CHAPTER 6 Stress Stress- negative emotional experience accompanied by predictable biochemical, physiological, cognitive and behavioral changes directed

either towards altering the stressful event or accommodating to its effects Stress Characteristics- negativity, chronicity, controllability, ambiguity, overload, timing Stressors- events perceived to be stressful Stress is consequence of persons appraisal process and assessment of whether personal resources are sufficient to meet the demands of the environment Major Stressors- money, economy, work, relationship, housing cost, job stability, family responsibilities, health problems of family, health problems of self, personal safety Person-Environment Fit- degree to which the needs and resources of a person and the needs and resources of an environment complement each other When resources more than adequate they may feel little stress but when person perceives that resources are not sufficient, they will feel stress Stress Responses Fight or Flight Response- response to a threat in which body rapidly aroused and motivated via the sympathetic nervous system and the endocrine system to attack or flee a threatening stimulus Mobilizes organism to attack or flee from threat Stress disrupts emotional and physiological functioning and when stress continues unabated it creates health problems Tend and Befriend- respond to stress which social affiliation and nurturant behavior toward offspring which depends on stress hormone oxytocin and may be especially true for women Related to oxytocin, stress hormone, influenced by estrogen, acts as impetus for affiliation Higher levels correlated with being more calm and relaxed General Adaptation Syndrome- organism responds to stress by passing through a nonspecific mobilization phase which promotes sympathetic nervous system activity, a resistance phase which makes efforts to cope with the threat and an exhaustion phase which occurs if organism fails to overcome the threat and depletes its physiological resources All stressors, regardless of type, produce same pattern of physiological changes Led to enlarged adrenal cortex, shrinking of thymus and lymph glands, ulceration of stomach and duodenum Alarm phase- organism mobilizes to meet threat Resistance phase- organism makes efforts to cope with threat Exhaustion phase- organism fails to overcome threat and depletes resources Limitations- Ignores appraisal process, homogenizes stress responses by ignoring emotions, personalities and biological constitutions, does not specify whether chronic activation or depletion of resources is important, and views stress as a result of GAS Stress Appraisal Primary Appraisal- perception of a new or changing environment as beneficial, neutral, or negative in its consequences and believed to be a first step in stress and coping Negative events further appraised for possible harm, threat or challenge

Harm is assessment of damage, threat is assessment of future damage, challenge is assessment of potential to overcome and even profit from event Secondary Appraisal- assessment of ones coping abilities and resources and the judgments as to whether they will be sufficient to meet the harm, threat, or challenge of a new or changing event SAM and HPA System Events labeled as stressful by cerebral cortex which sets of chain reaction mediated by appraisals Information from cortex transmitted to hypothalamuses, which initiates fight or flight responses Sympathetic arousal stimulates medulla of adrenal glands which secretes EP and NE and causes increased blood pressure, heart rate, sweating and constriction of blood vessels Hypothalamus releases CRH which stimulates pituitary gland to secrete ACTH which stimulates adrenal cortex to secrete cortisol which conserves carbohydrates and reduces inflammation SAM system can cause irregular sleep and heart rate patterns, which HPA axis can affect cortisol levels Excessive epinephrine and norepinephrine increase blood pressure and heart rate, provoke variation in heat rhythms, precursor to sudden death, and may contribute to psychiatric disorders Excessive cortisol can destroy hippocampus neurons leading to problems with verbal functioning, memory and concentration and may lead to senility, can lead to belly fat HPA factors more significant than SAM factors Stress impairs immune systems capacity to respond to hormonal signals that trigger inflammation Chronic stress can result in insomnia through combination of emotional arousal and neuroendocrine activation Chronic SAM Activation- suppress immune function, increase blood pressure, increases free fatty acids which results in atherosclerosis Chronic HPA Activation- suppress immune function, increase abdominal fat, increase hippocampal atrophy Reactivity- predisposition to react physiologically to stress Predisposed by generic make up, prenatal experience, early life experiences Especially vulnerable to stress-related health consequences Level of damage caused by stress dependent upon recovery rate from stress Cortisol affects immune system, making stress widen window of susceptibility for illness Allostatic Load- accumulating adverse effects of stress, in conjunction with preexisting risks, on biological stress regulatory systems Allostatic load builds up, defined as physiological costs of chronic exposure to fluctuating or heightened neural or neuroendocrine response to multiple physiological systems that results from reported or chronic stress Effects- Decreases in cell immunity, inability to stuff off cortisol in response to stress, lowered heart rate variability, elevated epinephrine levels, abdominal fat, memory problems, and elevated blood pressure Many of these changes occur naturally as a consequence of aging Made worse if cope with stress through high-fat diet, less frequent exercise, and smoking

Measurement of Stress Study stress through self-reports, life change, emotional distress, behavioral measures physiological measures such as heart rate or blood pressure, and biochemical markers such as elevated catecholamines or alterations in cortisol levels Difficult to show that particular chronic stressor is factor contributing to illness, hard to measure objectively, measurement may target neuroticism rather than actual stress Often rely on multiple measures due to inherit limitations of each form of measurement Acute Stress Paradigm- individual goes through moderately stressful procedures so that stressrelated changes in emotions and physiology can be assessed When people perform stressful tasks they show psychological distress and indicators of sympathetic activity and neuroendocrine response Chronic stress exaggerates response to acute stress Positive events perceived as less stressful than negative events For people who hold negative views of themselves, positive events can have detrimental effects on health Uncontrollable and unpredictable events are more stressful than controllable and predictable events Ambiguous events more stressful than apparent events More vulnerable to central than peripheral stressors because it affects central aspects of self Chronic Strain- stressful experience that is a usual but continually stressful aspect of life Most people can adapt to moderate or predictable stressors Overcrowding and noise pose few or no long-term health consequences Children, elderly, and poor are adversely affected by chronic stress due to little personal control Anticipation of stress can be more detrimental than actual stress itself Aftereffects of Stress- decrease in performance and attention span Persists long after the stressful event itself is no longer present Observed in response to wide range of stressors including noise, high task load, and crowding Physiological responses to stress may be maintained rather than reverting to baseline Maintained through rumination or anxiety PTSD- syndrome that results after exposure to a stressor of extreme magnitude, marked by emotional numbing, the reliving of aspects of trauma, intense responses to other stressful events Reduced interest, detachment, constriction of emotions, excessive vigilance, sleep disturbance, guilt, impaired memory, avoidance, and exaggerated startle response Substantial variation in cortisol patterns for long time, alterations in immune function Women more likely than men Predicts cardiovascular and lung disorders Stressful Life Events- events that force an individual to make changes in his or her life Stress increases in correlation to extent of life change Measurement of life events is often too vague, or values do not accommodate individual variation and are biased towards events that individuals choose which are less stressful May be unreliable because certain people may be biased to report more stress than others Daily Hassles- minor stressful events that have a cumulative effect

Cumulative impact can predispose to illness and can interact with major life events to increases stress Physical or sexual abuse, particular in family environment related to chronic stress and poor interpersonal stress management Poverty, exposure to crime, neighborhood stress, and low SES all related to low health Stress and Work Work stressors easiest to identify, most preventable, and accounts for growing percentage of disability and social security payments Excessive work and deficient exercise can contribute to poorer health habits and chronic neuroendocrine and cardiovascular activation can contribute to cardiovascular disease Dependent upon interaction between amount of work and perception of work Related to role conflict and role ambiguity which can result in high blood pressure and elevated heart rate Poor social relationships can create stress-related health consequences while positive social relationships can buffer against stress High demand with low control related to stress-related health consequences Unemployment related t o physical illness, alcohol abuse, difficulty achieving sexual arousal, low birth weight, elevated inflammation and compromised immune function Also associated with depression, anxiety, symptom expression, and self-reported illness Reemployment can largely reverse these trends Job instability related to increases risk for death and job stability protects health CBT is not particularly effective in reducing work related stress Genuine changes in work place and work-based interventions that teach stress management are more effective Women who work and care for children show higher levels of cortisol, cardiovascular reactivity and strain, especially among single women Combining work with parenting role in women can increase well-being, self-esteem and selfefficacy but only if each does not compromise the other role Men are more stressed by financial and work stress, women by home stress CHAPTER 7 Coping Stress Moderators- internal and external resources and vulnerabilities that modify how stress is experienced and its effects Impact on stress itself, on relation between stress and psychological responses, on relation between stress and illness, and on degree to which a stressful experience intrudes into other aspects of life Coping- series of transactions between person with resources, values and commitments and a particular environment with its own resources, demands and constraints Influenced by external resources of time, money, education, occupation, friends, family, and standard of living, presence of positive life events and absence of negative life events Greater the resources, more effective the coping

Coping efforts center on reducing harmful environmental conditions, tolerating or adjusting negative events, maintaining positive self-image, maintaining emotional equilibrium, continuing satisfying relationships with others, enhancing the prospects of recovery Coping Style- propensity to deal with stressful events in a particular way Similar to personality traits but are more specific to stressful events Proactive coping requires ability to anticipate and detect stressors, manage them, self-regulate, control, direct and correct their actions Avoidant Coping- tendency to cope with threatening events by withdrawing, minimizing, or avoiding them Includes cognitive disengagement, denial, and predicts decreased distress, pain but with poor recovery Approach Coping- tendency to cope with stressful events by solving them directly Approach coping may produce stress in short term but is more likely to overcome it long term Includes seeking social support, positive reappraisal, problem-focused coping, and predicts increase in cognition and decrease in stress and pain Problem Focused Coping- attempts to do something constructive about the stressful situations that are harming, threatening or challenging an individual Emotion Focused Coping- efforts to regulate emotions associated with stress Problem focused emerges during childhood while emotion focused emerges during adolescence Emotional coping divided into emotional distress and emotional approach Coping through emotions is especially beneficial to women and may be due to soothing and identity affirmation Emotional Approach Coping- process of clarifying, focusing on, and working through the emotions experienced in conjunction with a stressor Coping Outcomes- beneficial effects that are thought to result from successful coping which include reduced stress, adjusting more successfully, maintaining emotional equilibrium, having satisfying relationships with others, and maintaining positive self-image More successful if reduce arousal such as blood pressure, heart rate, pulse, and skin conductivity Negative Emotional Response Negative Affectivity- pervasive negative mood marked by anxiety, depression and hostility Express distress, discomfort, and dissatisfaction across wide range of situations Type D personality- characterized by experience of negative emotions, coupled with inhabitation of expressing these emotions in social context Distress and social inhibition considered to be mutually toxic to mental and physical health Neuroticism- related to increased risk for arthritis, diabetes, kidney or liver disease, stomach or gallbladder problems, ulcers, asthma, arthritis, headaches, and coronary artery disease Particularly important role in disorders related to pain Disease Prone Personality- depression, anger, hostility and anxiety Related to higher risk of death, and poor adjustments to treatment Can create false impression of poor health when none exists, leads people to worry, be more aware of symptoms, and attribute symptoms to new or existing health conditions More likely to use health services even when illness is no worse Positive Emotional Response

Positive emotion related to lower cortisol levels, better responses to vaccinations, resistance to illness following exposure to flu virus, lower levels o CHD, and lower risk of some causes of death Optimism results in better coping with stress and reduced risk for illness Optimism promotes more active and persistent coping efforts Fosters sense of personal control, problem-focused cooping, social support seeking, and emphasis on positive aspects of stressful situations Optimism may be detrimental when efforts are not met with success Stress and Support Social Support- information from other people that one is loved and cared for, esteemed and valued, and part of a network of communication and obligation Most vital protective resource of all Not having social support can produce additional stressors as well as failing to resolve existing ones Elderly, widows, victims of sudden events, have difficulty with social support Simply believing in viability of support or contemplating it can have benefits Both men and women benefit more from female support and male support may actually increase stress Dogs are best pet at providing social support by decreasing cortisol stress-hormone and increasing opioid function Social support lowers likelihood of illness, speeds recovery and reduces risk of mortality Tangible Assistance- provision of material support by one person to another such as services, financial assistance or goods Informational Support- provision of information to a person experiencing stress by friends, family and other people in the individuals social network, believed to help reduce the distressing and health-compromising effects of stress Help understand stressful event better and determine what resources or coping strategies must be mustered to deal with it Emotional Support- indications from other people that one is loved, valued and cared for Benefits come more from perception of support than reality of it Cost of social support is monopolizing anothers time and attention which can produce guilty, can threaten self-esteem Invisible Support- support from another person outside of ones awareness Direct Effects Hypothesis- coping resources, such as social support, have beneficial psychological and health effects under conditions of both high and low stress Evidence from social integration due to social support Buffering Hypothesis- Social support acts as reserve and resource that blunts effects of stress or enables the individual to cope with stress more effectively Evidence from degree to which people feel that there are other people available who will care for them Marriage is best protector against stress, especially for men while exiting a marriage, being unmarried, or being in an unsatisfying marriage all bring health risks especially for women Supportive family in childhood has long term benefits for health and coping

Matching Hypothesis- hypothesis that social support is helpful to an individual to the extent that the kind of support offered satisfies the individuals specific needs Support useful only when provided by right person for right reason Social support detrimental to health only when peers are themselves unhealthy Giving support has health benefits for giver as well as receiver Stress Control Psychological Control- perception that one has at ones disposal a response that will reduce, minimize, eliminate or offset the adverse effects of an unpleasant event, such as a medical procedure Related to self-efficacy which is perception that one can take the necessary actions to obtain a specific outcome in a specific situation Related to emotional well-being, successful coping, good health behaviors, good cognitive tasks and good health Especially important for the vulnerable such as medical patients, children, and elderly Control Enhancing Interventions- interventions with patients who are awaiting treatment for the purpose of enhancing their perceptions of control over those treatments People with high desire for control may especially benefit from control-based interventions but control may actually be aversive if it gives people more responsibility than wanted Self-Esteem- global evaluation of ones qualities and attributes Most protective at low levels of stress, high levels of stress can overwhelm capacity of selfesteem Related to self-esteem are personal qualities of ego strength such as dependability, trust, and lack of impulsivity High levels of ego strength as children results in longer lives as adults Conscientiousness, self-confidence, easy-going disposition, and intelligence also associated with good cooping Experiencing positive events and describing, memorizing and sharing them with others improves wellbeing Vacations are beneficial, especially for middle-aged men Coherence about life, sense of purpose, sense of humor, trust in others, and religion predict health Stress Management Mindfulness training- reduces stress, anxiety and distress by engaging prefrontal cortical regions of brain which regulate affect and down regulate activity of limbic areas related to negative emotion Emotional disclosure- writing or communication can have long-term benefits for health but may create short-term distress Talking with others allows one to gain information, elicit positive reinforcement and emotional support, organize ones thoughts and be able to find meaning and affirm ones identity Difficulty in identifying and expressing emotion (alexithymia) related to health risks Coping effectiveness training- teaches people how to appraise stressful events in order to disaggregate the stressors into specific tasks and specific coping strategies are developed for each

Stress Management- program for dealing with stress in which people learn how they appraise stressful events, develop skills for coping with stress, and practice putting these skills into effect Learn that stress is psychological appraisal rather than factor inherent in events Observe behavior and record stressful circumstances and record maladaptive efforts Identify stressful circumstances, and recognize and eliminate negative self-talk Skill acquisition and practice, and finally effectors to reduce stress by first setting specific goals then indentifying what behaviors will meet those goals Self-instruction- reminding oneself of specific steps required to achieve goal Self-affirmation- affirmation of values and personal qualities to enhance psychological and physiological health Relaxation training- reduces heart rate, muscle tension, blood pressure, inflammatory processes, lipid levels, anxiety and tension through mediation, guided imagery, yoga and hypnosis Time Management- prioritize goals, avoid distractions, and emphasize social skills and health habits, to avoid stress Assertiveness training- how to deal with interpersonal stressors CHAPTER 8 Illness and Symptoms Most common pain complaints are back pain, pain in extremities, headache, abdominal pain, bloating, food allergies, and heart palpitations Women more likely than men to report symptoms Neurotics report systems quicker and more frequently but may exaggerate symptoms Whites report infrequent symptoms while Hispanics reported frequent symptoms Introverted people more likely to report symptoms than extroverted people Stress can precipitate and aggravate experience of symptoms People in a negative mood are more likely to report symptoms than those in a positive mood People who have experience with medical condition estimate prevalence of symptoms to be greater and often regard condition as less serious than people with no history Highly prevalent risk factors regarded as less serious than rare or distinctive risk factors May ignore risk factors that are unexpected or amplify symptoms they do not expect Painful symptoms more likely to prompt treatment than non-painful symptoms Healthcare system abused by excessive or delayed visits 1/2 to 2/3 of complaints believed to be psychological not medical More common for general practitioners rather than specialists Medical Student Diseases- medical students more likely to report illness as consequence of learning about illnesses Worried Well- individuals free from illness who are nonetheless concerned about their physical state and frequently and inappropriately use medical services Concerned about physical and mental health, inclined to see minor symptoms as serious Increasing due to media preoccupation with health Somaticizers- individuals who express distress and conflict through bodily symptoms Recommended to screen for traumatic life events Hypochondriacs may seek attention through the medical care of others

Secondary gains- benefits of being treated for illness including the benefits of sleep, freedom from unpleasant tasks, cared for by others, time off from work Common-sense Model of Illness- people hold implicit commonsense beliefs about their symptoms and illness that results in organized illness representations Illness Representations- organized set of beliefs about an illness or type of illness including its nature, cause, duration and consequences Lend coherence to persons comprehension of illness experience Includes identity of illness, causes, consequences, and control or cures Have models for acute, chronic and cyclic illness Gives basis for interpreting new information, influence their treatment seeking decisions which lead them to alter or fail to adhere to medication and influence future expectations Illness and Health Care System Very young and very old use health services most because children develops acute illness and old develop chronic conditions Women use medical services more than men because they recognize discomfort quicker, have more medical procedures, medical visits are less disruptive, become ill more often, and medical care is more fragmented Lower SES groups use medical services less often than upper class but gap has narrowed Seeking treatment influenced by degree to which illness disrupts social functioning and degree to which individual is pressured to seek treatment Lay Referral Network- informal network of family and friends who offer their own interpretation of symptoms before any medical treatment is sought Lay referral network is preferred mode of treatment in many communities Alternative Therapy- As many as 1/3 Americans may use alternative therapy Includes relaxation, chiropracty, massage, imagery, diet, herbal medicine, megavitamin, selfhelp, energy healing, biofeedback, hypnosis, homeopathy, acupuncture 61% of internet users report using internet for health information 96% physicians believe online information has positive impact Holistic health- belief that health is a positive state that is actively achieved Emphasizes self-help, health education, self-healing, low-technology intervention, and nontraditional interventions such as herbal medicine, acupuncture, massage, spiritual healing and dance therapy Makes relationship between patient and doctor more open, equal and reciprocal Illness and Delay Delay behavior- delay between recognizing a symptom and obtaining relevant treatment Delay if symptom is similar to previous minor symptom or symptom is easily accommodated Delay extends beyond first treatment visit and patients may delay taking treatment Delay may be form of denial and avoidance Delay on part of caregiver more likely if patient deviates from expected profile or when symptom may represent multiple illnesses

Appraisal delay- delay between recognizing a symptom exists and deciding that it is serious Illness Delay- delay between recognizing a symptom implies an illness and seeking treatment Behavioral Delay- delay between deciding to seek treatment and actually doing so Medical delay- delay in treating symptoms which results from problems within the medical system such as faulty diagnoses or lost test results Expense of treatment is major factor as is regularity of contact with physician CHAPTER 9 Health Care System Organization Nurse Practitioner- receive specific training in primary care so they may provide routine medical care for patients Affiliated with physicians in private practice, see own patients and provide all routine medical care, prescribe treatments, monitor illness progression, and see walk-in patients Physician Assistant- graduates of 2-year programs who perform routine health care functions, teach patients about treatment regimens and record medical information Authority- Typical hospital functions as bureaucracy with administration at top and doctors at bottom as employees Private hospital has two lines of authority, one medical and one administrative which can be at odds Medical authority is technical skill and expertise and administrative line runs hospital Doctors are top of medical authority but not directly employed by hospital but rather admit their patients in exchange for laborites, custodial services, equipment and teaching facilities Goal of cure is doctors responsibility while goal of care is patients responsibility while goal of core is responsibility of hospital Walk-in clinics used to direct minor cases away from hospital which is designed to handle severe cases DRGs have led hospitals to going from overcrowded to underused which promotes them to see as many patients as possible for shorter stays Increasingly insurance companies control administration of hospital Health Care System and Payment Patients increasingly adopting consumerist approach to health care Have full patient cooperation and participation to induce treatment, especially for lifestyle adjustments Difficult having time to explain all of symptoms, conveying one are ill effectively and caregiver must adequately identify illness which can be complicated by over-the-counter medication As efficiency and cost-cutting has increases, quality of care has decreased The ill elderly and poor fare especially poorly in HMOs as compared to fee-for-service Pressure to increase patient visits results in longer waits and shorter visits and problem is compounded if required to see several specialists Mean length stay in hospital is 5 days or less Private Fee-for Service care- condition under which patients privately contract with physicians for services and pay them for services rendered

HMO- organizational arrangement for receiving health care services by which an individual pays a standard monthly rate and then uses services as needed at no additional or greatly reduced cost Managed Care- health care arrangement in which an employer or employee pays a predetermined monthly fee to a health care or insurance agency that entitles the employee to use medical services at no additional or greatly reduced cost PPO- network of affiliated practitioners that has agreed to charge pre-established rates for particular medical services Prepaid plans often operate on referral basis so that provider first sees patient determines what is wrong then recommends specialists for follow up Referrals are desirable because providers often paid according to the number of cases they see DRG- patient classification scheme that specifies the nature and length of treatment for particular disorders used by third party reimbursement systems to determine the amount of reimbursement Determines nature and length of treatment for particular disorders Assumes patients are homogenous group that is clinically similar and should require approximately the same types and amounts of treatment, length of hospitalization, and cost If patient falls within classification, reimbursement for care will be forthcoming from third party (state, federal or insurance company) Those that fall outside of classification scheme are subject to review and extra costs are not paid Argued that produces more efficient care, thus reducing costs Rewards institutions for detection and treatment of complications or co-occurring conditions but often does so at expense of ignoring psychological factors and contribute to a tendency to discharge patients early Colleague Orientation- physician orientation towards gaining the esteem and regard of ones colleagues, fostered by any health care provider arrangement that does not involve direct reimbursement to physicians by patients Because patient no longer pays directly for service, provider may not be directly concerned it patient satisfaction In theory, provides high technical quality of care based on referrals but also results in less incentive for emotionally satisfying care Malpractice- Malpractice suits drastically increased recently Overuse of complex machinery can result in patient harm as can complexity of health care system Most suits due to incompetence and negligence but increasingly citing communication errors Patients use suits to find out what happened, to receive an apology and receive assurance mistake will not occur again Health Care System and Communication Doctors are inattentive, too quick to direct patient towards a diagnosis, interrupted by staff, use alienating medical jargon and overly simply explanations coupled with infantilizing baby talk which forestalls questions Depersonalize patients to keep them quiet and limits questions, especially employed at stressful moments Communication eroded when doctors encounter patients with disorders they would rather not treat

Less proficient care for blacks, Hispanics, low SES or elderly Satisfaction when race of doctor and patient is same Female doctors conduct longer visits, make more positive comments and show more nonverbal support than male doctors and doctors prefer male patients more Doctors prefer healthy to sick patients, and acutely ill to chronically ill patients Within first few minutes of diagnose as many as 1/3 patients cant repeat diagnosis and do not understand important details Neurotic or stressed patients have greater difficulty attending to and comprehending diagnosis Patients with new disorder and little prior information show greatest distortion in explanations As patients age, comprehension decreases and additional illnesses increases, complicating comprehension Patients focus on pain, doctors focus on underlying illness, severity and treatment Patients may give misleading history of condition to avoid embarrassment Patients whose treatment have failed are more likely to return than those that have succeeded Learning is fostered more by positive than negative feedback but because more negative feedback is provided than positive feedback, care does not necessarily improve Dissatisfied patients less likely to comply with treatment and to turn to alternatives Must train doctors on communication with immediate feedback on performance and emphasize importance of non-verbal communication cues and enlist patient participation in communication by trying to see illness from perspective of patient Adherence Non-adherence varies from 15-93% when averaged across conditions is about 26% 30% fail to comply for short-term antibiotics 50-60% fails for modifying health behavior 80% fail to follow through for behavior change recommendations 25% if cardiac rehabilitation patients fail 85% of patients fail to adhere completely too prescribed medications Creative Non-adherence- modifying or supplementing prescribed treatment regimen Results from personal theories about disorder and treatment Adherence Improvement- Good communication fosters adherence which entails clear, jargonfree explanation of etiology, diagnosis, and treatment with warm and caring doctor and if patient is asked to repeat instructions, if instructions are written down, if unclear recommendations are clarified, and if instructions are repeated Adherence highest for medical advice and decreases with vocational, social, and psychological advice with complex self-care having lowest adherence Lack of time, money, or distractions at home and work predict non-adherence Highly fearful patients before and after surgery and those that became fearful after surgery showed negative side effects Moderately fearful coped with post-surgery stress more effectively Patients with too much fear didnt process information due to distraction and patients with too little fear didnt process information due to lack of attention Response to surgery also influenced by degree of preparation for post-surgery

Health Care System and Children Children may misinterpret hospitalization as punishment and may show behavioral regression or embarrassment over procedures and distressed parents exacerbate childrens distress Both anxiety reducing and coping skills training effective at reducing fear and distress but later is more effective Useful for child to understand what illness is, what it feels like, and how they will get better to reduce anxiety Age 2-4- concern of separation anxiety Age 4-6- concern of developing new fears Age 6-10- concern about outcome of procedure Age below 7- information best presented before procedure Age above 7- information best presented several days before procedure CHAPTER 10 Pain Pains are critical to survival because they provide low-level feedback about function of body Make unconscious adjustments according to pain Symptom most likely to lead person to seeking treatment Complicates illness and can hamper recovery Often accompanies other mental or physical disorders which further complicates diagnosis Depression, stress anxiety can worsen experience of pain Influenced by context in which it is experienced Cultural variation in reaction speed to pain and intensity of response and expression of pain Women show greater sensitivity to pain than do men Measure pain with informal vocabulary people use to describe pain Chronic pain disorder patients show significant loss of gray matter in brain regions involved in processing of pain in prefrontal, Cingular, and insular cortex Pain Behaviors- behaviors that arise as manifestations of chronic pain such as distortions in posture, gait, facial or audible expressions, and avoidance of activity Acute Pain- short-term pain that results from specific injury Results from specific injury, self-limited, disappears when damage is repaired Lasts for 6 months or less Chronic Pain- pain that may begin after an injury but that does not respond to treatment and persists over time and affects 30-50 million people in US Begins with acute episodes, but does not decreases with treatment or passage of time Chronic Benign Pain- persists for 6 months or longer and relatively unresponsive to treatment Varies in severity and may involve any number of muscle groups Recurrent Acute Pain- series of intermittent episodes of pain that is acute but chronic inasmuch as condition recurs for more than 6 months Chronic Progressive Pain- longer than 6 months and increases in severity over time Associated with malignancies or degenerative disorders Chronic pain requires more interventions than acute pain and involves more complex interaction of physiological, psychological, social and behavioral factors

Functional disability is more important than pain intensity in distinguishing acute from chronic pain Those with chronic pain lose leisure activities, withdraw from friends and family, lose income, reduced self-care, reduced standard of living and self-esteem, communicate poorly with family and sexual relationships deteriorate and shuns social contact, reduces physical activity, avoids loud noises and bright lights Supportive spouses may actually maintain pain and disability and compensation for pain can increases perceived severity of pain and amount of disability experienced Pain and Perception Gate Control Theory of Pain- experience of pain is reflected in sensory, psychological and behavioral responses Negative emotions exacerbate pain, pain exacerbates negative emotions Nociception- pain perception Results from mechanical damage to tissue of body, thermal damage due to temperature exposure or polymodal nociception of damage due to pain triggered from chemical reactions First sense injury, release chemical messengers in response, conducted to spinal cord and passed to reticular formation and thalamus into cerebral cortex which indentify site of injury A-delta fibers- transmit sharp pain and effect sensory aspect of pain C-fibers- transmit dull, aching pain and effect motivational and affective aspect of pain Endogenous Opioid Peptides- natural opiates like heroine and morphine pain control drugs Natural pain suppression system that are triggered only by specific factors Acute stress reduces sensitivity to pain (stress induced analgesia) Pain and Personality Pain-Prone personality- constellation of personality traits that predispose a person to experience chronic pain Pain can alter personality and pain experiences too complex and varied to be reduced to basic personality Chronic pain patients show constellation of neurotic traits such as hypochondrias is, hysteria and depression Pain indirectly results in depression by reducing activity and preconceptions of control which increases perception of pain and likeliness of pain behavior Suppressed anger related to experience of more pain and dysfunction in opoiud system Chronic pain also related to anxiety disorders and substance abuse disorders Chronic pain may activate a latent psychological vulnerability Pain Management Pain Control- no longer feels anything in an area that once hurt Person feels sensation but no pain or reduces pain significance Active coping strategies superior to passive coping strategies Attending directly to pain rather than avoiding it is more effective Favorable assessment of coping strategies is more beneficial than unfavorable assessment Medication-Morphine is highly effective painkiller with side-effect of addiction and builds up of tolerance Local anesthetics or spinal blocking agents can influence transmission of pain

Antidepressants reduce anxiety and improve mood by also affect the downward pathways from brain that modulate pain Nerve blocking agents have side effect of anesthesia, limb paralysis and loss of bladder control and pain may return in short time Over concern of addiction results in under medication Surgery- Survival intervention involves cutting pain fibers to prevent pain sensations Effects are often short-lived with substantial cost which may in fact cause additional pain Counter irritation- inhibiting pain in one part of body by stimulating or mildly irrigating another Spinal cord stimulation or exercise, which is especially successful for elderly, used Biofeedback- identify bodily process, then track it, through continuous feedback, learn what thoughts or behaviors modify bodily function but is no more effective than simple relaxation Progressively reduce bodily arousal through relaxation by deepening breaths Modestly successful for acute pain and chronic pain if paired with other methods Hypnosis- distract away from pain experience in order to reduce awareness of pain Especially successful when used in conjunction with other techniques such as drugs Acupuncture- counter-irritation technique Informing patient of how acupuncture works reduces fear and increases pain tolerance May release endorphins Effective for short term but not long term pain Distraction useful, especially for acute low level pain Guided imagery- used to induce relaxation and distraction Control for slow-rising pains and discomfort of painful medical procedure Alternatively may be used to direct attention actively to confront pain Taught to see problem as manageable, to be active in responding to pain rather than passive, learn how to monitor thoughts, feelings and behavior, how and when to employ overt and covert behaviors to make adaptive responses, attribute success to their own efforts, the importance of relapse preventions and to control emotional reaction to pain Pain Management Program-coordinated, interdisciplinary efforts to modify chronic pain by bringing together neurological, cognitive, behavioral, and psychodynamic expertise concerning pain which aims to not only make pain more manageable but also to modify lifestyle as a consequence of pain Begin with qualitative and quantitative assessment of pain including location, quality, severity, duration, onset and history Then develop individualized program that is structured and time limited with concrete aims, rules and goals which include reducing intensity of pain, increasing activity, decreasing medication, improvijdign psychological function, returning to work reducing perception of disability, reducing need to use health care services Include group education, relaxation and exercise t raining, CBT treatment for catastrophic thinking and depression Involve family members to develop positive perceptions of each other and reduce counterproductive behavior Placebo- any medical procedure that produces an effect because of its therapeutic intent and not any specific physical or chemical nature Benefits enhanced when substance produces benefits of its own in addition to placebo effects

Work by releasing opioids, bodys natural painkillers and show reduced activity in pain-sensitive regions of brain Effectiveness dependent upon how caregiver presents themselves and the treatment and how patient responds Patients with high need for approval or low self-esteem show strong placebo effects More placebo appears to be like a real medicine, more effective it is Dependent upon societal expectations of the effectiveness of medication CHAPTER 11 Chronic Illness 50% of population has chronic condition and 1.7 million die every year in US More than 1/3 adults (age 18-44) have at least one chronic condition Medical management accounts for of healthcare spending Chronically ill suffer psychology distress from condition in form of depression and anxiety In some cases distress is a pre-existing condition or risk factor in other cases a result Distress contributes to increased mortality and exacerbates symptoms Psychiatric and medical problems coupled with illness-related worries are better predictor of quality of life than course of illness itself Quality of Life- degree to which a person is able to maximize their physical, psychological, vocational, and social functioning and is an important indicator of recovery from or adjustment to chronic illness Study in order to discover exactly how illness affects habits, provide basis for intervention, compare therapy techniques, inform decisions to maximize benefits Self-report of health condition better predictor of mortality than medical and psychological knowledge Chronic Illness and Emotion Denial- defense mechanism in which people avoid implications of illness Can serve as a protective function by preventing individual from dealing with full consequences Can be detrimental during rehabilitation if it interferes with self-management treatment Anxiety- levels high when waiting for results, receiving diagnosis, awaiting invasive treatment, anticipating side effects, enduring lifestyle changes, feeling dependent, and when lacking information Anxiety is not only intrinsically distressing but also results in poorer coping with condition Depression- neurotic or psychotic mood disorder marked especially by sadness, inactivity, difficulty with thinking and concentration, significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness and occasional suicidal thoughts or attempts 1/3 medical inpatients with chronic disease report depression with qualifying Depression can be sign of impending physical decline, especially in older men Exacerbates the risk and course of chronic disorders, interferes with adoption of co-managerial role, and confers enhanced risk of mortality and suicide Shares symptoms of fatigue, sleeplessness and weight-loss with illnesses themselves and if attributed to illness then depression may go untreated Depressed patients may extreme decisions regarding treatment

Depression increases with severity of illness Experience of pain and disability in particular result in depression Physical limitations predict depression early on while psychological factors predict it later Treatment of depression through CBT may not only reduce depression but symptoms of illness as well Chronic Illness and Self Self-Concept- integrated set of beliefs about ones personal qualities and attributes Self esteem is evaluation of self-concept which includes body image, achievement, social functioning and private self If chronic illness threatens personal achievements, self-concept can be damaged Conversely, when achievements are not threatened, patients cope better Maintaining cognitive functioning is important in pursuing goals and predicting survival Patients encouraged to disclose private desires if impeded by chronic illness in order to reveal alternative options and establish new ambitions Body Image- perception and evaluation of ones physical functioning and appearance Poor image related to low self-esteem and increased likelihood of depression and anxiety Influence adherence and co-managerial role and can be improved through psychological and educational interventions with the exception of facial disfigurement and extensive burns Emphasizing social self-efficacy and other aspects of appearance and health may improve body image Chronic Illness and Coping Fear, uncertainty about future, limitations of abilities and pain management are most common concerns Social support, distancing, positive focus, cognitive avoidance, and behavioral avoidance are most common strategies Chronically ill rely upon passive more than active coping strategies Avoidant coping is associated with increased distress and risk factor in adverse response to illness and may exacerbate illness itself Self- Lower distress among patients using active, positive coping strategies with high internal locus of control and believe in self-efficacy Patients who fail to incorporate chronic illness into self-concept or falsely incorporate it as acute illness may fail to follow treatment Blame- Self-blame for chronic illness is widespread and in some cases are correct Self-blame leads to guilt and depression but may also lead to control and acceptance while blaming others is always maladaptive and forgiveness is related to fewer health complaints Control- When level of possible self-control is low, efforts to exert it may be maladaptive Sense of self-control can be enhanced by involving patient in decision making process Chronic Illness and Relationships Work- Chronic conditions can affect work status and should be addressed early on through job counseling, retraining programs, and discrimination advice Patients who reduce or lose work may lose insurance coverage, thus increasing harm done Social Relationships-Patients may have difficulty with social relationships in terms of pity and remorse yet may inadvertently elicit such behavior from people

Chronic illness affects family as a whole and may create role s train in family members Children may be especially vulnerable to additional responsibilities and may rebel Despite this, no evidence that divorce rates or family conflict is higher in chronically ill patients Care Giving- Care for chronically ill is notoriously irregular and burden often falls on family, especially women Process of care-giving, especially in the elderly and those with additional stressors, may further erode health of care-giver Care-giving may strain relationship between care-giver and patient and depression of patient may affect care-giver and they may require interventions for social support themselves Chronically ill women experience more deficits in social support than men because they are less likely to be married or get married and it may be exacerbated by low levels of income and disability and even if married, chronically ill women are more likely to be institutionalized than husbands and following diagnosis may carry a disproportionate burden of household responsibilities Children- Children may not understand nature of diagnosis and treatment and require assistance of parents to follow treatment regimen Children may experience withdrawal, rebellion, low self-esteem, and regressive behavior, and are exacerbated if families do not communicate and assist properly Children may develop maladaptive coping strategies such as repression Parents with realistic attitudes, informed, free of depression, avoid expressing distress and can control illness are beneficial Children encourage in self-care with realistic restrictions and that engage in physical and academic activities do better Chronic Illness Management Adherence- Complexity, length, degree of interference, side-effects, and degree of lifestyle change influence degree of adherence Self-efficacy and knowledge about necessity of treatment requirements improve adherence Physical Rehabilitation- use bodies as much as possible, sense changes in the environment and in themselves so as to make appropriate physical accommodations, learn new physical and management skills if necessary, pursue a treatment regimen, and learn how to control the expenditure of energy Must develop capacity to read body signs that signal onset of a crisis, how to respond to crisis, and maintain treatment Group interventions may have higher adherence than individual interventions Exercise can improve quality of life, reduce pain, reduce fatigue, and enhance self-efficacy Stress management can be incorporated to reduce stress exacerbating chronic illness Ability to continue physically intimate relationships can be protective of mental health and relationship satisfaction among chronically ill Therapy- more likely to be episodic than continuous Collaboration between therapist and physician is crucial Respect for psychological defenses more crucial for chronically ill than acutely ill Therapist must have comprehensive understanding of illness and treatment Patient Education- programs designed to inform patients about their disorder and its treatment and to train them in methods for coping with a disorder and its corresponding limitations

Coping skills that increase knowledge, reduce anxiety, increase sense of purpose and meaning in life, reduce pain and depression, improve coping, promote adherence, increase confidence in ability to manage pain and side effects Benefits of expressive writing are particularly salient for chronically ill Combinations of stress management, relaxation training, and blood pressure monitoring effectively reduce stress Mindfulness training- approach stress mindfully rather than automatically and may effectively reduce stress, depression and anxiety Acceptance and commitment therapy- accept their illness and avoid impossible goals Support Groups- groups of individuals who meet regularly and usually have a common problem or concern which help people cope because they provide opportunities to share concerns and exchange information with similar others Discuss issues of mutual concern arising from consequences of chronic illness Provide mutual advice and share emotional responses and can provide unmet needs from friends and family Support groups limited primarily to well-educated, middle-class, white women CHAPTER 12 Death and Children Infant Mortality Rate- number of infant deaths per thousand High US infant mortality rate (6.7 per 1000) with African American infants twice as likely to die as white infants with racial disparities increasing US does not provide free or low-cost maternal care during pregnancy which lack there-of is main cause of infant mortality Sudden Infant Death Syndrome- common cause of death among infants due to cessation of breathing Occurs in lower-class urban environments with smoker mother and sleep on stomach or side Adjustment for parents is better if have other children, dont blame themselves, and had contact with infant before death Causes of Death- Main cause of death among children below age 15 is accidents (40%) which have declined in recent years Cancer is second leading cause and its incidence is rising but treatment is also increasing such that over 80% if those treated survive for 5 years or more after Understanding of Death- think of death as sleeping up to age 5 Do not understand that death is final and irreversible and thus are curious about it Between 5 and 9 children understand that death is final but do not yet have a biological understanding of it and personify death as a ghost or demon Idea that death is universal and inevitable develops between age 9 and 10 Young adults envision death violently which parallels the leading cause of death for their age group being automobile accidents and homicide Homicide is over 6 times more prevalent for young black men than young white men Suicide and cancer, followed by heart disease and AIDS are other causes of death for young adults Next to death of child, death of young adult is most tragic

Death and Adults Age-adjusted death rates have declined 43% since 1960s US citizens live to be 77.7 years on average and death is usually due to chronic, not acute illness Death becomes more realistic and more fearful in middle age as it becomes more prevalent and factors leading to it become more present Mid-life crisis may be an externalization of the fear of death Premature Death- death that occurs before the average projected age of 77 Main cause of premature death (death before age 77) is heart attack or stroke Death rates in middle-aged group have declined due to a 60% drop in cancers, especially lung cancer, due to reduced smoking as well as decline in heart disease and stroke Elderly more prepared for death than the young and typically die of degenerative diseases such as cancer, stroke, or heart failure Terminal phase of illness is general shorter because of more competitors for death Depression, poor mental health and dissatisfaction with life predict decline in health while sense of purpose and close family ties predict longer life Women typically live longer than men with women living 80 years and men 75 years on average Death and Self As physical decline progresses, self-concept may decline and patients may socially withdraw themselves from friends and family May be part of a natural grieving process or fear of depressing others or resentment of the living Communication between patient and doctor may break down as death becomes more realistic and death is still considered a taboo social topic and is rarely discussed among friends and family Five Stages of Death- denial, anger, bargaining, depression, acceptance Denial- defense mechanism to avoid implications of illness Sheer quantity of issues to deal with may overwhelm patient Anger- resentment towards those that are healthy and are particularly difficult for friends and family to deal with Bargaining- trading good behavior for good health, often with religious connotations Depression- mental and physical exhaustion with anticipatory grief over loss of past activities and prospect of future activities Prepares individual for future and thus best not to intervene immediately but rather let depression run its course Acceptance- peaceful indifference and calm appearance Whether or not patient accepts their death or resists it is irrelevant to survival prospects Do not necessarily proceed through all stages or go through each only once or in a particular order and does not address the importance of anxiety Grief- feeling of hollowness, preoccupation with image of deceased person, expression of hostility to others, and guilt over death Inability to concentrate on activities, yearning for loved one, depression, and restlessness especially during first 6 months May feel pressure from others to move on and blaming health care provider can complicate grieving while blaming spouses lifestyle can reduce grieving

Survivor left with lots of time with little to do but grieve and they may have physical problems of their own and may be left with unfamiliar tasks and fewer resources Excessive grief and rumination can increase stress and depression Grief is more aggravated in men, in caregivers, and those with sudden loss Financial strain to widows is biggest source of depression while for widowers it is household management Child survivor may not fully comprehend death or reasons for death and may blame themselves, especially if it is the death of a sibling Death and Health Care System Patient Self Determination Act- includes right to neglect resuscitation in the event of a cardiopulmonary arrest Increased support for the right to suicide or assisted suicide among general population but decreased support for euthanasia among doctors with it criminalized in 35 states Euthanasia- ending the life of a person who has a painful terminal illness to end suffering Living Will- will prepared by a person with a terminal illness, requesting that extraordinary lifesustaining procedures not be used in the event that the persons ability to make this decision is lost Many doctors ignore interests of patients and needlessly extend pain and suffering Substantial inequality in access to life-sustaining technology, do not yet have adequate guidelines regarding cost-effectiveness and appropriateness of use and have not yet reached consensus on time and place in which people can choose the circumstances of their death 41% of Americans who die do so in hospitals Terminal Care- medical care for terminally ill Hard on staff and involves unpleasant custodial work along with emotional strain which may cause staff to become emotionally indifferent and may not respond in accordance with patients desires Palliative Care- care designed to make patient comfortable but not to cure or improve the patients underlying disease and is part of care for terminally ill Curative Care- care design to cure a underlying disease Informed Consent- should be told the nature of condition and treatment and should be involved in own treatment Safe Conduct- act as helpful guides to patient during new and frightening stages of life Significant Survival- helps patient use time meaningfully Anticipatory Grief- aided in working through anticipatory sense of loss and depression Timely and Appropriate Death- allowed to die when and how they want as much as possible Hospice Care- care designed to provide warm, personal comfort for terminally ill patients Acceptance of death in a positive manner, emphasizing relief of suffering rather than cure Painful or invasive therapies are discontinued and psychological comfort is stressed Patients encouraged to personalize lives and family are encouraged to visit No basis that hospice care increases depression or that care is less beneficial than hospitals but difficulty maximizing utility of hospices and attracting trained staff Home Care- care for dying patients in home which is easier on patient but harder on family

Escalation of hospital costs and fact that some managed care programs do not fully cover hospital or hospice stays for some terminal illnesses has caused many to elect for home care, especially if dying is a long process Death Management Therapy with dying is short term, based on energy level of patient, and involves helping patient with unfinished business Family therapy which focuses on communication, death-related plans and decisions, and finding meaning in life and death is important Most difficult with terminally ill children because of tendency to rationalize excuses for not discussing death with them even though they are more aware of death than believed to be Parents may blame themselves for childs death and this may interfere with addressing the needs of the dying child or other children CHAPTER 13 Coronary Heart Disease Number one killer in US, accounting for one out of every five deaths Due to alterations in diet and reduced levels of activity 32% of deaths each year are premature deaths CHD- illness caused by narrowing of coronary arteries (atherosclerosis) When blood vessels become narrowed, flow of oxygen and nourishment is obstructed Can cause pain (angina pectoris) that radiates across chest and arms and may result in heart attack due to immune functioning, especially inflammatory process due to pro-inflammatory cytokine which stimulates buildup of atherosclerotic plaque Strong predictor of heart disease is level of C-reactive protein produced in live in presence of inflammation which is prognostic sign that blood vessels walls are being damaged by it Metabolic Syndrome- diagnosed when person has three or more of following problems: obesity around waist, high blood pressure, low levels of HDL (good cholesterol), difficulty metabolizing blood sugar which is risk factor of diabetes, high levels of triglycerides (bad cholesterol) Cardiovascular reactivity may be inherited in families and is exacerbated by low socioeconomic status and harsh family environment with risk factors clustering as early as age 14 All known risk factors account for of all known CHD cases Coronary Heart Disease Risk Factors Stress- damages endothelial cells which facilitate the depositing of lipids, increase inflammation, and contribute to development of atherosclerotic lesions Diminished vagal rebound during recovery from stress is indicative of CHD risk Low sense of social status, especially in males and African Americans, is risk factor for CHD Exaggerated platelet and hemodynamic reactivity associated with CAD may contribute to plaque rupture and risk of clots (thrombogenesis) Reacting to stress through hostility may interact with other risk factors such as elevated cholesterol to enhance overall risk Although deaths from CHD have decreased overall in recent years, racial gap between black and white has increased

Job strain with high demand and low control, discrepancy between education level and occupation, low job security, little social support, high work pressure, vigilant coping strategy are risk factors of stress for CHD Lives defined by high demand with low control are general risk factor for developing atherosclerosis Migrants and mobile populations in urban and industrialized societies have a higher rate of CHD Sex- CHD is leading cause of death in US women Onset of CHD is 10 years later for women than men but more women die from CHD than men 1/10 women age 45-64 have some form of heart disease, while women have some form age over 65 Reason for discrepancy is that treatment focuses on men over women, does not occur as often for women as men, more dangerous when it does occur later in life, poorer recovery for women, and more women disabled after heart attack Women may be protected in young age due to HDL which is linked to premenopausal womens high levels of estrogen and estrogen in turn diminishes sympathetic nervous system arousal Premenopausal women show smaller increases in blood pressure, neuroendocrine, and metabolic responses than men and older women Women gain weight after menopause, adding to risk, but estrogen therapy does not reduce risk Anger- Expression of anger, especially anti-social cynical anger, increases risk of heart disease, predicts poor survival, and may trigger heart attack and is implicated in hypertension, stroke and diabetes as well Anger related to higher levels of pro-inflammatory cytokines and metabolic syndrome Men shower higher hostility and are found more among minorities and those with low SES Reflects oppositional orientation that develops in childhood from feelings of insecurity and negative feelings and may be fostered through parental interference, punitiveness, lack of acceptance, conflict or abuse Hyperactivity in children may also be risk factor for CHD Hostility may be interpersonal manifestation of cardiovascular reactivity Stress causes vasorestriction in peripheral areas of heart and accelerates heart rate and damages coronary arteries Rise and fall of catecholamine levels due to stress which prompts continual change in blood pressure undermines the resilience of blood vessels Hostile people are less likely to maintain CHD treatment Depression- confers 1.5 to 2.0 risk for CHD or if already have CHD then confers 1.5 to 2.5 risk for mortality Behavioral consequences include non-adherence and treatment delay Biological consequences include inflammation and serotonin dysregulation Related to inflammation, heart disease, heart attacks, and heart failure in elderly Depression prior to heart surgery is predictor of long-term mortality and depression after surgery predicts quality of life May exert influence through elevated heart rate, low heart rate variability, low cardiovascular reactivity, heightened inflammation, and delayed recovery Treated with serotonin reuptake inhibitors which reduces formation of clots by preventing aggregation of platelets in arteries thus acting as blood thinners

Coronary Heart Disease and Heart Attacks Heart attack deaths have decreased in recent years High incidence of death due to delayed treatment following heart attack or interpretation as symptomatic of lesser disorder Heart attack during the day and with family present and if blacks or elderly increases delay Victim of heart attack can cause nightmares, chronic anxiety, depression and poor expectations Treatment for heart attack can produce anxiety by having heart rate monitored Involvement in treatment improves self-efficacy and recovery Ischemia-deficiency of blood to the heart due to obstruction or constriction of the coronary arteries which is often associated with chest pain Cardiac Invalidism- psychological state that can result after a myocardial infarction or diagnosis of coronary heart disease, consisting of perception that patients abilities and capacities are lower than they actually are Improved by personally taking part in recovery process rather than being informed about it improve perception of spouses recovery process Important to train family members in CPR Coronary Heart Disease Management Cardiac Rehabilitation- active and progressive process by which people with CHD attain optimal physical, medical, psychological, social, emotional, vocational and economical status Achieved by reducing anxiety, providing relief from symptoms, limit progression of disease, promote adjustment and restore self-efficacy Treatment begins immediately after diagnosis with clot-dissolving drugs and medical procedures such as angioplasty and coronary artery bypass surgery Medication- Beta-blockers that resist effects of sympathetic nervous system also used but have unpleasant side effects of fatigue and impotence Aspirin commonly prescribed which helps prevent blood clots Statins used which target LDL cholesterol and are most effective Behavior Modification-Instructed to quit smoking, lose weight, control alcohol consumption and exercise Exercise improves cardiovascular health and psychological recovery Encouraged to return to work to ensure economic resources unless in a high stress job which requires reduction in activity but adherence ranges from 50-80% Trained to recognize, avoid, and cope with chronic stress and use CBT to deal with depression Interventions enhance social support and ensure that spouses do not catastrophize heart attack Hypertension Hypertension (CVD)- excessively high blood pressure that occurs when supply of blood through blood vessels is excessive, putting pressure on vessel walls Occurs when cardiac output is too high, putting pressure on arterial walls or as response to peripheral resistance to blood flow in small arteries of body Risk factor for heart disease and kidney failure Can adversely affect cognitive function producing problems in learning, reasoning, attention, and mental flexibility

Hypertension and Measurement Study CVD through increased blood pressure responses with predict symptoms in response to stress Identify stressful circumstances and examine rates of hypertension and how blood pressure ebbs and flows in response to environmental demands Use ambulatory monitoring to examine relationship between lifestyle factors and blood pressure in natural settings with person wearing a blood pressure cuff which assess blood pressure at intervals and has advantage of individual differences throughout day Hypertension Risk Factors 5% of hypertension is caused by kidney failure but 90% is of unknown essential causes Childhood-Childhood temperament promotes central weight gain in adolescence which in turn predicts CVD Blood pressure reactivity in childhood and adolescence predicts later development Sex-Prior to age 50, men are at greater risk but after age 55 both men and women are at 90% risk CVD factors are higher among minorities due to low SES Elevated blood pressure in women related to excessive family responsibilities, especially when paired with a job Genetics- Genetic factors play a role with children having 45% chance if one parent has CVD and 95% chance if both parents have CVD with genetic factors including reactivity, hereditary predisposition towards sympathetic nervous system reactivity in response to stress especially Emotion-Depression, hospitality, cynicism, repression, rumination, excessive striving and intense arousal that increase blood pressure are factors Environment-Crowded, high-stress, noisy, environments contribute to CVD Personality-Type D chronic negative affect, Type A confrontational orientation and anti-social personality is prognostic of CVD John Henryism- personality predisposition to cope actively with psychosocial stressors Becomes lethal predisposition when active coping is expected to be unsuccessful Race- Particular problem to black population tied to stress and low SES as well as hostility and racial difference in neuropeptide and cardiovascular responses to stresses Blacks are at increases risk for obesity, cigarette smoking, less decrease in blood pressure at night, greater salt intake Hypertension Management Behavior Modification- low-salt diet, reduction in alcohol, weight reduction, and exercise recommended Caffeine restricted as well Medication- Diuretics reduce blood volume by promoting excretion of sodium and are most effective Beta-adrenergic blocker decrease cardiovascular output and plasma rennin activity Central adrenergic inhibitors also used to reduce blood pressure by decreasing sympathetic outflow from central nervous system Peripheral adrenergic inhibitors used to deplete catecholamines from brain and adrenal medulla Vasodilators, angiotensin-converting enzyme inhibitors, and calcium channel blockers also used

Biofeedback- Use biofeedback, progressive muscle relaxation, hypnosis, meditation, all of which reduce blood pressure via the induction of a state of low arousal Deep breathing and imagery often added Self Control- Self-reinforcement, self-calming talk, goal setting, and time management typically added to CBT CBT, weight reduction and physical exercise are quite effective and CBT may reduce drug requirements and is especially effective with mild or borderline hypertensives People often do not adhere to treatment because they think stress management is sufficient to solve issue or do not even know they have CVD Correlation between beliefs about blood pressure and actual blood pressure is low Stroke Stroke- condition results from disturbance in blood flow to the brain, often marked by resulting physical or cognitive impairments and in the extreme, death Third major cause of death in US with a mortality rate of 30% within first month after stroke and those that survive often suffer some form of permanent impairment Symptoms- Occurs when blood flow to localized areas of brain is interrupted which can lead to arteriosclerosis or hypertension When arteriosclerotic plaques damage cerebral blood vessel, damaged areas may trap blood clots (thrombi) or produce circulating blood clots (emboli) that block blood flow Can also be caused by cerebral hemorrhage (bleeding caused by rupture of blood vessel in brain) After a stroke, at increased risk for subsequent strokes Stroke Risk Factors High blood pressure, heart disease, cigarette smoking, high red blood cell count, and transient ischemic attacks which are little strokes that produce temporary weakness Emotion- Acute triggers for stroke include negative emotions, anger, and sudden change in posture in response to startling event Anger expression also appears Likelihood increases with age, occurs more often in men than women and more often in blacks and those with diabetes Depression and anxiety predict stroke, especially in white women and blacks Group at greatest risk is black men age 45-64 Stroke and Brain Damage Motor difficulties common and occurs on side of body opposite to side of brain affected by stroke Left Brain Damage- communication disorders, cognitive disturbances, reduction in intellect, difficultly learning new tasks and tasks requiring short term memory React with anxiety and depression Right Brain Damage- difficult processing visual feedback and may believe they are going insane Indifferent but have difficulty identifying and describing feelings (alexithymia) Stroke Management

Almost always involves increased dependence upon others Overprotective caregiver, poor relation with caregiver, or negative caregiver results in depression while positive emotions are associated with better recovery Medication- Aspirin can greatly reduce risk by preventing coagulation Few weeks use of aspirin following a stroke can reduce risk of recurrence by as much as a 1/3 Antidepressants and cholesterol-lowering drugs promote growth of new neurons Therapy- Treated with psychotherapy, cognitive remedial training, movement therapy, use of structured stimulating environments Use both individual and group counseling with home visits from volunteers or counselors Constraint-induced movement therapy which targets upper extremities is effective which requires patient moving impaired limb to relative exclusion of less affected limb Must education patient on limitations they have and show them how to overcome limitations Right-brain damage patients taught to turn head Neuro-rehabilitation- Rewire affected areas of the brain Diabetes Type II Diabetes- non-insulin dependent metabolic disorder characterized by high blood glucose in the context of insulin resistance, often co-occurs with risk for heart disesase Third most common illness and a leading cause of death with nearly 8% of population having diabetes At risk for hypertension and stroke as well In past 40 years, incidence has increases 6 times Typically a middle or old age disorder Becomes more prevent with obesity and affects younger ages Symptoms-Symptoms include frequent urination, fatigue, dryness of mouth, impotence, irregular menstruation, loss of sensation, and frequent infection of skin, gums, or urinary system, cramps in legs feet or finger, slow healing of cuts or bruises, intense itching and drowsiness Majority of type 2 diabetics are overweight (90%) and is more common in women and low SES More common in minorities, especially Native Americans who may have 50% of population with diabetes Cause-Rising levels of glucose in blood trigger pancreas to release insulin and when process goes awry, sets stage for diabetes Cells in muscle, fat and liver lose ability to respond fully to insulin (insulin resistance) Pancreas temporarily increases insulin and insulin-producing cells may give out with insulin production dropping so that balance between insulin action and secretion becomes deregulated Consequences-Thickening of arteries due to buildup of waste in blood which leads to high rates of CHD Leading cause of blindness among adults and accounts for 50% of all patients who require renal dialysis for kidney failure Associated with nervous system damage, including pain and loss of sensation Foot ulcers may result and amputation may be required Diabetes and Stress Abnormal glycemic responsiveness to stress which when coupled with experience of long-term stress may be implicated in development of disease

Stress aggravates type 2 diabetes after diagnosed by glucose metabolism being influenced by stress In presence of stress hormones such as cortical, insulin is less effective in facilitating glucose storage and may result in increased insulin secretion which can lead to overrating and inactivity and obesity and depression Diabetes Treatment Key to successful treatment is self-management Can be completely prevented by changes in lifestyle of high-risk individuals and trajectory can be greatly improved for those diagnosed Exercise, weightloss, stress management and dietary control are essential Reduce sugar and carbohydrate intake, reduce weight, exercise to use up glucose in blood People with good self-control do better job of achieving glycemic control Social support has mixed results Depression complicated prognosis and interferes with self-management and may require therapy Training to monitor blood sugar effectively and reduce stress Negative risk increases progress of disease and related to CHD among women Combination of behavior modification and medicinal therapy decreased risk for diabetes and CVD CHAPTER 14 Immune System Psychoneuroimmunology- interaction among behavioral, neuroendocrine, and immunological processes Functions to distinguish between what is self and what is foreign to body to attack and rid body of foreign matter Natural immunity provides defense against many pathogens Involves granulocytes which include neurotrophils and macrophages which engulf target pathogens Congregate at site of injury and release toxic substances which lead to inflammation, fever and promote healing Natural killer cells recognize and dissolve foreign matter by releasing toxins Specific immunity is slower and more limited Lymphocytes involved have receptors on cell surface to fit with one antigen and thus respond to only one kind of foreign matter and divide in response to foreign matter Non-specific Mechanism- innate, fast response Specific Mechanism- adaptive, slow response, produce antibodies specific to particular antigens Divided into humoral and cellular branches Humoral Immunity- driven by B cells, defends against bacteria and viruses prior to infection Cellular Immunity- driven by T cells, defends against fungi, viruses, parasites and cancer Helper T cells enhance function of T cells, B cells, and macrophages by producing lymphocytes which also serve a counter regulatory immune function that suppresses immune activity Measuring Immune System

Assess immune function by assessing function of immune cells, production of antibodies to latent viruses, levels of immune system products, wound healing or skin barrier recovery Assess capacity to produce antibodies to latent virus such that if body produces antibodies to these viruses it is not working properly enough to control them Degree to which body produces antibodies due to vaccine is sign of good functioning Can assess functioning through immune-related products in blood such as pro-inflammatory cytokines Immune System and Stress Short-term stressors produce fight-or-flight response and immune responses that anticipate risk of injury and possible entry of infectious agents Up-regulation of natural immunity and down-regulation of specific immunity Shift away from cellular immunity and towards humoral immunity Long-term stress adversely effects immune system function Stronger with preexisting vulnerabilities from old age and disease Stress threats to self may be especially likely to alter immune functioning Anticipatory stress reduces number of T cells Stress results in increased vulnerability to infectious diseases such as colds, flues, herpes, and chicken pox, mononucleosis, and EB virus SNS and HPA- Stress engages sympathetic nervous system and HPA axis, both of which influence immune function Activation of SNS increases immune activity, HPA activation suppresses it HPA axis releases glucocorticoids such as cortical which reduces number of white blood cells Aging-Related to Cellular aging by reduction in DNA complex at end of chromosomes (telomere) by 10 years which is positively related to high mortality rates in the elderly Immune System and Depression Among those already ill, stress predicts more severe illness and higher production of cytokines Stress increases negative emotions such as depression or anxiety Depression lowers lymphocytes, NK cell activity, number of blood cells and effects are stronger in old people and people already hospitalized The more depressed a person is, the more immunity is compromised Depression results in more inflammation, and delayed wound healing and positive emotions result in quicker recovery Lonely people have poorer health and more immunocompromise Insecure attachment showers low NK cell cytotoxicity, showering other health risks Separation or divorce with continued attachment results in poorer immune functioning in men and women Adverse effects of marital conflict greater for women than men Positive behavior during conflict can lead to steeper declines in stress hormones Caregivers have lower T cell count and stress can affect wound repair and those angry or depressed experience greater distress Coping-Optimism and active coping strategies are protective against stress Stress perceived as uncontrollable results in greater compromise to immune system Perceiving benefits in stressors, prioritizing goals, emphasizing relationships, and exercise protect against stress-related immune compromise

Relaxation increases NK cell activity and enhanced cellular immunity HIV and AIDS AIDS- Progressive impairment of immune system by HIV 33 million people worldwide have AIDS, 2 million of which are children, and half of which are women HIV- virus implicated in development of AIDS Attacks helper T cells and macrophages of immune system and is transmitted through body fluid Symptoms- Early symptoms mild with swollen glands, flulike symptoms, and then symptoms may abate with slow gradual viral growth Chronic diarrhea, wasting, skeletal pain, blindness, gynecologic infection in women Forgetfulness, inability to concentrate, motor retardation, decreased alertness, apathy, withdrawal, diminished interest and loss of sexual desire and later confusion, seizures, dementia and coma AIDS Risk Factors Sex- Women more at risk than men through sexual intercourse Race- Number of AIDS cases growing fastest in minority women African American and Hispanic women are less than one fourth of all US women yet represent 80% of AIDS cases Low SES blacks and Hispanics develop AIDS faster than whites Emotion- Depression commonly associated with diagnosis and more likely when no social support or stigmatization Thoughts of suicide common in geographically isolated groups Bereavement over death of others with AIDS can increase development of disease Most make positive changes to health following diagnosis Social Support- People with strong social support are more likely to disclose and thus receive support AIDS Management HAART- combination of antiretroviral medications HIV can no longer be discerned in blood in some patients Must take drugs regularly for them to be effective, and adherence is low Drug resistant strains increasing Intervention begins with education of risk and modes of transmission Overrate casual contact but underrate sexual intercourse as transmission source Fear-induced education is ineffective Sense of self-efficacy, positive evaluation of condom use, and perceived susceptibility predicts use of condoms Interventions targeting sexual negotiation skills have been effective Social support increases prevention Those working with HIV continue to work but those diagnosed when out of work are unlikely to find work Negative expectations of disease can result in decline in helper T cells and accelerate course of disease

Osychological inhibition can result in more rapid progress of disease Cancer Cancers result from dysfunction in DNA causing excessively rapid cell growth and proliferation with cancerous cells sapping bodily resources Second to CHD in causes of deaths in US Caner rates declined in lung, colorectal, breast and prostate which account for half of US cancer deaths Decline in smoking accounts for much of this decline and rest can be attributed to treatment improvements Cancer Risk Factors Family- 2/3 families has a family member who develops cancer More than 1/3 of cancer victims live at least 5 years after diagnosis Cancers run in families due to genetic factors as well as diet and lifestyle Race- Anglo men have highest bladder and malignant melanoma rate, Latino men and women have lowest lung cancer rate but Latina women show highest rate of cervix cancer, African Americans have prostate cancer rates higher than any other cancer in any other group, Japanese have high stomach cancer and Chinese have high rate of liver cancer Marriage- Married people, especially men, develop fewer cancers which exception being gender-related cancers Diet- Cancers higher in chronically malnourished and those with high fat and food additive diets Control- Lack of or loss of social support may influence course of cancer Emotion- Depression implicated in progress of cancer and can exacerbate other risk factors Avoidant or passive coping is also risk factor as does repressive coping in children Stress- Stress adversely affects ability of NK cells to destroy tumors Cancer Management Coping- Concern of bodily integrity following surgery and chemotherapy Adjustment problems greatest in women with a history of life stressors or lack of social support Married cancer patients have better survival rates than single cancer patients Stress from cancer can elevate cortical levels and alterations in HPA axis, increasing chance of recurrence Treatment- Cope by seeking social support, focusing on positive, distancing, cognitive-escape avoidance, behavioral escape-avoidance Exercise improves self-efficacy, physical functioning and improved emotions Medication, CBT, meditation, relaxation, hypnosis, and visual imaging used to reduce pain Use individual therapy to address anxiety or depression, CNS dysfunction, psychological problems exacerbated by cancer or management of pain Support groups may be most helpful for women without social support Arthritis Arthritis second only to CHD as most widespread chronic disease in US Rheumatoid Arthritis- crippling form of arthritis results from autoimmune process, usually attacking small joints of hands, feet, wrists, knees, ankles and neck

Immune system attacks thin membranes surrounding join causing inflammation, stiffness and pain and destroying bone and muscle Almost half of RA patients recover, with only about 10% being crippled Osteoarthritis- form of arthritis that results when the articular cartilage begins to crack and wear away due to overuse of a particular joint Women more affected than men Joint becomes stiff, inflamed, and painful Affects the elderly and athletes Keep ones weight down and aspirin, exercise recommended Gout- form of arthritis produced by a buildup of uric acid in the body, producing crystals that become lodged in the joints, the most commonly affected area being the big toe Affects mostly men Treated by diet, fluid intake and exercise and is only threatening if untreated Lupus- chronic, inflammatory form of arthritis that may be managed by anti-inflammatory medications or immunosuppressive medications depending on severity Affects mostly women Leads to chronic inflammation, producing pain, heat, redness and swelling Can be threatening if attacks connective tissue to bodys internal organs More common in Native Americans, Blacks and Asians than whites Managed through anti-inflammatory medications Arthritis Risk Factors Sex- Affects mostly women and is most crippling form of arthritis Age- Primarily affects those in 40-60 age range but can affect any age Emotion- Depression over loss of activity may feed back into pain process, enhancing pain Affect of stress and depression mediated by immune system Arthritis Management Treated with aspirin to relieve pain and inflammation, rest and supervised exercise Biofeedback, relaxation, problem-solving, reducing negative expectations, pain-coping moderately successful Among juveniles, disease flares up periodically until puberty and affects girls four times more than boys Diabetes Type I Diabetes- autoimmune disorder characterized by lack of insulin production by beta cells of pancreas Abrupt onset of symptoms due to lack of insulin production by beta cells of pancreas May appear following viral infection and probably has genetic contribution Immune system falsely indentifies cells in pancreas as invaders and destroys them Develops earlier in life, earlier for girls than boys between 5 and 6 or 10 and 13 Diabetes Symptoms

Frequent urination, unusual thirst, excessive fluid consumption, weight loss, fatigue, weakness, and irritability, nausea, craving for food (sweets) and fainting Vulnerable to hyperglycemia where skin becomes flushed and individual becomes drowsy with deep breathing and vomiting and abdominal pain ad coma may result Severe complications do not occur until 15-20 years after onset Diabetes Management Do not monitor accurately glucose levels but rely on feeling alone Doctors focus on keeping glucose levels steady, parents focus on avoiding hypoglycemia Managed through insulin injections Need to monitor glucose levels and food intake controlled by meal plan