill patient has to undergo in order to prepare himself for his final separation from this world " (p76) In the normal course of events, people will try to cheer someone up who shows signs of depression - look on the bright side, see positive things etc. Debatable whose benefit this is for, (think negative reinforcement), but of course all rings rather hollow with someone who is faced with their imminent death. KR suggests that this second type of grief is not often expressed anyway, more a case of a feeling which can be shared non-verbally. Often/sometimes spend time reviewing the meaning of their life, not thinking about the illness per se, and searching for ways to share this with the closest people in their lives. A closing statement of sorts

rapid recovery from illness social support

Lower pain levels Kulik & Mahler (1989) - spousal s study of recovery from heart bypass surgery - 56 males, measure quality of marriage (High or Low) and anxiety level, amount of SS was number of visits by wife. Comparison group was 19 unmarried patients (tracked non-spouse visits - there were few - treated as distinct, but essentially low SS). High SS had faster recovery, less pain medication High SS released 1.26 days sooner than low SS, and 0.58 days earlier than single Non-supportive marriage seemed to have a negative impact on recovery Perceived marital quality no effect... but little variation Associated with quicker recoveries from illnesses Associated with lower likelihood of returning to hospital following heart surgery

Does social support affect health?

Lynch (1977) reported that widowed, divorced or single individuals have higher mortality rates from heart disease than married people and suggested that heart disease and mortality are related to lower levels of s s. However, problems with this study include the absence of a direct measure of s s and the implicit assumption that marriage is an effective source of s s. Berkman and Syme (1979) reported the results of a prospective study whereby they measured s sin 4,700 men and women aged 30-69, whom they followed up for nine years. They found that increased social support predicted a decrease in mortality rate. Research has also indicated that birth complications are lower in women who have high levels of s s (Oakley 1992). Research has also examined the effects of s s on immune functioning and consequently health. For example, Arnetz et al. (1987) examined the immune function of 25 women who were either employed (n = 8) or unemployed (n = 17). The unemployed group received either standard economic benefits only or received benefits as well as a psychosocial support programme. The results showed that those who received the psychosocial support showed better immune functioning than those who received benefits only. It would seem that s s reduced immunosuppression.

Caring for dying patient

Many of the issues that arise when a disclosure policy is adopted are not amenable to rigorous investigation Even the breaking of bad news skillfully can only be guided by clinical judgement and experience. Numerous models suggested; all emphasise remembering to prepare (self and patient), avoiding common mistakes, encouraging emotional expression and following up later Very common for patients' first response to be a question about how long they will live. Research evidence (both direct and indirect) suggests that health professionals are commonly very bad at making such judgements Avoiding the question simply by saying that no-one can tell, however, may create further anxieties on part of the patient May require sustained discussion. Continuing care may involve many months or even years. During this time the patient may show irregular deterioration, general decline or specific problems. In cancer patients, for example, increased rate of nightmares during sleep may be noted. As death approaches, death-related decisions become important

Fear and pain

Many patients with an experience of p can have extensive f of increased p or of the p reoccurring which can result in them avoiding a whole range of activities that they perceive to be high risk. For example, patients can avoid moving in particular ways and exerting themselves to any extent. However, these patients often do not describe their experiences in terms of f but rather in terms of what they can and cannot do. Therefore they do not report being frightened of making the p worse by lifting a heavy object, but they state that they can no longer lift heavy objects. f of p and fear avoidance beliefs have been shown to be linked with the p experience in terms of triggering p in the first place. For example, Linton et al. (2000) measured fear avoidance beliefs in a large community sample of people who reported no spinal p in the preceding year. The participants were then followed up after one year and the occurrence of a p episode and their physical functioning were assessed. The results showed that 19 per cent of the sample reported an episode of back p at follow-up and that those with higher baseline scores of fear avoidance were twice as likely to report back p and had a 1.7 times higher risk of lowered physical functioning. The authors argued that fear avoidance may relate to the early onset of p. Some research also suggests that f may be involved in exacerbating existing p and turning acute p into chronic p. For example, Crombez et al. (1999) explored the interrelationship between attention to p and f. They argued that p functions by demanding attention which results in a lowered ability to focus on other activities. Their results indicated that p-related f increased this attentional interference, suggesting that f about p increased the amount of attention demanded by the p. They concluded that p-related fear can create a hyper-vigilance towards p which could contribute to the progression from acute to chronic p. These conclusions were further supported by a comprehensive review of the research. This indicates that treatment that exposes patients to the very situations they are afraid of, such as going out and being in crowds, can reduce f avoidance beliefs and modify their p experience (Vlaeyen and Linton 2000).

Finding differences in our theories

Many theories also look for differences between populations (e.g. men versus women; old versus young; doctor versus patient). We need to ask: • Are these differences artefacts of the statistics we use (e.g. if we ask a differences-based question we can find a difference, but if we ask an association-based question we can find an association)? A good example of this is that daughters have higher body dissatisfaction than their mothers (i.e. they are different) but daughter body dissatisfaction is correlated with their mothers (i.e. they are associated). The answer depends on the question asked and the statistical test used. • Are the variables that we use to explore differences (men versus women; old versus young) really dichotomous variables or artificially created as binary variables (what about all the people who fall somewhere between?)?

Effects of mindfulness

Massion et al. (1995) found that experienced m had significantly higher melatonin levels. Since higher melatonin levels are linked to improved immune function, they speculated that regular m might lead to improved outcomes for breast and prostate cancer.

The Gate Control Theory of Pain (GCT)

Melzack and Wall (1965), developed the GCT, which represented an attempt to introduce psychology into the understanding of p. non-pful input closes the nerve "g's" to pful input, which prevents p sensation from traveling to the central nervous system. Eg- hitting finger with hammer then rubbing it to ease p It suggested that, although p could still be understood in terms of a stimulus- response pathway, this pathway was complex and mediated by a network of interacting processes. Therefore the GCT integrated psychology into the traditional biomedical model of p and not only described a role for physiological causes and interventions, but also allowed for psychological causes and interventions.

Input to the gate

Melzack and Wall suggested that a g existed at the spinal cord level, which received input from the following sources: • Peripheral nerve fibres. The site of injury (e.g. the hand) sends information about pain, pressure or heat to the g. • Descending central influences from the brain. The brain sends information related to the psychological state of the individual to the g. This may reflect the individual's behavioural state (e.g. attention, focus on the source of the pain); emotional state (e.g. anxiety, fear, depression); and previous experiences or self-efficacy (e.g. 'I have experienced this pain before and know that it will go away') in terms of dealing with the pain. • Large and small fibres. These fibres constitute part of the physiological input to pain perception.

Risk Taking, Violence etc

Men are at considerably greater risk of accidental injury and death... Gender-based choices of occupational and recreational activities - placing men at greater risk. Male-female mortality differences peak markedly between 15-35 - are a substantial contributor to the overall life expectancy difference Men approx 3 times as likely to die from injuries, several times more likely to die from car accident, drowning, and all other external causes apart from falls Elderly women the most at risk here because of the high probability of major fractures. Paralleled by hospitalisation and disability - Gardiner et al (2000) 75% of intensive care admissions in Auckland were boys.

Domestic Labour

Men throughout the world undertake considerably less unpaid domestic labour than their female partners, regardless of the amount of paid work undertaken by the females. Both men and women seem to believe that unpaid labour should be divided equitably, but they both seem content (ish) with an objectively inequitable division Men tend to deal with ambiguities by ignoring Not studied much at all Childcare also predominantly woman's role, although there are measurable benefits to greater involvement for men - for them, their partner, and the child(ren) - in particular better emotional outcomes for sons

Modern-day placebo

More recently, p have been studied specifically and have been found to have a multitude of effects. For example, Haas et al. (1959) listed a whole series of areas where p have been shown to have some effect, such as allergies, asthma, cancer, diabetes, enuresis, epilepsy, multiple sclerosis, insomnia, ulcers, obesity, acne, smoking and dementia. Perhaps one of the most studied areas in relation to p effects is pain. Beecher (1955), in an early study of the specific effects of p in pain reduction, suggested that 30 per cent of chronic pain sufferers show relief from a p when using both subjective (e.g. 'I feel less pain') and objective (e.g. 'You are more mobile') measures of pain. In addition, as noted above, Diamond et al. (1960) reported a sham operation for patients suffering from angina pain and reported that half the subjects with angina pain were given a sham operation, and half of the subjects were given a real heart bypass operation. The results indicated that pain reduction in both groups was equal, and the authors concluded that the belief that the individual had had an operation was sufficient to cause pain reduction and alleviation of the angina.

Using biological risk data

Most psychological theories of behaviour and behaviour change indicate that risk perception is a central variable for understanding why people either do or do not carry out health-related behaviours. For example, from a social cognition model perspective, if a person believes that they are at risk from lung cancer we would predict that they would be less likely to smoke. Many interventions therefore aim to increase an individual's perception of risk as a means to change their behaviour. Recent developments in DNA testing have offered a more refined way to present this risk as it means that risk information can be tailored specifically to the individual's own risk of any specific illness based upon their genetic predisposition for that illness. Therefore, rather than telling a smoker 'Your smoking might well cause lung cancer because it has done in many other people', following DNA testing a smoker could be told, 'You, personally, have a 75 per cent risk of developing lung cancer if you smoke.' This is in line with theories of attitude change which argue that personally salient information is more effective than general information. It also offers the chance to explore whether such information has a negative impact upon the individual by inducing fatalism and a sense that their pending illness in the future is inevitable. Marteau and colleagues have carried out much research in this area and recently have completed two systematic reviews of the literature (Marteau et al. 2010; Collins et al. 2011). The first review focused on the impact of DNA-based disease risk estimates in the context of heart disease, lung, breast and bowel cancer, inflammatory bowel disease and Alzheimer's disease. All these diseases include a role for health-related behaviors. Further, the risk of developing each of these diseases could be reduced by a change in behaviour. The review identified 14 papers using either clinical trials (n = 8) or analogue studies using vignettes (n = 6). The results from the clinical studies showed no significant effects of personalized risk estimates on smoking cessation, physical activity or medication and vitamin use. An effect, however, was found for improvements in diet. The analogue studies also showed significant effects for intentions to change behaviour. In their second review, Collins et al. (2011) identified five studies addressing obesity, depression, heart disease and diabetes and focused on the potentially negative impact of receiving personalized risk estimates. They concluded from this review that such risk estimates do not generate either fatalism or changes in perceived control. Overall, the authors concluded that DNA-based risk estimations may not be as effective as hoped for changing behaviour. However, it would also seem that such risk estimations do no harm in terms of negative changes in beliefs about any given condition.

The Role of Life Events and Reinvention

Most research exploring successful weight loss maintenance emphasizes the impact of structured interventions or focuses on gradual changes in the individual's psychological state. Both approaches see change as the result of a 'drip drip' effect that occurs slowly over time. However, some changes in behaviour, and subsequent body weight, may occur in a more dichotomous fashion following a specific e and this has been explored using a number of different terms including 'teachable moments', 'l events', 'l crises', 'epiphanies' and 'medical triggers'. This is in line with l e theory, which was a central part of psychological theory and research towards the end of the twentieth century (eg. Brown and Harris 1978). In a recent qualitative study Ogden and Hills (2008) carried out a series of interviews with those who had shown sustained behaviour change in terms of either smoking cessation (n = 10) or weight loss maintenance (n = 24) and highlighted the role for a number of different life e. In particular, many participants described how their behaviour change had been triggered by events relating to their health (e.g. heart attack, symptoms of diabetes), relationships (e.g. divorce) or salient milestones (e.g. important birthday). The results also illustrated that the impact of these life e was mediated through three key sustaining conditions − namely, reduced choice over the previous unhealthy behaviour, reduced function of their past behaviour and a model of their health which emphasized behavioural causes and solutions. Using the example of weight loss maintenance, it was argued that the initial change in diet triggered by the life event is translated into sustained behaviour change if the e reduces the individual's choice about when and how much to eat, if it reduces the function and benefits attached to eating and if the individual believes that their weight problem is caused by their behaviour. Further, it was concluded that sustained behaviour change is facilitated through a process of r as individuals respond to the life e by r themselves as a healthier and thinner person.

The possible benefits of low control

Most theories of the relationship between c and stress suggest that high c (such as predictability, responsibility, etc.) relates to a reduction in stress and is therefore beneficial to health. However, in certain situations a perception of low c may result in lowered stress. For example, flying in a plane can be made less stressful by acknowledging that there is nothing one can do about the possibility of crashing. To an extent this perception of helplessness may be less stressful than attempting to control an uncontrollable situation.

Corr

Much of what we do depends on how we feel, what we know or believe, and what we value as significant. But the larger context of coping is an adaptation not just reaction, response or defence. defending merely attempts to ward off problems or challenges, while coping attempts to resolve or manage them. We don't need to get through stages, in reality there is not really anywhere to get. In dying, as in living, we merely have opportunities to live as well as we can and in accordance with our definitions of what constitutes quality living. A stage model risks stereotyping individuals who are dying because it is founded on generalisations. It is, however, attractive because the stages reflect how some react, and 'ring bells' with some, and of course as with many models it has an intuitive feel to it.

How does hostility link to illness?

Much research has shown an association between hostility and CHD. In particular, researchers have argued that h is not only an important risk factor for the development of heart disease (e.g. Miller et al. 1996) but is also a trigger for heart attack (Moller et al. 1999). However, it may not be h per se that predicts heart disease but how this h is expressed. Ramsay et al. (2001) and McDermott et al. (2001) explored associations between a range of components of h and symptoms of coronary artery disease (CAD) in men with CAD versus a control group of men attending a fracture clinic. Results at baseline and at two-year follow-up showed that the best predictor of CAD symptoms was not h but anger expression. Similarly, Siegman and Snow (1997) argued that the expression of anger and h might be a better predictor of stress reactivity and subsequent health outcomes than the state of either anger or h on their own. So how might h and the expression of hostility cause i? The link between h and heart disease illustrates a role for a physiological pathway with the associated heightened stress reactivity leading to cardiac damage. However, research also suggests that h may impact upon health through two other pathways. First, hostility is linked to unhealthy behaviours such as smoking, alcohol intake, caffeine consumption and poorer diet (e.g. Lipkus et al. 1994). Second, h may be associated with other moderating factors. For example, h individuals may avoid social support and refuse to draw upon any help when under stress. In fact, this is implicit within some of the measures of h with responses to statements such as 'No one cares much what happens to me'. H may also relate to coping as believing that 'It is safer to trust nobody' could be seen to reflect an avoidant coping style.

Can theories be tested?

Much research in health psychology aims to test a theory. We need to ask: • Can the theory ever be rejected (e.g. it didn't work but it was the fault of the sample/measures/ confounding variables - let's keep the theory)? • Can the theory ever be accepted (statistics are based on probabilities; our results are never true all the time but true within an accepted level of probability)? We can therefore learn to be more critical of theories in terms of the constructs we use and the ways in which we explore whether or not these constructs are related to each other. I visualize this as a form of dividing up the soup.

Making plans and implementation intention

Much research indicates that although an individual may make an intention to carry out a behaviour this intention is not always translated into practice. This is known as the intention−behaviour gap and appears to result from intenders who do not act rather than non-intenders who do act (Sheeran 2002). Research has highlighted a number of ways that this gap can be closed and in 1993 Gollwitzer defined the notion of implementation intentions which involve the development of simple but specific plans, after intentions, as to what an individual will do given a specific set of environmental factors. Therefore implementation intentions describe the 'what' and the 'when' of a particular behaviour. For example, the intention 'I intend to stop smoking' will be more likely to be translated into 'I have stopped smoking' if the individual makes the implementation intention 'I intend to stop smoking tomorrow at midday when I have finished my last packet'. Further, 'I intend to eat healthily' is more likely to be translated into 'I am eating healthily' if the implementation intention 'I will start to eat healthily by having a salad tomorrow at lunchtime' is made.

How does rehabilitation psychology fit in with other "scopes" of psychology practice?

Neuropsychology (Brain and behaviour) - vocational scope Rehabilitation Psychology (Physical illness and injury) Health Psychology (Health promotion and preventing ill health) Clinical Psychology (Mental health) - vocational scope Counselling Psychology (Wellbeing) - vocational scope

Illegal Euthanasia

New Zealand figures published 20031: Nationwide study indicated 5.6% of most recent deaths dealt with by doctors had involved euthanasia or PAS In 2.4% there was no discussion with patient Action taken partly with intent of hastening death in 13.6% of cases Of these, over half did not involve discussion with the patient Estimated 0.8-1.6% involved killing without the patient's explicit request Figures comparable to those obtained from studies in Belgium and Australia Figures not affected by the availability of palliative care. 1Mitchell, K, & Owens, R G (2003) British Medical Journal

Web-based Interventions

New developments in technologies have also led to the use of web-based interventions so that patients who may be unable or unwilling to attend to face-to-face consultations can now engage in a range of therapeutic strategies from their own home to fit in with their own time frame. For example, packages of web-based interventions have been developed for patients with a range of chronic illnesses such as diabetes, asthma, CHD and AIDS/HIV to deliver treatments such as CBT, relapse prevention, education and goal-setting. Many also address psychological problems such as depression and anxiety, OCD and body image disturbance. Rosser et al. (2009). carried out a systematic review of novel technologies for the management of chronic illnesses (both psychological and physical) and identified that most utilized web-based interventions (53 per cent) with other technologies being interactive CD-ROM programmes, online message boards, video presentations, email contact or virtual reality delivery. From this review they highlighted a number of packaged interventions such as 'MoodGYM', 'Diabetes Priority Programe', 'Beating the Blues' and 'CHESS'. Rosser et al. made three key observations about the studies they included in their review. First, they noted that sample sizes for the studies were extremely high (mean size at start of study n = 780) reflecting the ease with which patients can be targeted with this approach. Second, they highlighted the extremely high level of dropouts over the course of the studies as patients stopped engaging with the interventions (ranging, 0−84 per cent, mean sample size after dropouts n = 258). Finally, they noted that although the interventions were delivered remotely (i.e. by computer or email), 73 per cent still included some involvement with a therapist and that greater involvement with a therapist was associated with lower dropout rates. Overall, therefore, web-based interventions can reach large numbers of people who may not want to, or be able to, come into a consultation. They may be effective but they have high attrition rates and still seem to require therapist involvement to be more successful.

What to learn and not learn (Corr, 1993)

No clear support for the stage based model - not uncommon for a case-study based approach, of course. Kastenbaum (1986) raised 6 key points The existence of the stages has never been demonstrated No evidence has been presented that people move through from stage 1 to 5 Limitations of the method have never been acknowledged The insufficient distinction between description and prescription The totality of a person's life (which must impact on how a person experiences dying) is neglected in favour of the stages of dying The resources, pressures, and characteristics of the immediate environment can make a tremendous difference KR has never responded to the many criticisms, nor has she provided evidence beyond case notes and vignettes. But, she did draw the attention to the situation, and more particularly the needs of dying people and those involved. She also affected greatly the way people think about these issues. She said, " I am simply telling the stories of my patients who shared their agonies, their expectations, and their frustrations with us" p. xi very humble and nice, but in reality there was a selection and interpretation that was applied, silly to pretend/imagine otherwise. She clearly interpreted within her psychodynamic(ish) framework. The focus is on defence mechanisms - coping mechanisms, conflicts etc

Honesty - empirical aspects

Not disclosing the diagnosis to groups such as cancer patients once fairly common practice; where the diagnosis was disclosed, this would usually be on the advice of close family. Around 1950s/1960s, studies began to appear investigating people's views on disclosing Studies of the general public generally found a large majority agreeing that a dying person should not normally be told. However, when people asked about whether they would wish to be told, the large majority indicated they should. Physicians and surgeons who started to tell their patients in some cases asked patients their views on being told. Overwhelming majority glad to have been told, citing benefits such as reducing uncertainty, opportunity to plan ahead and prepare. Today it may be much more difficult to conceal information, given the access patients have to such things as online newsgroups etc. Similarly, the development of specialist palliative care services, hospice care etc. may often render concealment impractical.

Why People Don't Use Health Services

Not trusting practitioners ⚫ Worry about confidentiality ⚫ Worry about discriminatory practices ⚫ Worry about competence Emotional factors: ⚫ fear of serious disease ⚫ embarrassment Social factors ⚫ Not wanting to appear weak ⚫ More likely to use health care system if lay referral system encourages it Cost Iatrogenic conditions: medical problems resulting from a practitioner's error or as a normal side effect of treatment. ⚫ Condition is a byproduct of diagnosis or treatment Not sure it's a 'front and centre' reason for avoiding, but there are horror stories, and people have access to these, and they can be very emotive eg- weight gain from antidepressants ⚫ A convenient excuse for not accessing heaalthcare?

The experience of dying....

Note that in a sense we're all dying from the time we're born...... Nevertheless, it is in a sense still meaningful to talk of the experience of being a 'dying person' once one is aware that one has an incurable and potentially fatal illness. "Death is one of the attributes you were created with; death is part of you. Your life's continual task is to build your death" - Montaigne

Physical problems with obesity

O has been associated with cardiovascular disease, diabetes, joint trauma, back pain, cancer, hypertension and mortality. The effects of o are related to where the excess weight is carried; weight stored in the upper body, particularly in the abdomen, is more detrimental to health than weight carried in the lower body. It is interesting to note that although men are more likely than women to store fat on their upper bodies, and are therefore more at risk if o, women are more concerned about weight than men and most treatment studies examine women. The relationship between BMI and mortality is shown in Figure 15.6. It has been suggested that most problems seem to be associated with severe o and weight is in the top 10 per cent (Wooley and Wooley 1984); however, a study of 14,077 women indicated a direct linear relationship between BMI and risk factors for heart disease including blood pressure, cholesterol and blood glucose (Ashton et al. 2001). Similar studies have also reported a relationship between BMI increases in the lower range of the spectrum and hypertension (National Institutes of Health 1998), diabetes (Ford et al. 1997) and heart attack (Willett et al. 1995). Moore et al. (2008) also explored the impact of BMI measured 10 years prior to death in a large cohort of 50,186 women. The results showed a direct relationship between BMI and mortality (see Romero-Corral et al. 2006 for a systematic review of the literature). Further, in 2002, research by the House of Commons Special Select Committee in the UK estimated that 6.8 per cent of all deaths in England were attributable to o.

Stress and wound healing

One marker of how well the immune system is working is the speed of w.h and research indicates that stress is linked to this, which has implications for how patients are supported after surgery and the impact of any stressors on their health outcomes. Research in this area has either used acute and chronic clinical wounds, including patients post-surgery for hernia, oral surgery, burn injuries and coronary artery bypass grafting, or experimentally-induced wounds using either tape stripping, a blister chamber model or punch biopsies. W.h and stress have then been measured. A recent review explored the evidence in this field and identified 21 papers for a systematic review and 11 papers for a meta-analysis (Walburn et al. 2009). The results indicated that in 17 of the 21 studies stress was associated with impaired wound healing. The effect size was estimated at r = −0.42. This indicates a fairly strong impact of stress on wound healing. The authors conclude that although this link seems fairly well established, more needs to be discovered about what factors mediate this link, including variables such as health-related behaviours, social support and coping (see p. 324).

Exposure

One of the best predictors of future behaviour is past behaviour (see Chapter 3), as having already performed a behaviour makes that behaviour seem familiar and can increase an individual's confidence that they can carry out the behaviour again. Therefore, one of the simplest ways to change behaviour is through e to the behaviour, practice or skills training. In terms of eating habits, research shows that we eat what we are familiar with and have been e to. For example, Wardle et al. (2003) carried out a study whereby children aged 2−6 identified a vegetable they least liked and then were e to this vegetable for 14 days (compared to children who were either given information or were in the control group). The results showed that daily e resulted in the children eating more of the vegetable in a taste test and reporting greater preference for the vegetable than those in the other two groups. Similarly research indicates that children can identify and are willing to taste vegetables if their parents purchase them (Busick et al. 2008). Furthermore, not only does past behaviour predict future behaviour but it also predicts and changes cognitions that then predict behaviour. - condoms education eg - if I think 'condoms are difficult to put on' and my behaviour is 'I don't use condoms' and then I put one on a banana during a skills training session, my cognition will shift to 'actually I can use condoms' and my behaviour will change as well to 'I now use condoms'.

Changing Affect

One of the main criticisms of many psychological theories of behaviour and the strategies used to change behaviour is that they do not address an individual's emotions and consider people to be rational processors of information (van der Pligt et al. 1998; van den Berg et al. 2005). Some studies, however, have included a role for affect and this has taken various forms including visualization, affective attitudes, fear appeals and self-affirmation interventions

Does stress cause illness

One of the reasons that s has been studied so consistently is because of its potential effect on the health of the individual. Research shows that hypertension rates are more common in those with high s jobs such as air traffic controllers (Cobb and Rose 1973) than in less sd occupations such as nuns (Timio et al. 1988) and that higher life s is associated with greater reporting of physical symptoms (Cropley and Steptoe 2005). Both cross-sectional and longitudinal studies also show that stressful occupations are associated with an increased risk of coronary heart disease (CHD) (Karasek et al. 1981; Kivimaki et al. 2002). Further, Phillips et al. (2008) reported from their longitudinal study of 968 men and women aged 56 that the number of health-related life events at baseline and their s load predicted mortality by 17 years (266 participants had died) (see Focus on Research 12.1). In addition, Appels and Mulder (1989) and Appels et al. (2002) indicated that 'vital exhaustion' is common in the year preceding a heart attack. In one study people were given nasal drops either containing viruses responsible for the common cold or placebo saline drops. Their level of stress was then assessed in terms of life events during the past year (Cohen et al. 1991). The results showed that not everyone who was given the virus contracted the virus and not everyone who did contract the virus actually exhibited cold symptoms and became i. Stress was shown to predict, first, who contracted the virus, and second, who developed symptoms. However, these studies involved a cross-sectional, prospective or retrospective design which raises the problem of causality as it is unclear whether s causes i or i causes s (or s ratings). To solve this problem, some research has used an experimental design which involves inducing s and assessing subsequent changes in health. Because of the ethical problems with such a design most experimental work has been done using animals. A classic series of animal studies by Manuck, Kaplan and colleagues (e.g. Kaplan et al. 1983; Manuck et al. 1986) experimentally manipulated the social groupings of Bowman Gray monkeys who have a strong social hierarchy. The results showed that the monkeys illustrated not only behavioural signs of s but also a marked increase in the disease of their coronary arteries. In addition, s management, which involves experimentally reducing s, has had some success in reducing CHD (Johnston 1989, 1992) and in reducing recurrent cold and flu in children (Hewson-Bower and Drummond 2001).

Disease Prevention

One of the triumphs of modern medicine and public health has been the direct and indirect targeting of the causes of disease and injury (Sagan, 1987). Swamps containing malaria-bearing mosquitoes have been drained; childbirth now happens under sterile circumstances; food is now inspected and dated for freshness; automobile seat belt laws have been passed and largely heeded; vaccines have been developed and made widely available; and the general public has heeded warnings about the risk of smoking, and cigarette use is down. Over the centuries, life expectancy has increased by leaps and bounds around the world, largely because so many diseases and injuries have been prevented (Brandt and Gardner, 2000). Potentially fatal illness and Positive Health are not simple opposites, but neither are they completely independent of one another. One cannot easily evidence Positive Health if at death's door, and certainly not if one has crossed through it. So, Positive Health may be a prerequisite to preventing disease. The target of disease prevention is, of course, preventing or delaying illness, and its sole interest in health assets is their possible use in preventing illness (Heymann, 2008). Positive Health overlaps with disease prevention in two ways: (a) the use of interventions to prevent disease and (b) the focus on early antecedents and early intervention strategies. Positive Health is distinct from disease prevention in three ways. First, the targets of Positive Health are broader than just illness. For example, increased subjective well-being, mental health, exercise, and a good marriage are important for their own sake as well as being beneficial to reducing illness. Second, Positive Health is specifically interested in health assets and the benefits that these confer beyond signaling the absence of risk factors. Finally, Positive Health is specifically interested in using the information about health assets discovered empirically to create and deploy interventions that build those assets that are most relevant and to combine them with traditional interventions.

Eating differenly obesity

One recent study asked whether the o eat at different times of day to the non-o. Berg et al. (2009) used a sample of 3,610 women and men from Sweden and explored their BMI and meal patterns. The results showed that those who were o were more likely to skip breakfast, skip lunch and eat at night and reported larger portion sizes at meal times. Similarly, Laessle et al. (2007) explored whether the o ate differently in a laboratory study in Germany. The results showed that compared to normal weight participants the obese showed a faster initial rate of eating, took larger spoonfuls and had an overall greater intake of food.

Reinforcement

One way to change behaviour is to positively reinforce the desired behaviour and ignore or punish the less desired behaviour. For example, a child is more likely to eat fruit and vegetables if their parent smiles while they are eating them. One intervention introduced a 'Kid's choice' school lunch programme whereby children were given tokens for eating fruit or vegetables which could be later traded for prizes. The results showed that preference and consumption increased at two weeks after the programme (Hendy et al. 1995). However by seven months, when the programme had finished, levels had returned to baseline: rewarding behaviour may change behaviour but this may not persist when the rewards are removed. Research indicates that people often change their behaviour in the long term when the old unhealthy behaviour is no longer functional. For example, people stop smoking when it no longer offers them a way to spend time with friends or change their diet when they find different foods more enjoyable

Demands on men to engage in indiscriminate sexual behaviour?

Or, perhaps, engage in related activities such as heavy drinking, spending and boasting/embellishing about their sexual conquests. Man who fails to subscribe is at risk of mockery and contempt of other men... Of course, men that do subscribe are at increased risk of STIs Still questions on whether cultural expectations are met by actual behaviour. Actual behaviour likely to be different... stimulus control Importance of attitudes is open for debate - how, where and to whom they are expressed

Conditioning the immune system

Originally it was believed that the i system was autonomous and did not interact with any other bodily systems. However, research indicates that this is not the case and that not only does the immune system interact with other systems, but it can be conditioned to respond in a particular way using the basic rules of classical and operant conditioning. The early work in this area was carried out by Ader and Cohen (1975, 1981) and showed that changes in the immune system brought about by an i suppressive drug could be paired with a sweet taste. This meant that after several pairings, the sweet taste itself began to bring about i suppression. These results were important for two reasons. First, they confirmed that the i system could be manipulated. Second, the results opened up the area for PNI and the possibility that psychological factors could change an individual's i response.

Characteristics of the Treatment (Non-interactive theories)

Other researchers have focused on treatment c and have suggested that the c of the actual process involved in the placebo t relate to the effectiveness or degree of the placebo effect. For example, if a treatment is perceived by the individual as being serious, the placebo effect will be greater. Accordingly, surgery, which is likely to be perceived as very serious, has the greatest placebo effect, followed by an injection, followed by having two pills versus one pill. Research has also looked at the size of the pill and suggests that larger pills are more effective than small pills in eliciting a change.

Coping and Positive Outcomes

Over recent years there has been an increasing recognition that stressful events such as life events and illness may not only result in negative outcomes but may also lead to some positive changes in people's lives. This phenomenon has been given a range of names including stress-related growth (Park et al. 1996), benefit-finding (Tennen and Affleck 1999), meaning-making (Park and Folkman 1997), growth-orientated functioning and crisis growth (Holahan et al. 1996). This finds reflection in Taylor's (1983) cognitive adaptation theory and is in line with a new movement called 'positive psychology' (Seligman and Csikszentmihalyi 2000). Though a new field of study, research indicates that coping processes that involve finding meaning in the stressful event, positive reappraisal and problem-focused coping are associated with positive outcomes (Folkman and Moskowitz 2000). (See Chapter 9 for further discussion of benefit-finding following illness.) Coping is considered to moderate the stress-illness link and to impact upon the extent of the stressor. Much research has involved the description of the kinds of coping styles and strategies used by people and a few studies suggest that some styles might be more effective than others.

Type of food obesity

Over recent years, research has focused on the eating behaviour of the o not in terms of calories consumed, or in terms of amount eaten, but more specifically in terms of the t of f. Population data indicate that calorie consumption has decreased since the 1970s and that this decrease is unrelated to the increase in obesity (see Figures 15.9, 15.10). However, these data also show that the ratio between carbohydrate consumption and fat consumption has changed; whereas we now eat less carbohydrate, we eat proportionally more fat (Prentice and Jebb 1995, see Figure 15.11). One theory that has been developed is that, although the o may not eat more than the non o overall, they may eat proportionally more fat. Further, it has been argued that not all calories are equal (Prentice 1995) and that calories from fat may lead to greater weight gain than calories from carbohydrates. To support this theory, one study of 11,500 people in Scotland showed that men consuming the lowest proportion of carbohydrate in their diets were four times more likely to be o than those consuming the highest proportion of carbohydrate. A similar relationship was also found for women, although the difference was only two- to threefold. Therefore it was concluded that relatively lower carbohydrate consumption is related to lower levels of o (Bolton-Smith and Woodward 1994). A similar study in Leeds also provided support for the fat proportion theory of obesity (Blundell and Macdiarmid 1997). This study reported that high fat eaters who derived more than 45 per cent of their energy from fat were 19 times more likely to be obese than those who derived less than 35 per cent of their energy from fat. Therefore these studies suggest that the o do not eat more overall than the non-obese, nor do they eat more calories, carbohydrate or fat per se than the non-o. But they do eat more fat compared with the amount of carbohydrate; the proportion of fat in their diet is higher. So how might a relative increase in fat consumption relate to o? As a possible explanation of these results, research has examined the role of fat and carbohydrates in appetite regulation. Three possible mechanisms have been proposed (Blundell et al. 1996; Blundell and Macdiarmid 1997): 1. The benefits of complex carbohydrates to energy use. It has been suggested that it takes more energy to burn carbohydrates than fat. Further, as the body prefers to burn carbohydrates than fat, carbohydrate intake is accompanied by an increase in carbohydrate oxidation. In contrast, increased fat intake is not accompanied by an increase in fat oxidation. Therefore carbohydrates are burned, fat is stored. 2. The benefits of complex carbohydrates to hunger. It has been suggested that complex carbohydrates (such as bread, potatoes, pasta, rice) reduce hunger and cause reduced food intake due to their bulk and the amount of fibre they contain. In addition, they switch off the desire to eat. Therefore carbohydrates make you feel fuller faster. 3. The costs of fat to hunger. It has been suggested that fat does not switch off the desire to eat, making it easier to eat more and more fat without feeling full.

Improving intervention research and a search for active ingredients

Over the past few years there has been a call to identify which aspects of which interventions are effective and to promote improvements in the reporting and design of new interventions to make the process more transparent and easier to replicate (eg. Abraham and Michie 2008; Michie et al. 2009; 2010; West et al. 2010). This call to improve intervention research has involved a number of approaches including the following: (1) the development of a taxonomy of behaviour strategies to code and label which strategies are being used; (2) matching these strategies to their target behaviour and target populations; (3) calculating which strategies are most effective at producing change in which behaviours and which populations. Once completed, this could result in an exhaustive taxonomy of strategies that could be used to improve how interventions are designed and reported. In a recent review Michie et al. (2011) carried out a synthesis of all the different types of taxonomy as a means to identify essential conditions for behaviour change and how these could be turned into actual behaviour change. From this process, the researchers created a behaviour change wheel with three levels illustrating the translational process from essential conditions, through intervention functions, to policy. • Essential conditions: the researchers identified three conditions which are deemed essential for behaviour and behaviour change: capability, motivation and opportunity. These constructs find parallels in many models of behaviour but are deemed to capture the essence of how and why we act as we do. • Intervention functions: it is argued that changing behaviour requires a change in these essential conditions and that a series of intervention functions can bring this change about. The nine functions identified in the behaviour change wheel reflect a synthesized version of the many strategies that are used to change behaviour and were derived from a detailed coding process. • Categories of policy: finally, the researchers argue that policy changes are needed to enable the interventions to occur. The end result of the behaviour change wheel would be that the policy enables interventions to occur, which in turn change the essential conditions of behaviour which bring about changes in behaviour. The model can be used to describe and understand why interventions do or do not work. It could also be used to design more effective interventions which could be linked to policy or even used to promote new policy.

Milgram's Obedience Study

Pain-induced learning (1963) Procedure: A study about 'learning' Ask questions to another 'subject' in the next room Authority figure instructs subject to administer increasing 'shock levels' in response to wrong answers true subject - engaged with medical proffession false subject - getting the "shocks" Question: How obedient will people be? measure: Shock level administered- Levels: 'moderate', 'strong', .very strong', 'intense', 'danger-severe', 'XXX' ▪ Result: 65% administered highest shock level even when the person was screaming/ stopped responding ▪ Interpretation: Perceived legitimate authority facilitates o 'The ordinary person who shocked the victim did so out of a sense of obligation - an impression of his duties as a subject - and not from any peculiarly aggressive tendencies.' (Milgram) other studies show people copy the group even if the group answers wrong in a lecture setting, professor asking questions and majority pretended that the wrong answer was correct, over time the respondant followed suit.

psychoneuroimmunology (PNI).

Part of stress resistance PNI is based on the prediction that an individual's psychological state can influence their immune system via the nervous system. This perspective provides a scientific basis for the 'mind over matter', 'think yourself well' and 'positive thinking, positive health' approaches to life. PNI can be understood in terms of: (1) what the immune system is; (2) conditioning the immune system; (3) measuring immune changes; and (4) psychological state and immunity

Bargaining death stage

Patients know from past experiences that there is the chance of being rewarded for good behaviour, and being granted a wish/achieving a goal. While the ultimate wish might be an extension of life, (cannot predict that anyway) more usually it involves the mobilisation of resources to achieve a goal. Another patient was in utmost pain and discomfort, unable to go home because of her dependence on injections for pain relief. She had a son who proceeded with his plans to get married, as the patient had wished. She was very sad to think that she would be unable to attend... With combined efforts, we were able to teach her self hypnosis which enabled her to be quite comfortable for several hours. She made all sorts of promises if she could only live long enough to attend this marriage. The day preceding the wedding she left the hospital as an elegant lady. Nobody would have believed her real condition. She was "the happiest person in the whole world", and looked radiant. I wondered what her reaction would be when the time was up for which she had bargained. I will never forget the moment when she returned... she looked tired and exhausted and - before I could say hello - said: "Now don't forget I have another son" p73 An attempt to postpone usually includes a prize and a self-imposed timeline. Most bargains are actually made with God, and kept confidential or only alluded to. Very common is the promise of service to God or righting of wrongs in exchange for some extra time. Objectively the problem is nobody can accurately predict the time of death anyway. Possible that the promises are associated with private guilt, so perhaps best not to brush aside but discuss further if the patient raises them

Catastrophizing

Patients with pain, particularly chronic pain, often show c. Keefe et al. (2000) described c as involving three components: (1) rumination - a focus on threatening information, both internal and external ('I can feel my neck click whenever I move'); (2) magnification - overestimating the extent of the threat ('The bones are crumbling and I will become paralysed'); and (3) helplessness - underestimating personal and broader resources that might mitigate the danger and disastrous consequences ('Nobody understands how to fix the problem and I just can't bear any more pain'). C has been linked to both the onset of pain and the development of longer-term pain problems (Sullivan et al. 2001). For example, in the prospective study described earlier by Linton et al. (2000), the authors measured baseline levels of pain c. The results showed some small associations between this and the onset of back pain by followup. Crombez et al. (2003) developed a new measure of catastrophizing to assess this aspect of pain in children which consisted of three subscales reflecting the dimensions of c − namely rumination, magnification and helplessness. They then used this measure to explore the relationship between c and pain intensity in a clinical sample of 43 boys and girls aged between 8 and 16. The results indicated that c independently predicted both pain intensity and disability regardless of age and gender. The authors argued that c functions by facilitating the escape from pain and by communicating distress to others.

Men have it easier when it comes to body image? (bodies men's health)

Patriarchal societies position men as important and valuable in their own right but women establish importance via relationships with, and value to, men Women bombarded with unrealistic stereotypes - men look, women are looked at? The evidence does suggest men are less concerned about their body image than women, but there are complexities. Most research done with females In the US, boys and girls as young as 6 (Gardener et al 1999; Thompson et al 1997) evaluate themselves as bigger than their ideal... Men, like women, show a discrepancy between how they perceive themselves and what they view as their ideal - but opposite to women, men typically want to be larger than they view themselves (note the contrast with children) Overweight individuals of both sexes want to be thinner, but 42% of healthy weight men want to be heavier, and 88% of healthy weight women want to be lighter (Raudenbush & Zellner, 1997) More complex than for women - for women body fat seems the key issue and for some, it's simply thinner is better For men, fat and muscle - it is possible to be too thin, and too fat - men usually have more fat and less muscle than they would like does not have the same effects as females, maybe has a different effect of over-exercising or taking steroids

Measuring Treatment Beliefs (Illness cognition)

People also have beliefs about their t, whether it is medication, surgery or behaviour change. In line with this, Horne (1997; Horne et al. 1999) developed a b about Medicine Questionnaire (BMQ) which conceptualized such beliefs along four dimensions. Two of these are specific to the medication being taken: 'specific necessity' (to reflect whether their medicine is seen as important) and 'specific concerns' (to reflect whether the individual is concerned about side-effects); and two of these are general beliefs about all medicines: 'general overuse' (to reflect doctors' overuse of medicines) and 'general harm' (to reflect the damage that medicines can do). These two core dimensions of *necessity and concerns* have been shown to describe people's beliefs about anti-retroviral therapy for HIV/AIDS (V. Cooper et al. 2002; Horne et al. 2004) and to be relevant to a range of beliefs about medicines for illnesses such as asthma, renal disease, cancer, HIV and cardiac failure (e.g. Horne and Weinman 1999). Research also shows that although individuals may report a consistent pattern of b, this pattern varies according to cultural background (Horne et al. 2004).

Who benefits from what type of support

People in different situations b from having different types of s - matching hypothesis - depends on type of problem in the case of 'controllable' events (e.g., new parents, victims of natural disaster, breakdown), people benefit from practical s. in the case of uncontrollable events (e.g., loss of spouse), people benefit from emotional s. Receiving ss from persons with similar problem has benefits - Kulik et al. (1996) - matching hospital roommates who had heart surgery, lower anxiety, more mobile post op, left hospital earlier: 8.04 days v. 9.17 days for those patients who did not have roommates who previously had the surgery

Behavioural Theories: What causes obesity?

Physical Inactivity •Only 20% of men & •10% of women are employed in active occupations •TV viewing - •13 hours/week in the 1960s, •26 hours/week in the 1990s Research Questions: Are changes in obesity-related to activity? Do obese people exercise less?

Does masculinity seem to imply to some that a man should have heterosexual sex with as many women as possible?

Popular images often equate masculinity with promiscuity (James Bond is a classic). How would a female Tiger Woods be viewed? But also a very limited oversimplification Men can demonstrate power, wealth and success via a large number of attractive sexual partners. Impotence literally means a lack of power. Stereotypes and expectations are not necessarily reflected in the attitudes, and more especially the behaviours of individuals. Probably more subtle influences - for both sexes However, it is the sexual behaviour of women that has changed in relatively recent years - women now begin sexual activity at an earlier age, and report more sexual partners than do men... In NZ, Paul et al (2000) found that 32% of girls reported intercourse before age 16 compared with 28% of boys. In Norway, Kvalem and Traeen (2000) reported 52% of 16-20 women had had intercourse, compared with 41% of 16-20 men. Still some more 'conventional' countries, and a deal of variation.

4. Community Approaches: Precede/Proceed Model

Program Evaluation Process evaluation is concerned with the activities of the program i.e. how well the program was delivered Impact evaluation determines whether the program achieved its objectives Outcome evaluation determines whether the program achieved its goal

fear appeals

Protection motivation theory (PMT, see Chapter 3) was the first social cognition model to include a measure for emotion in the form of fear and it was argued that fear can motivate behaviour change (Rogers, 1983). As a result of this, many health promotion campaigns include fear appeals such as the tombstone images for AIDs in the 1980s in the UK, pictures of emaciated and wasted people to discourage drug use in the 2000s and cigarette warnings on packets describing problems of impotency and damage to unborn children. Fear appeals typically provide two types of message relating to fear arousal and safety conditions as follows: 1 Fear arousal which involves: • There is a threat: 'HIV infection', 'lung cancer'. • You are at risk: 'Unsafe sex or sharing needles puts you at risk of HIV'. • The threat is serious: 'HIV kills', 'Lung cancer kills'. 2 Safety conditions which involve: • A recommended protective action: 'Use condoms', 'Don't share needles', 'Stop smoking'. • The action is effective: 'Condoms prevent HIV', 'Stopping smoking prevents lung cancer'. • The action is easy: 'Condoms are easy to buy and easy to use'. Together, fear arousals and safety conditions are designed to generate an emotional response (i.e. fear) and offer a simple way to manage the threat (i.e. behaviour change). However, research indicates that it is not clear whether, when or how fear appeals work. For example, originally it was believed that fear had a U-shaped impact on behaviour with maximum change resulting from moderate fear, while low fear caused no effect and high levels of fear resulted in denial, defensiveness and inaction (Janis 1967). Subsequent research, however, indicates that a more linear relationship may exist with greater levels of fear being the most effective at changing behaviour, although this might be due to the kinds of fear that can be generated in the laboratory setting (see Ruiter et al. 2001 for a review). In the light of contradictory evidence researchers have highlighted two new avenues for study. One involves the need for the development of new constructs and models to distinguish between different types of responses to fear and an analysis of different types of fear related information (e.g. Ruiter et al. 2001; Jessop and Wade 2008). The second involves the need to make fear appeals more effective. Self-affirmation theory is a promising approach to this.

Including Psychology in Theories of Pain

Psychology came to play an important part in understanding pain during the twentieth century. This was based on several observations. First, it was observed that medical treatments for pain (e.g. drugs, surgery) were, in the main, only useful for treating acute pain (i.e. pain with a short duration). Such treatments were fairly ineffective for treating chronic pain (i.e. pain that lasts for a long time). This suggested that there must be something else involved in the pain sensation which was not included in the simple stimulus-response models. It was also observed that individuals with the same degree of tissue damage differed in their reports of the painful sensation and/or painful responses. Beecher (1956) observed soldiers' and civilians' requests for pain relief in a hospital during the Second World War. He reported that although soldiers and civilians often showed the same degree of injury, 80 per cent of the civilians requested medication, whereas only 25 per cent of the soldiers did. He suggested that this reflected a role for the meaning of the injury in the experience of pain; for the soldiers, the injury had a positive meaning as it indicated that their war was over. This meaning mediated the pain experience. The third observation was phantom limb pain. The majority of amputees tend to feel pain in an absent limb. This pain can actually get worse after the amputation, and continues even after complete healing. Sometimes the pain can feel as if it is spreading and is often described as a hand being clenched with the nails digging into the palm (when the hand is missing) or the bottom of the foot being forced into the ankle (when the foot is missing). Phantom limb pain has no peripheral physical basis because the limb is obviously missing. In addition, not everybody feels phantom limb pain and for those who do, they do not experience it to the same extent. Further, even individuals who are born with missing limbs sometimes report phantom limb pain. These observations, therefore, suggest variation between individuals. Perhaps this variation indicates a role for psychology

Integrating the individual with their social context

Psychology is traditionally the study of the individual. Sociology is traditionally the study of the social context. Recently, however, health psychologists have made moves to integrate this individual with their social world. To do this they have turned to social epidemiology (i.e. the exploration of class, gender and ethnicity), social psychology (i.e. subjective norms) or social constructionism (i.e. qualitative methods). Therefore health psychologists access either the individual's location within their social world via their demographic factors or ask individuals for their beliefs about the social world. However, does this really integrate the individual with the social world? A belief about the social context is still an individual's belief. Can psychology really succeed with this integration? Would it still be psychology if it did?

The sample

Quantitative research requires larger samples that are representative so that the results can be generalized. Qualitative studies involve much smaller samples as generalization is not the aim. But . . . • Can a sample ever be representative and if so of whom? Samples may well be selected from a school, or a clinic, or even a city or country but can the data ever be representative of all schools, clinics, cities or countries? Yet we assume that data on people with diabetes who took part in the trial can tell us about people with diabetes in general even though the trial population were all under 65 and living in London. • Qualitative studies use small samples but can a study on seven people really tell us much apart from about those seven people? Are people so consistent that what seven people tell us can inform what we know about other people with a similar condition, illness or behaviour? And if it can't, then why do we only study seven people?

The success stories

Randomized controlled trials examining the effectiveness of interventions indicate that, although the majority of individuals may lose weight initially, the large majority eventually return to their baseline weight. Within each trial, however, a small minority not only lose weight initially, but s maintain this loss. Klem et al. (1997) examined the psychological states of 784 men and women who had both lost weight and maintained their weight loss and concluded that weight suppression was not associated with psychological distress. In contrast, as noted above, Wooley and Wooley (1984: 187) suggested that the minority of 's stories' are 'in fact condemned to a life of weight obsession'. What factors distinguish between the majority of failures and the minority of long-term s? To date, some studies have specifically examined this minority group. This research, together with data from the trials of obesity treatment, provides some preliminary insights into the factors that predict and/or correlate with s weight loss and maintenance. In particular, the literature highlights a role for a range of variables which can be conceptualized as *profile characteristics, historical factors, help-seeking behaviours, psychological factors and life events.*

Self-control and stress

Recently theories of s have emphasized forms of sc as important in understanding s. This is illustrated in theories of self-efficacy, hardiness and feelings of mastery. In summary, most current s researchers consider s as the result of a person-environment fit and emphasize the role of primary appraisal ('Is the event stressful?') and secondary appraisal ('Can I cope?'). Psychological factors are seen as a central component to the s response. However, they are always regarded as co-occurring with physiological changes.

Outcome measures e therapy study

Reported here are some results from pre- and post-intervention measures • Five-Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) • 39 items (on 5-point Likert scale of 1 = "Never or very rarely true" to 5 = "Very often or always true") • Items are grouped into five sub-scales • Observe • e.g., "I sense my body, whether eating, cooking, cleaning, or talking" • Act • e.g., "I find it difficult to stay focused on what's happening in the present" • Nonjudge • e.g., "I criticize myself for having irrational or inappropriate emotions" • Describe • e.g., "I'm good at finding words to describe my feelings" • Nonreact • e.g., "I perceive my feelings and emotions without having to react to them"

MEASURING NUTRITION

Household Surveys Food Diaries 24-hour dietary recall Food Frequency Questionnaire Diet History - eg- what is the highest weight you've been, relapse triggers etc. Supermarket Receipts

Acute pain

is defined as pain that lasts for six months or less. It usually has a definable cause and is mostly treated with painkillers. A broken leg or a surgical wound is an example of acute pain.

Control tactics

isolation - destroyed phones, relationships, used elevated status, called at work being rude to colleagues, threat to kill family or friends deprivation/exploitation -opposed study, required permission to access bank accounts, taking money, controlled access to vehicles, demanding, lists of how they could improve themselves. starts off with love bombing them slowly makes coercive techniques than when you threaten to leave they love bomb again which causes high dopamine. --- Trauma bonding or Stockholm syndrome

Metabolic Rate Theory for obesity

The body uses energy to carry out the chemical and biological processes which are essential to being alive (e.g. respiration, heart rate, blood pressure). The rate of this energy use is called the resting m r, which has been found to be highly heritable (Bouchard et al. 1990). One theory of o has argued that the o may have lower metabolic rates and that they burn up fewer calories when they are resting, and therefore require less food intake to carry on living. There is some tentative support for this suggestion. For example, research in the USA evaluated the relationship between mr and w g. A group in Phoenix assessed the m r's of 126 Pima Indians by monitoring their breathing for a 40-minute period. The study was carried out using Pima Indians because they have an abnormally high rate of o - about 80 to 85 per cent - and are considered an interesting population. The subjects remained stationary and the levels of oxygen consumed and carbon dioxide produced were measured. The researchers then followed any changes in weight and metabolic rate for a four-year period and found that the people who g a substantial amount of w were the ones with the lowest m r's at the beginning of the study. In a further study, 95 subjects spent 24 hours in a respiratory chamber and the amount of energy used was measured. The subjects were followed up two years later and the researchers found that those who had originally shown a low level of energy use were four times more likely to also show a substantial weight increase (Ravussin et al. 1988). Tataranni et al. (2003) used state-of-the art methods to assess energy intake and energy expenditure in 92 freeliving, adult Pima Indians in Arizona. These methods allowed the researchers to measure energy intake and total energy expenditure accurately outside the laboratory in order to test their role in the aetiology (cause) of o prospectively. The results demonstrate for the first time that baseline total energy intake is a key determinant of long-term changes in body weight in Pima Indians, and also confirm that a low resting metabolic rate is a risk factor for w g in this population. In addition, baseline energy expenditure, due to physical activity, was not found to be associated with changes in body w. These results indicate a possible relationship between m r and the tendency for w g. If this is the case, then some individuals are predisposed to become o because they require fewer calories to survive than thinner individuals. A genetic tendency to be o may therefore express itself in lowered m r's. However, most research does not support this theory. In particular, there is no evidence to suggest that o people generally have lower m r's than thin people. In fact, research suggests that ow people tend to have slightly higher m r's than thin people of similar height (Garrow 1987). The o also expend more energy than thin people for a given activity (Prentice et al. 1989). To explain these apparently contradictory findings it has been suggested that o people may have lower m r's to start with, which results in w g, and this itself results in an increase in m r (Ravussin and Bogardus 1989). This view has not gone unchallenged, however, and Garrow and Webster (1985) have argued that this is an unlikely explanation which is unsupported by the evidence. In sum, the 'slow m' theory of o may be held by many lay people, but it is no longer considered to be backed by research.

How should illness be treated? Biomedical model

The biomedical model regards treatment in terms of vaccination, surgery, chemotherapy and radiotherapy, all of which aim to change the physical state of the body.

two important health outcomes (Kaplan)

life expectancy and quality of life biological and physical factors mediate behavioural outcomes

Marriage - men's health

little systematic research on overall relationship quality. In terms of sexuality, it is assumed that older people are no longer sexually interested or active, and of course younger people tend to find the whole subject a bit distasteful

in vivo

living organism experiments

What does MBI stand for?

mindfulness based interventions

two ways to achieve better health outcomes (Kaplan)

modifications of mediators of behavioural outcomes - identifying tissue pathology and seeking its remedy eg- tumors removed = better health outcomes. Nothing wrong with medical model - direct treatment = best outcome. Medical model should be viewed as tool to improve behavioural outcomes. modification of behaviour apart from disease pathway for things that do not have a solution in health, look at ways to improve lifestyle. Studies show that behavioural modification for back pain improves health outcomes even though physiology is unaffected.

The "Disease-Prone Personality": A Meta-Analytic View of the Construct. Friedman, Howard S.1,2; Booth-Kewley, Stephanie1

the relationship between personality and disease "If personality is associated with a disease, it may be because certain aspects of personality are the result of disease processes. For example, some (though not all) patients with serious illnesses such as cancer become fearful or depressed" "Personality could be a causal factor in disease through a variety of very different types of mechanisms. First of all, personality could lead to disease through unhealthy behaviours. For example, if anxiety leads people to overeat and if obesity contributes to the development of diabetes, then anxiety is a causal factor for diabetes. In such cases of indirect causation, of course, curing the anxiety would not necessarily cure or prevent diabetes unless the obesity was also affected. Studies investigating the links between personality and disease should control for unhealthy behaviours (such as cigarette smoking, various influences of diet, etc.), but most do not, possibly because there are so many potentially relevant behaviours." "Multiple Influences: The Body as a System In many cases, it is likely that a variety of different causal influences and feedback loops will be at work in the relationship between personality and disease. For example, excessive anxiety may lead to smoking, drinking, and/or insomnia, which will set in motion a series of physiological processes (influenced partly by genetic makeup), which will, in turn, affect both various aspects of health and the anxiety itself, and so on. It is an oversimplification to say that any single factor is the cause of the disease that results." "In research on personality and disease, people cannot be randomly assigned to a given personality and then followed. So, no single study could ever "prove" a causal link." "Psychosomatic Diseases? The five diseases selected for study-asthma, headaches, ulcers, arthritis, and heart disease-are all widespread chronic diseases whose aetiology is not well understood. In many primitive societies, such diseases were blamed on demons (Murdock, 1980)." "The results point to the probable existence of a generic "disease-prone" personality that involves depression, anger/hostility, anxiety, and possibly other aspects of personality. However, except in the case of coronary heart disease, the evidence is weak. Nevertheless, there is sufficient evidence to argue for a key role in psychological research on the prevention and treatment of disease." "Based on the existing evidence, it does not appear that different diseases have different personality traits linked with them. If this finding holds up in future research, then constructs such as the asthma-prone personality, the coronary-prone personality, and so on will have to be revised. However, there may well exist a generic "disease-prone personality." "Perhaps the most striking single relationship is the apparent association between depression and disease (in particular, depression and the four diseases other than ulcers). In recent years, a great deal of attention has been directed to anger and hostility, but perhaps insufficient attention has been given to depression."

Taxonmy

the science of classifing and naming organisms

emotion vs problem focused coping

E-focused: Seeking social support Distancing Escape avoidance Self-control Accepting responsibility Positive reappraisal e discharge Cognitive redefinition Seeking meaning Defence mechanisms (denial, intellectualisation) P focused: Planful p-solving Confrontive coping Seeking social support Direct action Assistance seeking Information seeking Logical analysis

chronic vs acute stress for immunity

A/Intermittent stress (e.g., bouts of exercise) - actually associated with enhanced i...e responses (e.g., reception of vaccine), evolved for helping us C stress, however, may lead to i dysregulation - underexpression or overexpression of i...e molecules So, a s is good, c isn't.

Surgical treatments for obesity

Although there are 21 different s procedures for o (Kral 1995), the two most popular are the gastric bypass and gastric banding. Researchers in Sweden have carried out the large-scale Swedish o Subjects (SOS) study which explored nearly 1,000 matched pairs of patients who received either s or conventional treatment for their o (Torgerson and Sjostrom 2001). The results showed an average weight loss of 28kg in the s group after two years compared to only 0.5kg in the conventional group. After eight years the weight loss in the s group remained high (average of 20kg) while the control group had gained an average of 0.7kg. The weight loss in the s group was associated with a reduction in diabetes and hypertension at two years and diabetes at eight years. This study indicated that surgery can be effective for both weight loss and maintenance and brings with it a reduction in the risk factors for cardiovascular disease. The s management of obesity has been endorsed by expert committees in the USA (Institute of Medicine 1995) and the UK (Garrow 1997) and is recommended for those with a BMI over 40 (or > 35 with complications of obesity), who have not lost weight with dietary or pharmacological interventions, as long as they are made aware of the possible side-effects. O s, however, does not only affect weight. Some research has also explored post-operative changes in aspects of the individual's psychological state such as health status and psychological morbidity and a series of studies have shown significant improvements, particularly in those patients who show sustained weight loss. For example, cross-sectional research has illustrated improved quality of life in s patients compared to control subjects (De Zwann et al. 2002; Ogden et al. 2005) which has been supported by studies using either retrospective or longitudinal designs. In particular, in a large-scale follow-up of the SOS patients, Karlsson et al. (1998) reported an improvement in health-related quality of life operationalized in terms of mood disorders, mental well-being, health perceptions and social interaction. Bocchieri et al. (2002) carried out a comprehensive review of much of the literature examining the impact of obesity s on psychosocial outcomes and concluded that in general 'the empirical evidence . . . seems to be pointing in a positive direction'. Ogden et al. (2006a) carried out a qualitative study to explore patients' experiences of o s and concluded that by imposing control and limited choice upon how much and what they could eat, s and the process of making their stomach much smaller paradoxically made them feel more in control of their weight and eating behaviour (paradox of control) (see Focus on Research 15.1 for details). This is in contrast to much of the literature on communication and choice discussed in Chapter 10.

Two-stage process of identifying health assets

First, we reviewed the existing literature for candidates, which can be seen in Section 3. Second, we reanalyzed existing longitudinal studies to see which candidate health assets actually were associated with reduced disease risk once established risk factors were taken into account. We also conducted several reviews of the literature on subjective health assets and cardiovascular disease (CVD). First, we identified all the literature to date considering a broad set of subjective assets in relation to CVD (Boehm and Kubzansky, in press). In the second and third reviews, we broadened the scope to consider not only the epidemiologic literature but also findings regarding how relevant subjective assets might be related to pathways leading to CVD, namely, via behavioral and biological function (Boehm and Kubzansky, 2012; Boehm and Kubzansky, in preparation). Next, we identified research issues still to be addressed with respect to optimism interventions and improved cardiac health (Peterson and Kim, 2011). These reviews also serve as our early efforts to integrate across subjective and biological health assets (cf. Peterson, Park and Kim, 2012, in press). Our reviews highlighted several important issues. First, as we knew, the role of positive well-being in CVD has not garnered nearly as much research attention as the role of negative states and traits. When studies are done, they too often have a cross-sectional design rather than a more powerful longitudinal design. That said, when researchers have longitudinally investigated such constructs as positive affect, life satisfaction, optimism, vitality, and ikigai (meaning and purpose), relationships with good cardiac health are usually found. And, in the most compelling studies, negative states and traits are controlled, meaning that these positive effects indeed occur above and beyond any association with risk factors. Thus, the premise of our Positive Health project was confirmed. Second, depending on the details, there are nuances. Studies have sometimes used patient samples and sometimes healthy samples. Along these lines, studies have looked at disease onset and disease progression, including recovery. Subjective health assets appear somewhat more relevant for first disease onset than for disease progression. Third, the subjective health assets that have been considered in research, or might be considered, are numerous and presumably related. However, researchers have usually studied only one health asset at a time. Are there overriding factors—"latent variables"—that can bring some order here? Or do some particular health assets confer more benefit for cardiac health than others? We found some evidence, for example, that optimism is more strongly related to good health than are simple measures of hedonic wellbeing (cf. Ryff, Singer and Love, 2004). Fourth, given our focus on CVD, the relationship of health assets to other illnesses remains largely unknown. The case has been well made with respect to CVD. What about cancer or the common cold? Further studies using the lessons we have learned to date in our focus on CVD are needed. Fifth, there is limited work on the process by which subjective assets might mitigate CVD. This work generally follows a traditional epidemiologic approach, neglecting to explore the pathways that lead from health assets to good health. We suspect that mechanisms are numerous, including direct biological pathways as well as indirect behavioral pathways entailing lifestyle choices, like smoking, drinking, and exercising. In recent work, we have looked more deeply at what is known about the relationship between subjective assets and health-related behaviors (Boehm and Kubzansky, in preparation), and we have begun to make recommendations for important future directions. Finally, we observed in the course of our reviews that studies of Positive Health assets to date are held to a higher methodological standard than studies of risk factors. In order to be published in a peer-reviewed journal, a study of Positive Health assets must control for negative risk factors and show that the positive asset matters above and beyond the absence of the negative, whereas a study of risk factors can be simply that, with no attempt to show that risk factors matter above and beyond the absence of health assets. So, for example, anger is a risk factor for cardiovascular morbidity and mortality. Given that anger correlates with poor relationships, low optimism, and lack of meaning, it seems obvious to wonder if the influence of anger per se would be diminished were we to take into account good relationships with other people, levels of optimism, or meaning in life. In sum, our literature reviews show that subjective health assets indeed play a role in cardiovascular health. Although some inconsistencies exist, depending on measures and outcomes used, the evidence is strong. Moreover, for disease-related endpoints, the protective effect of positive psychological well-being is mostly independent of ill-being as well as other conventional coronary risk factors.

What causes infertility?

Goldman et al. (2000) list: Delayed childbearing Undetected pelvic inflammatory disease due to increased number of STDs (including gonorrhoea and chlamydia) Use of substances such as caffeine, nicotine, alcohol Chronic stress Exposure to work and environmental health hazards Often infertility is not attributable to one single cause 35-40% of infertility cases attributed to male factors (e.g., abnormal sperm count or mobility, injury to reproductive organs, retrograde ejaculation) 35-40% of infertility cases attributed to female factors (e.g., aging or depleted oocyte reserve, anovulation, structural abnormalities of the uterus) 20% from both members of the couple

The Obesogenic Environment

Physiological models emphasize a number of different mechanisms to explain o onset. They cannot, however, explain why the prevalence of o has increased so rapidly over the past few decades. Our genetics, neural mechanisms and metabolic rates take far longer to change than just years, and yet o is now considered an epidemic. To address this change, researchers have turned their attention to the role of the external world which has been labelled this (Hill and Peters 1998). For example, they have highlighted the impact of the food industry with its food advertising, food labelling and the easy availability of energy-dense foods such as fast foods and takeaways. They have identified environmental factors which encourage us to live an increasingly sedentary lifestyle such as a reduction in manual labour, the use of cars, computers and television and the design of towns whereby walking is prohibited through the absence of streetlights, pavements and large distances between residential areas and places of entertainment or shops, and they have focused on factors which make it more and more difficult to eat well and be active such as the presence of lifts and escalators which detract from stair use and the cheapness of prepared foods which discourages food shopping and cooking. Accordingly, this obesogenic environment creates a world in which it is easy to gain weight. Furthermore, the changes in our environment coincide with the increased prevalence of o. From a public health perspective, therefore, environmental factors are key to understanding o and any attempts to prevent o onset should focus on changing the environment. In line with this, governments provide subsidies for leisure centres, trying to make them more accessible for everyone. There are local campaigns to encourage stair climbing by putting prompts near lifts and stairwells and there is legislation limiting food advertising. Furthermore, some companies encourage their staff to be active in their lunch breaks by organizing walking groups and offering gym facilities, and school and work canteens are supported in their attempts to offer healthier meals. In the same way that many governments have now finally responded to the knowledge that smoking kills by banning it in public places, steps are being made to intervene at an e and policy level to control the o epidemic. From a psychological perspective, however, understanding the e factors which promote obesity does not seem to be a sufficient explanatory model. Psychology focuses on beliefs and behaviour and as Prentice (1999: 38) argued, 'o can only occur when energy intake remains higher than energy expenditure, for an extended period of time. This is an incontrovertible cornerstone on which all explanations must be based.' Research has therefore examined the role of behaviour in explaining o, and behavioural theories of obesity focus on physical activity and eating behaviour.

subjective health

Rating of one's own h based on s criteria.

critique of KR (Corr, 1993)

Some have criticised because dying is not a psychiatric illness, rather a normal part of life. Fair enough, and to interpret it in that way would be problematic I don't necessarily agree that KR does, but there is a bent that way. In general, some of us criticise psychology generally for being too focused on illnesses... and a more recent tendency to pathologise many aspects of life Most people who are dying (most people generally) don't need psychotherapy at all Craven and Wald (1975) noted "what people need most when they are dying is relief from distressing symptoms of disease, the security of a caring environment, sustained expert care, and assurance that their families will not be abandoned (p1816). Befriending, a caring community and expert skills matched to the current needs... Model profoundly limited, but appealing intuitively and influential Drawn from a particular social population dying in particular ways at a particular time and location. Based on one author's clinical impressions. Based on a psychodynamic approach - heavy emphasis on defence mechanisms and conflicts. Most probably ignored the perspective in which it's grounded, and not sensitive to its limitations. As with many models, the potential for misuse (and the actual misuse) was substantial - staging and stereotyping of behaviours often not helpful, and KR seems to know that from reading it - but didn't explicitly move away from it (the reverse) and people do like shortcuts Not rational to think that there would be five steps - much more varied, individualistic, and rich process than that, surely? Is there a sensible reason to describe these as stages - is this really a linear process - if anger and bargaining are aspects or dimensions of coping, why are they stages rather than discriminable coping strategies? In what sense are they an obligatory, adaptive, or optimal response to dying? Is there a right way to die? Is it fair, and ethical, to impose an agenda such as this on someone that already has plenty to cope with? This, in essence, is a descriptive narration of a fairly specific group of people dying, interpreted and transformed into a set of normative guidelines - probably wasn't KR's intention, but has been done by her followers and her language certainly facilitates it.

KETO

https://www.healthline.com/nutrition/ketogenic-diet-101 The ketogenic diet - very low-carb, high-fat diet - shares many similarities with Atkins & low-carb diets. Involves drastically reducing carbohydrate intake & replacing it with fat. This reduction in carbs puts your body into a metabolic state called ketosis.

Three main brain areas involved in stress

prefrontal cortex amygdala hippocampus

in vitro

test tube experiments

positive health definition

the empirical study of health assets.

World Health Organization definition of health (1948)

a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity spectrum: illness/wellness continum - death/optimal wellness with various things in between - disability, neutral, lifestyle. health is multifaceted looks at what can improve outcomes just bc you are at risk to experience something doesn't mean you will - what can we do to prevent

Weight-related victimisation

• Reported by 24% of teenagers • Thin boys and obese girls • Distress and binge eating (Neumark-Sztainer et al., 2002) • Fat-teasing • Reported by 18% of 9-year olds • 14% of 12-year-olds (Hill & Murphy, 2000)

Obesity-Related Abnormalities: Mechanical Problems

▪ Breathing disorders (sleep apnea, asthma) ▪ Osteoarthritis ▪ Urinary stress incontinence ▪ GERD - gastroesophageal reflux disease.

Response approach to stress

- A r, focusing on reaction to s....ors - Psychological components of behaviour, thought patterns and emotions - Physiological component of heightened bodily arousal - Psychological + physiological responses = strain - Circular though, s...or defined by s response, s response defined by s...or

recruitment of e therapy study

Advertisements to students and staff through posters, emails, or Facebook pages as well as presentations in lectures

Death and Psychology 2

Besides the psychological issues confronting the dying person, a whole range of fields has opened up over the years relating psychology and death, including: Psychological aspects of bereavement Anxiety surrounding death Concepts of life and death End-of-life decision making Psychological experiences related to death e.g. dreams, NDEs

Anxiety Reduction placebos

Downing and Rickels (1983) argued that p decrease a, thus helping the patient to recover. For example, according to gate control theory, anxiety reduction may close the gate and reduce pain, whereas increased a may open the gate and increase pain (see p. 344). P may decrease anxiety by empowering the individual and encouraging them to feel that they are in control of their pain. This improved sense of control may lead to decreased a, which itself reduces the pain experience. P may be particularly effective in chronic pain by breaking the a-pain cycle

Obesity Has Multiple Pathophysiologic Origins

Epigenetic Genetic Physiologic Behavioral Sociocultural Environmental

Fathers

Fatherhood is viewed as natural and desirable, but it has not been positioned as central to a man's existence the way motherhood has been for women Dutch families study (Kalmijn, 1999) found that fathers more involved in childrearing generally had happier and more stable marriages, and this seemed to be mediated by the fact that their wives were happier... 8-yo write essays about why their father is best wrote almost exclusively about his involvement in the family

Primary Appraisal

Harm-loss - amount of damage that has already occurred. eg- checking car when crashed Threat - expectation of future harm. Challenge - ability to benefit from a situation by using more than routine resources to meet demand.

"Fat-but-fit" paradox

However: •Recent research indicates that obese people are not necessarily at higher risk for disease than the non-obese • People with a high BMI are more likely to have health problems. • But 20% may be doing fine. •"Healthy Obese" • Metabolically healthy with adequate fitness levels have 30-50% lower risk of mortality than unfit obese people (Ortega et al., 2013) *metabolic fitness - may be key.

How Do Placebos Work?

If p have a multiple number of possible effects, what factors actually mediate these changes? Several theories have been developed to try to understand the process of p effects. These can be described as non-interactive theories in that they examine individual characteristics, characteristics of the treatment and characteristics of the health professional, or interactive theories in that they involve an examination of the processes involved in the interactions between patients, the treatment and the health professional.

How might this look for Brian?

Illness Representations: Consequences "my life is over" Timeline and control indicated Symptoms: Functional impairment Muscle spasms Can't think clearly Emotional Response Scared/terrified Pissed off/ Depressed Coping: Stayed busy (worked on bike) "learnt as many new skills as I could" Leaned on family Appraisal: "Getting normalcy back" "Learned it took more energy to be 'pissed off" "Learned I could do things to make me happy"

Life events theory

In an attempt to depart from both the Selye and Cannon models of stress, which emphasized physiological changes, ... was developed to examine stress and stress-related changes as a response to life experiences. Involves schedule of recent experiences (SRE)

Methods as separate to data

In health psychology we carry out research to collect data about the world. We then analyse these data to find out how the world is, and we assume that our methodologies are separate to the data we are collecting. In line with this, if we ask someone about their implementation intentions, it is assumed that they have such intentions before we ask them. Further, if we ask someone about their anxieties, we assume that they have an emotion called anxiety, regardless of whether or not they are talking to us or answering our questionnaire. However, how do we know that our methods are separate from the data we collect? How do we know that these objects of research (beliefs, emotions and behaviours) exist prior to when we study them? Perhaps by studying the world we are not objectively examining what is really going on but are actually changing and possibly even creating it.

Kastenbaum (1986)

Kastenbaum (1986) has suggested: Set aside stages Refrain from suggestions of linear directedness Try and be clear about our methods Emphasise description, not prescription Take into account the totality of the coping person's life Attend to influences in the person's immediate environment.

The stress process

Lazarus 1. s...ful event or situation 2. primary appraisal - what does this mean? - harm/loss, threat or challange 3. secondary appraisal - what can I do? - self efficacy expectation 4. s and coping

cognitive appraisal stress

Lazarus In 1950's became convinced that the main source of variation in the arousal of s and its effects on functioning is the way an individual evaluates the personal significance of what is happening (the demand). The notion of a (vs perception) Also, "s occurs when a particular situation threatens the attainment of some goal" Lazarus et al., (1952) s...ful or not: Irrelevant, neutral, positive Two key factors to assess Whether the demand threatens wellbeing (primary appraisal) Your resources available to meet the demand (secondary appraisal) both appraisals are interrelated

Determinants of Health Behaviours

Learning - Reinforcement Positive reinforcement, e.g. physical exercise leads to increased energy throughout the day Negative reinforcement, e.g. weight loss leads to less achy knee joints Extinction: When the consequences that maintain a behaviour are eliminated, the response tendency gradually weakens. e.g. stopping exercise once you've reached the ideal weight Punishment: behaviour brings in an unpleasant consequence, e.g. injured self jogging Modelling: health behaviours can be influenced by parents, high status individuals (celebrities), peers 1. Social support & encouragement from others Social support vs. Loneliness... 2. Personality Big Five (OCEAN) 3. Stress Pathways to behavioural consequences

Social Readjustment Rating Scale (SRRS)

List of events rated for degree of life change they demanded Weightings central - many of these events are rare, and of course incredibly stressful Think PNI - evolution has encountered these before... obviously many of them occurring in short time-frame is not good Stress to more frequent events? https://www.sciencedirect.com/science/article/pii/0022399967900104?via%3Dihub https://journals.sagepub.com/doi/pdf/10.1177/00131640021970952

Finding associations in our theories

Many of our theories argue that different constructs are associated with each other (e.g. self efficacy predicts behavioural intentions; control-related illness cognitions predict coping). We need to ask: • Are these associations true by definition (e.g. control cognitions relate to coping only because control cognitions are part of the definition of coping)? • Are the associations true by observation (e.g. smoking causes cancer because smoking is separate to cancer but then causes cancer to occur)?

Pain and the Neurotic Triad

Minnesota Multiphasic Personality Inventory (MMPI) Hypochondriasis, Depression, Hysteria Pattern exists for both organic and psychogenic p p acceptance - therefore may be key in properly coping with p Some personality types are prone to experience p more

Men (are less likely to):

Moderate dietary fat or alcohol Maintain a healthy body weight Gender differences for health behaviours are particularly strong in areas of eating, food choice. The only health-related behaviour men typically engage in more than women is physical activity - consistent with tough, athletic stereotypes Express interest in making health-related lifestyle changes - young men (not yet), older men (too late) - evidence is that healthy lifestyles in younger and middle adulthood -> longevity and wellbeing: in later adulthood QoL

Secondary appraisal of stress

More active and aware of Cognitive-evaluative process focussed on what can be done about the stressful situation. eg- calling someone, googling info Evaluation of coping options/assessment of resources Active searching for information and meaning on which to predicate action Action, gather information, do nothing, relaxation or defence mechanisms Interrelated with primary appraisal e.g., evaluation of our resources may determine whether threat or challenge dominates Perhaps more aware of this...

psychological wellbeing and social support

More ss = higher psychological well-being Depressed persons have lower ss Found in U.S. and Japanese studies of older adults: more ss = lower depression rates and fewer neurotic symptoms Longitudinal studies less likely to be depressed 1 year later- HIV+ gay men - Hays et al. (1992) less likely to display anxiety - chronic disease - Sherbourne & Hays (1990) College students less likely to visit campus infirmary - Reis et al. (1985)

Research using self report

Most research relies on sr m such as questionnaires. The results from these studies can then be analysed statistically to test various hypotheses about the mechanisms by why mindfulness is assumed to exert its health benefits. Techniques used here are structural equation modelling

Family Violence Death Review Committee Report 5: 2009 -2015

Much more male agressors killing female victims 54% versus female agressors killing victims 1%

Medical decisions at end-of-life

Much of this topic is subsumed under heading of 'euthanasia' but whole range of other decisions may arise, including: Decision to provide food and fluids Decision to withdraw food and fluids "Do not resuscitate" decisions "Terminal sedation" Physician-assisted suicide

Biomarkers of allostatic load

Neuroendocrine Examples: Cortisol, epinephrine, norepinephrine, dopamine (neurotransmitter involved in many neurological activities, also increases bp and hr) Immune Examples: Interleukin-6 (cytokine), tumour necrosis factor alpha (cytokine involved in tumour apoptosis) Metabolic Examples: High density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), glucose, insulin Cardiovascular and Respiratory Examples: Blood pressure, heart rate Anthropometric Examples: Waist-to-hip ratio, BMI

Barriers to seeking help (psychological health)

Not many people receive h. For example, some statistics show that only around 20% of young people receive help for their p problems. Some of the reasons include: - Access problems (e.g. living in rural area) - Perceived stigma to seeking help (especially for older people) Lack of available psychologists - Long delays and waitlist - Cost

Summing up (obesity)

O is related to several health problems and a number of theories have been developed in an attempt to understand its aetiology. In particular, research has suggested that there may be a strong genetic predisposition to o, which is reflected in underactivity and the relative overconsumption of fat. However, the research examining the causes of o is often contradictory, suggesting that the story is not yet complete. In terms of interventions, research indicates that all forms of intervention are effective at promoting weight loss but weight maintenance is particularly poor for dieting-based treatments. The fact that all treatments have side-effects raises the question 'Should o be treated at all?' The answer seems to be that it should be treated as long as the costs and benefits of any intervention are assessed and both physical and psychological consequences are taken into account.

Problems of disclosure

Once it started to become more common to disclose, it became necessary to look at the ways in which individuals receiving such news adapted and coped. Classic early study that of Elisabeth Kubler-Ross, running seminars originally for professionals caring for dying people but eventually including patients too.

Coping

Over the past few years the literature on this has grown enormously and has explored different types of styles, the links between this and a range of health outcomes and the nature of coping itself. How individuals cope with illness was described in Chapter 9 with a focus on crisis theory, cognitive adaptation theory and benefit-finding.

Death in Society

Patterns of death changing - developed societies much less likely to experience death from acute infection, more likely from slower degenerative processes For many years was common practice to withhold information from patients who were dying; since middle of last century this has become less common, partly as result of: Empirical research Ethical demands Growth of specialist palliative care services Has led to situation in which large numbers of people have to cope with the fact that they're dying - involving range of psychological issues

Determinants of Health Behaviour

Perception and Cognition Perceived symptoms of illness influence health behaviours e.g., pain, fever, etc. Cognitive factors influence health behaviours e.g., knowledge about the possible implications of behaviours (will this behaviour put my health at risk or help me achieve better health?) Unrealistic optimism can impair health behaviour

Health psychology also aims to put theory into practice. This can be implemented by:

Promoting healthy behaviour. For example: • Understanding the role of behaviour in illness can allow unhealthy behaviours to be targeted. • Understanding the beliefs that predict behaviours can allow these beliefs to be targeted. • Understanding beliefs can help these beliefs to be changed. Preventing illness. For example: • Changing beliefs and behaviour could prevent illness onset. • Modifying stress could reduce the risk of a heart attack. • Behavioural interventions during illness (e.g. stopping smoking after a heart attack) may prevent further illness • Training health professionals to improve their communication skills and to carry out interventions may help to prevent illness.

What is health psychology?

Psychology is both an academic & applied discipline involving scientific study of behaviour & mental processes. ▪ Classic definition: '... the aggregate of the specific educational, scientific & professional contribution of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identification of aetiologic and diagnostic correlates of health, illness and related dysfunction' (Matarazzo, 1980) ▪ Pragmatic definition: Health psychology is the study of psychological processes that influence health, illness & health care health related behaviours plays a big role in affecting health outcomes

Quantitative studies

Q studies are the mainstay of more traditional forms of empirical research and involve collecting numerical data through questionnaires, experiments (or trials) or computer tasks. Such data is often assumed to be more objective and controlled than ** data. But being critical involves asking questions such as: • Is Q data really objective and value-free? The researcher chooses what questions to ask, how the data should be coded, what sample to select, what variables to analyse, what tests to use and what story to tell in the final paper. All these processes involve subjective judgements which are value-laden.

Rumination

R is defined as 'unintentional preservative thoughts in the absence of obvious external cues' (Cropley and Millward Purvis 2003) and has been linked with anxiety, physical symptoms and depression. R about work is essentially thinking about work out of work hours when the individual no longer wants to think about work. In terms of its relationship with job strain, research shows that higher job strain is associated with more of this. Further, research indicates that people report more r thoughts about work when alone than with family or friends (Cropley and Millward Purvis 2003). Job strain would seem to be damaging to health and may also result in r. If people go home at the end of a busy day to partners or children they are less likely to r and thus continue feeling the stress of work than if they go home to be on their own.

Coping (death)

Remember Lazarus defined coping as: "constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" Lazarus and Folkman, 1984, p141. Coping goes well beyond an automatised adaptive strategy/behavioural pattern, it involves efforts to manage - doing, not doing, acting, not acting etc

Effect of stress on the hippocampus

Repeated s has been linked to remodelling of h circuitry - the shortening of dendrites, loss of spine synapses, suppression of neurogenesis Permanent damage to the h could: Impair h involvement in episodic, declarative, contextual, and spatial memory Impair h in regulating HPA activity (impairs the ability of the h to terminate s response)

Stress and social hierarchy

Sapolsky's Baboons: Prolonged s (low on s h) effects: Hypertension, increased vulnerability to atherogenic effects of high-fat diet (formation of fatty deposits in the arteries). Whitehall Study (1967): 18,000 men in British Civil Service Showed a steep inverse association between social class (grade of employment) and mortality from a wide range of diseases

SRM stands for

Self-Regulatory Model of Illness Behaviour

General Adaptation Syndrome (GAS)

Selye's concept of the body's adaptive response to stress in three phases—alarm, resistance, exhaustion.

Positive Events and Social Supports as Buffers of Life Change Stress

Sheldon Cohen and Harry M. Hoberman In a sample of college students, both perceived availability of so support and number of p events moderated the relationship between negative life s and depressive and physical symptomatology In the case of depressive symptoms, the data fit a "buffering" hypothesis pattern, i.e., they suggest that both social support and positive events protect one from the pathogenic effects of high levels of life stress but are relatively unimportant for those with low levels of stress. In the case of physical symptoms, the data only partially support the buffering hypothesis. Particularly, the data suggest that both social support and positive events protect one from the pathogenic effects of high levels of stress but harm those (i.e., are associated with increased symptomatology) with low levels of stress.

Stress and the common cold

Sheldon Cohen teamed up with David Tyrell in the c c Unit in England to study the relationship between s and development of the c c. Experiment: 400 healthy volunteers inoculated with c viruses, quarantine them in apartments (1-3 people), and monitor closely for infection and illness Results: Psychological s was associated in a dose-response manner with an increased risk of acute infectious respiratory illness, and this risk was attributable to increased rates of infection rather than to an increased frequency of symptoms after infection.

Modern Technologies

So far this chapter has described a number of key theories and strategies that have been used to change health-related behaviour. Recent developments in modern technologies have provided the opportunity for new ways to deliver such strategies and new sources of information that may help individuals change what they do. These include the use of 'ecological momentary interventions' (via palmtop computers or mobile phones), web-based interventions, the presentation of individualized biological risk data and the use of the mass media (see Figure 8.6). Some of these target individuals while others target populations as a means to change behaviour in a broader sense. Behaviour change interventions such as smoking bans, taxation and restricting or banning advertising are described in Chapter 4 in the context of addictive behaviours.

Social Support and Health Behaviour

Social support - how many people they could call on to support them in difficult situations Allgower, Wardle & Steptoe (2001) found that: Individuals low on social support have been found to be more likely to not eat breakfast, sleep irregular hours, lack regular physical activity Further, among women, social isolation was associated with not eating fruit and not using sunscreen

Naturalistic setting of stress

Some researchers study stress in a more n environment. This includes measuring stress responses to specific events such as a public performance, before and after an examination, during a job interview or while undergoing physical activity. n research also examines the impact of ongoing stressors such as work-related stress, normal 'daily hassles', poverty or marriage conflicts. These types of study have provided important information on how people react to both acute and chronic stress in their everyday lives.

Critique of the common-sense model

Strengths - Responsive to changes in behaviour over time - Suggests coping is an on‐going, cyclical process throughout the rehabilitation journey - Recognises the importance of both emotional and cognitive aspects of adjustment and influence of others - Evidence supporting model across range of illnesses Limitations - Can we really disentangle emotions from cognitions? - Are some representations more important than others? - Is the interaction between illness representations more important than their individual contribution? - How does actual health status fit in (e.g. progressive illnesses)? - How does that affect the appraisal of coping effectiveness?

(focus on research 12.1) Life Events and Mortality

Stressful life events and 17 years mortality (Phillips et al. 2008). This is an impressive piece of work exploring the links between life events and mortality as it uses a prospective design with an exceptionally long follow-up (17 years) and predicts the ultimate outcome variable − death. In addition, the sample is substantial and the study differentiates between health-related life events and health unrelated events. Methodology: Participants Data was collected as part of the West of Scotland Twenty-07 study and the follow-up was the 07 which followed a cohort of participants from 1988 to 2000/1. Baseline life events data for this paper was collected in 1992/3 and the follow-up data 17 years later in 2000/1. The sample was from the Glasgow area in Scotland and was around 56 years old when the study started in 1988. The sample for this study was 968 men and women and by follow-up 266 had died. Procedure: Trained nurses interviewed participants in their own homes at each time point and participants completed questionnaires. The following measures were taken: • Occupational status. This was assessed in terms of the occupational status of the head of household and was classified as manual versus non-manual. • Smoking behaviour. Participants were asked 'Do you ever smoke tobacco now? I am thinking of a pipe, cigars and your own roll-ups as well as cigarettes you might buy?' If they answered 'No' they were also asked 'Did you ever used to smoke any kind of tobacco?'. Participants were then classified as 'never smokers', 'ex-smokers' or 'current smokers'. • Height and weight. This was assessed to compute body mass index (BMI). • Resting blood pressure. This was taken after five minutes of relaxed sitting. • Major life events. Life events over the past two years at each time point were assessed by presenting participants with eight cards which listed a number of major life events in the following domains: health, marriage, relationships, bereavement, work, housing, finance, general. The participants were asked to indicate up to six events which had happened to either them or someone they cared about. They were then asked to specify how much each event had disrupted or changed their life and how stressful it had been 'then' and 'now'. • Mortality. This was assessed using the death certificates of those who had died which were sent to the study office. Data analysis: The results were analysed using Cox's regression models to predict all-cause mortality from life events while adjusting for sex, occupational status, smoking, BMI and systolic blood pressure. Results: By the 17-year follow-up 27 per cent (n = 266) had died. The mean age of death was 66 years and the major causes of death were cancers (34 per cent), cardiovascular (24 per cent), respiriatory (12 per cent) and other causes (30 per cent). More men (33 per cent) than women (23 per cent) had died and more people classified as manual (32 per cent) compared to non-manual (21 per cent) had died. Predicting All-Cause Mortality: Overall life events experience predicted 17-year mortality in terms of disruption at the time, disruption now and stressfulness now. These were significant even after all potential risk factors were controlled for. The Type of Life Event: Health-related life events significantly predicted 17-year mortality in terms of disruption at the time, disruption now, stressfulness at the time and stressfulness now (again controlling for risk factors). Non-health related events were not significantly predictive of mortality. Number of Life Events: Overall, the number of life events predicted 17-year mortality, however when looked at separately, while health-related life events were predictive, non-health related events were not. Conclusion: This study illustrates a strong link between life events and mortality over a long period of time in a large sample. Further, it indicates that it is not life events per se but those that are health-related that have significance. However, it is unclear whether this is due to the psychological impact of such events (e.g. having an operation or being diagnosed with a worrying illness) (i.e. these events are stressful) or whether it is just a marker for serious morbidity.

positive health stats

Strong positive correlation between health & GDP • Countries with better health status tend to have higher incomes than countries with worse health status, a relationship known as the "Preston curve" (Preston, 1975) Higher income = good for economy and overall health. People who are happy in their work have more productivity and make more money

mood and immunity

Studies indicate that positive m is associated with better i functioning (as measured by sIgA), that negative m is associated with poorer functioning (Stone et al. 1987) and that humour appears to be specifically beneficial (Newman and Stone 1996). Johnston et al. (1999) explored the impact of m on the progression of the disease, disability and survival in patients with amyotrophic lateral sclerosis/motor neurone disease. The study used a prospective design with 38 consecutive patients completing measures of m (anxiety and depression), self-esteem, well-being and disability at time of diagnosis and after six weeks. Survival and disability were also measured after six months. Ten patients had died by six months. Controlling for disease severity, the results showed that those who died reported lower m at the six-week interview and that low m at six weeks was also predictive of greater disability in the survivors

Stress and immunity (lecture)

T cells (mature in thymus): Includes T helper cells, T suppressor cells, cytotoxic T cells Macrophages: "big eaters" --- specialised cells involved in the detection, phagocytosis and destruction of bacteria and other harmful organisms. In addition, they can also present antigens to T cells and initiate inflammation by releasing molecules (known as cytokines) that activate other cells. Natural Killer Cells (NK): major role in fighting tumours and viruses B cells (mature in bone marrow): - Develop into plasma cells (which are a source of antibodies - Y-shaped proteins that identify and neutralise foreign objects)

psychsocial modifiers for social support

The *perceived* comfort, caring, esteem or help received from others - the amount of assistance individuals believe is available to them The *existence* or quantity of social relationships - the amount of assistance individuals receive

What is obesity? (lecture)

The World Health Organization says: Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health. Key facts • Worldwide obesity has nearly tripled since 1975. • In 2016, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 650 million were obese. • 39% of adults aged 18 years and over were overweight in 2016, and 13% were obese. • Most of the world's population live in countries where overweight and obesity kills more people than underweight. • 38 million children under the age of 5 were overweight or obese in 2019. • Over 340 million children and adolescents aged 5-19 were overweight or obese in 2016. • Obesity is preventable.

How effective is self help?

The answer is: "We don't know". - Because we don't know who starts such programnes and what their situation was like before and after. - Evidence from book-based therapies show that less than 50% of people finish a self help program that they have started. - Unless psychologists engage with e Therapy themselves more, there could be some apps around that cause more damage than do good.

Evidence for the dimensions of illness cognitions

The extent to which beliefs about i are constituted by these different dimensions has been studied using two main methodologies - qualitative and quantitative research. Qualitative Research: Leventhal and his colleagues carried out interviews with individuals who were chronically ill, had been recently diagnosed as having cancer, and with healthy adults. The resulting descriptions of illness suggest underlying beliefs that are made up of the aforementioned dimensions. Leventhal argued that interviews are the best way to access i c as this methodology avoids the possibility of priming the subjects. For example, asking a subject 'To what extent do you think about your illness in terms of its possible consequences?' will obviously encourage them to regard consequences as an important dimension. However, according to Leventhal, interviews encourage subjects to express their own beliefs, not those expected by the interviewer. Quantitative Research: Other studies have used more artificial and controlled methodologies, and these too have provided support for the dimensions of illness cognitions. Lau et al. (1989) used a card-sorting technique to evaluate how subjects conceptualized illness. They asked 20 subjects to sort 65 statements into piles that 'made sense to them'. These statements had been made previously in response to descriptions of 'your most recent illness'. They reported that the subjects' piles of categories reflected the dimensions of identity (diagnosis/symptoms), consequences (the possible effects), time line (how long it will last), cause (what caused the illness) and cure/control (how and whether it can be treated). A series of experimental studies by Bishop and colleagues also provided support for these dimensions. For example, Bishop and Converse (1986) presented subjects with brief descriptions of patients who were experiencing six different symptoms. Subjects were randomly allocated to one of two sets of descriptions: high prototype in which all six symptoms had been previously rated as associated with the same disease, or low prototype in which only two of the six symptoms had been previously rated as associated with the same disease. The results showed that subjects in the high prototype condition labelled the disease more easily and accurately than subjects in the low prototype condition. The authors argued that this provides support for the role of the identity dimension (diagnosis and symptoms) of i representations and also suggested that there is some consistency in people's concept of the identity of i. In addition, subjects were asked to describe in their own words 'What else do you think may be associated with this person's situation?' They reported that 91 per cent of the given associations fell into the dimensions of illness representations as described by Leventhal. However, they also reported that the dimensions of consequences (the possible effects) and time line (how long it will last) were the least frequently mentioned. There is also some evidence for a similar structure of illness representations in other cultures. Weller (1984) examined models of illness in English-speaking Americans and Spanish-speaking Guatemalans. The results indicated that i was predominantly conceptualized in terms of contagion and severity. Lau (1995) argued that contagion is a version of the cause dimension (i.e. the i is caused by a virus) and severity is a combination of the magnitude of the perceived consequences and beliefs about time line (i.e. how will the i affect my life and how long will it last?) - dimensions that support those described by Leventhal. Hagger and Orbell (2003) carried out a meta-analysis of 45 empirical studies which used Leventhal's model of i c. They concluded from their analysis that there was consistent support for the different i c dimensions and that the different cognitions showed a logical pattern across different illness types.

Output from the gate

The g integrates all of the information from these different sources and produces an output. This output from the g sends information to an action system, which results in the perception of pain

The chronic model of illness

The most commonly-held view of the link between stress and illness suggests that stress leads to disease due to a prolonged interaction of physiological, behavioural and psychological factors. For example, c work stress may cause changes in physiology and changes in behaviour which over time lead to damage to the cardiovascular system. In particular, c stress is associated with atherosclerosis, which is a slow process of arterial damage that limits the supply of blood to the heart. Further, this damage might be greater in those individuals with a particular genetic tendency. This c process is supported by research indicating links between job stress and cardiovascular disease (Karasek et al. 1981; Kivimaki et al. 2002). Such an approach is parallel to Levi's (1974) 'stress-diathesis' model of illness which is illustrated in Figure 12.2.

stress and HIV

The relationship between s and illness progression has particularly been explored in the context of h. For example, Pereira et al. (2003) explored the progression of cervical problems in women with h. Women who are h positive are more at risk from cervical intraepithelial neoplasia (CIN) and cervical cancer. Pereira et al. explored the relationship between the likelihood of developing the lesions associated with CIN and life s. The results showed that higher life s increased the odds of developing lesions by sevenfold over a one-year period. Life s therefore seemed to link with illness progression.

What causes obesity?

The theories relating to the causes include -physiological theories -the role of the o environment -behavioural theories

systematic review of randomized controlled trials - behavioural therapy for chronic non-specific low back pain in adults

Their extensive search of the databases produced six studies of sufficient quality for inclusion and involved methodological practices such as blinding of outcome assessment, adequate length of follow-up and a highquality randomization procedure. The analysis showed that behavioural treatments effectively reduced pain intensity, increased functional status (e.g. return to work) and improved behavioural outcomes see chap 4 fr more studies similar to this and for children too

Costs/Benefits of visiting doctor

Therapeutic ⚫ Effective treatments, specialists ⚫ Don't like being medicated, being poked and prodded Practical ⚫ Busy, costs Emotional ⚫ Pros and cons - sympathy, company, embarrassment, insecurity Sick role ⚫ Absolved from day-to-day responsibilities, but co-operate (adhere) and get better

Allotosis and allostatic load

There has been a movement away from 'fight or flight' models of stress in the last decade - and now the physiological and health effects of stress are discussed in terms of these A - process of achieving stability (homeostasis), a result of responding to our environment AL - the cumulative biological wear and tear that result from excessive cycles of response McEwen & Seeman (1999) https://nyaspubs.onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1749-6632.1999.tb08103.x

emotional expression and immunity

There is evidence that certain coping styles linked to e ex may relate to illness onset and progression. For example, some studies have looked at suppression and denial and have reported associations with poorer health outcomes (e.g. Kune et al. 1991; Gross and Levenson 1997). Other studies have focused on e (non-) e and an e inex coping style known as 'type C', and have described a link with illness (e.g. Solano et al. 2001, 2002; Nyklic˘ek et al. 2002), while other researchers have highlighted the importance of a repressive coping style (e.g. Myers 2000). This research consistently indicates that non-ex of e, particularly negative emotions in stressful situations, can be harmful for health. There is also evidence that encouraging e ex through writing or disclosure groups may be beneficial. This work has been particularly pioneered by Pennebaker (e.g. 1993, 1997) using his basic writing paradigm. This has involved randomly allocating participants to either the experimental or control group with both groups being asked to write for three to five consecutive days for 15 to 30 minutes each day. The experimental group is asked to 'write about your very deepest thoughts and feelings about an extremely emotional issue that has affected you and your life. In your writing I'd really like you to let go and explore your very deepest emotions and thoughts . . .'. The control group is asked to write about more superficial topics such as how they spend their time. This intervention has been used with a range of people including adults, children, students, patients, maximum-security prisoners and survivors of the Holocaust who disclose a range of traumatic experiences including relationship break-ups, deaths and abuse. The writing paradigm has been shown to impact upon a range of outcome measures. Some research has shown a reduction in subsequent visits to the doctor (e.g. Pennebaker and Beall 1986; Greenberg and Stone 1992), re-employment following job loss (e.g. Spera et al. 1994), absenteeism from work (Francis and Pennebaker 1992), reduction in self-reported physical symptoms (Greenberg and Stone 1992; Petrie et al. 1995), pain reduction in patients with rheumatoid arthritis (Danoff-Burg et al. 2006) and changes in negative mood (Petrie et al. 1995). In terms of PNI, e ex through writing has also been shown to affect the immune system. For example, it has resulted in changes in T helper cell responses (Pennebaker et al. 1988; Petrie et al. 1998), natural killer cell activity (Futterman et al. 1992; Christensen et al. 1996) and CD4 (T lymphocyte) levels (Booth et al. 1997). It has even been shown to improve wound healing after a small punch biopsy (Weinman et al. 2008). Therefore this simple intervention provides support for the PNI model, suggesting a link between an individual's psychological state and their immune system. However, as with all associations, research indicates that the impact of e ex might vary according to aspects of the task and aspects of the individual (discussed in flashcards below). Smyth and Pennebaker (2008) refer to this as the 'boundary conditions' that may or may not make the intervention work.

The role of morality in MBI's

There is no prescribed way of m in this (to avoid clashing with other belief systems), but this does not mean that it plays no role. Everybody entering such a program will have been exposed to m through socialisation and even education and bring with them their own guidelines. There are reports that people develop more compassion naturally, even when loving-kindness meditation is not explicitly instructed (Maex, 2011). ¨ Cullen (2011) argues that the intention to cause harm and mindfulness are mutually exclusive states.

Corr (1993) 3 lessons to learn -1

Those who are coping with dying are still alive and often have unfinished needs which they want to address. This is fundamental and paramount. Dying patients are living human beings. Coping with dying is a human and vital process. From Death of a Salesman - Linda about her dying husband "He's a human being, and a terrible thing is happening to him. So attention must be paid" (Miller, 1948)

Illness Prevention

Three levels of prevention: Primary Prevention - actions taken to avoid disease or injury e.g. healthy eating, immunisation, wearing sunscreen Secondary Prevention - actions are taken to identify & treat an illness early e.g., cervical screening mammograms, blood pressure checked Tertiary Prevention - actions to slow lasting damage, prevent disability and rehabilitate e.g. palliative chemotherapy, doing exercises for physiotherapy, taking medication to control arthritic inflammation

What do we die from?

Top Ten Causes of Death - top is pnemonia in the 1900s and heart disease in 2003 https://www.who.int/gho/mortality_b urden_disease/causes_death/top_10/ en/ Corona Virus - over 15 million people died https://www.worldometers.info/coronavirus/

Psychological issues at end of life

Traditionally dealt with by simple avoidance - patient often not told of prognosis or even diagnosis, thus avoiding the expectation that patient will experience end-of-life concerns. Does patient really remain in ignorance? "I know I'm dying, but I pretend to my parents that I don't; it's the only thing I have left that I can do for them" (child dying from cancer)

Associations between Research in Different Settings

Using different measures given that stress research takes place in both the laboratory and in more naturalistic settings and uses both physiological and self-report measures it is important to know how these different studies relate to each other. This is illustrated in Focus on Research 11.1 (below) Psychophysiological effects of relaxation training in children (Lohaus et al. 2001). Background Stress is conceptualized as involving both physiological and subjective changes that can be assessed using laboratory and self-report procedures. This study assessed the impact of two types of relaxation training on different aspects of the stress response. It is interesting as it allows an insight into how these different aspects of stress may interrelate.It also illustrates the impact of relaxation training on children who are a rarely studied subject group. Aims - The study aimed to explore the relative impact of two types of relaxation training on children's physiological and self-report responses. The training types were progressive muscle relaxation and imagery-based relaxation. Participants The study involved 64 children from a school in Germany who were aged between 10 and 12. Design- The study used a randomized control trial design and participants were randomly allocated to one of three arms of the trial: progressive muscle relaxation, imagery-based relaxation or the control group. The Interventions Each intervention involved five training sessions. Each session lasted about 30 minutes. The children were asked to sit quietly for 5 minutes (baseline period), then they took part in the intervention, and the children were then asked to sit quietly again for 5 minutes (follow-up). • Progressive muscle relaxation. Children were asked to tense and relax specific muscle groups for a period of 7 minutes. These were hand muscles, arms, forehead, cheeks, chest, shoulders, stomach and thighs. • Imagery-based relaxation. Children in this group were asked to imagine that they were a butterfly going on a fantasy journey such as to a meadow, a tree or a boat. • Control group. Children in this group listened to audiotapes of neutral stories which were designed not to elicit any feeling of either tension or relaxation. Measures The study involved physiological and self-report measures. Subjective measurements were taken before and after the baseline period, after the intervention and after the follow-up period. Physiological measurements were taken continuously throughout. • Physiological measures. Measures were taken of heart rate, skin temperature and skin conductance level. • Self-report measures. Measures were also taken of the children's mood (e.g. sensation of perceived calmness, subjective feeling of wellness, feeling of perceived attentiveness) and their physical well-being (e.g. calmness of their heart beats, subjective body warmth, perceived dampness of the hands). Results - The results were assessed to examine the impact of relaxation training regardless of type of relaxation and also to explore whether one form of relaxation training was more effective. • Physiological changes. The results showed that imagery relaxation was related to a decrease in heart rate and skin conductance but did not result in changes in skin temperature. In contrast, progressive muscle relaxation resulted in an increase in heart rate during the training session. • Self-report changes. The results showed increased ratings of mood and physical well-being during baseline and training sessions for all interventions. Conclusions- The authors conclude that relaxation training can result in psychophysiological changes but that these vary according to the type of training. What is also interesting, however, is the degree of variability between the different measures of change. In particular, differences were found in the changes between different aspects of the children's physiology - a change in heart rate did not always correspond to a change in skin temperature. Further, changes in physiology did not always correspond to changes in self-reported mood or physical well-being. Therefore a measure indicating that heart rate had gone down did not always correspond with a self-report that the individual's heart was more calm.

Corr (1993) 3 lessons to learn - 2

We cannot become effective providers of care unless we listen actively to those who are coping with dying and identify with them their needs. This is so basic as to be almost obvious, if one did not know that it is practiced far less often than preached. How can one ever presume to care for another human being if one does not actively listen to the needs and priorities of that person? How can one be an effective care provider if one is content to act on the basis of generalisations about people? How can one dare to approach another human being in order to act as a provider of care without entering into a relationship with them within which the play at least a part (if not the main role) in defining their own coping tasks?

Self-affirmation

When presented with messages trying to get them to change their behaviour, many people resist, using a number of strategies such as avoidance, ignoring and finding fault in the arguments used, or criticizing the mode of presentation (Jacks and Cameron 2003; Harris and Epton 2009). This is particularly the case if the message evokes a strong emotional response such as fear. (Steele 1988) provides a framework not only for understanding the process of resistance but also as a means to encourage people to overcome this resistance and respond to the message in the desired way. It is grounded in the idea of 'self-integrity' and argues that people are inherently motivated to maintain their self-integrity and their sense of self as being 'adaptively and morally adequate' (Steele 1988). If their integrity is challenged by information indicating that their behaviour is damaging, then they resist this information as a means to preserve their sense of self. However, from this perspective such resistance can be reduced if the individual is encouraged to enhance their self-integrity by affirming their self-worth by focusing on other factors that are core to how they see themselves but unrelated to the threat (Harris and Epton 2009). A self-affirmation intervention can take many forms and studies have used methods such as providing positive feedback on a test, asking participants to rate themselves on a series of key values, writing an essay on their most important value or asking a series of questions about a universally valued construct such as kindness (e.g. 'Have you ever forgiven another person when they have hurt you?'). This process proceeds as follows using the example of someone who is obese: • Fear appeal: 'being overweight can cause heart disease'. • Emotional response: 'anxiety'. • Resistance: Ignoring the message/thinking 'research is always wrong' or 'that leaflet isn't very well designed'. • Self-affirmation intervention: 'Think of times when you have been kind to others'. • Emotional response: 'I am reassured', 'I am a good person'. • Reaction to fear appeal: 'Maybe I should lose some weight'. Self-affirmation interventions are designed to do the following (Napper et al. 2009): • Make a central and positive aspect of a person's sense of self more salient. • Provide a reminder of 'who you are'. • Offer reassurance that there are others aspects to the individual's sense of self other than that which is challenged by the fear appeal. Harris and Epton (2009) provide a comprehensive review of 24 studies using self-affirmation interventions in the context of a range of different health problems and behaviours. In particular, they show that self-affirmation can increase message acceptance for information relating to caffeine consumption, smoking, sun safety, alcohol intake and safe sex (e.g. Sherman, et al. 2000; Harris and Napper 2005; Harris et al. 2007). It can change affect (Harris and Napper 2005; Harris et al. 2007) and attitudes (Jessop et al. 2009) and in general cause increases in behavioural intentions (Harris et al. 2007). Finally, the review also indicates that self-affirmation interventions can change behaviour in the short term (e.g. immediately taking a leaflet or buying condoms) but to date there is little evidence on longer-term changes in behaviour. Further, those most at risk (e.g. heavy drinkers, heavy smokers) seem to be more responsive to self-affirmation interventions than those less at risk.

Styles, Processes and Strategies of coping

When discussing c, some research focuses on 'styles', some on 'processes' and some on 'strategies'. At times this may just reflect a different use of terminology. However, it also reflects an ongoing debate within the literature concerning whether c should be considered a 'trait' similar to personality, or whether it should be considered a 'state' which is responsive to time and situation. The notion of a 'style' tends to reflect the 'trait' perspective and suggests that people are quite consistent in the way that they c. The notions of 'process' or 'strategy' tend to reflect a 'state' perspective suggesting that people c in different ways depending upon the time of their life and the demands of the situation.

Symptom Perception

Whether or not we perceive ourselves as having a symptom seems to be influenced by four main sources of information: ⚫ Bodily data • Interaction between internal and external data eg- people telling you you don't look well ⚫ Mood • Stress, depression, anxiety all associated with greater symptom perception (with a pre-existing chronic condition) ⚫ Cognitions ⚫ Social context does not mean there actually is something wrong

The need to focus on prevention of illness

With an increased ageing population, there will be fewer health professionals in the workforce per capita:

What is the relationship between health and illness? Biomedical model

Within the biomedical model, health and illness are seen as qualitatively different - you are either healthy or ill, there is no continuum between the two

What is the role of psychology in health and illness? Biomedical model

Within traditional biomedicine, illness may have psychological consequences, but not psychological causes. For example, cancer may cause unhappiness but mood is not seen as related to either the onset or progression of the cancer.

Accidents

a are a very common and rarely studied cause of injury or mortality. Research has also examined the effects of stress on a and correlational research suggests that individuals who experience high levels of stress show a greater tendency to perform behaviours that increase their chances of becoming injured (Wiebe and McCallum 1986). Further, Johnson (1986) has also suggested that stress increases a at home, at work and in the car.

physiological fight or flight

a reaction caused by adrenaline that prepares one to either fi the stressor or take fl. Systems activated during stress: Neuroendocrine System - HPA Axis (hypothalamic pituitary axis) - Sympathetic Nervous System - SAM Axis (sympathetic adrenal medullary axis) HPA Axis -- Adrenal Cortex Releases glucocorticoids (GC) SAM Axis -- Adrenal Medulla -- Releases epinephrine, norepinephrine or adrenaline and noradrenaline (to help memorize) ad = near/next to Renal = Kidney Cortex = Bark (tree) Medulla = Marrow

esteem support

affirming qualities and skills of the person as part of social support

God is good

all the time

appraisal

an evaluation of the emotion-relevant aspects of a stimulus

Estimated contributions of different factors to health status.

behaviour 40% genetics 20% medical 10% other 30%

measuring coping

c - 60 items Brief c 28 - still long.. Carver, C. S. (1997). You want to measure c but your protocol's too long: Consider the Brief c. International Journal of Behavioral Medicine, 4, 92-100. https://link.springer.com/content/pdf/10.1207/s15327558ijbm0401_6.pdf The following questions ask how you have sought to c with a hardship in your life. Read the statements and indicate how much you have been using each c style.: I haven't been doing this at all A little bit A medium amount I've been doing this a lot

subjective wellbeing is linked to

cardiovascular health - mecahnisms unknown heart disease

A suggestion is that men are influenced by

cultural stereotypes (stimulus control) to ignore physical symptoms, repress emotions, to be unconcerned about prevention and screening, and delay help-seeking. Usually, put down to biology... Not so, no consistent differences in pain perception, general delay in symptom recognition etc in males Contingencies... Individual differences substantial The suggestion that males might adopt public behaviours that conform to the cultural stereotype, but in many cases private health experiences might differ Stimulus control Maybe the wrong questions being asked is it about who goes to the Dr with what complaints? or what happens in the consultation? maybe focus on when men do seek help, and improve interventions and consultation style?

Health Systems Conceptual Framework

determinants health and wellbeing interventions resources and systems see scrnsht

severity of illness

dysfunction and prognosis should be considered Kaplan

How to change behaviour

effortful vs effortless Effortful changes include decisions to eat more healthily, to stop smoking or to do more exercise. In contrast, effortless change is mostly a reaction to external changes in the environment as people alter their behaviour in response to a world that has also changed. Stopping smoking because it has been banned in public places or drinking less fizzy drinks because the machines have been removed from schools are examples of effortless changes. Most psychological approaches encourage effortful changes in behaviour through interventions targeted at the individual. In contrast, public health interventions focus more on structural and environmental changes that bring about shifts in behaviour without the individual necessarily knowing they are involved in an intervention or even that they have changed their behaviour.

What are the Aims of Health Psychology?

emphasizes the role of psychological factors in the cause, progression and consequences of health and illness. The aims can be divided into (1) understanding, explaining, developing and testing theory, and (2) putting this theory into practice.

Cognitive methods

focuses on the individual's thoughts about pain and aims to modify cognitions that may be exacerbating their pain experience. Techniques used include attention diversion (i.e. encouraging the individual not to focus on the pain), imagery (i.e. encouraging the individual to have positive, pleasant thoughts) and the modification of maladaptive thoughts by the use of Socratic questions. Socratic questions challenge the individual to try to understand their automatic thoughts and involve questions such as 'What evidence do you have to support your thoughts?' and 'How would someone else view this situation?' The therapist can use role play and role reversal (see Chapter 8 for a discussion of cognitive behavioural therapy − CBT − and Socratic questions).

The Five Facet Mindfulness Questionnaire (FFMQ)

has 37 statements with a Likert scale. •Scores are calculated for five different subscales: 1. Observing: "I notice the smells and aromas of things" 2. Describing: "I'm good at finding the words to describe my feelings" -- critiqued as contravertial as the person may not be the best at describing, may be introverted etc 3. Acting with awareness: "I break or spill things because of carelessness, not paying attention, or thinking of something else" 4. Nonjudging: "I tend to evaluate whether my perceptions are right or wrong" 5. Nonreacting: "I perceive my feelings and emotions without having to react to them"

The Inventory of Social Supportive Behaviors (ISSB)

is a 40-item self-report measure that was designed to assess how often individuals received various forms of assistance during the preceding month. Long form has good psychometric properties, and relates well to stress, distress etc adaquate test-retest and internal consistancy reliability (Barrera et al., 1981) significantly correlated with network size and percieved support (Barrera et al., 1981) But, some problems the amount of support received is correlated with negative health symptoms the available support may have not been needed during the assessment period there is often little or no association between actual and perceived support

health asset defintion

is an individual factor that produces longer life, lower morbidity, lower health care expenditure, better prognosis when illness does strike, and/or higher quality of life. Aerobic fitness, supportive friends and family members, and a sense of purpose in life are likely examples. As noted, Positive Health, as a discipline, is patterned after positive psychology, an approach in which mental health is defined as more than the simple absence of mental illness but rather as the presence of specific psychological assets of PERMA—positive emotion, engagement, relationships, meaning, and achievement (Peterson, Park and Seligman, 2005; Seligman, 2011; Seligman and Csikszentmihalyi, 2000).

Differences seem to be due to

lifestyle and behaviour, rather than being male... if one can disentangle that! In the US Army, female army personnel are twice as likely as male personnel to be injured (Snedecor et al., 2000) In an analysis of driving male and female personnel had equal rates of motor vehicle accidents and injury (Bell et al., 2000) Accidents were not predicted by sex, but by younger age, heavy drinking patterns, and habitual failure of seatbelt use. The suggestion is the adoption of a risky lifestyle (typical of males) is the key, not being male per se. General population - consistent evidence that males are much more likely to experience traffic-related accidents etc... but differences almost entirely accounted for by exposure to risk - time and distance travelled, alcohol, speed etc...

Suicide: men's health

low rates of self-protective behaviours are paralleled by a high suicide rate - generally 4 times higher than females with the notable exception of Asian countries, where rates are equal, and in China slightly higher for females social and cultural factors implicated, rather than some innate self-destructive property of being male Marginalised men at increased risk - Maori and Europeans the most risk --- migrants, indigenous, gay, and other minorities, age: 15 to 24 and 40 to 50 in NZ Taylor et al (1998) - SES stronger predictor for men, suggesting women better able to draw on other (less tangible?) resources Alcohol consumption related, Woods et al (1997) showed suicide attempts seemed to cluster with other risky behaviours - alcohol, drugs, smoking, fighting... Methods - males more immediate, more certain methods favoured

Men's health: Coping

men seem to cope less well, elevated suicide levels during separation, bereavement - not evident for women. Fewer personal and social resources for emotional coping? Less likely to seek psychological help - do current popular approaches fit well for men? Talking therapies, counselling, psychotherapy etc? Men who use services are generally less satisfied than women, rate therapists less positively - men want solutions instead of just listening and empathy Culturally-based reluctance to discuss problems, and a perceived failure to be a man? Different therapeutic approaches needed? More behaviourally based? Challenge male stereotypes, apply feminist principles? Is the emphasis on sharing and trust simply more appropriate for women?

(social support and health) Direct (main) effects hypothesis

posits that SS can help people at both low and high levels of stress, and hence having high levels of SS is always advantageous to health s relationships could influence their attitudes and behaviours related to health - like wearing seatbelts, encourage others to exercise, stop smoking, eat balanced diet Absence of social relationships: loneliness Rook (1987) - studied effects of companionship on health, SS measured, s companionship measured. SS assisted people in the time of stress (buffering) and s companionship led to positive well-being regardless of stress levels

Experimenter Bias

refers to the impact that the e's expectations can have on the outcome of a study. For example, if an e were carrying out a study to examine the effect of seeing an aggressive film on a child's aggressive behaviour (a classic social psychology study), then the experimenter's expectations may themselves be responsible for changing the child's behaviour (by their own interaction with the child), not the film. This phenomenon has been used to explain placebo effects. For example, Gracely et al. (1985) examined the impact of doctors' beliefs about the treatment on the patients' experience of placebo-induced pain reduction. The results showed that the subjects who were given the drug treatment by the doctor who believed they had a chance to receive the analgesic showed a decrease in pain whereas the patients whose doctor believed that they had no chance of receiving the painkiller showed no effect This study highlights a role for an interaction between the doctor and the patient and is similar to the effect described as 'eb' described within social psychology. eb suggests that the e is capable of communicating their expectations to the subjects who respond in accordance with these expectations. Therefore, if applied to placebo effects, subjects show improvement because the health professionals expect them to improve.

Stress and immunity

s can cause illness through physiological changes such as raised heart rate, blood pressure, heartbeat irregularities and an increase in fatty deposits (see earlier). It can also result in changes in i function. Research on rats showed that s such as tail pinching, a loud noise and electric shocks could produce i suppression (Moynihan and Ader 1996). Research in humans shows a similar picture. One area of research which has received much attention relates to the impact of caregiver s. In an early study, Kiecolt-Glaser et al. (1995) explored differences in wound healing between people who were caring for a person with Alzheimer's disease and a control group. Using a punch biopsy, which involves removing a small area of skin and tissue, they explored the relationship between caregiver stress and the wound healing process. The results showed that wound healing was slower in the caregivers than the control group. The wound healing paradigm has also been used to show links between s and slower healing in students during an exam period (Marucha et al. 1998) and slower healing using high resolution ultrasound scanning which is more accurate than the more traditional measurement strategies involving photography (Ebrecht et al. 2004). Herbert and Cohen (1993) carried out a meta-analysis of 38 studies which had explored the s i system link. They concluded that stress consistently resulted in changes in i function in terms of proliferative response to mitogens and NK cell activity, and was related to greater numbers of circulating white blood cells, immunoglobulin levels and antibody titers to herpes viruses. They also concluded that greater changes in i response were found following objectively rather than subjectively rated s events and that immune response varied according to the duration of the s and whether the stressor involved interpersonal or non-social events. Given that s can change health behaviours (see earlier), it is possible that stress causes changes in the i system by changing behaviour. Ebrecht et al. (2004) examined this possibility by assessing the link between perceived stress and wound healing and controlling for alcohol consumption, smoking, sleeping, exercise and diet. The results showed that s was related to wound healing regardless of changes in behaviour, indicating that the s i link may not be explained by an unhealthy lifestyle. In contrast, however, a review of 12 studies exploring the impact of smoking and smoking cessation on recovery following surgery concluded that a longer period of smoking cessation prior to surgery was related to fewer post-operative complications. Health behaviours may not have an association with wound healing when measured following a punch biopsy and when smoking is measured at the same time, but in real life and when smoking changes are assessed, there may well be a link. Research also indicates that s may relate to illness progression. Kiecolt-Glaser and Glaser (1986) argued that s causes a decrease in the hormones produced to fight carcinogens and repair DNA. In particular, cortisol decreases the number of active T cells, which could increase the rate of tumour development. This suggests that s while ill could exacerbate the illness through physiological changes. Such s may occur independently of the illness. However, s may also be a result of the illness itself, such as relationship breakdown, changes in occupation or simply the distress from a diagnosis. Therefore, if the illness is appraised as being s, this itself may be damaging to the chances of recovery.

Measuring Stress

s has been m both in the laboratory and in a naturalistic setting, and using both physiological m's and those involving self-report

Lazarus stress theory model

s is experienced when a person perceives that the "demands exceed the personal and social resources the individual is able to mobilise." this is called the 'transactional model of s and coping. ' 1. Event-- appraisal, primary and secondary: moderating factors = personal and situational 2. coping efforts 3. outcomes of coping 4. dispositional coping styles 5. optimism and information seeking

reducing the potential effect for stress by enhacing social support

so network size is related to prestige, income and education Diversity, men vs women Individual temperaments affect so support Supports deteriorate with chronic s Children may be taught supportive skills e.g. sharing, talking nicely Join clubs, organisations etc Support may be provided by employees in the workplace Community intervention programs provide support

Positive Health: 3 classes of assets

strengths that can contribute to a healthier, longer life. • These a's might include 1. *biological* factors such as high heart rate variability. 2. *subjective* factors such as optimism. 3. *functional* factors such as a stable marriage. • Positive health = excellent status on all 3 a's. *There will be a question on this on the in class test!!!*

the acceptance of pain involves eight factors

taking control, living day-by-day, acknowledging limitations, empowerment, accepting loss of self, a belief that there's more to life than pain, a philosophy of not fighting battles that can't be won and spiritual strength. In addition, the authors suggest that these factors reflect three underlying beliefs: (1) the acknowledgement that a cure for pain is unlikely; (2) a shift of focus away from pain to non-pain aspects of life; and (3) a resistance to any suggestion that pain is a sign of personal weakness. see chap 4 for further studies

problem focused coping

tends increase attention to the stressful situation. used when something can be done about situation. Types: p-solving - analysing situation and taking direct action. confrontational coping - taking assertive action. seeking social support - seeking information.

traditional treatment approach to obesity

was a corrective one, the assumption being that o was a product of overeating and underactivity. Treatment approaches therefore focused on encouraging the o to eat 'normally' and this consistently involved putting them on a diet. Stuart and Davis (1972) developed a behavioural programme for o involving monitoring food intake, modifying cues for inappropriate eating and encouraging self-reward for appropriate behaviour, which was widely adopted by hospitals and clinics. The programme aimed to encourage eating in response to physiological hunger and not in response to mood cues such as boredom or depression, or in response to external cues such as the sight and smell of food or the sight of other people eating. In 1958, Stunkard concluded his review of the past 30 years' attempts to promote weight loss in the obese with the statement, 'Most o persons will not stay in treatment for o. Of those who stay in treatment, most will not lose weight, and of those who do lose weight, most will regain it.' More recent evaluations of their effectiveness indicate that although traditional behavioural therapies may lead to initial weight losses of, on average, 0.5kg per week (Brownell and Wadden 1992), 'weight losses achieved by behavioural treatments for o are not well maintained'. However, it is now generally accepted that o is not simply a behavioural problem and, as Brownell and Steen said somewhat optimistically in 1987, 'psychological problems are no longer inferred simply because an individual is overweight'. Therefore traditional behavioural programmes make some unsubstantiated assumptions about the causes of o by encouraging the o to eat 'normally' like individuals of normal weight.

social community ties and mortality

was assessed using the 1965 Human Population Laboratory survey of a random sample of 6928 adults in Alameda County, California and a subsequent nine-year mortality follow-up. The findings show that people who lacked social and community ties were more likely to die in the follow-up period than those with more extensive contacts. Berkman and Syme, 1979

How the gate works

¤ *KEY in this theory:* g can be opened or closed If open: transmission cells send impulses freely closed/partially closed: output of transmission cells is inhibited.

Acute vs chronic pain

¨ A p - temporary, lasts less than 6 months ¤ Typically has a definable cause; treated with pkillers ¤ Associated with an increase in anxiety levels ¨ C p - lasts longer than 6 months ¤ E.g. from rheumatoid arthritis ¤ Associated with high anxiety levels, hopelessness, helplessness ¤ Influences other behaviours - e.g., sleep n sleep deprivation then increases sensitivity to p

Pain and the role of affect

¨ Anxiety ¤ Anxiety and worry make worse; problem with chronic, which is harder to treat ¤ High trait anxiety predicts experience complex, can be outcome or predictor ¨ Fear ¤ Fear and fear avoidance beliefs (e.g., "It will hurt if I walk") can exacerbate and predict transition from acute to chronic ¤ Fear of it might lead to hyper-vigilance of it and thus more intense experience of it. ¤ Treatment could work on reducing these avoidance behaviours.

Trait/skill definitions of mindfulness

• Being a psychological construct, mindfulness needs to be inferred and cannot be measured directly. • Most definitions include references to attention, awareness and a nonjudgemental attitude. - Intentional • Kabat-Zinn (1994) defined it as "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally".

session 3 e therapy study

• Guided breathing meditation • Physical movement meditation exercise • Slideshow presentation on types of awareness, negative bias, and walking meditation (also home practice) common narratives when learning meditations - "I can't just sit there and do nothing" "I shouldn't be feeling this way" -- although the brain can think that, the panic gland never believes that" - Terry Pratchett, Darwin's watch

Positive Health: Benefits

• Increased longevity. • Decreased health costs. • Better mental health (especially in aging). • Better prognosis when ill. • Higher achievement.

Mindfulness in psychological therapy

• The systematic use of this began in the 1990s. The following widely-used therapy types are all sometimes grouped together as (MBIs): • Dialectical Behavior Therapy (DBT) • Acceptance and Commitment Therapy (ACT) both use partly • M-Based Stress Reduction (MBSR) • M-Based Cognitive Therapy (MBCT) both gold standard, manual you can follow, ridgid couse but you can be sure that there is no other influencing factors, you know what is being delivered, standardized

Cognitive behavioural therapy

• The link between thoughts and feelings. • Therapy as a collaboration between patient and therapist. • The patient as scientist and the role of experimentation. • The importance of self-monitoring. • The importance of regular measurement. • The idea of an agenda for each session set by both patient and therapist. • The idea that treatment is about learning a set of skills. • The idea that the therapist is not the expert who will teach the patient how to get better. • The importance of regular feedback by both patient and therapist. CBT can vary according to client group and the problem being addressed, but involves a more structured form of intervention than most therapies and often includes the following cognitive and behavioural strategies: 1 Keeping a diary: many behaviours and thoughts occur without people being fully aware of them. For CBT, clients are asked to keep a diary of significant events and associated feelings, thoughts and behaviours. This process of self-monitoring enables clients to understand the patterns in their lives. For someone trying to change their diet, a diary could reveal that they eat while watching the TV or turn to food at work when feeling under stress. 2 Gradually trying out new behaviours: many behaviours are habitual and over time we learn to practise those behaviours which make us feel good and avoid those that make us feel uncomfortable. For CBT, clients are asked either on their own or with the therapist to try out new behaviours or face activities that have been avoided. This enables people to build confidence and familiarity with new behaviours and try to unlearn old behaviours. 3 Cue exposure: many people find that unhealthy behaviours can be triggered by certain situations (e.g. the desire to smoke when drinking alcohol). For CBT, clients are sometimes exposed to such situations when with the therapist in order to help them learn new coping responses and extinguish the old unhealthy reactions to these situations. For example,people addicted to drugs may be gradually exposed to the paraphernalia of drugs (e.g. silver foil, needles, cigarette papers, etc.) as a means to change their response to them. 4 Relaxation techniques: clients may use music, repeated clenching and relaxing of muscles, recordings of soothing voices or recordings of subliminal messages as a means to aid relaxation. This can help them to reduce their anxiety and negative thoughts about aspects of their lives. 5 Distraction techniques: distraction can be a powerful method for managing anxiety or preventing unhealthy responses to certain situations. In CBT, clients can be helped to find distraction strategies that work for them. For example, if a person feels the need to smoke when with certain friends, they can be taught how to focus on other aspects of their lives at these times or encouraged to use a telephone help line. 6 Cognitive restructuring: central to CBT is the notion that behaviour is maintained through a series of distorted cognitions and a vicious cycle between thoughts and behaviours which is perpetuated by irrational self-talk. Such distorted cognitions are: • Selective abstraction, which involves focusing on selected evidence (e.g. 'drinking alcohol is the only way I can unwind after work'). • Dichotomous reasoning, which involves thinking in terms of extremes (e.g. 'If I am not in complete control, I will lose all control'). • Overgeneralization, which involves making conclusions from single events and then generalizing to all others (e.g. 'I failed last night so I will fail today as well'). • Magnification, which involves exaggeration (e.g. 'Stopping smoking will push me over the brink'). • Superstitious thinking, which involves making connections between unconnected things (e.g. 'If I do exercise, I will have another heart attack'). • Personalization, which involves making sense of events in a self-centred fashion (e.g. 'They were laughing, they must be laughing at me'). CBT then uses a number of cognitive strategies to challenge and change these distorted cognitions and replace them with more helpful ones. The main approach involves Socratic questions with the therapist challenging the client's cognitions by asking for evidence and attempting to help the client to develop a different perspective. Questions could include: 'What evidence do you have to support your thoughts?'; 'How would someone else view this situation?'; 'When you say "everyone", who do you mean?'; 'When you say "all the time", can you think of times when this is not the case?' To aid this process the therapist can use role play and role reversal so that the client can watch and hear someone else using their cognitions and learn to see how unhelpful and irrational they are.

What Happens When There is a Mismatch?

Although physicians and patients agree that patients should play a role, neither tends to act this way. If the patient wants to participate and the the practitioner doesn't want them to, the conflict will result. If the practitioner wants the patient involvement but the patient doesn't want to participate both are uncomfortable.

WHAT IS A HEALTHY DIET? COMPONENTS OF FOOD

Carbohydrate Proteins Fat Fibre Water Trace Elements

How do patients impair communication?

Not indicating distress Indicating too much distress Poor communication of symptoms

Dangers of non-adherence

The patient fails to get better The patient may get worse Misdiagnosis Resistant organisms Poly-pharmacy (concurrent use of multiple medications: 10-20% of patients have an unnecessary prescription 5-10% further doctor visit 5-10% extra 1-2 days off work 0.25-1% 1-3 days in hospital

level of support e therapy

- is more effective if there is higher level of support for patients. - A certain minimum level of support is necessary to keep patients engaged and motivated to finish the homework tasks. - There is some concern that meaningful relationships between patient and t cannot be established online, but this may not be such a problem (at least for t's for mild psychological problems).

Cultural scaffolding of sexual violence against women

Elements of gender socialisation support the practices of rape & sexual assault (Gavey, 2005) Male 'active sex drive' vs female 'passive gatekeepers' 'rape culture' E.g. raised by "Roast Busters" incident Sills et al (2016) interviews with young people in NZ: victim-blaming, "slut-shaming," rape jokes, the celebration of male sexual conquest, & demeaning sexualized representations of women are prevalent. Health impacts - e.g. sexual coercion, & limits on women's ability to choose - e.g. relationship forms, practices like 'safe sex'.

Health and Behaviour

This area of health psychology is driven by the fact that many chronic illnesses and early mortality can often be prevented by individual behaviours.

Development and Health: Adulthood and Old Age

increased health behaviours with age Why? Those who perform the health behaviours outlive their less-active peers? Or - perceived susceptibility and perceived severity increase with age? exercise decreases with age The elderly tend to exaggerate the danger that exertion poses to health Underestimate their physical abilities

Context of rehabilitation in Aotearoa/ New Zealand

- Differences in NZ how the treatment is funded - ACC supports after an accidental injury - Ministry of Health supports medical conditions - Is one better than the other? - What if injury not recorded at the time of the accident? - Particularly an issue for TBI - Invisible injury - Often occurs as part of multiple trauma - How do you know if symptoms are due to trauma or something else?

Anxiety symptoms

- Excessive, uncontrollable, and often irrational worry. - Moderate correlation with depression. - Can interfere with daily functioning: fatigue, fidgeting, breathlessness, difficulty concentrating, irritability, restlessness. - Includes phobias, social a, panic attacks, generalized a disorder, separation a

Rehabilitation psychology in context: psychological treatment for chronic pain

- Psychoeducation - Mechanisms of chronic pain - Gate control theory - Pain physiology: central sensitization - Mind-body connection - Hurt ≠ Harm - Arousal reduction - Relaxation - Interoceptive exposure - Mindfulness - Behavioural activation - Goal setting - Pacing - Graded increases in activity - Return to valued activities - Cognitive therapy: - Identifying unhelpful thought patterns (e.g., catastrophizing) - Thought challenging - Replacing with more adaptive thinking - Skills training - Sleep management - Stress management - Communication skills - Problem‐solving skills

What do rehabilitation psychologists do?

- Psychological assessment - Basic neuropsychological assessment - Intervention delivery - Interdisciplinary working - Community‐based practice - Working with families/whanau - Disability advocacy - Research - Inform health policy and guidelines - Service evaluation

What is e-therapy?

- Psychological t that clients complete under the supervision and guidance of a psychologist. - The level of support and guidance can be very minimal (via emails, SMS, or phone call). - Compared to face-to-face t (45-60 min per week), psychologist's time is reduced to around 5-20 min per week.

cognitive processes of stress

- The meaning constructed by a person is crucial in the stress reaction - Experience - new experiences evaluated in the same way - Psychological meaning (personal significance) is the proximal cause of stress. - Distal causes are larger categories: E.g., SES, ethnicity, sex, age More likely to be shared meaning, but not all men/women/Māori/Pakeha etc react in the same way. Need to know more about individuals

Working with family/whanau

- Traditional models of chronic care management have typically paid little attention to family involvement. - Why is the consideration of family important for the patient? - Patients with supportive families are more likely to do better in rehabilitation than those who do not have such support (e.g., Braga et al., 2005) - Carers within the family may be burdened in different ways - Financial - Changes in roles - Emotional - Important considerations include: - Socioeconomic factors - Cultural factors - Psychological support

In conclusion: Rehabilitation psychology

- focuses on adjustment to illness and injury - Takes into account positive and negative aspects of the illness - Wide range of settings and contexts - May extend to a community‐based focus and involvement of family/whanau - Wide context encompassed in treatment informed by health psychology and rehabilitation models - Aims to fit psychological interventions with needs of client

Super Health

- less frequent and briefer ailments. - rapid wound healing. - enhanced recuperative ability. - greater physiological reserves. https://ppc.sas.upenn.edu/services/resilience-training-army - different facets of wellbeing how can we boost resilience? Can we have beyond optimal health? By boosting resilience we can increase wellbeing , resilience can be taught PTSD - post traumatic growth - several years after growth in areas that they would not have had if not for the trauma. NOT everyone experiences this. The more resilient you are the less likely you are to experience this. Can increase positive health We resist change, it takes something challanging for us to change.

Functional assets positive health

- notable sensory acuity • (e.g. seeing, hearing, feeling (physically and emotionally), smelling and tasting). - exceptional central nervous system function • (e.g., balance, coordination, cognition, and memory). - social integration • (A dynamic and structured process in which all members participate in dialogue to achieve and maintain peaceful social relations). Emotional intelligence is an eg

Examples of self help apps

-Moodtrack Diary: Private Mood Tracker & Mood Tracking Journal Graph your moods on the fly. Privately track as little or as often as you want (mood-swings? no problem!), whenever you want (at home, on the go, and even without Internet!), and look back to see your moods over weeks, months, and years to learn about yourself and live better! - Stress & Wellness Assessment based on Heart Rate Variability analysis during two different protocols. First protocol compares analysis during Normal Breathing with that during Deep Breathing to find out the most possible levels of Adrenals and Wellness as well as its capacity. - Gratitude Journal As it says, Gratitude is the mother of all virtues. Try write down the little things you are grateful for your day in this lovely journal. It will change your attitude towards life.

Online MBI's

-important to look at method as it could be a different method of what topic you are intending to look at for assignments as there are many diff formats etc. • Spijkerman et al. (2016) reviewed 15 of these (8 MBSR, 2 MBCT, 5 ACT) • Delivered usually through a w/s • Varying degrees of guidance was provided (e.g. individual email coaching or o message boards) • Small but significant effect size for anxiety, depression, and stress • Thus, lower effect size than traditional M's • High drop-off rate noted

Risk factors for obesity

1. Genetics - twin studies, adopted and the familial studies provide evidence for the role of genetics in obesity 2. Age - an increased risk with age 3. Sex - women have higher BMI than men 4. SES 5. Sedentary Lifestyle 6. Psychological Factors 7. Eating Behaviours - hypercaloric diet 8. Sleeping Behaviours

Some Problems with pain research

1. P cannot be observed and is a subjective experience. Therefore measuring p is problematic. Self report measures are reliant upon the individual attempting to give an accurate description of how they feel which may well be influenced by how they want other people to believe that they feel and the ability of the existing measures to describe their experience. More objective measures such as the observation of pain behaviour or medication use may miss the subjective nature of the p experience. 2. P research highlights the interaction between biological and psychological processes. This is particularly apparent in the GCT and the role of affect and cognitions in mediating the pain experience. However, how these different processes actually interact remains unclear. Why is it that focusing on pain actually makes it hurt more? 3. P research emphasizes the role of psychological factors in promoting chronic p and exacerbating acute pain. Little, however, is known about pain onset. Why do some people get headaches while others do not? Why is there such cultural variation in where and when people experience p? (see Chapter 9 for a discussion of symptom onset). 4. P is difficult to measure, difficult to define and treatment studies often use different protocols, different outcomes and different time points. This makes synthesizing evidence across studies difficult. This is discussed in detail in Eccleston et al. (2010) and Moore et al. (2010).

How does social support lead to better health?

1. stress appraisal, coping and health behaviours 2. cardiovascular function, neuroendocrine and immune function 3. health outcomes such as lower blood pressure, heart rate and higher nk cell activity

What is the relationship between the mind and the body? Biomedical model

According to this model of medicine, the mind and body function independently of each other. This is comparable to a traditional dualistic model of the mind-body split.

The role of technology (mental health)

Can t help overcome these barriers? Does e t fit in more with modern lifestyle or the generation of "digital natives"?

But does body image cause the same level of distress?

Could be that the relative importance of physical appearance means that men recognise the discrepancy between their actual and ideal, but are less concerned about it... Relative dearth of research, while results are mixed, it seems that men are affected emotionally by poor body image Better at concealing it... contingencies just different? Anorexia nervosa and bulimia do occur in men - but rarely Tends to occur in specific groups where body weight, body fat etc are an issue - modelling, dancing, sports (esp, jockeys, diving, rowing, boxing etc), bulimia seems more common in homosexual men.

Iatrogenic Events - NZ

Iatrogenic diseases are adverse events that occur as a result of medical management and result in measurable disability. For example, radiation therapy and chemotherapy — necessarily aggressive for therapeutic effect - frequently produce such iatrogenic effects as hair loss, hemolytic anemia, diabetes insipidus, vomiting, nausea, brain damage, lymphedema, infertility, etc NZ = 6579 no. of studies, 12.9 adverse events, 1.9% permanant harm or death

acute stress disorder symptoms

In response to a traumatic event. - Reduced emotional responsiveness, awareness of surrounding, recurrent images, thoughts, flashbacks, reliving the experience. - Avoidance of stimuli associated with trauma.

How common is obesity?

In the UK the rates increased dramatically from 1993 to about 2007 but have been relatively stable for the past five or six years. If defined as a BMI greater than 30, reports show that in 1980, 6 per cent of men and 8 per cent of women were o and that this had increased to 13 per cent and 16 per cent in 1994, to 18 per cent and 24 per cent respectively by 2005 and to 22 and 24 per cent respectively in 2009. In 2009 the mean BMI was 27 for both men and women. For children in England, Chinn and Rona (2001) reported that in 1994, 9 per cent of boys and 13.5 per cent of girls were o w, that 1.7 per cent of boys and 2.6 per cent of girls were obese and that these figures were more than 50 per cent higher than 10 years earlier. Estimates for the USA suggest that roughly half of American adults are o w, that a third are o, that women have grown particularly h in recent years and that the prevalence of o w children has doubled in the past 20 years (National Institutes of Health 1998; Ogden et al. 2007). *Across the world, the World Health Organization (WHO 2006) estimates that 1.5 billion adults worldwide are o w and 400 million are o.* Figure 15.4 shows o rates across the world for men and Figure 15.5 shows rates for women. *The highest rates of o are found in Tunisia, the USA, Saudi Arabia and Canada, and the lowest are found in China, Mali, Japan, Sweden and Brazil; the UK, Australia and New Zealand are all placed in the middle of the range (WHO 2007).* Even though the rates are low in China and Japan they are steadily increasing and reports indicate that the prevalence of childhood o has tripled in Japan and that 1 in 10 children in China is now o (Ogden et al. 2007). Across Europe, the highest rates are in Lithuania, Malta, Russia and Serbia and the lowest are in Sweden, Ireland, Denmark and the UK. Overall, people in northern and western Europe are thinner than in eastern and southern Europe and women are more likely to be o than men.

The Development of Stress Models

Over the past few decades, ... have varied in terms of their definition of stress, their differing emphasis on physiological and psychological factors, and their description of the relationship between individuals and their environment.

Do the obese eat more than non

Research has also examined this, focusing on the: -amount consumed per se, -how they eat -the type of food consumed.

PSYCHOLOGY OF VEGETARIANISM

Types of Vegetarianism (continuum) Vegan / Vegetarians Pesco-vegetarians - eat fish Semi-vegetarians - avoid red meat Flexitarians - occasionally ate red meat Omnivores Psychosocial Factors in Vegetarianism Gender differences - more females vegetarian Pro-social behaviour, emotional well-being, more positive mood states, nature-relatedness

Behavioural theories obesity

have examined both physical activity and eating behaviour. Further details about exercise and diet can be found in Chapters 5 and 6.

Why Physicians Use Jargon

Habit The patient doesn't need to know Patient better off not knowing Keep interactions short Reduce emotional reactions Reduce recognition of errors Elevate practitioner's status Not aware of jargon

Beliefs of Personal Control

Health behaviour can be influenced by: Locus of Control: Internal (can be controlled) vs. External (cannot be controlled, inevitable) Self-efficacy Defined as: the belief that they can succeed at something When deciding to perform a health behaviour, people appraise their efficacy - how much effort is required, how complex is the task

Predictors of Access to Health Care

Patient satisfaction Patient understanding Patient recall Beliefs about illness Beliefs about medication understanding, satisfaction and memory = compliance Adapted from Ley, (1981)

WHY EXERCISE?

Physical benefits Increased longevity Reduced blood pressure Reduction in weight Reduction in diabetes Protection against osteoporosis Reduction in CHD Psychological benefits Decreased depression Decreased anxiety Stress reduction Self-esteem and self-confidence Increased social support Increased self-efficacy

Illness behaviour

is the activity by people who feel ill, with the purpose of determining the state of their health or finding a remedy Problem-solving mode Involves complaining to friends, relatives, seeking help from a practitioner -- active approach - trust experts but work together and are responsible for their health Sick-role behaviour is the activity by individuals who consider themselves to be ill, for the purpose of becoming well -- may not actually be ill -- defeatist approach - only trust experts to heal them Gets prescription filled, staying home to get better

(social support and health) buffering hypothesis

(Cohen & Wills, 1985): suggests that SS leads to better h by protecting people from the negative effects of high stress, and hence SS is particularly beneficial during stressful times numerous studies suggest SS is particularly beneficial in terms of h for people undergoing high levels of stress: military in combat, AIDS patients, persons experiencing natural disasters SS allows people to think about difficult situations more positively (Tangible) SS allows people to cope more effectively - Peirce et al. (1996) Financial stress study - more tangible SS lower levels of drinking - but not appraisal nor belonging - consistently, anyway

response shift of pain

*Changes in a person's internal standards of measurement. Our p perception can change as we grow and mature we realise it was not that bad. For example, when we are children we overreact. People's priority change when having chronic p, we don't sweat the small stuff. It is healthy but a hassle to measure

Measuring stress

*Physiological arousal* Polygraph - blood pressure, heart rate, respiration rate, galvanic skin response *Hormonal secretion* Corticosteroids - cortisol Catecholamines - epinephrine and norepinephrine Problems - sful, need good baseline etc *Psychological symptoms* Report of d...s not perfectly correlated with physiological arousal Physiological and psychological s can be independent, and need to both be accounted for in studies of s Use of mood, anxiety, and psychiatric scales. What are we measuring, stress or mental illness?

Strengths and weaknesses of SRRS

*Strengths* Representative of stressful events Part of design, usually Relatively quick and easy to complete *Weaknesses* Introspective self-report, people under stress tend to behave irrationally Some argue arbitrary, scatter-gun approach, and possibly measuring neuroticism: 'too many things to do', 'troubling thoughts about the future' Relate s to illness - but correlation weak - approx 0.3 People may interpret events differently, and the individual impact is not accounted for Not clear if some events are desirable or undesirable Or if individuals would view them the same way Threat vs challenge etc

The role of acceptance in pain management

- Acceptance: "Maybe acceptance isn't a good word, I think of it not as accepting it but just dealing with it." - "A willingness to experience continuing pain without needing to reduce, avoid, or otherwise, change it" - Associated with better physical, social, and emotional functioning - in other words, better adjustment! - But pain management can be a hard sell: Ferrari vs rusty bike - The process of acceptance (LaChapelle et al, 2008) - Realizing the need for help - Receiving a diagnosis - Realizing there is no cure - Realizing it could be worse - Redefining normal - Acceptance as an ongoing daily process

Depression symptoms

- Lowered mood or loss of interest or pleasure in daily activities - Weight change or change in appetite - Change in sleep (insomnia or hypersomnia) - Fatigue or loss of energy - Feelings of guilt or worthlessness - Impaired concentration skills Suicidal thoughts - (bereavement exclusion as grief might even be protective)

Cancer survivorship

- PTG relatively high in this population - likely to be beyond 50% (Stanton et al, 2006) - As cancer outcomes improve, more people are living longer with, through, and beyond cancer - Despite improved treatments, however, quality of life outcomes beyond cancer can remain impacted - The cancer experience can have many additional impacts beyond the physical: - Psychological - Cultural - Spiritual - Sexual and reproductive - Relationship - Work and education-related - Financial

Moving beyond the therapy room: Rehabilitation psychology in the community

- Participation is an important goal in rehabilitation - Vocational rehabilitation - Preparing for work re‐entry - Vocational goals as part of treatment - Addressing personal barriers (e.g., motivation, mood, stress) - Advocate for the client (e.g., changing attitudes in the workplace) - Health service - Interdisciplinary communication - Managing chronic conditions within the disability context - Enhancing self‐efficacy for service engagement (e.g., use of transport)

Beating the blues program (example of CCBT)

- Patients see a doctor who might then recommend this programme. - Patients complete this programme independently online, but occasionally have a consultation session with an assistant psychologist. The program typically follows this structure: - 15min introductory video then eight 1-hour sessions to promote helpful thinking styles. - Clients complete weekly homework, and regular progress reports are given to facilitator and client. - Other programs include: MoodGYM, Colour Your Life, Managing Your Mood, Overcoming Depression.

Concentration versus insight meditation

A common distinction made to describe meditation techniques is in terms of concentration (Samatha) versus i (Vipassana) meditation C meditation teaches focused attention on a single object or event (usually breath); often considered beginner's practice (although opinions vary) Open monitoring: expand attentional scope to any experience that may arise, without selecting, over-identifying, judging, or focusing on a particular object

Transactional Model of Stress

A four-step framework for evaluating an individual's coping process for a stressor; an individual evaluates the stressor and her or his coping resources before deciding how to respond and then whether the response was successful. Under the role of appraisal - primary and secondary interaction between person and environment. Imbalance between demand and resources of our ability to cope with the depands = stress

Selye's definition of stress

A non-specific response of the body to demands made upon it.

PALEO

A paleo diet typically includes lean meats, fish, fruits, vegetables, nuts & seeds — foods that in the past could be obtained by hunting & gathering. limits foods that became common when farming emerged about 10,000 years ago. These foods include dairy products, legumes & grains.

biomedical model

A perspective that explains illness solely in terms of biological factors. What causes illness? etc questions

Effect of stress on prefrontal cortex

Acute s can reduce working memory performance (Del Arco et al., 2007) -- why you might do worse when stressed in exam Psychosocial stress can impair attentional control (Liston et al., 2009) Dendritic spine loss (in rats) (Radley et al., 2006)

Meaning and pain

Although at first glance any p would seem to be only negative in its m, research indicates that pain can have a range of m to different people. For example, the p experienced during childbirth, although intense, has a very clear cause and consequence. If the same kind of p were to happen outside childbirth then it would have a totally different m and would probably be experienced in a very different way. Beecher (1956), in his study of soldiers' and civilians' requests for medication, was one of the first people to examine this and asked the question, 'What does p m to the individual?' Beecher argued that differences in p perception were related to the m of p for the individual. In this study, the soldiers benefited from their p. This has also been described in terms of secondary gains whereby the p may have a positive reward for the individual.

Activities inducing mindfulness

Anything that switches off the default mode network Experienced by everyone at some time and may be interpreted as creative, spiritual, existential, inspirational, calm, meaningful m practice is a deliberate attempt to induce such states regularly and in a variety of situations

Importance of pain beliefs

Back p Attitudes Questionnaire (Back-PAQ; Darlow et al., 2014 - doi 10.1136/bmjopen-2013- 004725 see scrn for questionaire

Who is responsible for illness? Health psychology

Because illness is regarded as a result of a combination of factors, the individual is no longer simply seen as a passive victim. For example, the recognition of a role for behaviour in the cause of illness means that the individual may be held responsible for their health and illness

biopsychosocial model limitations

But... • While sometimes the medical model acknowledges broader causation... • Even the biopsychosocial model focuses on sickness & its causes Psychological & environmental aetiology, physiological lesions. Disease categories, lesion characteristics, risk factors • Current climate demands focus on outcomes measures by physicians • Blood chemistry, physical characteristics etc • As opposed to 'behavioural' ones - longevity, health-related quality of life, symptomatic complaints, day-to-day functioning

Drug Treatments for obesity

D therapy is only legally available to patients in the UK with a BMI of 30 or more and government bodies have become increasingly restrictive on the use of anti-o d's. For example, both fenfluramine and dexfenfluramine were recently withdrawn from the market because of their association with heart disease even though they were both quite effective at bringing about weight loss. Current recommendations state that d should be used only when other approaches have failed, that they should not be prescribed for longer than three months in the first instance and should be stopped if a 10 per cent reduction in weight has not been achieved. Continued d use beyond this time should be accompanied by review and close monitoring (Kopelman 1999). There are currently two groups of anti-o d available which are offered in conjunction with dietary and exercise programmes. The first group work on the central nervous system and suppress appetite. The most commonly used of these are phentermine, which acts on the catecholamine pathway, and sibutramine, which acts on the noradronergic and serotonergic pathways. There is some evidence for the effectiveness of these d although they can be accompanied by sideeffects such as nausea, dry mouth and constipation (Lean 1997). The second group of d act on the gastrointestinal system and the more successful of these reduce fat absorption. Orlistat is one of these and has been shown to cause substantial weight loss in o subjects (Sjostrom et al. 1998; Rossner et al. 2000). It can be, however, accompanied by a range of unpleasant side-effects including liquid stools, an urgency to go to the toilet and anal leakage which are particularly apparent following a high-fat meal. Although Orlistat is designed to work by reducing fat absorption, it probably also has a deterrent effect as eating fat causes unpleasant consequences. Ogden and Sidhu (2006) carried out a qualitative study exploring patients' experiences of taking Orlistat and concluded that, although it constitutes a medical approach to obesity, it provides a window into the processes of adherence to medication and behaviour change and also has some interesting effects on the individual's psychological state. The results from this study suggest that adherence to the d was related to being motivated to lose weight by a life event rather than just the daily hassles of being o. Further, if the unpleasant, highly visual side-effects were regarded as an education into the relationship between fat eaten and body fat, then they helped to change the patient's model of their problem by encouraging a model that emphasized behaviour. Such a behavioural model of o was then related to behaviour change. This is similar to the importance of coherent models described in Chapter 9.

Incidental mindfulness

Discussion: Can you practise mindfulness without knowing that you are doing it? no

Amygdala

Essential for fearful and emotionally laden events (involved in anything unexpected or uncertain) Sends messages to hypothalamus - initiates stress response volume correlates with social network size (more friends = bigger) (Bickart et al., 2011) rats without a = removed fear -- not helpful

Legality

Euthanasia/PAS illegal in most places, although there are exceptions, including the Netherlands, Switzerland, Belgium, the state of Oregon and (briefly) NT in Australia Note principle of "double effect" - is permissible to perform an action which will hasten death subject to certain conditions: Act itself must be good or neutral, not intrinsically wrong The good consequence must be the intended one The bad consequence must not be the means of achieving the good one The good effect must outweigh the bad If these conditions are met, there is not usually legal problem

Personality as a moderator of the stress-illness link

Friedman and Rosenman (1959) initially defined type A behaviour in terms of excessive competitiveness, impatience, hostility and vigorous speech. Using a semistructured interview, three types of type A behaviour were identified. Type A1 reflected vigour, energy, alertness, confidence, loud speaking, rapid speaking, tense clipped speech, impatience, hostility, interrupting, frequent use of the word 'never' and frequent use of the word 'absolutely'. Type A2 was defined as being similar to type A1, but not as extreme, and type B was regarded as relaxed, showing no interruptions and quieter (e.g. Rosenman 1978). The Jenkins Activity Survey was developed in 1971 to further define type A behaviour. Support for a relationship between type A behaviour and CHD using the Jenkins Activity Survey has been reported by a number of studies (Rosenman et al. 1975; Haynes et al. 1980). However, research has also reported no relationship between type A behaviour and CHD. For example, Johnston et al. (1987) used Bortner's (1969) questionnaire to predict heart attacks in 5,936 men aged 40-59 years, who were randomly selected from British general practice lists. All subjects were examined at the start of the study for the presence of heart disease and completed the Bortner questionnaire. They were then followed up for morbidity and mortality from heart attack and for sudden cardiac death for an average of 6.2 years. The results showed that non-manual workers had higher type A scores than manual workers and that type A score decreased with age. However, at follow-up the results showed no relationship between type A behaviour and heart disease. More recently, however, research has focused on other aspects of p. For example, O'Connor et al. (2009) explored the role of conscientiousness on moderating the link between daily hassles and changes in health behaviours. Using a prospective design, 422 employees completed ratings of daily hassles and health behaviours over a four-week period. The results showed that greater daily hassles were linked to a higher intake of high fat snacks, a greater consumption of caffeinated drinks, higher levels of smoking but lower intakes of alcohol, vegetables and less exercise. Furthermore, the results indicated that these associations were influenced by conscientiousness. Much research has also focused on hostility and aspects of anger expression as being linked to stress and illness. Hostility has most frequently been measured using the Cook Medley Hostility Scale (Cook and Medley 1954) which asks people to rate statements such as 'I have often met people who were supposed to be experts who were no better than I', 'It is safer to trust nobody', and 'My way of doing things is apt to be misunderstood by others'. Agreement with such statements is an indication of high hostility. Hostility has also been classified according to cynical hostility and neurotic hostility. Research has asked 'Who is hostile?', 'How does hostility link to stress?' and 'How does hostility link to illness?'

What is the relationship between health and illness? Health psychology

From this perspective, health and illness are not qualitatively different, but exist on a continuum. Rather than being either healthy or ill, individuals progress along this continuum from health to illness and back again.

coping: denial

Good way to c or bad? Heart attack... In hospital after attack Returning home Perhaps when nothing can be done, d is a reasonable approach? Example of emotion focused c - Freud's defence mechanisms tend to be similar

acute model of illness

Heart attacks are more likely to occur following exercise, following anger, upon wakening, during changes in heart rate and during changes in blood pressure (e.g. Muller et al. 1994; Moller et al. 1999). They are a events and involve a sudden rupture and thrombogenesis. Johnston (2002) argues that this reflects an acute model of the link between stress and illness with acute stress triggering a sudden cardiac problem. This explains how exercise can be protective in the longer term but a danger for an at-risk individual. It also explains why and when a heart attack occurs.

Illness Representations

How a person views a particular illness Identity - • Label or interpretation of what symptoms mean • The symmetry rule: label‐ symptom match Causes - • Belief as to what lead to illness Timeline - • Expectation as to how long will be affected Consequences - • Perceived effects of illness on self and functioning Controllability - • Belief as to how much individual or others can treat illness

self efficacy and stress

In 1987, Lazarus and Folkman suggested that se was a powerful factor for mediating the s response. Se refers to an individual's feeling of confidence that they can perform a desired action. Research indicates that se may have a role in mediating s-induced immunosuppression and physiological changes such as blood pressure, heart rate and s hormones (e.g. Bandura et al. 1988; Wiedenfeld et al. 1990). For example, the belief 'I am confident that I can succeed in this exam' may result in physiological changes that reduce the stress response. Therefore a belief in the ability to control one's behaviour may relate to whether or not a potentially stressful event results in a s response.

What does it mean to be ill?

In his study of the beliefs of young healthy adults, Lau (1995) also asked participants Their answers indicated the dimensions they use to conceptualize this: • Not feeling normal, for example, 'I don't feel right'. • Specific symptoms, for example, physiological/psychological. • Specific i, for example, cancer, cold, depression. • Consequences of i, for example, 'I can't do what I usually do'. • Time line, for example, how long the symptoms last. • The absence of health, for example, not being healthy. These dimensions of i have been described within the context of i cognitions (also called i beliefs or i representations).

Operant Conditioning and pain

Individuals may respond to pain by showing pain behaviour (e.g. resting, grimacing, limping, staying off work). Such p behaviour may be positively reinforced (e.g. sympathy, attention, time off work), which may itself increase p perception.

Subjective measures

It is acknowledged that self-report measures such as questionnaires and interviews are subjective. This raises problems such as: • Are participants just saying what they believe the researcher wants them to say? • Does the participant have the language and insight to express what they really feel? • Can people really differentiate their feelings, beliefs or behaviours into the level of detail expected by numerical scales with 5 or 7 or even 100 options?

Mindfulness diary

It is very common for m teachers to encourage using this where observations around one's m are recorded daily Additionally, recording length of daily session serves as a reminder for participants to practice (and is already an intervention) The narrative part of this helps reflect on application of m in everyday life It helps us really how often we are actually absentminded (in psychometrics called response shift) It also helps build insight - increased meta-emotional awareness (under which circumstances do you tend to behave in a certain way?)

How Does Stress Cause Illness?

Johnston (2002) argued that stress can cause illness through two interrelated mechanisms and developed his model of the stress-illness link which involves *chronic and acute* processes (see Figure 12.1).

Mastery and stress response

Karasek and Theorell (1990) defined the term 'feelings of m', which reflected an individual's control over their s response. They argued that the degree of m may be related to the s response.

What is stress? (lecture)

Many lay definitions of s E.g. Pressure, tension, emotional response Research definitions: s...or: external environment s or d...s: response to s/or Eu...s: positive or beneficial stress Acute s: short term Chronic s: ongoing and longer-term

Laboratory setting for stress

Many stress researchers use the acute stress paradigm to assess stress reactivity and the stress response. This involves taking people into the l and asking them either to complete a stressful task such as an intelligence test, a mathematical task, giving a public talk or watching a horror film, or exposing them to an unpleasant event such as a loud noise, white light or a puff of air in the eye. The acute stress paradigm has enabled researchers to study gender differences in stress reactivity, the interrelationship between acute and chronic stress, the role of personality in the stress response and the impact of exercise on mediating stress-related changes (e.g. Pike et al. 1997; Stoney and Finney 2000).

Understanding media campaign

Media campaigns use a number of the psychological strategies described above to encourage us to change our behaviour. These include modeling (i.e. using people who are like us), fear appeals (i.e. being shocking), visual imagery (i.e. to change affect and maybe reduce denial or resistance), targeting a specific audience (i.e. those at the right stage of change and with a good level of motivation) and encouraging people to focus on the negative aspects of what they do (i.e. in line with motivational interviewing to create cognitive dissonance). The elaboration likelihood model (ELM, Petty and Cacioppo 1986) was developed as a model of persuasion and provides a framework for understanding why some media campaigns might be more successful than others and how they could be improved. The ELM is a popular model in the area of persuasion across a range of fields including political persuasion, media influence and health behaviour change. It argues that in order for people to change their beliefs and behaviour, they need to do the following: • Be motivated to receive the argument. • Centrally process the argument. This will occur if: • The message is congruent with their existing beliefs. • The message is personally relevant to them. • The individual can understand the argument. This central processing involves an assessment of arguments being presented which are then incorporated into the person's existing belief systems. This can result in a strong change in beliefs and longer-term changes in behaviour if this central processing determines that the case being made is strong and relevant. However, if the case is deemed to be weak and not personally relevant, weak changes will occur. For example, if an overweight person has started to find it hard to climb the stairs and has realized that her clothes no longer fit, then she will be motivated to change and a message could be centrally processed. Such a message could be 'Eating less fat and more fruit and vegetables can help you lose weight, fit into your clothes and have more energy'. But what if a person is not motivated in the first place? Given that most media campaigns are aimed at changing behaviour in those who are not already performing this behaviour, then many of these people will not fulfil the criteria for central processing as they will not be motivated. If this is the case, the ELM offers another route called 'peripheral processing'. This involves the following: • Using direct cues and information. • Maximizing the credibility of the source of the message. • Maximizing the attractiveness of the source of the message. For an overweight person who suffers no symptoms of breathlessness and has a wardrobe of larger clothes, the message above will not work. The campaign will therefore need to work harder to make a difference. For example, it could use indirect cues and information such as 'Weight loss clubs can be fun and are a good way to meet people'. It could increase the credibility of the message by using a more scientific approach (e.g. men in white coats, charts, data) and could make the message more attractive (e.g. a good-looking man in a white coat, images of friendly-looking people at a club, a smiling person selling fruit and vegetables). According to the ELM, messages using this peripheral processing route can change beliefs and behaviour but are likely to be less effective or long-lasting.

social support

Most frequent forms of ss Type of s received often depends on the circumstances. Tend to receive more forms of s during stressful situations. Emotional, informational, and esteem s occurred more frequently than tangible s. Esteem s was associated with less depression

INADEQUATE PLANT INTAKE AMONG ADOLESCENTS

Neumark-Sztainer et al. (2002) Minnesota Adolescent Health Survey (n = 36,284) Studied adolescents age 12-17 Psychosocial Correlates of Inadequate Plant Consumption Low family connectedness Weight dissatisfaction Poor academic achievement Frequent dieting (only inadequate fruit consumption) Binge eating, substance abuse, past suicide attempts

Images - lean and muscular... many many - what do women find attractive?

Not all men develop concerns, just as not all women do... Evidence suggests men overestimate the male body size that women find attractive Lynch and Zellner (1999) - college men tended to select hyper-muscular body sizes as those that women would prefer - but college women chose male body sizes slightly larger than 'normal', but noticeably smaller than those chosen by men Not found in middle-aged adults - a problem among the young

Daily Hassles and stress

One off events (acute) vs day-to-day unpleasant events Hassles scale and student hassles scale Range of scales - early work by Lazarus, and Holm, and others in more recent years Started with 100+ items... Frequent hassles Weight concerns Health of family member Sex Finance Home maintenance Time pressures Misplacing things

primary vs secondary appraisal

P a asks "Am I okay?" S a asks "What can I do?" Situations that signal harm or potential harm that is personally significant and in which there are few options for controlling what happens are appraised as stressful. Stress a include harm or loss, which refer to damage already done; a of threat, which refer to the judgment that something bad might happen; and a of challenge, which refer to something that may happen that offers the opportunity for mastery or gain as well as some risk of an unwelcome outcome. Situations that are a'd as high in personal significance and low in controllability, for example, are usually a as threats, and situations that are high in personal significance and high in controllability are more likely to be a as challenges. eg - Someone might view lonliness as a stressor but does not reach out and talk to people to solve lonliness (threat). Another person might be lonely and take action and reach out to people (challange).

Self-Efficacy

Some research has emphasized the role of se in pain perception and reduction. Turk et al. (1983) suggested that increased pain se may be an important factor in determining the degree of pain perception. In addition, the concept of pain locus of control has been developed to emphasize the role of individual cognitions in pain perception (Manning and Wright 1983).

Historical factors

Some research points to an individual's previous dieting attempts and their weight h as important for successful weight loss and maintenance. In particular, studies indicate that a h of dieting for longer and a higher number of dieting attempts predict success (Hoiberg et al. 1994; Ogden 2000). In contrast, Kiernan et al. (1998) concluded that success was greater in those who did not have a h of repeated weight loss. Whether the 'try, try and try again' ethos holds for dieting therefore remains unclear. It is also possible that changes in smoking behaviour (e.g. Klesges and Klesges 1988) and an individual's reproductive h may be contributory factors to success as weight gain and maintenance often follow smoking cessation and childbirth (e.g. Ohlin and Rossner 1990).

The Necessity-Concerns Framework (Horne, 1997, 2003, 2006)

Studies across range of illnesses, countries and cultures indicate that the Necessity-Concerns framework is useful for explaining/understanding low adherence

Should Obesity Be Treated at All?

The problems with treating o raises this question In order to answer this it is necessary to examine the benefits of treatment, the treatment alternatives and the role of individual responsibility.

Coping definition

The process by which people try to manage the perceived discrepancy between the demands and resources they appraise in a situation May manage by correcting or mastering the problem, or by changing perception of it. Involves a dynamic series of appraisals and reappraisals of the person ‑ environment. Changing meaning/understanding Examples - Dr advises you're at risk of... A classification of coping strategies problem-focused (alter problem) emotion-focused (alter emotional resp)

4. social cognition

The scientific study of how people make sense of their social world: ▪ How they perceive, represent, interpret, & remember information about themselves, others & social groups ▪ Information processing in its social context ▪ Key question: Is the combined total more than the sum of its parts? What does sc offer over & above the contributions of social & cognitive psychology?

Problems with life events theory

The use of the SRE and similar measures of l experiences have been criticized for the following reasons: 1. The individual's own rating of the event is important. It has been argued by many researchers that life experiences should not be seen as either objectively stressful or benign, but that this interpretation of the event should be left to the individual. For example, a divorce for one individual may be regarded as extremely upsetting, whereas for another it may be a relief from an unpleasant situation. Pilkonis et al. (1985) gave checklists of life events to a group of subjects to complete and also interviewed them about these experiences. They reported that a useful means of assessing the potential impact of life events is to evaluate the individual's own ratings of the life experience in terms of: (1) the desirability of the event (was the event regarded as positive or negative?); (2) how much control they had over the event (was the outcome of the event determined by the individual or others?); and (3) the degree of required adjustment following the event. This methodology would enable the individual's own evaluation of the events to be taken into consideration. 2. The problem of retrospective assessment. Most ratings of life experiences or life events are completed retrospectively, at the time when the individual has become ill or has come into contact with the health profession. This has obvious implications for understanding the causal link between life events and subsequent stress and stress-related illnesses. For example, if an individual has developed cancer and is asked to rate their life experiences over the last year, their present state of mind will influence their recollection of that year. This effect may result in the individual over-reporting negative events and under-reporting positive events if they are searching for a psychosocial cause of their illness ('I have developed cancer because my husband divorced me and I was sacked at work'). Alternatively, if they are searching for a more medical cause of their illness they may under-report negative life events ('I developed cancer because it is a family weakness; my lifestyle and experiences are unrelated as I have had an uneventful year'). The relationship between self-reports of life events and causal models of illness is an interesting area of research. Research projects could select to use this problem of selective recall as a focus for analysis. However, this influence of an individual's present state of health on their retrospective ratings undermines attempts at causally relating life events to illness onset. 3. Life experiences may interact with each other. When individuals are asked to complete a checklist of their recent life experiences, these experiences are regarded as independent of each other. For example, a divorce, a change of job and a marriage would be regarded as an accumulation of life events that together would contribute to a stressful period of time. However, one event may counter the effects of another and cancel out any negative stressful consequences. Evaluating the potential effects of life experiences should include an assessment of any interactions between events. 4. What is the outcome of a series of life experiences? Originally, the SRE was developed to assess the relationship between stressful life experiences and health status. Accordingly, it was assumed that if the life experiences were indeed stressful then the appropriate outcome measure was one of health status. The most straightforward measure of health status would be a diagnosis of illness such as cancer, heart attack or hypertension. Within this framework, a simple correlational analysis could be carried out to evaluate whether a greater number of life experiences correlated with a medical diagnosis. Apart from the problems with retrospective recall and so on, this would allow some measure of causality - subjects with higher numbers of life events would be more likely to get a medical diagnosis. However, such an outcome measure is restrictive, as it ignores lesser 'illnesses' and relies on an intervention by the medical profession to provide the diagnosis. In addition, it also ignores the role of the diagnosis as a life event in itself. An alternative outcome measure would be to evaluate symptoms. Therefore the individual could be asked to rate not only their life experiences but also their health-related symptoms (e.g. pain, tiredness, loss of appetite, etc.). Within this framework, correlational analysis could examine the relationship between life events and symptoms. However, this outcome measure has its own problems: is 'a change in eating habits' a life event or a symptom of a life event? Is 'a change in sleeping habits' a stressor or a consequence of stress? Choosing the appropriate outcome measure for assessing the effects of life events on health is therefore problematic. 5. Stressors may be short term or ongoing. Traditionally, assessments of life experiences have conceptualized such life events as short-term experiences. However, many events may be ongoing and chronic. Moos and Swindle (1990) identified domains of ongoing stressors,which they suggested reflect chronic forms of life experiences: • physical health stressors (e.g. medical conditions) • home and neighbourhood stressors (e.g. safety, cleanliness) • financial stressors • work stressors (e.g. interpersonal problems, high pressure) • spouse/partner stressors (e.g. emotional problems with partner) • child stressors • extended family stressors • friend stressors. They incorporated these factors into their measure - the Life Stressors and Social Resources Inventory (LISRES) - which represented an attempt to emphasize the chronic nature of life experiences and to place them within the context of the individual's coping resources. Moos and Swindle argued that life events should not be evaluated in isolation but should be integrated into two facets of an individual's life: their ongoing social resources (e.g. social support networks, financial resources) and their ongoing stressors.

Problems with the Non-Interactive Theories

Theories that examine only the patient, only the treatment or only the professional ignore the i between patient and health professional that occurs when a placebo effect has taken place. They assume that these factors exist in isolation and can be examined independently of each other. However, if we are to understand placebo effects then perhaps theories of the i between health professionals and patients described within the literature (see Chapter 10) can be applied to understanding placebos.

Stress resistance

To reflect the observation that not all individuals react to s in the same way, researchers developed the concept of ... to emphasize how some people remain healthy even when s occur (e.g. Holahan and Moos 1990). ... includes adaptive coping strategies, certain personality characteristics and social support. s reactivity, s recovery, allostatic load and s resistance all influence an individual's reaction to a s. They also all affect the s-illness link.

western versus buddist mindfulness

W approaches often define m by referring to nonjudgmental awareness. • In B, m is dynamically integrated into the noble eightfold path, which includes ethical conduct. This implies an evaluative process of judging between wholesome and unwholesome practice. B is about more than acceptance, but about active thought transformation. • B's goal is wise m, and that is where the practices of wisdom and ethics interact with concentration. M as memory is reminding oneself of the principles of cause and effect and impermanence. And of oneʼs practice. • So, can W programmes in theory train m drug dealers?

NZ Life Expectancy

WHO (2018) Male 80.5 years Female 84 years Average 82.2 years World life expectancy ranking: 15 https://www.worldlifeexpectancy.com/new-zealand-life-expectancy

8. The dual process model

psycholgical processes direct path to physical health both indirect paths to behaviour these processes determine behaviour that influences health. Eg - feeling stressed direct pathway to health status and indirect pathway to smoking, drinking, eating, sex etc Much more at play - psychoneuroimmunology

stress appraisal

refers to the process by which individuals evaluate and cope with a s event. This theory is concerned with individuals' evaluation of the event, rather than with the event per se. People differ in how they construe what is happening to them and their options for coping. For example, someone might be diagnosed with diabetes, one person might take action to change their diet and take meds but another person might be s about it.

Increased risk of STIs

safe sex practices advocated for HIV transmission prevention are also effective for other STIs Intentions to use condoms and the actual behaviour are affected by context - specifically alcohol use and sexual arousal. Self-control/temporal discounting problem, easy to say it will be so when there is a temporal gap. Cognitive models, looking at individuals weighting of various cognitive factors predict actual sexual behaviour very poorly Unmarried males generally more reluctant than females to suggest condom use Seems to be related to beliefs about a reduction in male pleasure, and tendency among heterosexuals to view condom use as purely method of contraception, as opposed to infection control Implicit assumption of the latter is that there is a possibility one partner is infected, doesn't fit well with cultural notions around romance and sex... Males tend to view as female's responsibility, females tend to view as a joint responsibility

psychoneuroimmunology

the study of how psychological, neural and endocrine processes together complexly affect the immune system and resulting health. Nervous System: Physiological Reactivity linked to Endocrine, cardiovascular and immune systems. Leading to Physical and Psychological Health Status which then leads to a salient event in the external environment, leading to Psychological Appraisal which loops back to the begining. eg- chronic stress or puberty

Taxonomy of meditation

• Nash and Newberg (2013) • CDM: Cognitive-directed method • ADM: Affective-directed method • NDM: Null-directed method

Proteins

Important for the body's synthesis of new material Composed of amino acids

EXERCISE RELAPSE

Relapse predicted by: Lower SES Smoking A belief that exercise is an effort Lower enjoyment No history of exercise No support from a spouse No available time Poor access to facilities Lower value on health

International Classification of Functioning, Disability and Health (ICF; WHO, 2002)

- Body: bones, muscles, ligaments → impairment - Activity: speaking, walking, jumping → limitations - Participation: work, social, athletic → restrictions - Environmental factors: living conditions, occupational situation, social circumstances - Personal factors: age, background, personality

Travelling through the gate

1. Signals of noxious stimulation from nerve fibres at injury site enter g mechanism. 2. Brain also sends information about the psychological state of the individual (e.g. attention, anxiety, memory of previous experience). 3. If signals pass through g mechanism, they activate transmission cells. 4. Transmission cells send impulse to the brain.

Development and Health-Behaviour

During Gestation and Infancy substances are passed from mother to child through the placenta & umbilical cord. malnourishment may lead to low birth weight infections may be passed e.g., rubella harmful substances may be passed, alcohol leading to foetal alcohol syndrome

What is the role of psychology in health and illness? Health psychology

Health psychology regards psychological factors not only as possible consequences of illness but as contributing to it at all stages along the continuum from healthy through to being ill

how to live longer

Kirkwood (1994) and Smith (1993) have offered the following advice if you wish to maximise your life expectancy: Be female Don't smoke Be a light drinker Be Japanese Enjoy sex They do concede that not all these options were open to everyone....

three key social conditions as explanations of health inequalities:

Medical interventions, environmental factors and behavior.

Psychological state and immunity

Research has focused on the capacity of ... factors to change ... functioning. In particular, it has examined the role of mood, beliefs, emotional expression and stress.

Self help is already happening

The traditional way has been s h books, but this is increasingly shifting to electronic formats. - There are now more than 1 million smartphone or tablet apps available for download in the Apple AppStore and the Google Android system. - These include various wellness apps, for both physical and psychological wellbeing. - There are more than 5,000 health and fitness apps for smartphones.

Mindfulness as a "complex" intervention

• According to the guidelines of the Medical Research Council of the UK • This is because of the complexity of behaviours required by the course facilitators and participants to engage in, variability of outcomes and the fact that interventions typically permit (even encourage) a degree of flexibility to meet needs of participants hard to identify what aspect of m is effective

Four foundations of mindfulness

• Insight meditation is based on the Satipatthana Sutra or this • In stages, you develop m of the 1. body 2. feelings or sensations 3. mind or consciousness, and 4. dhamma (mental objects) -- Dhamma refers to Buddhist eight fold belief doctrine and is often interpreted to mean the 'teachings of the Buddha' (doing the right things to end suffering) • One thus learns to see the truth of reality or the true nature of phenomena as arising and fading away

definition problems with understanding placebos

• What are specific/real versus non-specific/unreal effects? For example, 'My headaches went after the operation': is this an unreal effect (it was not predicted) or a real effect (it definitely happened)? • Why are psychological effects non-specific? (e.g. 'I feel more relaxed after my operation': is this a non-specific effect?). • Are there p effects in psychological treatments? For example, 'I specifically went for cognitive restructuring therapy and ended up simply feeling less tired': is this a p effect or a real effect?

Processes Studied in Health Psychology

▪ Multiple developmental influences, but in particular 1. Behaviourism 2. Social Psychology 3. Cognitive Psychology

WHAT IS EXERCISE?

Differentiated by intention Physical activity: a bodily movement resulting in energy expenditure - intentional and automatic Exercise: repetitive movement - intentional Differentiated by outcome Physical activity for fitness Physical activity for health Differentiated by location Occupational activity - at work Leisure activity - during leisure time

The Patient/Practitioner Relationship

People differ in the role they want to play in their treatment Patients who take an active role recover better and faster Practitioners differ in the level of participation they are willing to allow

Violence against women

Physical, psychological, & sexual abuse, isolation & economic control (Ministry of Women's Affairs, 2013). Coercive control: 'the entrapment of women in personal life' (Stark, 2007). 'Gender-based violence' (GBV) is a developing term (Council of Europe, 2007). Based on how a particular society assigns & views gender roles & expectations

BreastScreen Aotearoa

Screening is presented as a way to save one's life. "You're mad if you don't" https://www.youtube.com/watch?v=pfZGAtO9nQE

2. The Theory of Planned Behaviour (TPB)

The Theory of Planned Behaviour posits that intentions determine health behaviours. Determinants of intentions: 1. Attitude regarding the behaviour The likely outcome of the behaviour, the value of the outcome 2. Attitude about subjective norm Expectations of others (family, friends), motivation to comply 3. Perceived behavioural control The ease of performing the behaviour (is it dependent on specific factors?) Also linked to self-efficacy - behavioural beliefs x evaluation of outcomes = attitude towards the behaviour - normative beliefs x motivation to comply = subjective norms - control beliefs x perceived facilitating versus inhibiting power = perceived behavioural control --- leads to intention and then health behaviour

What events are appraised as stressful?

*Salient events*: personally relevant Family, friends, work etc *Overload*: Multitasking- Single stressor that adds to a background of other stressors often appraised as more stressful than when it occurs alone *Ambiguous events*: unclear tasks- Clearly defined develop coping strategy Ambiguous time and energy comparing approaches often no identifiable strategy to cope *Uncontrollable events*: if task is not predicted- Predicted and controllable events less stressful than random uncontrollable ones

What if you had a spinal cord injury?

- Clip: https://www.youtube.com/watch?v=M7OJ‐RIfRoM - While it is important to support physical rehabilitation, psychological factors play a key role in how well a person copes and recovers following an illness or injury

The Big Five and Health Behaviour

- Extraversion - linked to drinking, some smoking behaviour (often occasional smoking), but it has also been linked to screening (self-check) - Openness - also linked to willingness to try new screening/treatment approaches - Neuroticism - characterised by depression & anxiety linked to heart disease. Before Friedman and Booth-Kewley's (1987) review, neuroticism was believed to be more related to health complaints rather than actual symptoms (i.e, neurotic people were just whiny). - Conscientiousness: What do we mean when someone is conscientiousness? Conscientiousness is believed to be composed of the following factors: Self-control - the ability to inhibit impulsive thoughts, feelings, and behaviours Traditionalism - characteristic levels of conventionality and norm adherence Responsibility - reliability and socialization Industriousness - achievement and persistence Order - organised, efficient and regimented

Key aspects of therapeutic relationship in rehabilitation (Kayes et al., 2016)

- Interviews with patients from a range of healthcare contexts (stroke, TBI, SCI, MS) - What matters most when working with rehabilitation professionals? - Core theme: trust that professional is trying to do the right thing for them - Four sub‐themes 1. Be my professional - being present, open and honest 2. Show me you know how - being flexible to meet personal needs 3. Connect with me - responding to what matters most to them 4. Value me and my contribution - treating client as the expert

Treating obesity: Traditional Approach

- address inappropriate eating habits and physical exercise. • But after losing weight, most regain the weight. • Success linked to self-efficacy and social support •Psychological problems with obesity treatment: • Research has found increased depression with obesity treatment • Dieting can lead to bingeing - precipitated by anxiety, frustration, depression, & unpleasant emotions • Weight cycling and regain; denial, guilt, low self-esteem •Physiological problems with obesity treatment: • Yo-yo dieting and negative health consequences

Subjective (psychological/feelings) assets positive health

- zest. - hope. - internal locus of control: taking responsibility for you life, having a measure of control, not thinking only external factors influence you, sense of autonomy. - life satisfaction. - happiness. - positive emotions. - curiosity. - optimism.

Behavioural Conditioning

A Clockwork Orange (film 1971) Alex given drug to induce extreme nausea (response) whilst also being forced to watch graphically violent films (stimuli) for two weeks At treatment end, Alex is unable to even think about violence without crippling nausea, i.e., conditioned response in presence of the paired stimuli Fiction or reality? This is an example of classical conditioning, and describes the use of aversion therapy. eg of aversion therapy - alcholism drug antabuse Addiction believed to have its roots in this, e.g. positive stimuli associated with consumption of food, alcohol, drugs, etc. In healthcare Many examples, b is important - study of old man complaining of pain moving more freely when ignored by staff. Healthcare proffesionals can either impede or enhance health by their b.

Stress and immunity models

A complex aspect of studying s and i function is that studies often report contradicting results in terms of i molecule function. Some studies report an association between s and i suppression (such as the ones previously discussed), but stress has also been found to exacerbate inflammatory diseases (e.g., multiple sclerosis, arthritis, Crohn's disease) Immunosuppression Model vs. Glucocorticoid Resistance Model separate but not unrelated *memorize both models for test*

Themes in rehabilitation psychology

Adjustment The therapeutic context Moving outside the therapy room The family context A brief outline of psychological treatment (chronic pain) Important constructs: acceptance, resilience, post-traumatic growth A brief outline of psychological treatment (psycho‐oncology)

Stress recovery

After reacting to stress, the body then recovers and levels of sympathetic and HPA activation return to baseline. However, there is great variability in the rate of recovery both between individuals, as some people recover more quickly than others, and within the same individual across the lifespan. Chafin et al. (2004) reported that classical music (not jazz or pop music) improved recovery in the laboratory after a three-minute stressful challenge involving a mental arithmetic task.

Eating behaviour obesity

An alternative approach to understanding the causes of o. Chapter 5 described a number of different approaches to understanding eating behaviour. These perspectives emphasize mechanisms such as exposure, modelling and associative learning, beliefs and emotions, body dissatisfaction and dieting, all of which can help explain o. For example, it is possible that the obese have childhoods in which food is used to reward good behaviour, or have parents who overeat, or hold cognitions about food which drive eating behaviour. It is also possible that dieting when moderately overweight (or just feeling fat) triggers episodes of overeating which themselves cause increases in body fat. It is therefore important to ask the following questions to link diet and obesity: 'Are changes in food intake associated with changes in o?', 'Do the o eat for different reasons than the non-o?' and 'Do the o eat more than the non-o?'

Younger men, far higher risk of injury or accidental death than women

An illogical pervasive sense of invulnerability Far fewer health-promoting behaviours than females College males attitudes and behaviours related to health focused on activity, females on diet Men know much less about healthy lifestyles, and culture seems to put the responsibility on to women (partners and mothers) analyses of media have shown the message is that men should not concern themselves with such things, *as they are not capable* After marriage, women attempt to control/influence partner's health behaviours, men don't attempt to influence/control women's... at least not their health-related ones... Men make less use of healthcare services and screening than women The effect still present when gynaecological services are accounted for psychological services - boys more likely to be taken by parents or referred by teachers, but men less likely to seek for themselves Independent, strong, resilient, self-reliant, emotionally restrained...

Elizabeth Kubler-Ross (KR)

Argued that dying in modern times is more gruesome in many ways More lonely, mechanical, and dehumanised. Lonely and impersonal because most often the person is taken from their familiar environment to a hospital. Think learning/classical conditioning In some cases the dying person is treated as a person with no right to an opinion - decision making is often taken from their hands. Not talking about euthanasia - but more where they are to be located, what treatments etc. Physiological symptoms are treated using many different approaches and many skilled people - but is there any time left for the dying person? In her book - outlined stages of dying

Mechanism of Action mindfulness

Coffee et al. (2010) 10.1007/s12671-010-0033-2 Pearson et al. (2015) 10.1007/s12671-014-0300-8 Western m-based interventions have received much attention in recent years, but research has now entered a phase where the effectiveness of m no longer needs to be demonstrated, rather the mc by which this happens does (Williams & Kabat-Zinn, 2011). More detailed mc are to be tested empirically. A challenge also continues to be agreeing on a suitable definition of m

Mechanism 4 of allostatic load: inadequate response

Cortisol not being produced during chronic stress, sometimes leading to an overactive immune system through other pro-inflammatory processes (Miller et al., 2002). i hormonal stress r which allows other systems, such as the inflammatory cytokines, to become overactive. The Lewis rat is an example of an animal strain in which increased susceptibility to inflammatory and autoimmune disturbances is related to i levels of cortisol (34;35).

diet and stress

D can influence health either through changes in body weight or via the over- or underconsumption of specific d components (see Chapter 5). Greeno and Wing (1994) proposed two hypotheses concerning the link between stress and e: (1) the general effect model, which predicts that stress changes intake generally; and (2) the individual difference model, which predicts that stress only causes changes in e in vulnerable groups of individuals. Most research has focused on the individual difference model and has examined whether either naturally-occurring stress or laboratory-induced stress causes changes in e in specific individuals. For example, Michaud et al. (1990) reported that exam stress was related to an increase in e in girls but not in boys; Baucom and Aiken (1981) reported that s increased e in both the overweight and dieters and Cools et al. (1992) reported that s was related to e in dieters only. Furthermore, O'Conner et al. (2008) concluded from their study that the snacking-s relationship was stronger in those with higher levels of dietary restraint, more emotional e, greater disinhibition, higher levels of external e, women and obese participants. Research has also addressed whether the link between stress and e behaviour can be explained by cortisol reactivity. Research indicates that there is much individual variability in the extent to which individuals react to s (see Chapter 11). Newman et al. (2007) carried out a laboratory-based study in which 50 women were subjected to a stressor in the laboratory and then completed ratings of daily hassles and snack intake over the next 14 days. The results showed that, overall, higher levels of daily hassles were associated with a higher intake of snacks. However, when this association was related to the responses to the s, daily hassles resulted in snacking only in those that showed greater cortisol reactivity. Therefore gender, cortisol reactivity, weight, levels of d and aspects of e style (see Chapter 5) seem to be important predictors of a link between stress and e. However, the research is not always consistent with this suggestion. For example, Conner et al. (1999) examined the link between daily hassles and snacking in 60 students who completed diaries of their snacking and hassles for seven consecutive days. Their results showed a direct association between increased daily hassles and increased snacking but showed no differences according to either gender or dieting. Such inconsistencies in the literature have been described by Stone and Brownell (1994) as the 's eating paradox' to explain how at times s causes overe and at others it causes undere without any clear pattern emerging.

Impact on practitioner

Evidence that the task of performing euthanasia may place heavy burden on practitioner: "I haven't been in church for nine years ... But at that moment I thought, you can't go back there either. You have crossed a line where the Catholic church says you can never cross that line, it is not for a human being ... to cross that line ... which is a line that is put upon you by the church, but also by the normal Christian-Jewish morality which has been there for ages. The whole culture, the whole way of approaching ethics, morality, society as it runs, is based on some agreement that you do this and you don't do that. And it is one of the agreements, maybe on good grounds, but it is one of the agreements you cross, it is like ... losing your virginity ... It is very important, and one time it happens ... and you never can go back." (Dutch nursing home doctor)

Family - men's health

Experiences of mothers and motherhood well studied, not so for men Generally theories/models based on gender differences (men incapable of parenting, women have a psychological need) are rejected. However, still an implicit assumption that men's relationships with their families are peripheral, and could be filled by anyone with the correct chromosomes. Males generally grow up with the expectation that they will father a child(ren). Despite social commentators deploring a lack of family values etc there is no hard evidence that men are not (or less) interested in fatherhood and its responsibilities and rewards

Examples of family involvement in psychological interventions

Family day at pain management programme - Offers family members the chance to: - Increase their understanding of chronic pain - See what their loved ones have been learning and to participate in some activities - Process for themselves the impact that chronic pain has had on the whole family Family sessions in psycho‐oncology - Facilitation of communication between all family members allows opportunity to: - Express individual needs for all family members - Triage according to needs (within service or elsewhere)

Coping with death

Ideally coping processes should be delineated to be informative for (and undertaken by) three groups - the dying individual, family/loved ones, and caregivers. All take part in the coping processes, and each have a different experience and or perspective on the process. Hard to see how KR's model is informative for practice beyond its stressing of listening - beyond that it simply provides names/labels for processes/defences. Ideally a model would be informative and provide indicators of best practice etc to guide and encourage caregivers.

Measuring illness cognitions

Leventhal and colleagues originally used qualitative methods to assess people's i c. Since this time other forms of measurement have been used. These will be described in terms of questionnaires that have been developed and methodological issues surrounding measurement.

Social context - not always accurate...

Medical students' disease ⚫ Studying symptoms leads to greater focus on one's own symptoms (e.g., of fatigue) that then get interpreted as indicative of disease. Mass Psychogenic Illness ⚫ Widespread symptom perception among a large group of individuals, without any evidence for physical or environmental cause. - eg- covid symptoms immediately people assume they have covid. ⚫ Factors contributing to this effect are: • Cognitive exaggeration of common symptoms • Modeling - copying behaviour of people around us • Emotional distress (e.g., anxiety) - esp if an illness is present in our environment

Denial death stage

Most apparently reacted to the awareness of a terminal illness with a statement like "No, not me, it cannot be true" Look for reasons for an incorrect diagnosis, second opinions etc etc. Anxious denial seemed related to how the news was presented - if the patient was informed abruptly or prematurely by someone without an established relationship with them KR views denial as a healthy buffer to allow the patient to collect themselves and mobilise other defences. Denial usually quite transient and replaced by a partial acceptance. Very few seem to maintain denial until the end. In a behavioural sense, some aspects of stimulus control - denial when discussing with family, and a different approach with health staff members. What are the contingencies? Who do we need to be brave for? KR talked in terms of the unconscious, in which we all regard ourselves as invincible, followed by a gradual acknowledgement.

1. Behaviourism (processes in health psych)

Operant conditioning (Skinner) Classical conditioning (Pavlov) Classical conditioning (Watson) The scientific study of how reward & punishment (stimuli) affect emotion & b (response) Empirical approach: Vary contingencies of reward & punishment & measure effect on b Try to describe, predict & control b without going inside the 'black box', i.e. the mind B is heavily influenced by environmental events If b is learned, it can also be unlearned / modified through conditioned learning

The role of psychological factors in obesity

P has a role to play in o in terms of its onset and the role of beliefs and behaviours, how people cope with and adjust to this condition, how it is managed and the consequences on an individual's physical and psychological well-being.

Paradox of control

Patients conceptualized weight gain as a result of uncontrollable factors and chose to have surgery through a belief that they were out of control of their weight and eating and through a desire to hand over control to an external force. Further, although the initial stage post-surgery was characterized by a sense of shock, the majority of patients described how they adjusted to the physical limitations imposed by the operation and developed a new sense of control over both their weight and eating. This new sense of c appeared to take two forms. For some, it took the form of an externally imposed c that was welcomed as a release from their previous sense of responsibility and ongoing battle with themselves. Many, however, experienced an internalization of control resulting in a new psychological state. Further, this new state of mind appeared to generalize to other areas of life with many reporting not only feeling more in c over what they ate but also over their lives in the broadest sense. The authors labelled this process the p of c described how by imposing a reduction in food intake and taking choice away from the individual, surgery p resulted in an improved sense of c not only over what the patients ate and how they felt around food but also over all other areas of their lives.

Change approaches to suit men, or develop strategies to help men feel more comfortable?

Silverberg (1984) argued that exploration of feelings, development of insight etc associated with traditional psychotherapy was simply inappropriate for many men He argued action and behaviour oriented approaches, rationality, and analysis of the problem were a better fit. Feminists have argued the opposite - that uncritical acceptance of stereotypic notions is less helpful than confronting and questioning the traditional male strategies. Perhaps too value laden, and judgemental ... Certainly one can argue that recognising and challenging gendered aspects of lifestyle, attitudes and expectations that contribute to personal and familial difficulties (a consciousness raising in a sense) may be helpful. Some men more likely to respond than others, but for those that do, the real world doesn't change that easily or quickly, and that is the one we must function in.

The Role of Psychosocial Factors in Pain Perception

The GCT was a development from previous theories in that it allowed for the existence of mediating variables, and emphasized active perception rather than passive sensation. That theory, and the subsequent attempts at evaluating the different components of p perception, reflect a three-process model of p. The components of this model are: physiological processes; subjective-affective- cognitive processes; and behavioural processes. Physiological processes involve factors such as tissue damage, the release of endorphins and changes in heart rate

Glucocorticoid Cascade Hypothesis of Hippocampal Aging

Theory states: excess (GC) damage the brain (Sapolsky et al., 1986) and can lead to 'unsuccessful aging' Excess GC: atrophy of h dendrites Overexposure to GC: permanent loss of h neurons

Chronic and acute model and activation

These physiological changes can be further understood in terms of Johnston's (2002) chronic and acute model of the stress-illness link. Chronic stress is more likely to involve HPA activation and the release of cortisol. This results in ongoing wear and tear and the slower process of atherosclerosis and damage to the cardiovascular system. Acute stress operates primarily through changes in sympathetic a with changes in heart rate and blood pressure. This can contribute to atherosclerosis and kidney disease but is also related to sudden changes such as heart attacks.

Characteristics of the Individual (Non-interactive theories)

i trait theories suggest that certain i have c that make them susceptible to placebo effects. Such c have been described as emotional dependency, extroversion, neurosis and being highly suggestible. Research has also suggested that individuals who respond to placebos are introverted. However, many of the c described are conflicting and there is little evidence to support consistent traits as predictive of placebo responsiveness.

Emotion focused coping

may interfere with getting medical treatment may involve unhealthy behaviours tends to promote avoidance. this may be beneficial if stressor is uncontrollable. not thinking about something upsetting can lead to chronic physiological arousal associated with negative adjustment decreased immune functioning, higher blood pressure and heart rate Types: seeking social support - emotional support distancing - making cognitive efforts to detach from the situation or create a positive outlook. escape-avoidance - wishful thinking or escaping/avoiding situation through sleeping or drugs. self-control - attempts to modulate feelings or actions regarding the problem. accepting responsibility - acknowledging role in the problem. positive reappraisal - creating a positive meaning in terms of personal growth.

Acute clinical pain

¨ E.g., p following abdominal surgery ¨ Many patients experience greater than-necessary p following surgery ¤ Can lead to: Increased infection, slow wound healing (p and related stress impairs immune and endocrine functioning) Medical complications and potentially death

Qualities of pain

¨ Sharp ¨ Dull ¨ Burning ¨ Cramping ¨ Itching ¨ Aching ¨ Shooting ¨ Throbbing How long does it last? How did it originate?

benefits of stress reduction

• Better concentration/focus • More stable moods • Improved communication/relationships • Better physical health • Increased sense of control of time and activity Lazarus

Buddhism and the West

• Evidence of early influence of b on ancient Greece • Did not spread systematically to w until 19th Century - e.g., German philosopher Arthur Schopenhauer • Famous novel by Hermann Hesse Siddhartha (1922) (1788-1860) (1877-1962)

Deaths - specific vs general causes (positive health)

• Given issues with disease process, some turn to ultimate behavioural outcome - death • Some focus on medical cause of death, others on the behavioural outcome death without reference to medical cause... often confused • Classic example • Steering Committee of the Physicians' Health Study Research Group (1988; 1989) - participants took aspirin (325 mg/day) or placebo to reduce deaths FROM heart disease • Significant reduction in these deaths, labeled "wonder drug", cover of Newsweek magazine etc • Always useful to look at and think about the data... 22,000 randomised. • Reduction in MI but increase in other cardiovascular causes - overall rate of death was the same for group - increased other categories harming health is the cause or outcome of death important?

Session 5 e therapy study

• Guided breathing meditation • Physical movement meditation exercise • Slideshow presentation on accepting and emotion regulation

Setting of e therapy study

• Refurbished classrooms at North Shore Campus of Auckland University of Technology • Sessions were conducted between 17:00-19:00h to minimize noise disturbance from nearby • Sessions ran for 6 weeks during winter to early spring • Usually one researcher and one clinical psychologist were also present • They helped set up the room (e.g., remove tables from the center, heat the room 30min before start of session, test equipment)

Obesity-Related Abnormalities: Metabolic and Organ Dysfunction

▪ Appetite dysregulation ▪ Abnormal energy balance ▪ Endocrine dysfunction ▪ Elevated leptin levels ▪ Insulin resistance ▪ Dysregulated adipokine signalling (hormones) ▪ Abnormal endothelial function ▪ Hypertension ▪ Infertility ▪ Nonalcoholic fatty liver disease (NAFLD) ▪ Dyslipidemia (abnormal lipids/fatty substances in blood) ▪ Systemic inflammation ▪ Adipose tissue inflammation

stroop and race healthcare

▪ Social categories are activated automatically during interactions with other people ▪ Interactions & decision-making potentially influenced by stereotypic beliefs & biased knowledge ▪ Perhaps, helps us understand evidence showing that, for certain social groups, clinicians ... ▪ offer less information, less support & are less clinically proficient ▪ provide different treatments, preventive interventions & referral to specialist services automatic assumptions = lower level of care ingroup vs outgroup

3. cognitive psychology (processes in health psych)

▪ The scientific study of basic mental abilities/processes ▪ perception, learning, memory, language, problem-solving, etc. - 'information-processing approach' ▪ Empirical approach: Vary information input, measure performance output - only intereted in observable effects ▪ Posits psychological processes that account for observed effects c ability not always able to process accurately ▪ Classic examples: Stroop Effect

Nutritionism

*Alleged* paradigm that assumes that it is the scientifically identified nutrients in foods determine the value of individual foodstuffs in the diet. The idea that the nutritional value of food is the sum of all its individual nutrients the implication that the only point of eating is to promote bodily health. "the widely shared but unexamined assumption that the key to understanding food is indeed the nutrient." Arose for good reason - but now used for bad Not all calories are created equal --- calorie counting Veggies vs Lollies

Family Violence Death Review Committee Report 5: 2009 -2015

Agencies and professional 'empower' women to separate But physical separation does not mean safety: Dobash and Dobash, national study on Murder in Britian: "Men simply would not 'allow' it to end & might go to great lengths to ensure that it continued, including persistent phoning, uninvited visits to her home, stalking, & threats of violence, murder & suicide." Not a choice-based decision, impeded by the predominant aggressor's coercive & controlling behaviours. 2009-2015, 55% of NZ offending male predominant aggressors either believed female primary victims had committed infidelity or had new male partner. Meyer, S. (2012). Why women stay: A theoretical examination of rational choice and moral reasoning in the context of intimate partner violence. Australian & New Zealand Journal of Criminology, 45(2), 179-193. https://doi.org/10.1177/0004865812443677 Children & Finance important factors

Community Health Promotion Example: SunSmart Program

Australia and New Zealand have the highest rates of melanoma skin cancer in the world? Why? You are 7 times more likely to get melanoma in AUS/NZ than in the UK Slip! Slop! Slap! Campaign initiated in 1980 Incidence of skin cancer - started to decline (though, vitamin D deficiency has increased!)

Summary of accessing healthcare treatment

Many interventions, many reviews Haynes et al., (2002) - Cochrane systematic review --- "complex strategies for improving adherence to long-term medication prescriptions are not very effective despite the amount of effort and resources they consume" (p. 9) Even successful interventions have modest or short-lived effects. Most focus on unintentional non-adherence, with implicit the assumption that effective communication and patient education are the key --- But much non-adherence is intentional, and almost all are likely to have multiple determinants

Chronic pain

Women consistently report a higher prevalence of chronic pain than men (Croft et al., 2010). At least 3 theories: the gender-role theory that assumes it is socially more acceptable for women to report pain, exposure theory that suggests women are exposed to more pain risk factors, and vulnerability theory proposing that women are more vulnerable to developing musculoskeletal pain (Picavet, 2010).

Women's use of violence

Women slightly more likely than men to report using physical aggression against intimate partners (e.g. Archer, 2000). Only physical aggression, does not place occurrence of women's violence within broader social, cultural, or historical context. Conflict Tactics Scale - problematic decontextualised categorisation of violent acts. Did not examine sexual assault, stalking, or coercive control; much higher rates of these types of violence committed by males (Straus, 1999; Tjaden & Thoennes, 2000) NZ FV death review

Nutritional Psychology

the intersection of human behaviour and cognition in relation to the consumption of food and drink. Applied to: Treatment for obesity, cancer, heart disease, eating disorders, in palliative care Health Behaviours such as healthier diet, vegetarianism

Issues with stimulus centred approaches

- S-R in nature... apparent failure to consider individual and developmental differences - Initially didn't have importance/weighting component - Retrospective - bias towards negative events or bias towards biological or psychosocial events - Not necessarily independent - Acute vs chronic - scales don't fluctuate between the two - Many in SRRS are relatively rare - we'll consider daily hassles later - Link to health? Assumes everyone finds the same events stressful - which is not true - some may find events stressful less than others or at different times in their life

Problems with stress research

1. Defining s can be difficult as it can be assessed using self-report or physiological changes which have their problems. Self-report can be open to bias and a desire to appear more or less stressed depending upon the person and the situation. Physiological measures may be intrusive and actually create s and may change the way in which a person responds to their environment. 2. The appraisal model suggests that people appraise the s'or and then appraise their coping mechanisms. This conceptualizes these two processes as separate and discrete. However, it is likely that they are completely interdependent as a s'or is only really sful in the context of whether the individual feels they can or cannot cope with it. 3. s is considered to be made up of both psychological and physiological changes. However, how these two sets of processes interact is unclear as it is possible to perceive stress without showing physiological changes or to show a physiological reaction without labelling it as s.

How should illness be treated? Health psychology

According to health psychology, the whole person should be treated, not just the physical changes that have taken place. This can take the form of behaviour change, encouraging changes in beliefs and coping strategies, and compliance with medical recommendations

5. The biomedical model

Admittedly oversimplified... What causes illness? Chemical imbalances, bacteria, viruses, genetic predispositions Syndromes expressed as signs or symptoms are associated with lesions or underlying pathology Who is responsible for illness? No-one - an individual is a victim of an external force -- mental illness from this model can remove stigma of the persons fault. Brain illness name vs mental illness How should illness be treated? vaccination, medication, surgery Pathology is focus of treatment and research - actual person is often disregarded Interventions made to eradicate lesion, or prevent its pathogenesis (development) most of our healthcare systems are based on this model Who is responsible for treatment? The medical profession -- psych is becoming much more holistic What is the relationship between health & illness? Illness & health are different: You are either ill or healthy. qualitatively What is the role of psychology? There are psychological consequences, but not causes

Modelling

M healthy behaviour can also change behaviour: a child is more likely to smoke if their parents smoke. This series of studies used video material of 'food dudes' - older children enthusiastically consuming refused food - which was shown to children with a history of food refusal. The results showed that exposure to the 'food dudes' significantly changed the children's food preferences and specifically increased their consumption of fruit and vegetables as the participants m their behaviour on that of the 'food dudes' in the video.

Mindfulness prior to MBIs

M is certainly not a new invention of MBIs. All major religions of the world contain traditions and techniques that foster m (chanting, prayer, etc). However, the term has never been used that way before. Every religion has its mystics. However, it is safe to argue that Buddhism places much more explicit emphasis on m than other religions. Recently, new forms of Christian meditiation have become popular. But most Westerners make contact with m training via yoga, a Buddhist group or as part of psychological therapy. Psychotherapy has been using related concepts (free association, decentering, deautomization etc.), but these are not directly equivalent to m. Meister Eckhart (1260-1327)

Behaviour (health inequalities)

McKeown (1979) examined health and illness throughout the twentieth century and argued that contemporary illness is caused by 'influences . . . which the individual determines by his own behaviour (smoking, eating, exercise, and the like)' (p. 118). More recent data support this emphasis on chronic illnesses which are related to behaviour. For example, in 2008 Allender et al. published data on the most common causes of death across Europe (including the UK) and concluded that cardiovascular diseases and cancer account for 64 per cent of male and 71 per cent or female deaths (Allender et al. 2008a, 2008b). Similar figures are also found in the USA where cardiovascular diseases and cancer accounted for 56 pet cent of deaths in men and 55 per cent of deaths in women (National Center for Health Statistics 2009).

Allostatic processes

Mediators of a: cortisol, epinephrine, norepinephrine Primary Effects: cellular events, impact on protein transcription, etc. Secondary Outcomes: effects on organs and tissues (e.g., hypertension, common cold) Tertiary Outcomes: diseases or disorders (e.g., cardiovascular disease, severe cognitive decline)

Individual Variability in the Stress-Illness Link

Not everyone who experiences stress becomes ill. To some extent this is due to the role of variables such as coping, control, personality and social support which are described in detail later on. However, research indicates that this variability is also due to individual differences in s reactivity, s recovery, the allostatic load and s resistance.

Effectiveness of MBSR studies (lecture)

Pearlman et al. (2010) exposed novice and experienced meditators to painful thermal stimuli and asked them to engage in focused attention in one condition and open monitoring in another. During the open m. condition, experienced meditators reported the same intensity of pain, but much less unpleasantness. Another study found lower pain sensitivity in experienced meditators compared to controls, as well as changes in cortical structure (Grant et al., 2009). Zeidan et al. (2009) gave people 1-hour mindfulness training for 3 days and then gave painful electrical stimulation. m training reduced pain ratings and anxiety. Mathematics distraction had some effect on mild pain, but relaxation did not work.

Social cognition: putting theory into practice

Series of steps that can be followed to develop an intervention based upon the TPB, although he argued that the steps could also be applied to other models. Step 1: Identify Target Behaviour and Target Population. --- Sutton argued that it is crucial that the target population and behaviour are clearly defined so that all measures used can be specific to that behaviour and population. This is in line with Ajzen's (1988) notion of correspondence or compatibility. For example, the behaviour should not just be 'healthy eating' but 'eating lettuce with my sandwich at lunchtime in the work canteen'. Accordingly the target behaviour should be defined in terms of action (eat healthily), target (lettuce), time (lunchtime) and context (at work). Step 2: Identify the Most Salient Beliefs about the Target Behaviour in the Target Population Using Open-Ended Questions. --- Sutton then suggests that those developing the intervention carry out an elicitation study to identify the most salient beliefs about the target behaviour in the target population being studied. Elliot et al. (2005) designed an intervention to encourage drivers' compliance with speed limits and asked questions such as 'What do you think are the advantages of keeping within the speed limit whilst driving in a built-up area?'. The most common beliefs are known as modal beliefs and form the basis for the analysis. Step 3: Conduct a Study Involving Closed Questions to Determine Which Beliefs are the Best Predictors of Behavioural Intention. Choose the Best Belief as the Target Belief. --- To further help to decide which beliefs to target in the intervention Sutton (2002, 2010) suggests carrying out a quantitative study including the salient beliefs identified in Step 2 involving the target population. These data can then be analysed to explore the best predictors of behavioural intentions as a means to decide whether all or only some of the TPB variables need to be included in the intervention. Step 4: Analyse the Data to Determine the Beliefs that Best Discriminate Between Intenders and Non-Intenders. These Are Further Target Beliefs. --- Next, Sutton suggests that the same data set be used to assess which beliefs (including those identified in Step 2) differentiate between either intenders versus non-intenders or those who either do or do no not carry out the target behaviour. These are now the key beliefs to be addressed in the intervention. Step 5: Develop an Intervention to Change These Target Beliefs. --- Finally, Sutton describes how the intervention should then aim to change these beliefs which mostly involves giving strong messages to contradict and change the target population's beliefs. Using this approach, Elliot et al. (2005) used messages to target individuals' beliefs as follows: Target belief Keeping to 30mph will make it difficult to keep up with the traffic. Strong message Many drivers think that if they keep to the speed limit they will have difficulty keeping up with the traffic. However, this is a perception rather than a reality for the most part. Consider what driving in a 30mph area is typically like. Even on larger 30mph roads, there are roundabouts, traffic lights, pedestrian crossings and other things that make it necessary for traffic to slow down or stop. If a vehicle in front starts to pull away from you, you will often find that by maintaining a speed of 30mph you will catch up with that vehicle further up the road, because they have had to stop or slow down. They will have saved no significant amount of time and they will have gained little or no advantage. From this perspective the TPB can be used as a framework for developing a behaviour change intervention. However, as Sutton (2002b; 2010) points out, although this process provides clear details about the preliminary work before the intervention, the intervention itself remains unclear. Hardeman et al. (2002) carried out a systematic review of 30 papers which used the TPB as part of an intervention and described a range of frameworks that had been used. These included persuasion, information, increasing skills, goal-setting and rehearsal of skills. These have recently been developed and integrated into a causal modelling approach for the development of behaviour change programmes (Hardeman et al. 2005). Sutton (2002b) indicates that two additional frameworks could also be useful. These are guided mastery experiences which involve getting people to focus on specific beliefs and the 'elaboration likelihood' model (Petty and Cacioppo 1986), which involves the presentation of 'strong arguments' and time for the recipient to think about and elaborate upon these arguments. Studies have also used a range of methods for their interventions including leaflets, videos, lectures and discussions

Stress and changes in behaviour

Stress has been mostly studied in the context of CHD. However, there are also studies exploring links between illnesses such as cancer, diabetes and recovery from surgery. Research exploring the links between stress and CHD highlights the impact of stress on the classic risk factors for CHD, namely raised blood cholesterol, raised blood pressure and smoking. These risk factors are strongly influenced by behaviour and reflect the behavioural pathway between stress and illness (Krantz et al. 1981). In line with this, some research has examined the effect of stress on specific health-related behaviours. Smoking, alcohol, eating, exercise, accidents, illness

Illness as a stressor

Such a may influence individuals' behaviour in terms of their likelihood to seek help, their compliance with interventions and medical recommendations, and also their adopting healthy lifestyles. Therefore a may cause behaviour changes, which are related to the health status of the individual.

critique of health belief model

Support for the HBM: People who feel more susceptible to illness get more vaccinations, have regular dental visits, get regular breast and cervical tests, exercise, than those who feel less susceptible Lack of support for HBM: Habitual behaviours Are these really determined by weighing up pro's and con's, E.g. teeth brushing, healthy eating Problems with the model: Difficult to measure perceived susceptibility and perceived seriousness (varies across studies)

Should young men be treated as victims of social, media, and cultural stereotypes, or just stupid???

The parallel question is already answered to some extent young women are treated as victims of social, media and cultural stereotypes, rather than just stupid... Why the differences, what is the right answer? Dynamic, system, interrelated interactions... biology, environment - neither male nor female behaviour occurs in a vacuum, nor do they occur independently of each other

Who is responsible for treatment? Biomedical model

The responsibility for treatment rests with the medical profession.

Mindfulness excersises in MBSR

• Apart from m meditation, participants practice yoga, breathing exercises, as well as mindful eating, mindful walking, mindful dishwashing... • The body scan exercise gets participants to lie down with their eyes closed. Gradually, they are asked to observe the sensations in the various parts of the body, one at a time.

Cognitive Behavioural (CBT) Model

• CBT is based on the idea that how we think (cognition), how we feel (emotion) and how we act (behaviour) all interact. • ABC Model - Activating event - Belief - Consequence https://www.youtube.com/watch?v=WRRdSm4ZjX4

Do the obese exercise less?

• Early research by Bullen et al. (1964) involved time-lapse photography to determine whether obese girls at a summer camp were less active than non-obese girls • During swimming - more floating than swimming • During tennis - inactive for 77% of the time (vs. nonobese who were inactive 56% of the time) • Other research shows: • Obese walk less and are less likely to use stairs or escalators • But: cause or effect?

Biopsychosocial Model

• What does the b worldview explicitly exclude? - spiritual aspects of health? - values? - purpose and meaning in life? - facilitating inter-connectedness? --- social currency doesn't necessarily mean you have to interact with people but be around them. holistic but still linear, focus on illness

"Jumbo Jets Crashing"

•"when extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors . The results of the New York study suggest the number may be as high as 98,0004 . Even given the lower estimate, deaths due to medical error exceed the number attributable to the 8th leading cause of death . More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516) 6." •To err is human: Building a safer health system 1999 - raised awareness •"the iatrogenic death rate is equal to about three loaded jumbo jets crashing and killing everyone aboard every two days!" (Journal of the American Medical Association, July 5, 1995, 274:29-34). •According to the Australian Department of Health eight per cent of hospital patients are injured or die due to the doctor or hospital errors. A study conducted jointly by the Adelaide and Newcastle universities examined admissions at 28 South Australian and New South Wales hospitals. •The study found that the medical profession is the third leading cause of death in Australia

Sarafino (2002) states that health behaviours:

Change over time Depend on the motivation of the person Acquired through experience & observation Eventually, become habitual Over time become less dependent on reinforcement than environmental cues. Eg -Brushing teeth, wearing a seat belt, applying sunscreen

A transactional/relational response to stress

- Dynamical person-environment interactions - The relative balance of environmental demands and psychological resources. not perfect but conceptually useful model psychological resources to cope with events --balance, should be matched to be not stressed low stress and high psychological demand = bored eg- medical student working at maccas, or when I was working in the kiwifruit - pressure in the environment is needed a bit more (Lazarus et al)

Breast Cancer

Breast Cancer #1 leading cause of cancer deaths in women High levels of anxiety around BC prevalence & death rates among women (Galgut, 2010; Altheide, 2002; Lerner, 2001; Lupton, 1994)

The Women's Health movement

Asserted women's rights to: medical information, bodily integrity & autonomy; reproductive choice; freedom from violence; equity in society, work & pay; access to education. "Women's health is concerned with maintaining a positive state of physical and mental wellbeing... women's health does not just occur in hospitals or doctor's waiting rooms, is not just concerned with mothers and babies, reproduction, childrearing and food, and is not only about women-specific illnesses and treatment services. Women's health issues focus on the principles of prevention, involvement and equity." (New Zealand Women's Health Committee Report to the Board of Health, 1988).

Conclusion: women's health

Before the 1990s, women were ignored in health research Most health topics can be explored using a women's health lens. Some big issues identified by women in the 1970s remain e.g. gender bias in medical practice, gendered inequalities in society. Research must continue to explore women's health psychological factors in the context of the social determinants of health and wellbeing.

Measuring beliefs about medicines

Beliefs about Medicines Questionnaire (BMQ) (Horne, Hankins & Weinman, 1999) Assesses mental representations of medications BMQ-General - pharmaceuticals as a treatment generally- Harm, Overuse BMQ-Specific - specific to meds prescribe for an illness - Necessity (for maintaining health), Concerns (over potential negative effects)

serious games

- "...the use of digital g technology to address a specific set of learning objectives or behavioral goals" (Schuller et al., 2013, p.48). - Apart from use with autism, it is not so much used for serious psychological problems, but more for psychoeducation. - Example is www.maseltov.eu to promote integration and cultural diversity: - Or to teach emotion and face recognition for autism

Psychosocial impact of illness and injury

- Depression and anxiety - Changed sense of self - Self‐efficacy and confidence - Self‐worth - Fatigue and poor sleep - Irritability and frustration - Cognitive difficulties - Fear for the future - Impact on social relationships and roles - Impact on work productivity/participation

Rehabilitation psychology

- Recognised scope of practice in psychology by the APA since the late 1990s - Focuses specifically on how people adjust to illness and injury to optimise recovery and functioning - Illness and injury can be a huge shock - need to adapt to new limitations - Need to deal with what happened before we can look forward - Physical rehabilitation doesn't work if people don't want to do it - Current services don't address these factors well

Resilience

- The ability to maintain stable psychological, social, and physical functioning when adjusting to the effects of illness or injury. - The the process of adapting well in the face of adversity - People may experience difficult emotions but may also have effective ways of coping - Resilience linked to improved outcomes (e.g., Bodde et al, 2014) - Patients requiring amputation due to complex regional pain syndrome: resilience linked to improved quality of life and lower psychological distress - Therefore: "Improving resilience of patients in in‐ and outpatient rehabilitation clinics might be an additional treatment in rehabilitation care" - What contributes to resilience: - Quant study: self‐efficacy and low levels of negative mood were strong predictors of resilience in spinal cord injury (Guest et al, 2015) - Qual study: psychological strength, social support, perspective, adaptive coping, spirituality or faith, and serving as a role model or inspiring others contributed to resilience after spinal cord injury (Monden et al, 2014)

Biological assets positive health

- high heart rate variability. - high HDL/LDL ratio (High density vs low density lipoprotein: good vs bad cholesterol). - high VO2 max (maximal oxygen uptake in one minute). - greater telomere length (affect how our cells age). - low BMI (Body mass index) - high levels of neuropeptide Y (reduces anxiety & stress, reduces pain perception etc.) - low levels of fibrinogen (helps in the formation of blood clots). biological involves internal markers - risk factor does not mean your behavioural outcomes cannot improve quality of life. The overall picture and interaction of the 3 assets are more important than just one.

Links between the acute and chronic models/processes

Both processes are intrinsically interlinked. C stress may simply be the frequent occurrence of a stress; a stress may be more likely to trigger a cardiac event in someone who has experienced c stress; and a stress may also contribute to the wear and tear on the cardiovascular system. Furthermore, both the c and a processes highlight the central role for stress-induced changes in behaviour and changes in physiology.

Stress reactivity changes in physiology

are known as 's r' and vary enormously between people. For example, some individuals respond to s events with high levels of sweating, raised blood pressure and heart rate while others show only a minimal response. This, in part, is due to whether the s is appraised as sful (primary appraisal) and how the individual appraises their own coping resources (secondary appraisal). However, research also shows that some people are simply more reactive to s than others, regardless of appraisal. Two people may show similar psychological reactions to stress but different physiological reactions. In particular, there is some evidence for gender differences in s reactivity, with men responding more strenuously to s than women and women showing smaller increases in blood pressure during s tasks than men (Stoney et al. 1990). This indicates that gender may determine the s response to a s event and consequently the effect of this response on the illness or health status of the individual. It is thought to be dispositional and may either be genetic or a result of prenatal or childhood experiences.

psychological principles (three basic levels)

▪ Awareness of patient's psychological state Knowledge of basic psychological issues relevant to context (e.g. condition), patient-centred communication. This is important to see if they will respond and participate in treatment. Support network, lifestyle considered. ▪ Intervention in the form of brief counselling Emotional care, motivational support, behavioural advice, informational & educational care ▪ Therapy from relevant psychological therapist Knowing when & where to refer, screening, engaging in/with a care team, follow-up, case management, etc. person is given ownership of their own health

Stress hormones

- *Cor*tisol Released by the Adrenal *Cor*tex Function: increases blood sugar (gluconeogenesis), divert energy to exercising muscle, enhance cardiovascular tone Binds to receptors of fat cells, liver, pancreas Suppresses digestion, growth, reproduction, immune system - Epinephrine (also known as Adrenaline) Released by the Adrenal Medulla Function: vasoconstriction (increased blood pressure), increase heart rate (binds primarily to heart cells) These first two have immidiate effects compared to nor which has less effect and is slower - Norepinephrine (also known as Noradrenaline) Released from the Adrenal Medulla constitutes only 20% of the catecholamines (hormones) secreted from the Adrenal Medulla Already prevalent in the bloodstream - released by the sympathetic nerves Function: increases heart rate, release glucose to skeletal muscles

From the client's perspective

- May have suffered significant emotional trauma - Removed from usual support systems, family, work, home, and friends - Alone in an unfamiliar environment - In some cases likely to face ongoing disability - Uncertainty and worry about future - Each person will react differently to the rehabilitation journey

Factors that influence positive adjustment

- Severity of illness less predictive of adjustment than social and psychological factors/influences - Characteristics such as a robust sense of self‐efficacy and an ability to problem‐solve and deal with difficulties have been identified as good predictors for adjustment (Kilic et al., 2013) - For those who do not adjust well: the earlier negative symptoms are treated, greater the likelihood of adaptive emotional recovery occurring

Clinical contexts

- Sports injuries - Neuromuscular disorders (multiple sclerosis, muscular dystrophy) - Neurological trauma (traumatic brain injury, spinal cord injury) - Chronic pain conditions (neuropathic pain, fibromyalgia) - Cardiovascular rehabilitation (heart attack, stroke) - Pulmonary rehabilitation (COPD) - Limb amputation - Transplantation - Diabetes - Burns

Physiological measures for stress

are mostly used in the laboratory as they involve participants being attached to monitors or having fluid samples taken. However, some ambulatory machines have been developed which can be attached to people as they carry on with their normal activities. To assess s reactivity from a p perspective, researchers can use a polygraph to measure heart rate, respiration rate, blood pressure and the galvanic skin response (GSR), which is effected by sweating. They can also take blood, urine or saliva samples to test for changes in catecholamine and cortisol production.

Predicting good health

• Factors such as life satisfaction, happiness, positive emotions, optimism, self-regulation, meaning and purpose, engagement, and social support predict good health. - high optimism = low cardiovascular dieases. - optimism and positive emotion linked to better recovery after cardiac events.

Body types

• Fat around the abdomen is particularly troublesome • Increased risk for: cardiovascular disease, diabetes, hypertension, and cancer • "apples" (central fat distribution) vs. " pears " (peripheral distribution) • Obesity is also linked to joint and back problems

Present study of e therapy

• Trial a w approach to deliver a group-based MBI with university students and staff • Thus not straying away too far from the traditional MBI group format • First introductory session with the facilitator present in person and afterwards joining via videoconferencing • Measure mindfulness and psychological distress through self-report • Grant Rix • Natasha Rix facilitated the intervention with caregivers

sick role

"behaviour and obligations expected from a sick person a concept created by American sociologist Talcott Parsons in 1951" "contrary to the thinking of the traditional medical model of disease, there is no absolute definition of disease that excludes social factors. Still, most researchers will want (at some point) to distinguish between "chest pain" and "death due to coronary occlusion," between "stiff joints" and "destruction of articular cartilage," and so on." 1. exempt from normal social responsibilities - obligatory -- if they do normal social responsibilities they are not considered truly sick 2. requires help - they cannot heal themselves. A genuine illness is seen as beyond the control of the sick person and not curable by simple willpower and motivation. Therefore, the sick person should not be blamed for their illness and they should be taken care of by others until they can resume their normal social role. 3. recovery is a must - must attempt to get well as being s is temporary. The sick person is expected to see being sick as undesirable and so are under the obligation to try and get well as quickly as possible. 4. must seek professional help -- After a certain period of time, the sick person must seek technically competent help (usually a doctor) and cooperate with the advice of the doctor in order to get better. must meet all 4 criteria otherwise, you are not considered s "Parsons did not disagree with the dominance of the medical model of health in determining illness, yet argued that being ill was not just a biological condition, but also a social role (with a set of norms and values assigned to the role). Parsons saw illness as a form of deviant behaviour within society, the reason being that people who are ill are unable to fulfil their normal social roles and are thus deviating away from the consensual norm. Parsons argued that if too many people claimed to be ill then this would have a dysfunctional impact on society, therefore entry into the 'sick role' needed regulating."

Gender, age and sociocultural differences in coping

*c changes over the lifespan:* c in children depends on cognitive and language skills Adolescents - girls social support, self blame, boys distraction Middle-aged persons tend to use problem-focused coping whereas the elderly use more emotion-focused c *Men report more problem-focused and women more emotion-focused c:* But, men alcohol/drugs, exercise, avoid, women vent emotionally, seek support, avoid When balanced for income/SES etc... Higher incomes and educational level report using more problem-focused c Praying/hoping vs acting

Adjustment

- A central theme in rehabilitation psychology - A process of modifying behaviours and thinking with the goal of achieving satisfactory quality of life - Good psychological adjustment depends upon (Beaumont, 2004): - insight into the events and psychological changes that have occurred - personal acceptance of these changes - modification of self‐view, beliefs, and personal goals - acquisition of appropriate coping strategies - Within the context of rehabilitation, initial adjustment particularly relates to: 1. diminished functional capacities 2. altered interactions with the physical and social environments 3. making sense of the illness or injury

sparx

- A fantasy game that helps fight depression - For adolescents experiencing mild to moderate depression. - Uses a 3-D fantasy gaming environment to deliver Cognitive-Behavioral Therapy. - User interacts with a character who provides psychoeducation, assesses mood, sets reallife challenges (e.g. homework tasks). - User chooses a character to restore balance in the world infested by GNATs (gloomy, negative, automatic thoughts) - Uses problem solving, relaxation, identify negative thinking, cognitive restructuring etc

mental health statistics

- Around 10% of people in Western countries currently experience some form of depression or anxiety. - By age 19, a quarter of people will have experienced a depressive disorder (Lewinsohn et al., 1998). - These statistics are not too different in other cultures, e.g. in South Korea: 2.5% of the population have major depression. - Korea's suicide rate doubled from 1997 to 2007 and is now the highest in OECD countries. - This is global problem, with high social and economic costs.

computerized CBT (CCBT)

- C is a popular and effective therapeutic approach for treating depression and anxiety. - Its structured approach to t and exercises makes it very suitable for use as e t. - Only mild cases should use c - urgent cases (e.g. suicide danger) need to receive urgent face-to face help.

Effects of stress

- Digestion Less saliva is being produced, small intestine stops functioning, large intestine empties (lighter to flee this way) -Growth Growth hormones deplete during s, and can stop growth in extreme circumstances (stress dwarfism in children) Can have a negative impact on bone density in adults -Reproduction Reproductive hormones diminish - can lead to amenorrhea (no menstruation) Immune Function Cortisol can lead to a decrease in lymphocytes -

Meta-analyses of links with PTG (e.g., Grace et al, 2015)

- Employment - Longer education - Subjective beliefs about change post‐ injury* - Stronger beliefs about treatment control* - Greater use of adaptive coping strategies* - Longer time since injury/diagnosis - Lower levels of depression* - Lower levels of distress* - Higher life satisfaction* - Sense of personal meaning* - Relationship status - Older age

Post-traumatic growth

- Evidence that people can experience positive change in response to a traumatic event - Elements of post‐traumatic growth include: - Undertaking new opportunities - Improved interpersonal relationships - Increase in spirituality - Greater appreciation of life - PTG goes beyond an ability to resist challenges (i.e., resilience) and involves quality transformation - moving beyond baseline functioning in terms of relationships as well as views of self and life. - Involves changes in values, beliefs, and behaviour

Therapist factors - Scott Miller's work

- Four primary determinants of effective treatment (Duncan et al., 2010): - Treatment model/interventions - Positive expectancy (i.e., placebo effects) - Extra‐therapeutic factors (e.g., social support) - Therapeutic relationship/alliance - Much of client improvement is attributable to factors that cut across all different types of counselling/psychotherapy/psychological approaches - Therapeutic relationship - Not only a matter of what the therapist brings to the table in terms of building the therapeutic relationship (e.g., empathy, acceptance, genuineness)... - But how clients experience these characteristics offered by therapists is critical

Is e therapy working?

- Many reviews have confirmed that e is just as effective as "treatment as usual", which means a lot of money can be saved by using e. - However, there are some methodological difficulties when testing the effectiveness of e (e.g., what is an appropriate control group?). - half of the people drop out and we don't know why that is. - So, the conclusion is that e "appears" to be as effective as other types of t. - More effective for depression, anxiety, eating disorders, cannabis use, gambling, and a little less for chronic pain or fatigue. - But booster sessions may be required.

Are symptoms always real?

- Medical Student Syndrome: is a condition frequently reported in medical students, who perceive themselves or others to be experiencing the symptoms of the disease(s) they are studying -Mass psychogenic illness... seen at a school from teacher suggestion then everyone felt sick but no cause or illness Stress is not helpful, but seeking advice is always important

Do patients like e therapy?

- Only about 40% of patients use e when offered, and then, only around 50% of people finish e. - More people finish e if they receive guidance and support from a t. - But once people have started, they tend to like e. - The most common reasons for discontinuing e are: lack of time, too demanding, preferring face-to-face contact. - But people often like the flexibility and anonymity

The future advantages of e therapy

- Our lifestyles are changing with tech. T needs to change with it - Being a psychologist is sometimes likened to being a coach: You teach your client skills, but they have to apply it themselves. - But unlike a sports coach, the psychologist is usually not there when the client needs to deal with the problems. - Using this means any data we are collecting are likely to be more accurate. - For example, patients often complete diaries and homework last minute and not when they are supposed to. Now the psychologist can find out! - Speech pattern recognition - Intelligent reminding - More multidisciplinary therapy (e.g. combined with physical exercise, nutrition intervention) - Robots

ICF Summary (International Classification of Functioning)

- Provides a framework for the description of health and health‐related states. - Describes changes in body function and structure: - what a person with a health condition can do in a standard environment (capacity) - what they actually do in their usual environment (performance) - Emphasis is on health and functioning rather than disability. - Encourages shift from exclusively using diagnostic labels to instead developing a the more complete picture of health status by describing behavioural and functional aspects of chronic diseases.

Illness and injury have the potential to be central parts of our lives

- Shift over the last century from infectious illness to chronic illness as major cause of sickness - Injuries are the fifth leading cause of health loss and the third leading cause of premature mortality (MoH, 2013) - Likelihood of occurrence of illness and injury increases with age - Because people now live with illness for many years, psychological adaption and coping have become particularly important considerations

The perspective of health psychology

- Take a moment to think of a time when you last had a cold - What did you notice (e.g. symptoms)? - How did you feel? - What did you think? - What did you do? - What might you do next time you get a cold? - Even for a very minor common illness it is: - quite a complex process! - involves an important psychological component

e therapy current challanges

- Technical issues (e.g. battery life, Internet access) - Privacy concerns - Ethical issues (location of service and liability insurance) - Making e attractive for more people - Is it better as an add-on to t? In other words, to support face-to-face t?

health literacy

- With easy access to information via the Internet, people experiencing health problems are now much more informed than before. - Many people search for a prior self-diagnosis online. - This may sometimes be dangerous if it leads to misdiagnosis. - Health professionals (including psychologists) need to be aware of this.

Factors influencing recovery following injury

- patients' perspectives - Qualitative study - semi‐structured interviews - High‐performance athletes - recovery experience following anterior cruciate ligament reconstruction (ACLR) - Sports: soccer, hockey, indoor cricket, netball - Themes - Coming to terms with the longevity/timeline of injury - Knowledge acquisition - gaining clarity about what to expect through rehabilitation process - Accessibility to professional support - physical and psychological - Learning to deal with the psychological aspects to recovery - acceptance and motivation - Some participants reported that they struggled mentally throughout the recovery process but were given little in the way of professional support for this. - Targets for psychological input: psychoeducation, expectations and coping skills, goal setting

WHAT SHOULD WE BE EATING? Michael Pollan's Food Rules

1. Don't eat anything your grandmother wouldn't recognize as food. 2. Don't eat anything with more than 5 ingredients. 3. Stay out of the middle of the supermarket - shop the perimeter. 4. Don't buy anything that won't eventually rot. 5. Always leave the table a little hungry. 6. Enjoy meals with the ones you love - not in front of the TV. --- Eat mindfully! 7. Don't buy food where you buy your fuel.

Types of eating

1. External eating - Schachter's Externality theory of obesity 2. Emotional eating - Psychosomatic theory (Bruch, 1964) 3. Restrained eating (Herman & Polivy, 1980)

Beck's Depression Inventory 2

21 items where each item presents four statements from which the respondent needs to select one option • The four statements are scored 0, 1, 2, or 3 • A higher score reflects greater degree of d • e.g., I to not feel sad to I feel unbearably sad

percieved stress scale in class

3 2 2 2 1 -- 3 4 2 3 -- 1 2 2 = 23 females average score is slightly higher normally mean was 13.7 (female) --- 6.6 SD my score 1 sd above how well you are coping with s -- higher = more risk of infection

Stage-matched intervention

A stage model approach to behaviour highlights how people show different levels of motivation to change their behaviour at different stages. Therefore someone at the pre-contemplation stage is less likely to attend a smoking cessation clinic or wear a nicotine replacement patch than someone at the contemplation or action stages. A stage approach has often been combined with the many strategies described above so that interventions can be targeted to people according to where they are in the process of change. This has taken the form of either tailored or stage-matched interventions. Participants are initially asked to rate their motivation as a means to assess their stage and then the intervention is delivered accordingly. At times this results in people being refused entry into the study as they are at the pre-contemplation stage and deemed not ready to change. Overall, it means that interventions tend to be more effective as the intervention makes more sense to the individual and those who would not have responded to the intervention are removed from the study. Stagematched interventions have been used across a number of behaviours such as smoking cessation (Di Clemente et al. 1991; Aveyard et al. 2006), cervical cancer screening (Luszczynska et al. 2010) and in conjunction with a range of intervention approaches such as CBT, counselling, implementation intentions and planning.

A role for psychological factors in stress

Both Cannon's and Selye's early models of stress conceptualized stress as an automatic response to an external stressor. This perspective is also reflected in versions of life events theory, which suggests that individuals respond to life experiences with a stress response that is therefore related to their health status. However, the above criticisms of life events theory suggest a different approach to stress, an approach that includes an individual who no longer simply passively responds to stressors but actively interacts with them. This approach to stress provides a role for an individual's psychological state and is epitomized by Lazarus's transactional model of stress and his theory of appraisal.

Coping and the stressor

According to Lazarus and colleagues, one of the goals of c is to minimize the s. Much research has addressed the impact of c on the physiological and self-report dimensions of the s response. For example, Harnish et al. (2000) argued that effective c terminates, minimizes or shortens the s.

Obesity in New Zealand

Adult obesity statistics • The New Zealand Health Survey 2018/19 found that: • around 1 in 3 adults (aged 15 years and over) were obese (30.9%) • the prevalence of obesity among adults differed by ethnicity, with 66.5% of Pacific, 48.2% of Māori, 29.1% of European/Other and 13.8% of Asian adults obese • adults living in the most socioeconomically deprived areas were 1.6 times as likely to be obese as adults living in the least deprived areas* • the adult obesity rate has increased from 29% in 2011/12, but has not changed significantly since 2012/13. Child obesity statistics • The New Zealand Health Survey 2018/19 found that: • around 1 in 9 children (aged 2-14 years) were obese (11.3%) • the prevalence of obesity among children differed by ethnicity, with 28.4% of Pacific and 15.5% of Māori obese, followed by 9.9% of Asian and 8.2% of European/Other children • children living in the most socioeconomically deprived areas were 2.7 times as likely to be obese as children living in the least deprived areas* • there has been no significant change in the child obesity rate since 2011/12.

Percieved social support

Assessed based on people's p's of the different types of s various relationships provide Interpersonal s Evaluation List - Cohen et al. (1983) https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1559-1816.1983.tb02325.x?casa_token=BAsu7LoB92QAAAAA:IC8fQxznJAvdt2yBXZCCJiO72--3HjopxLF02ZJwc15TKkJ2KM2LShVBojSCNtyrvtIUWwS5hbSqoFL8 http://www.midss.org/content/interpersonal-support-evaluation-list-isel Emotional/Appraisal, belonging, esteem, tangible Types of Social s: Emotional/Appraisal s -expressions of empathy, caring, concern Belongingness s- Ability to talk to others - predicts well-being, decreased levels, increased symptoms Tangible or instrumental s- direct assistance, concrete assistance, mobilisation of social s- rule of relative need (those that need help should get it), rule of relative advantage (need is not the only factor) Esteem/validation s - affirming self-worth expression of positive regard, encouragement, agreement heart surgery study - 1 year after surgery with ۸ esteem support from spouses, ۸ emotional well-being, ۷ daily disruptions, ۷ symptoms of heart trouble

examples of powerful add-ons of e therapy

Assistance with life skills: - Giving prompts to people with autism for social situations. - Or help with name and face recognition for people with prosopagnosia or dementia

Development and differences

Chromosomal differences, but irrespective of that, foetuses will develop as female unless exposed to high levels of androgens (testosterone) in utero Prenatal testosterone levels influence not only sexual dimorphism but also brain development and future behaviour But, think about ongoing interactions, rather than key differences... chromosomes, hormones, environment all play roles X-linked disorders Psychological disorders Differences beyond obvious - other organs - e.g., liver, kidney etc Male brains seem to be more functionally asymmetrical "In general" Males better visuospatial function - language highly lateralised Females better language function, and it's less highly lateralised

Excersise and stress

E has been linked to health in terms of its impact on body weight and through its beneficial effects on CHD (see Chapter 6). Research indicates that s may reduce e (e.g. Heslop et al. 2001; Metcalfe et al. 2003) whereas stress management, which focuses on increasing e, has been shown to result in some improvements in coronary health. One recent study explored the impact of gardening on relief following experimentally induced s (Van den Berg and Custers 2011). For this study 30 allotment gardeners performed a stressful Stroop task (see Focus on Research 6.1, p. 145) and were then randomly allocated to outdoor gardening or indoor reading on their allotment plot. The results showed that although both groups showed a decrease in salivary cortisol this was greater in the gardening group. It is not clear, however, whether this is due to gardening as a form of e, gardening as a form of creativity or whether simply being outdoors created this effect.

Lay Referral Systems

Friends, relatives and co-workers (the internet) form a lay referral (not expert) system which aids in interpretations of symptoms. • Australian adolescents are more likely to seek advice for a health problem from parents and peers before seeing the family doctor • I expect there's now abundant 'googling' of symptoms People construct common sense models of different illnesses, involving illness identity, causes and underlying pathology, timeline, and consequences

Stress and cancer

Growing evidence... Possible mechanisms: Diminished activity/responsiveness of NK cells Alterations in DNA repair and apoptosis (programmed cell death) More likely that s impacts the progression and reoccurrence of c, rather than the incidence

What causes illness?

Health psychology suggests that human beings should be seen as complex systems and that illness is caused by a multitude of factors and not by a single causal factor. Health psychology therefore attempts to move away from a simple linear model of health and claims that illness can be caused by a combination of biological (e.g. a virus), psychological (e.g. behaviours, beliefs), and social (e.g. employment) factors.

Alcohol and stress illness link

High intake has been linked to i such as CHD, cancer and liver disease (see Chapter 4). Research has also examined the relationship between s and consumption. Many authors have suggested that work s, in particular, may promote use (e.g. Herold and Conlon 1981). The tension-reduction theory suggests that people drink for its tension reducing properties (Cappell and Greeley 1987). Tension refers to states such as fear, anxiety, depression and ds. Therefore, according to this model, negative moods are the internal s, or the consequence of an external stressor, which cause consumption due to the expected outcome. For example, if an individual feels tense or anxious (their internal state) as a result of an exam (the external stressor) and believes that consumption will reduce this tension (the expected outcome), they may drink to improve their mood. This theory has been supported by some evidence of the relationship between negative mood and drinking behaviour (Violanti et al. 1983), suggesting that people are more likely to drink when they are feeling depressed or anxious. Similarly, both Metcalfe et al. (2003) and Heslop et al. (2001) reported an association between perceived s and drinking more (if a drinker). Furthermore, it has been suggested that medical students' lifestyle and the occurrence of problem drinking may be related to the s they experience (Wolf and Kissling 1984). In one study, this theory was tested experimentally and the health-related behaviours of medical students were evaluated both before and during a s examination period. The results showed that the students reported a deterioration in mood in terms of anxiety and depression and changes in their behaviour in terms of decreases in exercise and food intake (Ogden and Mtandabari 1997). However, consumption also went down. The authors concluded that acute exposure to s resulted in negative changes in those behaviours that had only a minimal influence on the students' ability to perform satisfactorily. Obviously chronic s may have more damaging effects on longer-term changes in behaviour.

What is social support?

Initially, it was defined according to the number of friends that were available to the individual. However, this has been developed to include not only the number of friends supplying ss, but the satisfaction with this support (Sarason et al. 1983). Wills (1985) has defined several types: • Esteem support: whereby other people increase one's own self-esteem. • Support: whereby other people are available to offer advice. • Companionship: which involves support through activities. • Instrumental support: which involves physical help. Lett et al. (2005) also put forward a definition of social support that differentiates between two types: • Structural support (or network support): which refers to the type, size, density and frequency of contact with the network of people available to any individual. • Functional support: which refers to the perceived benefit provided by this structure. This has also be classified into available functional support (i.e. potential access to support) and enacted functional support (i.e. actual support received) (Tardy 1985). The term 'social support' is generally used to refer to the perceived comfort, caring, esteem or help one individual receives from others (e.g. Wallston et al. 1983).

Cannon's fight-or-flight model

One of the earliest m of stress was developed by C... (1932). This was called ... which suggested that external threats elicited the ... response involving an increased activity rate and increased arousal. He suggested that these physiological changes enabled the individual to either e from the source of stress or f. Within C's model, stress was defined as a response to external stressors, which was predominantly seen as physiological. C considered stress to be an adaptive response as it enabled the individual to manage a stressful event. However, he also recognized that prolonged stress could result in medical problems.

stress and immunity summary

Overall, the literature suggests that chronic s can lead to i dysregulation in the following ways: - Induction of chronic low-grade inflammation - Chronic low-grade inflammation has been found among depressed and chronically s'd individuals - Delayed wound healing: - Increased susceptibility to upper-respiratory infections: Common Cold Unit study, over 13 months dementia caregivers report more upper-respiratory infections - Weakened vaccine responses: E.g., dementia caregivers and influenza vaccine - Disrupted i control of latent viruses: Herpes recurrence in s individuals - Impair i system's response to anti-inflammatory signal

recieved social support

Perceptions of ss more important than actual availability of s-- A sweeping generalisation, naturally Assessed based on the amount of support received in a particular period of time - Inventory of ss..ive Behaviours - how often in the past 4 weeks received s...ive behaviours - Barrera et al. (1981) ISSB measure

mechanisms in allostatic load

Real or perceived threats initiate SAM and HPA responses... (brain's evaluation [appraisal?] important) Why does al develop? Four possible m: 1. Repeated hits from multiple stressors 2. Lack of adaptation 3. Prolonged response due to delayed inhibitory functioning 4.Inadequate response

Community Approaches: Precede/Proceed Model

The PRECEDE/PROCEED model by Green & Kreuter (1991) provides guidelines for designing, implementing and evaluating health programs. Program design phases Phase 1, Social diagnosis o (What's the problem?) Phase 2, Epidemiological diagnosis o (What diseases/conditions contribute to the problem?) Phase 3, Behavioural and environmental diagnosis o (What's causing the diseases/conditions?) Phase 4, Educational and organisational diagnosis o (What can facilitate behaviour change?) Phase 5, Administrative and Policy diagnosis (feasible project?) Phase 6, Implementation Program Evaluation: Phases 7-9

can you be too happy?

The answer depends on the outcome measured. If we look at success in school or work, the extremely h do a little less well than the merely h. (Those who are unh do poorly.) But if we look at success in social relationships, the relationship with h is strictly linear: one cannot be too h

Importance of Studying Women's Health

Women's health has been marginalised People assumed that men and women's health is the same Prior to 1990 - limited research attended to women's health issues Women have been ignored in general medical research 'Women's health' has been inappropriately reduced to 'reproductive health' Women have had health information withheld from them 'for their own good'.

Mindfulness

or headfulness either an add on or stand alone therapy short vs long term - response to psychological distress or part of lifestyle wellbeing and can be used as prep for future distress different from meditation - Mi state detatch yourself from getting caught up in everyday stressful situations awareness of thoughts and focusing on what you should be doing in the present, not worrying about future, past or things you cannot control taking charge of thoughts

exam tips

question will be similar case studies in past exams Friday 23 October 2020 10am-12.20pm (includes 20 minutes reading / planning time) Assessment will be posted on AUT Blackboard under the Assessment tab Submit assessment to Turnitin at 12.20pm 12 point font, 1.5 spacing, Times New Roman Font Value of planning out an essay answer (and short answers) - use bullet points before you start to write essay so that it is structured and addresses the question... Question 1 is weighted more - use your descretion on what to focus on from the course. Good to use citations, won't be penalized for not using James eg- stress and coping, health behaviour models, accessing healthcare Henry eg- don't just say eat healthier and stop drinking and smoking. Stages of change, health behaviour model. Then can talk about obesity, nutrition. Self-efficacy, locus of control, habit formation, positive health Can consider other models that are not mentioned in this paper sidenote - I could answer the eg q's and send for marking via email to see what I could improve on. intro and conclusion for all 3 essays think critically, don't just regurgitate lecture slides 1 to 1 and a half pages

The common-sense model of self-regulation (Leventhal et al., 1997)

to understand how individuals respond to fear-arousing communications. When a threat is perceived (e.g., physical symptoms or changes in function), individuals develop two parallel, yet interrelated, representations of the stimulus: cognitive and emotional These representations and their content specify the actions (i.e., behaviors) in which individuals engage to remove the health threat. (Mora & McAndrew, 2013) Stimuli -- representation of illness: identity, timeline, consequence, cause, control, coherence AND representation of emotions -- coping behaviours --- appraisal of outcome

Cognitions and behaviour of pain

¨ Self-efficacy ¤ Past positive experiences may improve p ¤ Locus of control ¨ Attention ¤ Attention to p increases p ¤ Distraction decreases p ¤ Additionally, p demands attention leaving less attention to other tasks

Measuring mindfulness

• Being a psychological construct, m needs to be inferred and cannot be m directly. •Reviews of recent m questionnaire show a wide range of different question content. •Only a small number of questionnaires are about m states (in other words, how m one feels at the present moment). •Most questionnaires provide trait measures. This does not imply that one's degree of m cannot change, but it is assumed to occur gradually with increased practice. •People with no experience in m training vary substantially in terms of their m score.

• Lifestyles, risk factors and health

▫ Health-protective behaviour is any activity people perform to maintain or promote their health e.g. eating sensibly, getting enough sleep ▫ Risk factors are characteristics or conditions that occur more often among persons who develop particular diseases than among those who do not eg- smoking or drinking excessively

anticipated challanges of e therapy study

• Problems with Internet connection or audio-visual technology • Attrition (drop-out) may remain a concern • Group t has been linked to lower effect sizes than individual formats (0.38 vs 0.50) • Despite the initial face-to-face session, individual may still not have sufficient rapport with facilitator • Other researchers were present to prepare the room and interact with the software • A clinical psychologist was present to assist participants with adverse effects

Treating obesity - dieting

• The history of dieting fads is a fascinating topic in itself. Many stick around longer than others. Some that did not, include: • chewing gum • diet soap • tapeworms • smoking

Session 2 e therapy

• session delivered via webinar • Brief introduction and familiarization with the technology by everybody incl. participants • Then same breathing meditation exercise for 10 to 15 min as at the end of the previous session • Then physical movement exercise similar to Taijichuan • Slideshow presentation on mindfulness and the brain • Mindful eating exercise • Home practice: body scan

7. The biopsychosocial model (Engel, 1980)

◼ adopts a holistic approach; takes into account social support, employment, beliefs, biology - viruses etc. ◼ adopts a systems approach of interrelated components nested within larger components network is important - research shows that if your friends know each other you have a stronger support network

Coercion tactics

Violence - threats, held hostage, rape Intimidation - kept child, tracking, jealousy, gun, threats (see slides for more).

Why are apple-shaped people at risk for health problems?

• Fat can be subcutaneous (under the skin) or • visceral (around the organs) • The greatest concern is that visceral fat can interfere with the functioning of vital organs • Fat deposits around the middle are associated with visceral fat (ie. Apple-shaped body)

FOOD AND ITS FUNCTION

Substance or materials we eat and drink to provide nutritional support for the body or for pleasure. Food is necessary for Growth Repair Energy Protection from disease

The general view is that men are not disadvantaged by the gender roles

differences are usually interpreted at an individual level, rather than on the basis of social pressures to conform to unhealthy gender-based stereotypes Individuals making free choices to behave self-destructively? c.f., with views of women's unhealthy dietary patterns - widely acknowledged as being influenced by cultural stereotypes and social expectations ... A concern for one's health is positioned as a feminine characteristic - men are naturally strong, unresponsive to pain and physical distress, and unconcerned by minor symptoms

FOOD PYRAMIDS & PLATES: WHICH ONE IS THE RIGHT ONE?

different variations some pyramids and plates are more inclusive - includes exercise, supplements, weight management etc. eg- vegan food pyramid, paleo, keto - Processed meat is bad for you

Death and Psychology

Besides the psychological issues confronting the dying person, a whole range of fields has opened up over the years relating psychology and death, including: Psychological aspects of bereavement Anxiety surrounding death Concepts of life and death End-of-life decision making Psycho-legal aspects of death Psychological experiences related to death e.g. NDEs

The Transtheoretical Model of behaviour change

known to many as the Stages of Change (SOC) model, states that with regard to chronic behaviour patterns such as smoking, individuals can be characterized as belonging to one of five or six 'stages' Stage definitions vary from behaviour to behaviour and across different versions of the model but in the case of smoking: 'precontemplation' involves an individual not thinking about stopping for at least 6 months; 'contemplation' involves an individual planning to stop between 31 days and 6 months, or less than 31 days if they have not tried to quit for 24 hours in the past year; 'preparation' involves the individual having tried to stop for 24 hours in the past year and planning to stop within 30 days (it has been accepted by the proponents of the model that having tried to stop should perhaps be dropped from this stage definition); 'action' involves the individual having stopped for between 0 and 6 months; 'maintenance' involves the individual having stopped for more than 6 months. In some versions of the model there is also a 'termination' stage in which the individual has permanently adopted the new behaviour pattern. A recent review comparing stop smoking interventions designed using the SOC approach with non‐tailored treatments found no benefit for those based on the model ([26]). Another review of the effects of applying the model to primary care behaviour change interventions has similarly found no evidence for a benefit ([30]) and nor has there been found to be a benefit of applying the model in promotion of physical activity ([ 2]). By contrast, there is good evidence that tailoring interventions in other ways, including triggers and motives are more effective than untailored approaches ([16]). WHY THE MODEL SHOULD BE ABANDONED The model has been little more than a security blanket for researchers and clinicians. First, the seemingly scientific style of the assessment tool give the impression that some form of diagnosis is being made from which a treatment plan can be devised. It gives the appearance of rigour. Secondly, the model also gives permission to go for 'soft' outcomes such as moving an individual from 'precontemplation' to 'contemplation' which is of no proven value. Thirdly, it provides scientific labels to categorise people who would otherwise have to be described using phrases that any non‐expert would understand: an individual is a 'precontemplator' not 'someone who is not planning on changing'. Appealing as this may be, it is not founded on evidence and arguably has been damaging to progress. The model tends to promote the wrong intervention strategy. For example, precontemplators tend to be provided with interventions aimed at 'moving them along' the stages, for example by attempting to persuade them about the benefits of changing. However, if their apparent lack of interest in changing arises from their addiction, these individuals may respond favourably to the offer of a new and promising treatment as appears to have happened when the drug Zyban was launched as a smoking cessation aid (e.g. [34]). The model is likely to lead to effective interventions not being offered to people who would have responded. There is now evidence in the case of smoking cessation that help should be offered to as wide a group as possible ([20]; [21]), but the SOC model can be taken as giving permission to those attempting to promote behaviour change to give weak interventions or no intervention to 'precontemplators'. This approach fails to take account of the strong situational determinants of behaviour. Behaviour change can arise from a response to a trigger even in apparently unmotivated individuals. WHY THE MODEL SHOULD BE ABANDONED The model has been little more than a security blanket for researchers and clinicians. First, the seemingly scientific style of the assessment tool give the impression that some form of diagnosis is being made from which a treatment plan can be devised. It gives the appearance of rigour. Secondly, the model also gives permission to go for 'soft' outcomes such as moving an individual from 'precontemplation' to 'contemplation' which is of no proven value. Thirdly, it provides scientific labels to categorise people who would otherwise have to be described using phrases that any non‐expert would understand: an individual is a 'precontemplator' not 'someone who is not planning on changing'. Appealing as this may be, it is not founded on evidence and arguably has been damaging to progress. The model tends to promote the wrong intervention strategy. For example, precontemplators tend to be provided with interventions aimed at 'moving them along' the stages, for example by attempting to persuade them about the benefits of changing. However, if their apparent lack of interest in changing arises from their addiction, these individuals may respond favourably to the offer of a new and promising treatment as appears to have happened when the drug Zyban was launched as a smoking cessation aid (e.g. [34]). The model is likely to lead to effective interventions not being offered to people who would have responded. There is now evidence in the case of smoking cessation that help should be offered to as wide a group as possible ([20]; [21]), but the SOC model can be taken as giving permission to those attempting to promote behaviour change to give weak interventions or no intervention to 'precontemplators'. This approach fails to take account of the strong situational determinants of behaviour. Behaviour change can arise from a response to a trigger even in apparently unmotivated individuals. It is common in the case of psychological theories for which there is accumulating evidence that they are not proving helpful, to argue that better measurement is needed or that the theory has not been applied properly. This particular model is no exception (e.g. [ 6]). In the end one is often forced to acceptance that fundamental precepts of the theory are misplaced and arguably that is the case here. WHAT TO DO NOW? A better model of behaviour change is clearly needed. There are of course many other decision‐making models, such as the Health Belief Model ([10]) and the Theory of Planned Behaviour ([10]). What is needed is one that operates at the same level of generality as the SOC model and encompasses decision‐making processes and motivational processes that are not necessarily accessible to conscious awareness. The model needs to take account of the fact that the behaviours concerned reflect the moment‐to‐moment balance of motives. At a given time an individual may 'want' to do one thing (e.g. smoke a cigarette) but feel they 'ought' to do something else (e.g. not smoke it)—but these feelings and beliefs are not present most of the time—they arise under specific circumstances.