1. Module: Health Psychology Lecture:Stressful medicine Date:09 March 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: C.Bridle@warwick.ac.uk www.warwick.ac.uk/go/hpsych

2. Aims and Objectives Aim: To provide an overview of the psychological aspects of stress and coping Objectives: You should be able to describe … the psychological and physiological effects of stress and their underlying mechanisms of action the main perspectives on stress, i.e. response, stimulus and process the psychological antecedents of stress and stressors common to the clinical context ideas for removing or reducing the negative impact of stressors among patients

3. Psychological Appraisal Health-Related Behaviour Physiological Reactivity Acute & Chronic Stress Indirect Path Factors: Background Stable Social Situational Direct Path Dual Pathway Model: From Psychology to Physiology

4. What are the Effects of Stress? Four classes of effect Affective: shock, distress, anxiety, fear, depression, anger, frustration, lowered self-esteem, learned helplessness, guilt Behavioural: smoking, alcohol, helpseeking delay, poor adherence, relapse, social withdrawal, illicit drugs, risky sexual behaviours Cognitive: poor attention, errors in decision-making, hypervigilance for threats, bias to interpret ambiguous events as threatening, mood-consistent memory Physiological: activation of nervous system, hormone production, metabolic function, immune function, fatigue, disease and illness

5. Physiological Effect: Immune Dysregulation Down-regulation by stress Medical students, battery of measures obtained before, during and after exam period (+ 1 month) Higher pre-exam stress scores associated with lower post-exam NK cells higher urinary cortisol Up-regulation by stress reduction intervention Older population, protocol assessment schedule from previous study 2 hour imagery-based relaxation intervention 30% increase in NK cell activity compared to control (Kiecolt-Glaser et al., 1984) (Kiecolt-Glaser et al., 1985) A psychological process (stress) can down-regulate immune response, and a psychological intervention can enhance immunocompetence

6. Physiological Effect: Pharmacological Response Stress alters response to viral and bacterial vaccines, including respiratory viruses, hepatitis-B, and influenza An example: Adult participants provide a range of stress-related data, e.g. questionnaires and biological samples Baseline antibodies measured and influenza vaccine delivered Follow-up measures of antibodies at 1 and 4 months Does stress attenuate antibody response at follow-up? (Miller et al., 2004) YES: stressed people had significantly fewer antibodies Interestingly, in this study perceived stress at baseline was a better predictor of subsequent antibody response!

7. Physiological Effect: Stressed In-Patients On the ward Slower wound healing More post-surgery complications Longer in-patient stay More staff time per day More analgesia use Less satisfaction with treatment - associated with poor adherence After discharge Longer recovery, e.g. return to work More service use, e.g. related symptoms Less use of rehabilitation services Increased risk of co- morbidity and early mortality Stress not only increases risk of illness among the healthy, but also impedes recovery / worsens prognosis among the ill

8. Understanding Stress Three perspectives to understand stress: Response:Focus on the effect (physiological) Stimulus:Focus on the cause (stressor) Process: Focus on the person-environment interaction (transaction)

9. Physiological Response to Stress: Fight or Flight to Feed and Breed Sympathetic NS Acute Stress Response Increased Decreased cardiac rate, BP, respiration rate, glycogenolysis, peripheral diversion of blood catecholamines and cortisol immune surveillance, gut function, kidney function, fat stores, sex steroids Parasympathetic NS Conservation Response Decreased Increased Central Nervous System Biomarkers (Cannon, 1914)

10. (Hans Selye, 1956) Stress is a non-specific physiological response to a threat to one’s physical or emotional well-being Three stages of physiological response: Alarm: fight or flight response - nervous, endocrine and immune systems activated for defence against threat Resistance: conservation response initiated to return homeostasis, but becomes counterproductive if alarm continues Exhaustion: depletion of physiological resources - collapse of adaptive responses, immune failures and disease outcomes General Adaptation Syndrome (GAS)

11. Sympathetic Parasympathetic STRESS Acute Physiological Response to a Stressor … then a parasympathetic response to restore homeostasis Homeostasis What happens if the 'acute' stress response continues?

12. Sympathetic Parasympathetic Chronic Stress GI: ulcers, IBS, esophageal reflux; RS: amenorrhea, impotence; ReS: asthma, hyperventilation; CV: essential hypertension, migraine, Raynaud’s disease; Drm: eczema, acne, psoriasis; IS: tissue rejection, infection; Psy: cognitive impairment, low self-efficacy & self-esteem, anxiety, learned helplessness Slower recovery from sympathetic NS arousal, leads to the break down of adaptive systems: Homeostasis

13. Stress as a Non-Specific Physiological Response Focus on the physiological effects of stress helps us understand how stress influences health Important starting point but an insufficient explanation i.e. tells us nothing about the cause of stress Should we focus on the threatening stimulus as a way of understanding stress?

14. Stress as a Threatening Stimulus Social Readjustment Rating Scale (SRRS) 43 life events, e.g. divorce, marriage, job loss, etc. Each event ranked, relative to one another, on the degree of adjustment that would be required of the average person in order to adapt Rank used to quantify the degree of threat associated with each event, i.e. Life Change Units (LCUs) SRRS score is the LCU-total based on event exposure during past 12 months LCUs hypothesised to be positively related to illness (Holmes & Rahe, 1967)

15. Life Change Units and Disease (Holmes & Rahe, 1967) Life Change Units (Baseline) % People with Illness (2 Years) SRRS scores associated with subsequent illness Replicated many times – modest relationship Most prognostic value for SRRS scores >200 Score classification: Low < 149 Mild = 150-200 Mod = 200-299 Major >300

16. Top 10 Stressful Life Events LCUs 1. Death of a spouse 100 2. Divorce 73 3. Marital Separation 65 4. Jail term 63 5. Death of close family member 63 6. Personal injury or illness 53 7. Marriage 50 8. Fired at work 47 9. Marital reconciliation 45 10. Retirement 45 Other SLEs 13. Sexual difficulties 39 23. Son/daughter leaving home 29 30. Trouble with boss 23 38. Change in sleeping habits 16 43. Minor violation of laws 11 SRRS: Example life events with LCUs What life event would top your list of stressors? Is it in the SRRS? Is any event ‘obviously’ ranked incorrectly? Which one(s)? What does that say about ‘stress as a stimulus’?

17. Types of Stressor Stressors differ along a range of dimensions: Chronicity: discrete sudden traumas to continuous chronic stressors, e.g. car accident and diabetes Magnitude: life changing events to daily hassles, e.g. getting married / divorced and car parking at WMS Inclusiveness: individuals to societies, e.g. driving test and 11 September

18. Stress as a Threatening Stimulus Focus on the stimuli neglects the individual, i.e. the same SLE will be equally stressful for different people and equally stressful for the same people across time and repeated exposure Stress responses vary not only between people, but within people also, and in response to not only different events, but to the same event as well Is stress better understood as a subjective process?

19. Stress as a Subjective Process Stimulus Event Stress Response Stimulus Event Stress Response Appraisal & Coping A static, direct effect ? An indirect subjective process

20. Stimulus Event (a potential stressor) Primary Appraisal (event demands) Secondary Appraisal (oneself) Response (Coping) Health-Related Outcome (Stress) Transactional Model of Stress (Lazarus & Folkman, 1984) Causal chain of influence Stimulus events indirectly related to stress experience Processes of appraisal and coping intervene in the stressor-stress relationship Stress as a subjective post- appraisal outcome Input Intervening Processes Output

21. Intervening Processes Primary appraisal: Determines the adaptational significance of the event, i.e. is the event relevant and, if so, is it a challenge, harm or threat? Secondary appraisal: Evaluates available response options and opportunities, i.e. am I able to cope adequately with the event's adaptational demands? Coping: Cognitive and behavioural activities initiated in response to the appraisal process in order to manage the adaptational demands of the event What factors influence appraisal outcomes? You know the answer to this question already!

22. Appraisal Influences Factors influencing appraisal: Background: historical and current life context, e.g. culture, S-E-S, housing, marital stability, general health Stable: relatively enduring individual differences, e.g. emotional disposition, expectancies, explanatory styles Social: perceptions of supporting relationships, e.g. social support, identification, integration Situational: characteristics of the event, e.g. control, predictability, time since onset, novelty

23. Situational Characteristics FavourableHospitalisation*Additional ControllabilityLoss of controlIllness concerns PredictabilityUncertaintyTreatment worries Social SupportIsolationUncertain Prognosis Peripheral DomainCentral DomainFear of pain FamiliarityUnfamiliarityWorried about family AutonomyDependenceIndignity Sense of SelfComplianceAnger * or treatment, becoming ill, seeking help, etc. From a psychological perspective, going to hospital* is a huge stressor

24. Coping Coping can usefully be hierarchically ordered Activities: any and all cognitions and behaviours directed towards the management of stressor demands, e.g. Gathering relevant information, or Going to the pub Strategies: related coping activities clustered into meaningful groups, e.g. Planning, or Mental disengagement Dimensions: related strategies clustered into one of two inclusive dimensions according to focus, e.g. problem- focussed coping and emotion-focussed coping

25. Effects of Coping Coping changes the situation Directly: alters concrete aspect of the stressor context Indirectly: alters the way the situation is perceived Stimulates (re)appraisal of the ‘new’ situation Primary appraisal: challenge, harm or threat? Secondary appraisal: can I respond effectively? Evaluation of coping based on relative demands Adaptive: contributes to resolving demands Maladaptive: may or may not be effective in the short term, but contributes to, or creates, future demands

26. Coping Effectiveness Problem-focused coping: Attempts to manage or change concrete aspects of the stressor Emotion-focused coping: Attempts to remove or reduce the stressor's emotional distress Problem-focussed coping most effective when the stressor is amenable to change Emotion-focussed coping most effective when the stressor can not be changed Flexible coping likely the most effective, but often difficult in practice Effectiveness dependent on situational characteristics of the stressor Heuristic

27. Transactional Model Potential Stressor Primary Appraisal Secondary Appraisal Coping Health-Related Outcome Is the event relevant to me and, if so, what are its demands? Can I deal with the demands of the event? Problem- and / or Emotion- Focused Stable Factors Situational Factors Stimulus Event Psychological and / or Physical Social Factors Background Factors (Lazarus & Folkman, 1984)

28. Conclusions Stress has negative implications for both psychological and physical health Illness is inherently stressful, whilst treatment referral compounds the experience The harmful effects of stress can be avoided, removed or reduced in advance Transactional model provides an organising framework Proactive early intervention will enhance clinical effectiveness and patient health outcomes

29. Summary This session would have helped you to understand … the psychological and physiological effects of stress and their underlying mechanisms of action the main perspectives on stress, i.e. response, stimulus and process the psychological antecedents of stress and stressors common to the clinical context ideas for removing or reducing the negative impact of stressors among patients referred for treatment

30. Any questions? What now? Revision planning … … if you haven’t started already Before next week, let me know any broad areas of particular weakness / concern Next week’s session will provide a framework for revision