1. Chapter 11: Health Psychology – Stress, Coping, and Well-Being
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2. Health Psychology
Investigates the psychological factors related to wellness and illness, including the prevention, diagnosis, and treatment of medical problems
Psychoneuroimmunology
The study of the relationship among psychological factors, the immune system, and the brain
Health psychology investigates the psychological factors related to wellness and illness, including the prevention, diagnosis, and treatment of medical problems. Health psychologists consider questions about the ways in which illness is influenced by psychological factors such as the experience of stress. They examine the psychological principles underlying treatments for disease and illness. They are also concerned with issues of prevention: how health problems such as heart disease and stress can be avoided by more healthful behavior.In their view, the mind and body are clearly linked, rather than representing two distinct systems.
Health psychologists recognize that good health and the ability to cope with illness are affected by psychological factors such as thoughts, emotions, and the ability to manage stress. They have paid particular attention to the immune system, the complex of organs, glands, and cells that constitute our body’s natural line of defense in fighting disease.
In fact, health psychologists are among the primary investigators in a growing field Psychoneuroimmunology (PNI) It is the study of the relationship among psychological factors, the immune system, and the brain. PNI has led to discoveries such as the existence of an association between one’s emotional state and the success of the immune system in fighting disease .
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3. Stress and Coping Stress Psychophysiological disorders
The response to events that threaten or challenge a person
Psychophysiological disorders
Medical problems that are influenced by an interaction of psychological, emotional, and physical difficulties
stress, the response to events that threaten or challenge a person. Whether it be a paper or exam deadline, a family problem, or even a cumulative series of events such as those faced by Tara Knox, life is full of circumstances and events, known as stressors, that produce threats to our well-being. Even pleasant events—such as planning a party or beginning a sought-after job—can produce stress, although negative events result in greater detrimental consequences than positive ones.
psychophysiological disorders are actual medical problems are influenced by an interaction of psychological, emotional, and physical difficulties. Among the common psychophysiological disorders are headaches, skin problems, and high blood pressure.
On a psychological level, high levels of stress prevent people from adequately coping with life. Their view of the environment can become clouded (e.g., a minor criticism made by a friend is blown out of proportion). Moreover, at the greatest levels of stress, emotional responses may be so extreme that people are unable to act at all. People under a lot of stress also become less able to deal with new stressors. The ability to contend with future stress, then, declines as a result of past stress.
In short, stress affects us in multiple ways. It may increase the risk that we will become ill; it may directly produce illness; it may make us less able to recover from a disease; and it may reduce our ability to cope with future stress.
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4. The General Adaptation Syndrome
Alarm and mobilization stage
Become aware of the presence of a stressor
Resistance stage
Preparation to fight the stressor
Exhaustion stage
Negative consequences of the stress appear
The effects of stress are illustrated in a model devised by Hans Selye called the general adaptation syndrome (GAS) It suggests that the same set of physiological reactions to stress occurs regardless of the particular cause of stress.
The first stage, the alarm and mobilization stage, occurs when people become aware of the presence of a stressor. On a biological level, the sympathetic nervous system (Chapter 3) becomes energized, helping to cope initially with the stressor.
if the stressor persists, people move into the next stage of the model. In the resistance stage, people prepare themselves to fight the stressor. During resistance, people use a variety of means to cope with the stressor—sometimes successfully—but at a cost of some degree of physical or psychological general well-being.
If resistance is inadequate, people enter the last stage of the model, the exhaustion stage. During the exhaustion stage, a person’s ability to adapt to the stressor declines to the point where negative consequences of stress appear: physical illness, psychological symptoms in the form of an inability to concentrate, heightened irritability, or, in severe instances, disorientation and a loss of touch with reality. In a sense, people wear out, and their physical reserves are taxed to the limit.
The GAS model has had a substantial impact on our understanding of stress. By suggesting that the exhaustion of resources in the third stage of the model produces biological damage, it has provided a specific explanation of how stress can lead to illness. Furthermore, the model can be applied to both people and nonhuman species.
Contemporary health psychologists specializing in PNI have taken a broader approach than the GAS. Focusing on the outcomes of stress, they have identified three main consequences. First, stress has direct physiological results, including an increase in blood pressure, increased hormonal activity, and an overall decline in the functioning of the immune system. Second, stress leads people to engage in behavior that is harmful to their health, including increased nicotine, drug, and alcohol use, poor eating habits, and decreased sleep. Finally, stress produces indirect consequences that result in declines in health: a reduction in the likelihood of obtaining health care and decreased compliance with medical advice when it is sought.
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5. Categorizing Stressors
Cataclysmic events
Strong stressors that occur suddenly and typically affect many people simultaneously
Post-traumatic stress disorder (PTSD)
Phenomena where victims of major catastrophes re-experience the original event and the associated feelings in vivid flashbacks or dreams
Cataclysmic events are strong stressors that occur suddenly and typically affect many people simultaneously. Disasters such as tornadoes and plane crashes are examples of cataclysmic events that can affect hundreds or thousands of people simultaneously.
Although it might seem that cataclysmic events would produce potent, lingering stress, in many cases this is not true. In fact, cataclysmic events may produce less stress in the long run than events that are initially not as devastating. One reason is that cataclysmic events have a clear resolution. Once they are over and done with. Moreover, the stress induced by cataclysmic events is shared by others who have also experienced the disaster.
On the other hand, some victims of major catastrophes can experience posttraumatic stress disorder or PTSD, in which the original events and the feelings associated with them are experienced again in vivid flashbacks or dreams. Depending upon what statistics one accepts, between 5 and 60 percent of the veterans of the Vietnam War suffer from PTSD. Furthermore, those who have suffered child abuse or rape, rescue workers facing overwhelming situations, or victims of any sudden natural disaster or accident that produces feelings of helplessness and terror may suffer from the same disorder.
Symptoms of posttraumatic stress disorder include reexperiencing the event, emotional numbing, sleep difficulties, problems relating to others, alcohol and drug abuse, and—in some cases—suicide. For instance, the suicide rate for Vietnam veterans is as high as 25 percent higher than for the general population.
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6. Categorizing Stressors
Personal stressors
Major life events that produce an immediate major reactions that soon tapers off
Background stressors (daily hassles)
Minor irritations of life that we all face time and time again
Uplifts
Minor positive events that make one feel good
Personal stressors include major life events such as the death of a parent or spouse, the loss of one’s job, a major personal failure, or a diagnosis of a life-threatening illness. Typically, personal stressors produce an immediate major reaction that soon tapers off.
In some cases, though, the effects of stress are lingering. Victims of rape sometimes suffer consequences long after the event, facing major difficulties in adjustment.
Standing in a long line at a bank and getting stuck in a traffic jam are examples of the third major category of stressor: background stressors or, more informally, daily hassles. These are the minor irritations of life that we all face time and time again: delays, noisy cars and trucks, broken appliances, other people’s irritating behavior, and so on. Another type of background stressor is a long-term, chronic problem, such as experiencing dissatisfaction with school or job, being in an unhappy relationship, or living in crowded quarters without privacy (Lazarus & Cohen, 1977; van Eck, Nicolson, & Berkhof, 1998).
The flip side of hassles are uplifts, those minor positive events that make one feel good—even if only temporarily. As indicated in Figure 15-3, uplifts range from relating well to a companion to finding one’s surroundings pleasing. What is especially intriguing about uplifts is that they are associated with people’s psychological health in just the opposite way that hassles are: The greater the number of uplifts experienced, the fewer the psychological symptoms people later report.
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7. Learned Helplessness
A point when people conclude that unpleasant or aversive stimuli cannot be controlled
A view of the the world that becomes so ingrained that they cease trying to remedy the aversive circumstances
According to psychologist Martin Seligman, learned helplessness occurs when people conclude that unpleasant or aversive stimuli cannot be controlled—a view of the world that becomes so ingrained that they cease trying to remedy the aversive circumstances, even if they actually can exert some influence.
Take, for example, what often happens to elderly persons when they are placed in nursing homes or hospitals. One of the most striking features of their new environment is that they are no longer independent: They do not have control over the most basic activities in their lives. It is not hard to see how this loss of control can have negative effects upon people suddenly placed, often reluctantly, in such a situation.
The results of this loss of control and the ensuing stress are frequently poorer health and even a likelihood of earlier death.
Other research confirms that learned helplessness has negative consequences, and not just for elderly people. People of all ages report more physical symptoms and depression when they perceive that they have little or no control than when they feel a sense of control over a situation (Rodin, 1986; Joiner & Wagner, 1995; Shnek et al., 1995).
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8. Coping with Stress Coping Defense mechanisms
The efforts to control, reduce, or learn to tolerate the threats that lead to stress
Defense mechanisms
Reactions that maintain a person’s sense of control and self-worth by distorting or denying the actual nature of the situation
Emotional insulation
Cessation of emotional experience
The efforts to control, reduce, or learn to tolerate the threats that lead to stress are known as coping. We habitually use certain coping responses to help ourselves deal with stress. Most of the time, we’re not aware of these responses—just as we may be unaware of the minor stressors of life until they build up to sufficiently aversive levels (Snyder, 1999).
One means of dealing with stress that occurs on an unconscious level is the use of defense mechanisms. As we discussed in Chapter 14, defense mechanisms are reactions that maintain a person’s sense of control and self-worth by distorting or denying the actual nature of the situation. For example, one study examined California students who lived in dormitories close to a geological fault. Those who lived in dorms that were rated as being unlikely to withstand an earthquake were significantly more likely to doubt experts’ predictions of an impending earthquake than those who lived in safer structures (Lehman & Taylor, 1988).
Another defense mechanism used to cope with stress is emotional insulation, in which a person stops experiencing any emotions at all, thereby remaining unaffected and unmoved by both positive and negative experiences. The problem with defense mechanisms, of course, is that they do not deal with reality but merely hide the problem.
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9. Coping with Stress Emotion-focused coping Problem-focused coping
Method of managing emotion in the face of stress by seeking to change the way they feel or perceive a problem
Problem-focused coping
Attempts to modify the stressful problem or source of the stress
People also use other, more direct and potentially more positive means for coping with stress. Specifically, coping strategies fall into two categories: emotion-focused coping and problem-focused coping. In emotion-focused coping, people try to manage their emotions in the face of stress, seeking to change the way they feel or perceive a problem. Examples of emotion-focused coping include such strategies as accepting sympathy from others or looking at the bright side of a situation. In contrast, problem-focused coping attempts to modify the stressful problem or source of the stress. Problem-focused strategies lead to changes in behavior or to the development of a plan of action to deal with stress. Starting a study group to improve poor classroom performance is an example of problem-focused coping.
In most stressful incidents, people employ both emotion-focused and problem-focused strategies. However, they use emotion-focused strategies more frequently when they perceive circumstances as being unchangeable, and problem-focused approaches more often in situations they see as relatively modifiable (Lazarus, 1999; Stanton & Franz, 1999; Folkman & Moskowitz, 2000).
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10. Coping with Stress Hardiness Social support
Personality characteristic associated with a lower rate of stress-related illness
Commitment
Challenge
Control
Social support
A mutual network of caring, interested others
Most of us cope with stress in a characteristic manner, employing a coping style that represents our general tendency to deal with stress in a specific way.
Among those who cope with stress most successfully are people with the coping style of hardiness, a personality characteristic associated with a lower rate of stress-related illness. It consists of three components :
Commitment. Commitment is a tendency to throw ourselves into whatever we are doing with a sense that our activities are important and meaningful.
Challenge. Hardy people believe that change, rather than stability, is the standard condition of life. To them, the anticipation of change serves as an incentive rather than a threat to their security.
Control. Hardiness is marked by a sense of control—the perception that people can influence the events in their lives.
Hardy individuals approach stress in an optimistic manner and take direct action to learn about and deal with stressors, thereby changing stressful events into less threatening ones. As a consequence, hardiness acts as a defense against stress-related illness.
Researchers have found that social support, the knowledge that we are part of a mutual network of caring, interested others, enables us to experience lower levels of stress and to be better able to cope with the stress we do undergo.
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11. The A’s and B’s of Coronary Heart Disease
Type A behavior pattern
Individuals that are competitive, show a continual sense of urgency about time, are aggressive, exhibit a driven quality regarding their work, and are hostile both verbally and nonverbally
Type B behavior pattern
Individuals who are more cooperative, far less competitive, not especially time-oriented, and not usually aggressive, driven, or hostile
Type A individuals are competitive, show a continual sense of urgency about time, are aggressive, exhibit a driven quality regarding their work, and are hostile, both verbally and nonverbally—especially when interrupted while trying to complete a task. On the other hand, people who show the Type B behavior pattern are more cooperative, far less competitive, not especially time-oriented, and not usually aggressive, driven, or hostile. Although people are typically not “pure” Type A’s or Type B’s, showing instead a combination of both behavior types, they generally do fall into one or the other category (Rosenman, 1990; Strube
The importance of the Type A behavior pattern lies in its links to coronary heart disease. Studies have found that men who display the Type A pattern develop coronary heart disease twice as often and suffer significantly more fatal heart attacks compared with those classified as having the Type B pattern. Moreover, the Type A pattern predicts who is going to develop heart disease at least as well as—and independently of—any other single factor, including age, blood pressure, smoking habits, and cholesterol levels in the body
It’s important to keep in mind that not everyone who displays Type A behaviors is destined to have coronary heart disease. For one thing, a firm association between Type A behaviors and coronary heart disease has not been established for women; most findings pertain to males, not females. Furthermore, the evidence relating Type A behavior and coronary heart disease is correlational. Consequently, as we first discussed in Chapter 2, we cannot say for sure whether Type A behavior causes heart disease or whether, instead, some other factor causes both heart disease and Type A behavior. In fact, rather than focusing on Type A behavior as the cause of heart disease, it may make more sense to ask whether Type B behavior prevents heart disease (Powell et al., 1993; Orth-Gomér, Chesney, & Wenger, 1996).
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12. Psychological Aspects of Cancer
Emotional response
Optimism
Although a diagnosis of cancer is not as grim as you might at first suspect—several kinds of cancer have a high cure rate if detected early enough—cancer remains the second leading cause of death after coronary heart disease. The precise trigger for the disease is not well understood, but the process by which cancer spreads is straightforward. Certain cells in the body become altered and multiply rapidly and in an uncontrolled fashion. As these cells grow, they form tumors, which, if left unchecked, suck nutrients from healthy cells and body tissue, ultimately destroying the body’s ability to function properly.
Although the processes involved in the spread of cancer are basically physiological in nature, accumulating evidence suggests that the emotional responses of cancer patients to their disease may have a critical effect on its course. For example, one experiment found that people who adopt a fighting spirit are more likely to recover than those who pessimistically suffer and resign themselves to death.
The results suggested that the survival rates were related to the psychological response of the women three months after surgery In sum, according to this study, cancer patients with a positive attitude were more likely to survive than those with a more negative one.
Despite the contradictory evidence, health psychologists believe that patients’ emotions may at least partially determine the course of their disease. For example, psychologists specializing in psychoneuroimmunology (PNI) suggest that a patient’s emotional state affects the immune system, the body’s natural defenses that fight disease. Our bodies produce lymphocytes, specialized white blood cells that fight disease, at an extraordinary rate—some 10 million every few seconds—and it is possible that emotions affect this production. In the case of cancer, for instance, it is possible that positive emotional responses may help generate specialized “killer” cells that help to control the size and spread of cancerous tumors. Conversely, negative emotions may suppress the ability of the same kinds of cells to fight tumors (Andersen, Kiecolt-Glaser, & Glaser, 1994; Seligman, 1995; Schedlowski & Tewes, 1999).
Other research suggests that “joy”—referring to mental resilience and vigor—is related to the likelihood of survival of patients with recurrent breast cancer. Similarly, cancer patients who are characteristically optimistic report less distress throughout the course of their treatment (Levy et al., 1988; Carver et al., 2000).
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13. smoking Heredity factors Rite of passage Habit forming Quitting
Replacement therapies
Psychotherapy
Societal views
Smoking is the greatest preventable cause of death in the United States. Worldwide, three million people die prematurely each year due to the effects of smoking. Surveys show that most smokers agree with the statement “Cigarette smoking frequently causes disease and death.” And almost three-quarters of the 48 million smokers in the United States say they would like to quit.
Heredity seems to determine, in part, whether people will become smokers, how much they will smoke, and how easily they can quit. Genetics also influences how susceptible people are to the harmful effects of smoking. For instance, there is an almost 50 percent higher rate of lung cancer in African-American smokers than in white smokers. This difference may be due to genetically produced variations in the efficiency with which enzymes are able to reduce the effects of the cancer-causing chemicals in tobacco smoke
On the other hand, although genetics plays a role in smoking, most research suggests that environmental factors are the primary cause of the habit. Smoking at first may be seen as “cool” or sophisticated, as a rebellious act, or as facilitating calm performance under stressful situations In addition, smoking a cigarette is sometimes viewed as a “rite of passage” for adolescents, undertaken at the urging of friends and viewed as a sign of growing up
Ultimately, smoking becomes a habit. People begin to label themselves smokers, and smoking becomes part of their self-concept. Ultimately, a complex relationship develops among smoking, nicotine levels, and the smoker’s emotional state, in which a certain nicotine level becomes associated with a positive emotional state. As a result, people smoke in an effort to regulate both emotional states and nicotine levels in the blood
Because smoking has both psychological and biological components, few habits are as difficult to break. Among the most effective tools for ending the smoking habit are drugs that replace the nicotine found in cigarettes. Another approach is exemplified by the drug Zyban, which, rather than replacing nicotine, raises dopamine levels in the brain, thereby reducing the desire to smoke.
Behavioral strategies, which view smoking as a learned habit and concentrate on changing the smoking response, can also be effective. Initial “cure” rates of 60 percent have been reported, and one year after treatment more than half of those who quit have not resumed smoking. Counseling, either individually or in groups, also increases the rate of success in breaking the habit. The best treatment seems to be a combination of nicotine replacement and counseling. What doesn’t work? Going it alone: Only 5 percent of smokers who quit cold-turkey on their own are successful
In the long term, the most effective means of reducing smoking may be changes in societal norms and attitudes toward the habit. For instance, many cities and towns have made smoking in public places illegal, and legislation banning smoking in such places as college classrooms and buildings—based on strong popular sentiment—is being passed with increasing frequency.
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14. Well-Being and Happiness
Subjective well-being
Person’s evaluations of their life, in terms of both their thoughts and emotions
Characteristics
High self-esteem
Sense of control
Optimism
Sociable
It’s a question pondered by philosophers and theologians for centuries, and now health psychologists are turning the spotlight on the question. They are doing so by investigating subjective well-being, people’s evaluations of their lives, in terms of both their thoughts and emotions. Considered another way, subjective well-being is the measure of how happy people are (Deiner, 2000).
Research on subject of well-being shows that happy people share several characteristics (Myers & Diener, 1996; Myers, 2000):
Happy people have high self-esteem. Particularly in western cultures, which emphasize the importance of individuality, people who are happy like themselves. They see themselves as more intelligent and better able to get along with others than the average person.
Happy people have a firm sense of control. They feel more in control of events in their lives, unlike those who feel they are the pawns of others and who experience learned helplessness.
Happy individuals are optimistic. Their optimism permits them to persevere at tasks and ultimately to achieve more. In addition their health is better (Peterson, 2000).
Happy people like to be around other people. They tend to be extroverted and have a supportive network of close relationships.
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15. Psychological Factors Related to Physical Illness
Physician-patient communication
Social prestige of physician
Technical nature of interview
Cultural values and expectations
Many people believe that physicians are so skilled that they can easily identify a patient’s problems through a thorough physical examination, the way a good mechanic can diagnose car problems. The reality is different, however.
One source of physician–patient communication difficulties is that physicians have relatively high social prestige and power, which may intimidate patients. Patients may also be reluctant to volunteer information that might cast themselves in a bad light, and physicians may have difficulties encouraging their patients to provide information. In many cases, physicians dominate an interview with questions of a technical nature, while patients attempt to communicate a personal sense of their illness and the impact it is having on their lives.
The reluctance of patients to reveal medical information fully to health care providers and the problems that providers encounter in eliciting information effectively produce major communication difficulties.
Furthermore, the view held by many patients that physicians are “all-knowing” can result in serious communication problems. For instance, many patients do not understand their treatment, yet fail to ask their physicians for clearer explanations of a prescribed course of action.
One reason for patient–physician communication difficulties is that frequently the material that must be communicated is too technical for patients, who may lack fundamental knowledge about the body and basic medical practices.
Cultural values and expectations also contribute to communication barriers between patients and their physicians. Providing medical advice to a patient whose native language is not English may be problematic. Furthermore, medical practices differ between cultures, and medical practitioners need to familiar with a patient’s culture in order to produce compliance with medical recommendations.
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16. Forms of Patient Noncompliance
Creative nonadherence
Adjust treatment prescribed by physician
Reactance
Negative emotional and cognitive reaction that results from the restriction of one’s freedom
One major consequence of patient–physician communication difficulties is a lack of compliance with medical advice. The problem is a serious one: Surveys show that perhaps as many as 85 percent of patients do not fully comply with their physician’s advice. In fact, some estimates suggest that almost 70 percent of the 750 million prescriptions for medicine that are written each year are not followed properly, at a cost of $100 billion each year (Kaplan, Sallis, & Patterson, 1993; Hammond & Lambert, 1994; Zuger, 1998).
Noncompliance can take many forms. For example, patients may fail to show up for scheduled appointments, not follow diets or not give up smoking, or discontinue medication during treatment. In some cases, they fail to take prescribed medicine at all.
Patients also may practice creative nonadherence, in which they adjust a treatment prescribed by a physician, relying instead on their own medical judgment and experience. In many cases patients’ lack of medical knowledge may be more harmful than helpful (Weintraub, 1976; Taylor, 1995).
Noncompliance is sometimes the result of psychological reactance. Reactance is a negative emotional and cognitive reaction that results from the restriction of one’s freedom. People who experience reactance feel hostility and anger. Because of such emotions, they may seek to restore their sense of freedom, but in a self-destructive manner by refusing to accept medical advice and perhaps acting in a way that worsens their medical condition. For instance, a man who is placed on a strict diet may experience reactance and tend to eat even more than he did before his diet was restricted (Brehm & Brehm, 1981; Rhodewalt & Fairfield, 1991).
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