2 DSM TERMS DSM II : Psychophysiological disorder DSM III : Psychological factors affecting physical disorderDSM IV : Psychological factors affecting medical conditions (other conditions that may be a focus of clinical attention)
3 Psychological Factors Affecting Medical Conditions DSM-IV-TR CriteriaA medical illness is present.Psychological factors have influenced the course of the condition, interfered with treatment, increased health risks, or exacerbated symptoms.
4 Stress and Health Behavioral medicine Health psychology Interdisciplinary approach involving medicine and behavioral scienceGoalsTo understand, prevent, and treat illnesses influenced by psychological factorsHealth psychologyBranch of psychology concerned with role of psychological factors in health and illnessIncludes:Stress and stress managementPrevention of diseaseCopyright 2009 John Wiley & Sons, NY
5 Konsep Stres/Apakah stres? Tidak ada definisi universal ttg stres. Definisi ttg stres berkaitan dgn bagaimana mengukurnya dan bagaimana men-treat stres tsb.- Response-based definitions- Situational definitions- Relational definitions
6 Response-based definitions The essence of stress is a particular pattern of behavioral, emotional or biological reactions to events.Tdk tgt pd peristiwanya, kalau responnya spt ini = stres, kalau tidak berespon spt itu = tdk stresHans Selye (1936): best known response-based to stressGAS (General Adaptation Syndrome):PHASE I : Alarm ReactionPHASE II : ResistancePHASE III : Exhaustion
7 Alarm reaction autonomic nervous system is activated by the stress Resistance organisms adapt to the stress through available coping mechanisms. Kalau stres terus berlanjut dan organisme tidak dapat berespon secara efektif Exhaustion organisms dies or suffer irreversible damage (Selye 1950)
8 What is stress? Selye’s General Adaptation Syndrome Stress as a responseProblem with response-focused definitions:Based on physiological and psychological responsesSimilar responses can occur to non-stressful stimulie.g., pleasurable events
9 Utk membedakan stres sebagai respon terhadap peristiwa yang mungkin atau mungkin pula tidak menimbulkan respon stres, pendekatan response-based menggunakan istilah stresor untuk peristiwa yang dapat menimbulkan respon stres.Stressor: an event that leads to stress responses.
10 What is Stress? Situational-based definitions Stress as a stimulusStressors include:Boredom, catastrophic life events, daily hassles, and sleep deprivationProblem with stimulus-focused definitionsBased on nature of stimuli rather than responseDifferences as to what constitutes a stressorMajor vs. daily hasslesAcute vs. chronic events
11 Relational definitions: Stress lies neither entirely in the event nor entirely in the person’s response, but rather in the relation between the two.Lazarus (1966)“Stress is experienced when a situation is perceived or appraised as taxing or exceeding the person’s adaptive resources”
12 Definition of StressSubjective experience of distress in response to perceived environmental problems (Lazarus, 1966)Whether event is stressful depends upon an individual’s perception or appraisalEmphasis on how we perceive or appraise the environment
13 Coping and Health Coping Two dimensions Attempts to deal with problems and negative emotions elicited by stressorsTwo dimensionsProblem-focused copingTaking action to solve problem (e.g. developing study schedule, supaya tidak menumpuk pada akhir semester)Emotion-focused copingMaking efforts to reduce negative emotional reaction (e.g. by distracting from problem: relaxing, seeking comfort from others)
14 Coping and Health Avoidance coping Involves aspects of both problem focused and emotion focused.The essence:Avoid acknowledging problem (e.g. denial)Neglecting to do anything to solve it (e.g. giving up or just wishing the problem would go away)The least effective way of coping
15 Coping and Health Effective coping varies by situation Distraction may be adaptive in some situations (chronic pain) and maladaptive in others (financial problems)
16 Coping and Health Positive emotions Provide some benefit Smiling, laughing, seeing the humor in things, finding ‘the silver lining’Can buffer or blunt the effect of stress, e.g. fewer grief related symptoms, better relationship with othersBetter health, live longer
17 Assessment of Daily Experiences (ADE) Measures the relationship between stress & healthLess reliance on retrospective reports than other measuresResponses collected at the end of each dayResults:Increases in undesirable events and decreases in desirable events precede onset of respiratory illness (Stone et al., 1987)
18 Coping Orientations to Problems Experience (COPE) Scale Measures the types of coping used to handle recent stressorsCoping methods of women with breast cancer (Carver et al., 1993)Humor linked to less distress (women who accepted their diagnoses and used humor)Avoidant coping (I try not to think about it) linked to more distress and greater progression of the disease.
19 Social Support and Health Types of social supportStructuralNetworks of social relationshipsNumber of friends, marital status, etcFunctionalQuality of social relationshipsFriends, family supportive and there when needed
20 Theories of stress-illness link Developed to understand how psychological factors such as negative emotions impact health and diseaseMost involve psychological and biological factorsDiathesis-stress modelsIndividual vulnerability to stressMuch research limited by self-report dataCopyright 2009 John Wiley & Sons, NY
21 Theories of Stress-Illness Link Stress may lead to health changes that are not directly due to biological or psychological factors but to changes in in health-related behaviors. High stress may result in:Changes in health related behaviorse.g., increased smoking, substance abuse (e.g. increased alcohol consumption) , lack of exercise, altered dietChanges in physiologye.g., cardiovascular reactivity, reduced immune system functionings
22 Biologically Based Theories Allostatic Load price paid if body must constantly adapt to stressDamage caused by prolonged exposure to stress hormones (e.g., cortisol)Impaired immune system functioningIncreased susceptibility to diseaseHigher allostatic load effects predicted greater risk for cardiovascular disease 2 years later (Seeman et al., 1997).Stress and the immune systemPsychoneuroimmunologyStudy of how psychological factors impact immune system
23 Stress and the Immune System Natural immunity the body first and quickest line of defense against infectious microorganismsConsists of macrophages (sel lekosit besar) and natural killer cells which stimulates release of cytokinesCytokinesKey elements in the immune systemTrigger fatigue, fever and HPA axis activation to fight infection. (Fever though unpleasant a sign that the body is responding as it should to infection)Excessively high levels linked to diseases in older adults
24 Stress and the Immune System Specific immunity cells that respond more slowly to infection, e.g.LymphocytesRespond more slowlyInclude T-helper and B cells.(T-helper release cytokines; B cells release antibodies that deals with specific patogens)
25 HPA axisHPA axis (hypothalamus – pituitary– adrenal cortex)Salah satu sistem neuroendokrin yang sentral untuk respon tubuh terhadap stresManifestasi stres di tubuh terlihat melalui kinerja aksis HPAPenelitian pada tikus dan primata yang mengalami trauma dini (dipisah dari ibu) menunjukkan peningkatan aksis HPA bila dihadapkan pada stres pada usia yang lebih dewasaCopyright 2009 John Wiley & Sons, NY
26 Stress and the Immune System Prenatal stress experienced by a mother can impact offspring behavior and immune system functioning (Coe & Lubach, 2005)Rhesus monkey infants, whose mothers were exposed to loud and unpredictable noise during pregnancy, showed emotion regulation difficulties.Also exhibited immune system disturbancesStress can trigger the release of cytokines such as interleukin-1 and interleukin-6, as if the body were fighting off an infection (Maier & Watkins, 1998).Inflammation and higher levels of IL-6 linked to coronary heart disease, arthritis, multiple myeloma, non-Hodgkin’s lymphoma, osteoporosis, and type 2 diabetes
27 Psychological Theories PsychodynamicAnger-in theory (Franz Alexander, 1950)Unexpressed hostility negative emotions which impact health“The various psychophysiological disorders are products of unconscious emotional states specific to each disorder”- Unexpressed anger/hostile impulses hipertension (anger-in theory)- Repressed dependency need ulcerCognitiveAppraisal of stressor is keyAppraising life events and experiences as exceeding one’s resources may be at risk for adverse health effects
28 Psychological theories Personalitypersonality traits have also been linked to immune system functioningLink between chronic negative emotion and cardiovascular diseasePredisposition to negative emotions also linked to reduced immune system functioningSlowed antibody production following a flu vaccine (Rosenkranz et al., 2003)Copyright 2009 John Wiley & Sons, NY
29 DSM IV-TRPsychological Factors Affecting Medical Conditions The presence of one or more specific psychological or behavioral factors that adversely affect a general medical condition (GMC)
30 Cardiovascular Disorders Diseases involving heart and blood circulation systemTwo cardiovascular disorders affected by stress:Essential hypertensionCoronary heart disease
31 Essential Hypertension High blood pressureIncreases risk for:Heart attack, stroke, atherosclerosis (clogged arteries)Tidak disadari silent killerEssential hypertensionNo evident biological cause90% of all hypertension is essential
32 Tekanan darah diindikasikan: Systolic pressureArterial pressure when the ventricles contract and the heart is pumping (jumlah tekanan pembuluh darah arteri ketika ventrikel berkontraksi dan jantung memompa darah)Diastolic pressureArterial pressure when the ventricles relax and the heart is resting (jumlah tekanan pembuluh darah arteri ketika ventrikel rileks dan jantung tidak memompa darah)Normal levels120 systolic80 diastolicHigh levels140 or higher systolic90 or higher diastolic
33 Etiologi: risk factors Genes substantial roleObesityExcessive intake of alcoholExcessive salt consumptionCopyright 2009 John Wiley & Sons, NY
34 Etiology: Role of Psychological Stress Real-world events (e.g., stressful interviews, natural disasters, job stress) can increase BPStressful lab tasks trigger BP increasesNegative mood induction, cold pressor test (putting a hand in cold water), giving a speech, mental arithmetic, etc.Unethical to test whether short term lab induced BP increases lead to prolonged hypertensionAmbulatory BP monitoring studies: (participants wear blood pressure cuff that takes reading as they go about their daily lives)Both positive and negative emotions linked to increases in BPParamedics high in anger and defensiveness had higher BP during stressful calls.
35 Etiology: Role of Anger Inappropriate and excessive levelsAngering easily most problematic, especially for menIn women, anger suppression, problematicType A behavior (Friedman and Rosenman)Three componentsAchievement striving/competitivenessUrgency/impatienceHostility
36 Etiology: Role of Anger CARDIA (Coronary Artery Risk Development in Young Adults) studyUrgency/impatience increased risk of developing hypertensionEspecially for menHostility increased risk for both gendersAchievement striving/competitivenessPredictor only for white menCopyright 2009 John Wiley & Sons, NY
37 Biological Risk Factors for Essential Hypertension Cardiovascular reactivity Extent to which BP and HR increase in response to stressPredicts later development of high blood pressure and increased risk of hypertensionInfluenced by heredityGenes linked to the neurotransmitter serotoninEspecially one or two long alleles in the promoter region of the serotonin transporter gene
38 Coronary Heart Disease Two formsAngina pectorisIntermittent chest pain caused by insufficient oxygen to heart (ischemia)Silent ischemiaInsufficient oxygen without painTriggered by physical exertion or stressMyocardial infarction (heart attack)Also caused by insufficient oxygen to heartTotal blockage of coronary arteryOften results in permanent heart damage
39 Table 7.2 Risk Factors for Coronary Heart Disease (CHD) AgeCigarette smokingDiabetesElevated BP or serum cholesterolAlcoholObesityLack of exerciseSex (men more likely to have CHD)
40 Etiology: Stress and Mycardial Infarction AcutePhysical exertion and episodes of angerAcute stress such as physical attackChronicMarital conflictFinancial worriesJob strainExcessive work load, lack of control over decision making, no opportunity to fully use one’s skills
41 Etiology: Other Psychological Risk Factors Type A behaviorPredicted CHD in some studies but not allBest type A predictors:Anger, hostility, cynicismAnger and hostility also related to other variables linked to CHD:Greater blood pressure reactivity to stressHigher levels of cholesterolAbnormal calcium depositsCigarette smoking and alcohol useMetabolic syndrome among adolescentsGreater activation of plateletsAnxiety and depression also linked to CHD
42 Asthma Severe constriction of the airways Biological risk factors Air passages narrowWheezing (suara ngik-ngik) and labored breathing (sesak nafas)RalesWhistling sound (rhonchi – seperti udara yg keluar dari air) on exhalationPerson feels as if they are suffocatingBiological risk factorsRespiratory infectionAllergens (zat yang menyebabkan alergi e.g. serbuk bunga)Air pollutionExerciseStressful life event and negative emotionsStress and negative emotion linked to lower peak flow and more reports of asthma symptoms.
43 Figure 7.7 Effect of Parenting Problems and Mothers’ Stress on Frequency of Asthma in Children
44 AIDS AIDS More than 25 million people worldwide have died of AIDS Acquired immunodeficiency syndromeMore than 25 million people worldwide have died of AIDSIn 2007, more than 33 million people are HIV-positiveWorldwide, women now account for nearly 50 percent of people infected with HIV
45 AIDS Prevention through behavioral change Modifying sexual practices Condom useEncouraging monogamy or reducing number of sexual partnersAbstinence only programs have not proven effective in decreasing risky behavior or reducing the risk of developing HIV.
46 AIDS Strategies for effective prevention Accurate information about HIV transmissionExplain risk factors (e.g., sharing needles)Identify cues to high-risk situations (e.g., alcohol use)Provide instruction in condom useTeach sexual assertiveness skillsHow to resist pressure to have sexCommunity efforts to make safer sex the norm
47 Gender and Health Women live longer than men Women in poorer health than menHigher rates of diabetes, lupus, arthritis, anemiaFormerly believed that estrogen protected women from cardiac diseaseHormone replacement studies fail to find reduced riskWomen less likely to exhibit Type A BehaviorNot necessarily less likely to experience angerMore likely to suppress
48 Gender and HealthGender differences in mortality decreasing. May be due to:Increasingly similar lifestylesMore women smoke and drinkLung cancer leading cause of cancer death since 1987In 2004, only one state earned a passing grade in efforts to curb smoking in womenDifferences in disease identification and treatmentLittle public awareness that cardiovascular disease is the main cause of death in womenStress test not a good predictor of heart disease risk in women, especially when no pain is presentWomen less likely to receive referral for cardiac rehab following heart attack.
49 Socioeconomic Status, Ethnicity, and Health Low SES linked to higher rates of health problems and mortality from all causesDifferences attributed to:Greater stress associated with SESEnvironmental constraintsLess access to healthy foodsMore liquor storesLess opportunity to exerciseLimited access to health servicesStress associated with discrimination and prejudice
50 Stress Management Techniques anyone can use to cope with stress Relaxation trainingMuscle relaxationDeep breathingCognitive restructuringModify maladaptive thoughtsEnhance perception of controlBehavioral-skills trainingTime management, prioritizing, assertivenessEnvironmental-changeWorkplace alterations, increase social support