1. Chapter 7 Health Psychology

2. For many years, applied (clinical) psychology was primarily concerned with treating illness. In health psychology, the primary purpose is to understand the causes of illnesses and ways to prevent them. This can be seen from the definition of Health given by the World Health Organization. Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity. The APA has added “promoting health” as a key element of it’s mission statement. Health Psychology has developed what is know as a biopsychosocial model of health and illness which recognizes the influences to different systems or perspectives. The biological influences such as genetic predispositions The behavioral or cognitive influences such as lifestyles and beliefs The sociocultural influences such as family, social support and culture.

3. Stress Stress is described as a negative emotional experience, accompanied by various physiological, cognitive, and behavioral changes. Many recognize stress as one of the leading causes of both physical and psychological problems in modern society. It has been noted however that stress seems to have a greater negative impact on some people than on others. Any adverse or challenging event, whether physiological or psychosocial, can be labeled a stressor, a cause of a stress experience. Acute stressors appear suddenly, do not last long, and call for immediate attention. The person will deal with the stress and then return to a state of homeostasis. Chronic stressors last for a long time and are a constant source of worry. This type of stress is more harmful, partially because of the hormone cortisol.

4. There are many different types of stressors. Work stressors: when the demands of the job are not matched with the persons ability to handle them. This can come from factors such as not enough time to get the job done or not having any control over how to do the job. Life events: such as getting married, changing jobs, having a kid. Actually just about anything that causes major changes in daily routines. Steptoe and Marmot, 2003 Used a sample of 227 British men and women ages 47-59. Rated them on seven stressors: job stress; environmental stress, such as neighborhood or housing; economic problems; lack of social support from relatives; loneliness; lack of feeling of control over one’s life; and lack of self-efficacy in relation to stressors. Also took blood samples and looked for physiological indicators of risk for heart problems. High ratings on only one area appeared to not be harmful, however having a high mean rating on all seven increased chances of both heart disease and depression.

5. Physiological aspects of stress Hans Selye (1956) suggested three physiological stages in the stress process and called it the general adaptation syndrome. The alarm stage: essentially the “fight or flight” response. The resistance stage: how the body attempts to reverse the effects of the alarm stage and deal with the stress. The exhaustion stage: when the person is repeatedly exposed to stressors and is no longer capable of dealing with it. Kiecolt-Glaser et al (1984) showed that people under stress have a lower T- cell count, diminishing the effectiveness of their immune system. There is also evidence that continued exposure to the hormome cortisol, released when a person is under stress, can lead to a reduced immune system and other physiological problems.

6. Cognitive Aspects of Stress Cognitive appraisal of outcomes of a disease seems to be associated with the actual outcomes. Those with a positive appraisal (more optimistic) seem to have better outcomes. HIV positive people who were pessimistic developed symptoms of AIDS quicker and died sooner. (Reed et al. 1999) Social self-preservation theory (Kemeny et al. 2005) suggests that emotions such as shame and sensitivity to rejection can lead to negative outcomes in terms of health. Psychoneuroimmunology (PNI) is based on the assumption that a persons psychological state can influence the immune system via the nervous system. It lends support to the idea that “positive thinking” can be a boost in fighting off diseases, both physical and psychological.

7. Social aspects of stress Humans are social creatures and the types of relationships we have can have a major effect on our well-being. Negative effects can be caused by stressful relationships. Abuse in the family Bullying Violent neighborhoods Positive effects can be caused by good relationships. Good friends Loving families Social support.

8. Coping and Coping Strategies Coping is defined as efforts to deal with a threat in order to remove it or diminish its impact. Folkman and Lazarus (1988) suggested two primary coping strategies. Problem-focused coping: Dealing with the stressor itself. Could be quitting a job, leaving an abusive relationship, or moving to a better neighborhood. This strategy is used primarily when a person feels in control of the stressful situation. Emotion-focused coping: Handling the emotional aspects of stress rather than changing the situation. Could be exercising, using relaxation techniques, taking drugs, or even just going to a movie or reading a book. This is used more when the situation can’t be changed, like in the death of a loved one.

9. Avoidance coping A type of emotion-focused coping where there is an attempt to avoid the negative feelings associated with the stressor. Alcohol or drug use. Sleeping Reading As you can see, some of these strategies can have negative consequences. They never get rid of the stressor, they just allow someone to ride it out. Proactive coping An action intended to avoid a stressful experience. Studying for a test Practicing for a recital Ursin and Erison (2004) found that people benefit from proactive coping and also from having a positive attitude, a belief that they can handle the stress in their lives.

10. Social support as a coping strategy Social support is the experience of being part of a social network, with mutual assistance and obligations, and the feeling that one is cared for. It can come from family, friends, co-workers, or various support groups. It can come in the form of emotional support (warmth and understanding), informational support (helping someone to understand and cope better) or practical support (tangible help such as a place to live). Taylor (2002) found that there is a gender difference in relation to social support. She found that women give more social support to others as well as seeking more social support in times of stress. She formulated what she called a theory of “tend and befriend”. Males tend to react in a “fight or flight” response to threat due to the influence of testosterone. Females tend to react in a “tend and befriend” response due to the influence of oxytocin. Several others also found these gender differences in both the giving and receiving of social support.

11. Taylor(2008) suggests that culture also plays a role in social support. He found that there was a difference in whether someone would seek social support depending on whether they came from an independent society such as in Europe and the U.S. or whether they came from an interdependent society such as many Asian cultures. Due to a concern about disruption of harmony in the group or losing face, the people from interdependent cultures are actually less likely to seek social support. Self-help groups for everything from HIV to alcoholism have become very popular in the west. Davison et al.(2000) found that white people and women are more likely to participate than non-whites or men. Internet groups have grown rapidly in the last few years. Klemm et al.(1999) found that women in these groups are more likely to provide emotional support whereas men are more likely to provide informational support. Wenzelberg et al.(2003) looked at a support group of women diagnosed with breast cancer and found that it was moderately effective in reducing perceived stress.

12. Relaxation as a Coping Strategy Autogenic relaxation: Autogenic means something that comes from within you. In this relaxation technique, you use both visual imagery and body awareness to reduce stress. You repeat words or suggestions in your mind to relax and reduce muscle tension. For example, you may imagine a peaceful setting and then focus on controlled, relaxing breathing, slowing your heart rate, or feeling different physical sensations, such as relaxing each arm or leg one by one. Progressive muscle relaxation: In this relaxation technique, you focus on slowly tensing and then relaxing each muscle group. This helps you focus on the difference between muscle tension and relaxation. You become more aware of physical sensations. One method of progressive muscle relaxation is to start by tensing and relaxing the muscles in your toes and progressively working your way up to your neck and head. You can also start with your head and neck and work down to your toes. Tense your muscles for at least five seconds and then relax for 30 seconds, and repeat.

13. Visualization: In this relaxation technique, you form mental images to take a visual journey to a peaceful, calming place or situation. During visualization, try to use as many senses as you can, including smell, sight, sound and touch. If you imagine relaxing at the ocean, for instance, think about the smell of salt water, the sound of crashing waves and the warmth of the sun on your body. You may want to close your eyes, sit in a quiet spot and loosen any tight clothing. Mindfulness-based stress reduction (MBSR): A technique developed by Kavat-Zinn at the U. Mass. Med. Center in 1979 which takes Buddhist teachings and applies them in a behavioral medicine framework. It combines meditation and yoga exercises to reach a state of relaxed “mindfulness”. That is an ability to be in the present moment without worrying about the past or future. It is an 8-week program which more than 16,000 people have completed. Shapiro et al. (1998) evaluated the program using premed students. Half of the people were put in the course and the other half were put on a “waiting list”. All were give survey about stress at the beginning of the semester and again during exam week. The results showed that though there were no differences in stress levels at the first, those who had undergone the training reported less stress and anxiety during exam week.

14. Health Psychology and Substance Abuse A substance is considered to be anything people ingest to alter mood, cognition or behavior. They include various drugs, alcohol, nicotine, even caffeine. Substance addiction implies that an individual cannot control their compulsion to use the substance and will continue to use the substance despite knowing about problems associated with its use. Psychological addiction relates to cravings. The situations associated with using the substance, as well as the individual’s moods, come to serve as triggers for the craving. Physiological addiction relates to symptoms such as tolerance and withdrawal. Though there are many substances, and even behaviors such as sex, gambling, and smart-phone use, that can become addictions, we will focus primarily on the substance abuse of nicotine.

15. Biological factors related to a smoking addiction The biological level of analysis works best to explain why smokers continue to smoke once they have started. It really is not applicable to why a smoker first starts to smoke. Nicotine, the active ingredient in tobacco, is a psychoactive drug. It increases heart rate and blood pressure by stimulating the release of adrenaline. It stimulates the release of dopamine in the brain’s reward center and gives a brief feeling of pleasure. Since this wears off quickly, it causes the person to continue to smoke to prolong the pleasure. It acts on acetylcholine receptors, as if it were the actual neurotransmitter. As a person continues to smoke, the brain adjusts by growing more acetylcholine receptors. Research shows that nicotine is as physiologically addictive as heroin and as psychologically addictive as cocaine. Research also shows that the younger a person is when they start to smoke, the more addictive the behavior is.

16. Cognitive and sociocultural factors related to a smoking addiction. These levels of analysis appear to be more related to why a person begins to smoke in the first place. Charlton (1984) found that young smokers associated smoking with fun and pleasure. The saw it as “cool”. Advertising in the U.S. used to be oriented toward making smoking look exciting to young people. Advertising on television and radio was banned in 1971. Since then, even though there isn’t a total ban in magazines and billboards, there are a number of restrictions. In other less developed countries, advertising is still aimed toward young people and associates smoking with high status and sexiness.

17. According to social-learning theory, smoking is a learned behavior. One of the most important factors in predicting smoking behavior is parental smoking. Bauman et al. (1990) found that 80 percent of adolescents aged 12-14 whose parents did not smoke had never tried smoking themselves. If the parents smoked, half of them had tried smoking. Another important factor is peer-group pressure. Unger et al. (2001) found that European American students were more likely to smoke if they had close peers who did. Asians and Hispanic students did not show this. He argued that it had to do with the culture. He said those who came from a more collectivist culture where there were stronger family influences were less likely to rebel and go along with the peer group. Social class also appears to be an important factor. At one time, smoking pre-rolled cigarettes was considered to be a status symbol. Now it is found that smoking is more common among people who live below the poverty level than those who live at or above the poverty level.

18. Prevention Strategies Many governments all over the world, especially in more developed countries, have implemented efforts to prevent people from smoking. As stated earlier, banning advertising of smoking products is one of the primary methods. Another method is to raise the cost of smoking by increasing taxes on smoking products. Another tactic is to ban smoking in public places, especially indoors. The World Health Organization (WHO), has worked hard to try to spread information about the dangers of smoking. They found that in 2008, 2 out of 3 countries have no information about tobacco use.

19. Treatments Nicotine replacement therapy: This is using nicotine gum, patches or sprays to help a person break the behavioral patterns of smoking without going into physical withdrawal symptoms. They can then be gradually tapered off. Drugs such as Zyban which act on the sites in the brain affected by nicotine. They help by relieving withdrawal symptoms and by blocking the effects of nicotine for those who relapse. Cessation programs provide information and sometimes behavior modification techniques to help a person quite. Individual programs are usually just meetings with a doctor or nurse. Group programs add an additional benefit of group therapy which supplies some accountability as well as support from those going through the same challenges. Evidence shows that a combination of these works best, but even then the percentage of those who successfully quit for a year or more is low.

20. Health Psychology and Obesity According to WHO, obesity has reached epidemic proportions globally, with the U.S. leading the way. Since 2004, obesity is affecting more people than malnutrition and hunger. Whether a person is overweight or obese is usually determined by a measure known as the body mass index (BMI). It is calculated by dividing a person’s weight in kilograms, by the square of their height in meters. (There are conversions for using pounds and inches,) A person with a BMI of over 30 is considered to be obese. A person with a BMI between 25 and 30 is considered to be overweight. There are those that argue that you have to take other factors such as body type into account.

21. Physiological aspects of obesity Genetic predisposition Stunkard et al. (1990) studied 93 pairs of identical twins reared apart. They found that 66-70 percent of variance in body weight was due to genetic factors. The speculated but with little actual evidence that this could by due to either metabolism or the number of fat cells in the body. Evolutionary explanation Some argue that humans are genetically programmed to eat food when it is available in order to store fat for leaner times. They argue that this was an advantage when we had to provide our own food through crops or hunting, since there were times of scarcity They say that the problem is that now food is relatively abundant and our lifestyles do not require us to be as physically active.

22. Sociocultural aspects of obesity Many argue that obesity rates are up due to sedentary lifestyles. They argue that we simply do not use as much energy on work and transportation as we used to. Prentice and Jebb (1995) found a positive correlation between increase in obesity and car ownership and television viewing, in the UK. Lakdawalla and Philipson (2002) estimated that 60% of total growth in weight was due to a decrease in physical activity, and 40% was due to an increase in calorie intake. Even though some argue that overeating is causing obesity, research shows that this is not true in general. Though some people are diagnosed with Binge-eating disorder (BED), that is not the norm. There are actually studies done in the UK that show that overall the amount of food be eaten has decreased. Prentice and Jebb (1995) found that it was not the amount we eat that has changed but what we eat. Calorie intake is up, despite actually eating less.

23. The fat proportion theory of obesity argues that the obese tend to eat proportionally more fat content rather than simply eating more food. Blundel et al. (1997) found that high fat eaters (more than 45% of energy came from fat content) were 19 times more likely to be obese than low fat eaters (less than 35% of their energy came from fat). Highly processed foods with high fat content are actually cheaper than healthier foods. This has lead to a health gap between people in different socioeconomic groups. Chou et al. (2004) found that wealthier people are less likely to have obesity problems. Peterson (2006) found the same thing to be true. He found that people with higher education tended to exercise more and eat healthier. He also found that they were more likely to listen to recommendations from research on how to improve health.

24. Cognitive factors related to obesity. In the West, the cultural ideal is the thin body, especially among females. This has lead to many women with a negative self body image, which in turn has lead to dieting. People who diet replace physiological hunger sensations with “cognitive restraint”, meaning they put a limit on what they can eat. Cognitive restraint theory holds that dieting in itself can lead to obesity, especially when there is extreme cognitive restraint and the diets lead to extremely low calorie intake. This theory holds that extreme restraint leads to the false hope syndrome. The diet does not make them lose as much or as quickly as they thought it would so they tend to give up and lose control. Many obese people are chronic serial dieters. This often leads to breaking the diet due to extreme hunger and developing the “what the hell effect”, where they slip and then overindulge.

25. Treatments Modern approaches to treatment of obesity are psychosocial in nature, recognizing that obesity is a complex condition with many causes. The try to combine diet with information about healthy living, exercise, cognitive restructuring, and relapse prevention. Blair-West (2007) suggests that dieting should be based on research and has set up a new treatment program in Australia that includes: Realistic goal setting: Weight loss of about 8% of body weight in a year. The goal should be on long term weight loss and maintenance rather than achieving big results quickly. Low-sacrifice diet: People should not try to give up all their favorite foods, just try to eat less of them if they have high fat content. They should learn to slow down and be mindful of what they are eating and savor the ones they love. Physical activity: The form does not matter, just increase it gradually, doing things you enjoy. Information: People should search out information about the dangers of being overweight and the health benefits of losing weight.

26. Cognitive-behavioral therapy (CBT): emphasizes the importance of targeting those thoughts and beliefs that prevent a patient form losing weight. They focus on the patients “permission giving beliefs”, for example, saying to yourself that it’s ok to eat because you’re upset or you are celebrating something. Stahre et al.(2007) conducted a study evaluating CBT and found that it was both effective and cost efficient. Dieting has not been found to be effective. Most research shows that weight loss from dieting is almost always followed by weight gain. Drug treatments: designed for short term use in combination with lifestyle changes. Appetite suppressants: increase the levels of neurotransmitters that effect mood and appetite. There is some evidence for the effectiveness, but they usually have side effects. Lipase inhibitors: reduce fat absorption. Unpleasant side effects are common.

27. Surgical treatments: can be used for severe obesity. Gastric banding involves putting a band around the upper part of the stomach. Gastric bypass is actually cutting off part of the stomach, often using stapling. The patients feel full sooner and therefore eat less. Maggard et al. (2005) performed a meta analysis on 147 studies and found them both to be effective, with bypass being more efficient overall than banding. Found that most people lost weight and kept it off for over 10 years with a general improvement in health. Overall, for all but the severely obese, it appears that lifestyle adjustment is the best method for controlling weight problems. Rather than dieting, one should adjust their diet to include more healthy food and at the same time increase exercise.

28. Health Promotion Most intervention and prevention programs are based on the idea that in order to change or influence peoples behaviors, you have to look at their attitudes and beliefs. Quite often this comes down to looking at their decision-making process. There are two primary theories on decision making that have influenced prevention and intervention strategies. The health belief model (HBM) The stages of change theory

29. The Health Belief Model This model was first developed by Rosenstock in 1974 and is one of the oldest social cognition models. It predicts that a person will change their behavior if they think that a negative health problem, like cancer, can be avoided by taking a recommended action, and that they will be successful. It assumes that people are rational and that there are a couple of factors that will influence their decision. The evaluation of threat or perceived vulnerability, meaning they have to see the negative outcome as having a real possibility of happening to them. Knowing that you can get cancer from smoking may be real, but if you think you haven’t been smoking long enough for it to happen, then it may not alter your behavior. Actually waking up and coughing up some funky stuff could make you take it more seriously. Cost-benefit analysis: Does the increased cost of eating healthy foods outweigh the benefits? Is it just too difficult to exercise since you are so out of shape? Is riding around smoking with your friends more important than the health benefits of quitting? Self-efficacy beliefs are important in this model. If you believe you will be successful, you are more likely to change your behavior.

30. Problems with the HBM It is focused on individual cognitions and does not take into account emotional, social or economic factors. It assumes people are rational, which is not always the case. People are often over optimistic about their health. Weinstein (1987) showed that people often rated their risk of developing disorders as lower than other people’s. He suggest several reasons for this. A tendency to believe that if a problem hasn’t happened yet, that it probably won’t. A tendency to believe that the problem is more rare than it actually is. A tendency to believe that if the problem arises, they can take some personal action then to alleviate it. A tendency to dismiss a problem that they have had little or no experience with. Cognitive dissonance can get in the way. A person who enjoys smoking will pay less attention to the health risks and more to the idea that it helps them relax. Certain foods may provide emotional comfort and therefore the person will discount or avoid information on the negative effects of eating that food.

31. Stages of Change Model Prochaska et al. (1982) studied 872 smokers who had given up smoking. They found 5 stages of change which highlighted to process of changing the behavior. They also said that the process was not linear, but involved shifting across the stages. Precontemplation: the person is not seriously considering a behavior change. Contemplation: the person recognizes that there is a problem but is not committed to change. Preparation: The person is seriously considering making a change and may be taking steps toward it. Action: The person is making the behavioral change. Maintenance: The person works to maintain the behavior change and avoid relapse. When using this model to predict success, it was found that both for smoking and weight loss, being in the preparation stage was a good indicator.

32. West and Sohal (2006) challenged this model. They looked at people who had just quit without any kind of plan and compared them to those who had set out to quit. They found that people who had just spontaneously quit were more likely to stay quit for at least 6 months than for those who had planned to quite. They called this “catastrophe theory” saying that people are more likely to react to a cue in the environment and decide to stop at once.

33. Health Promotion Strategies. The goal of health promotion strategies is to enhance good health and prevent illness. They try to help people increase control over and improve their own health. The primary health promotion campaigns try to: Raise awareness about heath risks and encourage changes in behavior. Change beliefs, attitudes and motivations. Change the environment; more stairs, less escalators, more exercise facilities. Provide public and private health services to help people change. Political action such as legislating more exercise time in school and changing food options in cafeterias.

34. Evidence on Effectiveness of Health Campaigns Holm (2002) looked at the effectiveness of campaigns in Denmark to influence food choices and found them to be effective as part of an overall health campaign. He found that they must address three levels: What the individual can do What can be done on the community level What should be done by the government. TRUTH, and anti-tobacco campaign in Florida in 1998-99. A massive campaign whose primary goal was to get young people to form groups and become involved in spreading the message that tobacco companies were manipulating young people in order to get them addicted to tobacco. Sly et al (2002) did a follow up study and found that the more a person was exposed to the main message, the more likely they were to stay quit.