Health Psychology
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.
Stressor
Stimulus that throws the body's equilibrium out of balance. Can be PHYSICAL or PSYCHOLOGICAL (affecting events at the level of the person), or SOCIAL (or a combination thereof).
Internal conflict
Stress can be caused by internal conflict; the emotional predicament people experience when they make difficult choices. There are three categories of internal conflict. 1. Approach-approach conflict 2. Avoidance-avoidance conflict 3. Approach-avoidance conflict
Cancer
Stress does not cause cancer, but it has been proven to assist in the growth of some cancerous tumors. 1. Suppressed immune system inhibits cell activity and weakens the immune system overall. 2. Can facilitate the growth of capillaries feeding into the tumor. (Bodies produce more capillaries to supply blood to that area). Beneficiary to injury or infection, but not to tumors as it will just give it more blood to grow. 3. Perception of control: can play a role in the progression of some kinds of cancer. Lack of control and helplessness caused patients to having a higher rate of recurrence ad to die earlier from the cancer.
Stress, emotions and heart disease
Stressors often elicit negative emotions (fear, anger, sadness, helplessness). Causes a rise in heart rate. Chronic stressors: can lead to feelings of helplessness, depression, and despair. (Depression associated with a greater likelihood of heart disease).
Kubler-Ross
Suggested five stages through which the dying person would progress: [DABDA] 1. Denial and Isolation 2. Anger 3. Bargaining 4. Depression 5. Acceptance Much criticism of the model, but should perhaps not be dismissed entirely Note: If you're discussing this, don't forget the "Isolation" part of "Denial and Isolation" - it frequently gets omitted in secondary sources
Health Psychology
TEXTBOOK: Is the field of study that is concerned with the PROMOTION of health and the PREVENTION and TREATMENT of illness as it relates to PSYCHOLOGICAL factors. SLIDES: Study of psychological and behavioral processes in health, illness, and healthcare. It is concerned with understanding how psychological, behavioral, and cultural factors contribute to physical health and illness. MINE: Health psychology is the field of study, that is concerned with the promotion of health, as well as the prevention and treatment of illnesses. It is concerned with how psychological, behavioural and cultural factors contribute to physical health and illness.
Coping
The actions an individual takes when regarding the stressor, its effects or his or her reaction to it.
Tend and befriend
The flight or fight model was found to not be applicable to females. Most studies had been carried out on men as menstrual cycles can affect measures of biological stress in women. Being pregnant and caring for children made it difficult to for female ancestors to flee in the past. 1. Tend; involves tending to children by quieting them when they were throwing a tantrum. 2. Befriend: creating and maintaining social connections in order to have protection and care from the stressors.
Perceived control
The perception of control can affect your performance. i.e. a perceived lack of control can lead to the onset of learned helplessness. If you perceive to have more control. your body will react less strongly towards the stressor.
Predictability
Perceiving a lack of control does not always cause stress. Many things beyond our control are at least predictable. i.e pop quizzes that are announced are less stress inducing than ones that aren't announced.
Approach-avoidance
Results when a possible course of action has both positive and negative aspects, and, thus, produces both approach and avoidance. i.e. you are offered a job that you wanted but would require you to move to a city in which you did not want to live.
Psychological Mechanisms
There are three main axes that work to provide an increase in the body's functioning energy levels; 1. Direct neural axis 2. Neuroendocrine axis 3. Endocrine axis These operate in acute, short term and long term stress respectively.
Patient Awareness
Presupposes that patient will be informed of diagnosis - in past, not always the case, but increasingly so today because of: - Considerable research in 1960s/1970s investigating attitudes towards being told, and effects of disclosing diagnosis - Recognition that family/relatives may not "know best" - Growth of hospice movement - Increased recognition of ethical issues
Life's hassles
Recent research has looked into life's daily hassles rather than major alterations made in life circumstances, as being more accurate predictors of distress and stress related illnesses. Those who report more daily hassles also report more psychological problems. Encountering daily hassles can induce a mild stressor to be experienced as being more stressful and apt to provoke a change in an individual's immune system. What you perceive to be a stressor depends on the amount of exposure you have to it, as well as it's nature (how much you perceive it to be an annoyance).
Allostasis
Refers to the multiple biological changes that allow you to adap to a stressor or a set of stressors in the short run, so that your body functions within a comfortable range.
Allostatic load
Refers to the stress carried by the body to maintain equilibrium. As the number or intensity of stressors increases, so does the allostatic load. Greater allostatic load increases the risk of medical and psychological symptoms. More demands made on your body than when in a calmer state, producing biological wear and tear. Allostatic load is not determined solely by environmental demands. It is affected by past experience with the stressor, genetic predisposition (body and personality) and life style factors.
Approach-approach
Results when competing alternatives are equally positive. This kind of conflict can be stressful, but it is not necessarily experiences as unpleasant because both options are pleasing. i.e receiving two really good job offers and wanting both equally.
Avoidance-avoidance
Results when competing alternatives are equally unpleasant. Making a choice can be very stressful. i.e taking job you really don't want or remaining unemployed (when you need to pay back a student loan urgently).
Work: floor plans and noise
Arrangement of work spaces can cause stress. Open plans are worse than close plans, because it does not provide auditory or visual privacy and noise made by the other workers cannot be avoided. Open plan: poor performance in work, higher blood pressure and presented a number of other symptoms, as well as a lower tolerance for frustration. Another stressor is job responsibilities.
Resistance
Second phase in GAS. Body mobilizes resources to achieve equilibrium, despite continued presence of stressor (also called adaption phase).
Sources of stress
Certain types of stimuli are more likely to cause more stress
Learned helplessness
Condition in which a person suffers from a sense of powerlessness, arising from a traumatic event or persistent failure to succeed.
Appraisal
Definitions of psychological or social stressor is more subjective than physical ones. Cognitive appraisal: How we ourselves perceive potential stressors. Occurs in two phases; 1. Primary appraisal 2. Secondary appraisal
It's how you think of it
Depending on how you appraise a stimulus, you will experience different emotions and your body will react in different ways. Got resources: challenge No resources: threat Cognitive appraisal: leads to you to conclude that a stimulus is dangerous, then negative emotions are triggered. Emotions become what you must respond to with coping strategies.
Exhaustion
Final phase in GAS. Continued efforts too achieve homeostasis lead to exhaustion, and stress response itself becomes damaging to the body.
Alarm
First phase in GAS. Body mobilizes itself to fight or flee from a threatening stimulus that is either physical or psychological. Increase in energy levels are increased.
Stress
General term describing the psychological and physical response to a stimulus that alters the body's equilibrium. 1. Part of body's response to threat 2. Through the immune system, the body responds in specific ways to particular threats (e.g. by producing antibodies to a particular infection) 3. Body also responds in nonspecific ways, i.e. parts of the response are common to any kind of threat 4. Stress response concerns these nonspecific reactions to threat.
Health Benefit Model
Health Benefit Model dimensions can be simply remembered as involving: [BVSE] 1. Perceived vulnerability 2. Perceived seriousness 3. Perceived efficacy 4. Perceived barriers - Many studies look for differences between particular groups (e.g. looking at those who delayed in presenting symptoms by comparison with those who were prompt). - If someone delays presenting a symptom it may mean they see their own vulnerability/seriousness/efficacy as low - or they may see barriers as high. - Four different people could all delay for four different reasons - we don't actually know how low (or in the case of barriers, high) someone must be on the dimension before it stops them taking action.
Runner's High
"Runner's high" - feeling of euphoria sometimes experienced by people undergoing sustained exercise - sometimes ascribed to the release of endogenous opiates a.k.a endorphins. Note: (a) opiates do not produce euphoria when used in the treatment of pain (b) people given drugs which block the effect of endorphins have been shown to be just as likely to experience the "high".
Factors mediating stress response
- Extent to which events produce stress response depends on a number of factors, including: i). PRIOR HISTORY - experiments show that animals stressed early in life showed better coping with stress later. ii). PREVIOUS EXPERIENCE- e.g. stress response of parachutists varies according to how many previous jumps they had completed iii). INFORMATION - e.g. hospital patients about to undergo surgery benefit from prior information about the procedure and what to expect iv). SOCIAL SUPPORT- evidence of lower incidence of problems amongst individuals with close confidant
Impact of bodily processes on psychological ones
- Healthy processes e.g. psychological consequences of exercise - Illness, e.g. psychological impact of terminal illness
Effects of social factors on health and illness
- Impact of gender-role conformity on health - Role of social support in recovery from illness
Ethics of concealment
- Is it ethically appropriate to conceal information from patient? - Is it ethically defensible to inform family and/or others before informing patient? - Should patient have right not to be told if they'd rather not? How could we know what patient would prefer?
Forms of acceptance in facing death
- Kubler-Ross's "acceptance" may be apparent in one form or another: "During the past week I have made great progress towards accepting my situation... I have spent quite a lot of time thinking, to some purpose. Despite the fact that thinking has taken up quite a lot of time and energy, it represents, in my opinion, a progress towards maturity which is an essential ingredient in all human life. After all, we are all born to die, it is just that I have recently learned that I will not live as long as I had originally hoped. The bonus is that I have time to prepare... I realised a few days ago I was not afraid to die."
Psychological processes on health
- Normal processes, e.g. stress response - Abnormal processes, e.g. psychological underpinnings of problems such as anorexia
Problems for the dying person
- Whole range of potential problems, not necessarily constant, through what may be a sustained 'dying trajectory' lasting many years. i). Immediate tasks ii). Getting on with living iii). Coping with dying
Psychological processes impacting on health
1. "Stress response" - serves to provide body with additional resources, at cost of neglecting certain other bodily functions and disrupting normal homeostasis. It is part of the way in which the body has evolved to deal with a stressor (stimulus that throws the body's equilibrium off balance). 2. Many other psychological processes may impact significantly on health and illness: - Numerous psychological factors cause problems such as anorexia nervosa to develop i.e. need for control over one's body, family history, perfectionism of self. -Simple psychological strategies may have measurable physiological effects on health, e.g. studies show improved immune functioning as result of expressive writing [Cause vs Cure] 3. Some extreme psychological characteristics may lead to physical health problems. 4. Some psychological interventions may produce an impact on health-related processes like our ability to resist illness (can improve resistance).
Facing Death
1. Although individuals may come to terms with mortality, this is not always easy for those around them: 2. Risk that such expressions of ease may be interpreted as rejecting by others.
Psychological models
1. An understanding of how psychology relates to health strongly relies on basic understanding of fundamental psychological processes in cognition, perception, learning, development, social interaction etc. 2. Specific psychological models may be developed to help understand particular areas on psychology "Health belief model" attempts to understand people's health-related behaviour in terms of their perception of (a) their own vulnerability to a problem (b) its seriousness (c) the efficacy of remedial action (d) barriers to action
LECTURE ONE SUMMARY
1. Behaviour and health becoming more closely intertwined - thus a need for health psychology. 2. Many psychological processes linked to health - e.g. effects of stress. 3. Mechanism of stress response largely directed towards increase in energy - at a cost 4. Impact of stress depends on individual's coping mechanisms 5. Whether or not event is stressful depends on range of factors
Flight or Fight Model
1. Cannon (1932) = 'flight or fight' model. 2. Noted role of hypothalamus and sympathetic nervous system in affecting adrenal glands and PRODUCING INCREASE IN circulating epinephrine (ADRENALINE). 3. Produces changes in heart rate, patterns of blood circulation etc. -Perception of stressor triggers alarm phase (1st phase of GAS; stressor perceived and FoF response activated). Glucocorticoids* realeased (group of hormones that are released when the stress response is triggered). It increases the production of energy from glucose and has an anti-inflammatory effect (to help restore the body's equilibrium after physical injury).
OVERALL SUMMARY
1. Death comes to us all, with little improvement in life expectancy for most of us. 2. People increasingly likely to be aware that their life expectancy is limited 3. Theorists like Kubler-Ross have suggested models to describe people's coping with dying 4. End of life may involve a range of decisions, not all within the law of the country concerned 5. Dying person has many tasks to deal with, but experience of dying may contain positives as well as negatives.
Professional Health Psychology
1. Early work largely academic, e.g. investigating role of psychological factors in health and illness, studies of doctor-patient communication, adherence to treatment etc. - 1960s study showed: -Patients in GP consultations were more likely to remember discussion at start vs end of consultation (primacy effect) -More likely to remember info about diagnosis than treatment and did not always have things explained clearly. - Result of active patient participation: changing GP's styles not only improved patients' understanding and recall, but also improved adherence to treatment regimes. 2. Recently health psychologists have extended their work into professional areas, e.g. pain clinics, cancer care, rehabilitation, eating disorders etc. (some of these areas overlap with work of trained clinical psychologists) 3. Other areas of work include public health (e.g. vaccination decisions, decisions about genetic testing), psychology of sport and exercise, chronic disease (e.g. diabetes care) etc. - e.g. work by Jeanne Reeve looking at how individuals at risk for genetic cancers responded to tests to see whether they carried the relevant gene.
Social support and stress
1. Evidence suggests that effects of stress may be ameliorated by presence of social support 2. Prospective research shows lower mortality amongst individuals with higher levels of social support 3. Spiegel, D., et al (1989, Lancet); Study found higher survival (on average 18 months longer) in breast cancer patients allocated to support group than in control patients. Note: (ascribed benefit primarily to improved patient adherence to treatment.
Type A behaviour pattern
1. First described in 1974 by Friedman and Rosenman, cardiologists investigating risk factors for CHD. 2. Three main characteristics of Type A: i). Time urgency ii). Competitiveness iii). Anger/hostility 3. Numerous studies suggest that Type A individuals are at substantially higher risk of CHD than Type B.
ENDOCRINE AXIS
1. Highly complex, involves several components. 2. Results in secretion of a number of hormones including ACTH, glucocorticoids and mineralocorticoids, and somatotrophin. 3. Range of effects including changes in blood volume and pressure and increased insulin resistance.
Areas of Health Psychology
1. Impact of psychological processes on health 2. Impact of bodily processes on psychological ones 3. Effects of social factors on health and illness Note: this type of categorisation breaks down, and much interaction between physical and psychological takes place. Also this is far from an exhaustive list of what health psychology is concerned with.
Psychological aspects
1. Initial reaction includes alarm and shock, triggering physiological changes 2. Activation of coping strategies 3. Resolution of problem if coping strategies successful, otherwise consequences such as fatigue, withdrawal, depression etc.
Type B behaviour pattern
1. Link between TABP and CHD remains even when other risk factors (e.g. family history, smoking) are allowed for. 2. Evidence appears to suggest that the anger/hostility component is main risk factor. 3. Note however that the link between TABP and CHD is not universal - e.g. in MRFIT study, type B CHD patients had similar outcome to type A. 4. Is type A risk factor or risk marker?
Relationship of stress to illness
1. Lots of attempts to show links between stress and illness, complicated by things like EXTENT and DURATION of stress and the ILLNESSES studied. 2. studies indicate increased rate of minor illnesses at times of stress 3. Some aspects of lifestyle that appear to reflect stress have been linked to problems like coronary heart disease (e.g. "Type A" behaviour pattern)
Social factors in health and illness
1. Many aspects of ill-health have been related to such factors as SOCIAL EXPECTATIONS; - e.g. many ways in which conformity to male gender-role expectations may increase risk of health problems and mortality in men - -Evidence suggests that moving away from both traditional male and female gender roles is beneficial. 2. Social factors also strongly implicated in much of health psychology, especially the role of social support in such areas as recovery from illness etc. - Lots of support = better chance of recovery.
Getting on with living
1. May be several years of more or less gradual deterioration, with progressive loss of various abilities. * Note that the deterioration is unlikely to be regular, producing considerable uncertainty. 2. Many normal activities of life can be continued, management of pain etc. can be highly effective for most patients. 3. Individual also likely to experience various fears regarding death.
Decisions regarding death
1. May involve range of decisions - not just making of a will, but possibly decisions such as funeral planning, whether to be buried or cremated and so on. May also involve deciding where to die: i). Home ii). Hospice iii). Hospital 2. Decisions also need to be made by professionals working in terminal care - DNR decisions - Withdrawal/witholding of food/fluids - - Turning off life support Active steps to hasten death * Note that the latter is a complex area, subsuming not only topics such as physician-assisted suicide (PAS) and euthanasia, but also so-called "terminal sedation" and "double effect" 3. Even where euthanasia is illegal (as in NZ) it continues to be practiced 4. Where it is legal, it may nevertheless place heavy burden on practitioners.
NEUROENDOCRINE AXIS
1. Medium-term response to stress, associated with increased levels of adrenaline 2. Signals pass from cortex through various neural structures to adrenal medulla leading to secretion of hormones (catecholamines) which produce increase in blood pressure, cardiac output, circulating FFAs etc., and decrease in renal function and peripheral blood flow 3. Slower to initiate (circulation slower than nerves!) -Increased level of adrenaline -Signals pass through various structures -Secretion in hormones - Increase in blood pressure, cardiac output etc.
Honesty - empirical aspects
1. Not disclosing diagnosis to groups such as cancer patients once fairly common practice; where diagnosis was disclosed, this would usually be on advice of close family. 2. Around 1950s/1960s, studies began to appear investigating people's views on disclosing 3. Studies of 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, large majority indicated they should. 4. OFTEN INFLUENCED BY SOCIAL FACTORS - e.g. more people would disclose to middle-aged businessman than to young mother. 5. Physicians and surgeons who started to tell their patients in some cases asked patients their views on being told. 6. Overwhelming majority glad to have been told, citing benefits such as reducing uncertainty, opportunity to plan ahead and prepare
Fears of death
1. Note that 'fear of death' far from simple concept, may involve: - Fear of pain - Fear of degeneration - Fear of separation - Fear of unknown 2. Some, but not all, amenable to reassurance 3. Some fears may be brought into sharp relief in dreams.... 4. Not difficult to interpret the symbolism of such a dream in the context of fear of death.
Health Psychology is
1. Relatively new area of research and application in psychology. 2. Concerned with the relationship between psychological factors and health/illness. 3. Two main historical threads in development - social psychology and clinical psychology, with some elements of cognitive too. 4. Area both of academic study (e.g. research, teaching) and practical application (e.g. work of professional health psychologists, clinical psychologists working in health field etc.)
Bodily processes producing psychological consequences
1. Studies looking at the ways in which both HEALTHY and UNHEALTHY processes may impact on psychology, including; -Psychological effects of EXERCISE - studies have demonstrated psychological benefits from variety of forms of exercise e.g. "runner's high" -Psychological impact of ILLNESS - e.g. development by Elisabeth Kubler-Ross of stage model of psychological response to terminal illness
Death in Society
1. The good news: - Since 1900 average life expectancy at birth has risen from around 45 to around 75 2. The bad news - Almost all of this is consequence of reduced infant mortality - For 40 year olds, life has increased only slightly, for 70 year olds hardly at all 3. It has been suggested that the maximum theoretical average life expectancy may be around 85 years. 4. Fairly consistent finding that women live longer - Exactly why is not clear; difference commonly around 6-10 years, although in some countries is reversed, commonly reflecting mistreatment of girl children - International study (Stanistreet, Bambra and Scott-Samuel 2006) performed stepwise MLR on mortality data from 51 countries, suggested that patriarchal attitudes in societies provided best predictor of male mortality. 5. . Among mammals, humans live longest Appears to be correlation between ratio of brain:body size and life expectancy of species
Homeostasis
1. The way in which the body keeps various systems 'matched' to each other to maintain optimal functioning. 2. Because in stress response energy is diverted specifically to certain parts of body, other parts may suffer relative deprivation.
DIRECT NEURAL AXIS
1. When a potential stressor has been recognised and signals are sent through sympathetic nervous systems to relevent end organs. 2. Provides for a rapid increase in available energy, but can be sustained for only relatively brief periods. -Stressor recognised -Signals sent through nervous system to relevant organs -Rapid increase in available energy for brief periods.
Chronic Stressor
A stressor of long term duration i.e. financial situations.
Acute Stressor
A stressor of short term duration i.e. a piece of glass in your foot.
Limits to Canon's model
Although Cannon managed to elucidate the mechanisms underlying the body's response to stress, the model has certain limitations, in particular: - Recognition that acute response to threat may also include 'freeze' as well as 'fight and flight' - Need to explore in greater detail the temporal aspects of stress response, especially distinctions between acute and long-term.
Uncontrollable stressors
Although warning of an upcoming stressor can reduce stress, vague information can make stress worse. Perceived control is only helpful when you can see how much worse things could have been; then you can feel positive about what you have controlled.
Finding Positives
Important to note that the experience may not be entirely negative: "I am seeing the world almost through a child's eyes. The details of the countryside, clumps of primroses and violets... the shape and colour of the newly opened ash branches give me great pleasure" AND "I have had experiences which I never would have had, for which I have to thank the cancer.... Humility, coming to terms with my own mortality, knowledge of my inner strength..."
Heart disease
Increased blood pressure created by chronic stress in combination with narrowing of arteries promotes ATHEROSCLEROSIS; build up of plaque (fatty deposits) on the inside walls of the arteries. Plaque accumulates, arteries narrow, heart has to work even harder to pump blood (lack of nutrients an oxygen). More damaged is dealt to the arteries cause the blood is being pumped much harder. Chronic wear and tear of the cardiovascular system can lead to things such as sudden death in an individual.
Life style can make a difference
Intensive change in diet, exercise and stress-management (meditation), and social support could help to halt the narrowing of the arteries and could even reverse atherosclerosis and minimize further damage to the heart.
Stress Response
Is the bodily changes that occur to help a person cope with a stressor; also called the 'fight-or-flight' response. 1. Stress response varies according to duration of stressor, not the type. 2. Basic role of stress response is to provide body with more resources to deal with current problem 3. As with all things, this provision of extra resources comes at a price i.e. fatigued state etc.
Secondary appraisal
Is the determination of the resources available to deal with the stressor. ("What can I do about this danger?"). After tis comes coping.
Primary appraisal
Is when an individual assesses the stimulus for the likelihood of danger. ("Am I in danger?).
Frustrations
May arise from loss of ability or, conversely, from changes in response of others despite continuing ability.
General Adaption Syndrome (GAS)
Model of stress developed by Hans Selyé in the 1950s, describing temporal sequence of body's reaction to stress in three stages: The overall stress response hat has three phases; 1. Alarm 2. Resistance 3. Exhaustion
Why health psychology?
Necessary to understand the interactions between behaviour and health, so that clinician can work to eliminate/minimize leading causes of death in society.
Work and economic factors
Some work stressor can be environmental; poor lighting, poor ventilation, noise, crowding, demand of work shifts etc. Other stressors relate to the actual job; physical and mental workload, level of perceived control over the job, time pressure. PERSONALITY: people bring their personal characteristics to work with them, and some of these can stress for both the individual and those who must interact with them.
Perceived control mismatch
When some people experience more stress when they perceive themselves as being more in control. i.e. cancer patients feeling stress from being responsible for and taking control of their medical treatment. [Perceived vs preferred].