Psychological and Social Factors influencing Health

- Revolution in public health — less deaths to flu, pneumonia, TB, measles, etc.
- Major Fatality Contributors: psychological and behavioral factors

Psychological and Social factors → can influence brain structure and function
- Important to endocrinological disorders (type 2 diabetes, CDV disorders, immune)

Physical Disorders: strongly inferred physical causes, visibly physical pathology

Somatic Symptom Disorder: physical damage/disease with no physical pathology

Psychosomatic Medicine: psychological factors affect psychophysiological disorder

Health and Health Related Behavior

- Second revolution in public health: infectious disease → psychological factors
- Behavioral Medicine - knowledge derived from behavioral science
- Prevention, diagnosis and treatment of medical problems
- Psychologists/physicians/health professionals; develop treatments + prevention
- Health Psychology: subtype of behavioral medicine: maintenance of health
- Analyze and recommend improvements in healthcare systems and policies

Psychological Factors (negative emotions/stress) → lead to physical disorders/disease

Risky behaviors → contribute to physical disorders or disease

Psychological / Social Factors on Health

1) Affect basic biological functions that lead to illness and disease
2) Long standing behavior patterns put people at risk to develop physical disorders

Behavioral Patterns → Disease

- Leading causes of death: heart disease, cancer, type 2 diabetes can be traced back to
lifestyle factors — smoking, diet, physical activity
The Nature of Stress
- Hans Selye: stress itself can cause ulcers, atrophy of immune system
- Environmental changes (stresses) = ulcers. → Stress Physiology
- Theory: Body goes through several phases in response to sustained stress
1) Alarm response — to immediate danger or threat
2) Resistance — to continuous stress, mobilize coping mechanisms
3) Exhaustion — Intense stress: permanent damage/death to body
→ Sequence of general Adaptation Syndrome (GAS)
- Stress can be a stimulus → physiological response

The Physiology of Stress

- Sympathetic nervous system mobilizes our body toward periods of stress
- Increases of strength and mental activity, endocrine system activity increase
- Endocrine neuromodulators/neuropeptides: affect NS via glands → bloodstream
- Corticotropin Releasing Factor (CRF) - by hypothalamus → pituitary gland
- Activates adrenal gland → cortisol (stress hormone)
- HPA axis closely related to limbic system
- Hippocampus + cortisol → turns off stress hormone (negative feedback)
- Primates: HPA loop - high cortisol = chronic stress = kill nerve cells (hippocampus)
- Hippocampal activity compromised: excess cortisol = cannot turn off stress
- Causes brain damage, less problem solving, susceptible to infectious disease

Contributions to Stress Response

- Stress physiology: influenced by psychological and social factors (Adler)
- Sapolsky baboons: social hierarchy with dominant → submissive members
- Life of subordinate animals are made difficult (stressful)
- Excess CRF secretion in hypothalamus, diminished sensitivity of pituitary
gland (stimulated by CRF)
- Dominant baboons: have predictability and controllability in life
- Constantly attack each other in top hierarchy

Stress, Anxiety, Depression and Excitement

- Physiology of emotional states: patterns of sympathetic arousal and NT activation
- Blood pressure may increase to overwhelming stress → sense of no control
- Self Efficacy: sense of control and confidence to cope with stress and challenge

Stress and the Immune Response

- Intensity of stress and negative affect at time exposure relationship
- Quantity and quality of social relationships affect: getting sick, virus
- Socializing can relieve stress
- Optimistic styles protect against developing a cold
 - Humans under stress increase rates of infectious diseases (colds, herpes, mono)
- Stressful situations lower immune system (divorce, relationship issues)
- Optimism and positive affect = better immune system
- Uncontrollability = lowers immune system functioning

- Chronic stress — effects of depression last longer

How the Immune System Works

- Immune system identifies and eliminates foreign materials (antigens)
- Antigens — bacteria, viruses, parasites
- Immune system also targets own cells that are aberrant or damages (tumors)

2 Parts of Immune System

1) Humoral
2) Cellular

→ Specific types of cells function as agents of both

- White blood cells (leukocytes) do most of the work
- Macrophages — first line of defense, surround antigens and destroy them
- Lymphocytes — B and T cells
- B cells— humoral immune system, neutralize antigens in blood/liquid
- Produce immunoglobins = antibodies
- Antibodies combine with antigens to neutralize
- Memory B cells: post antigen, immune system response: stronger
- T cells — cellular immune system, no antibodies, killer T cells
- Killer T cells destroy viruses and cancer cells
- Speed future responses to same antigen, regulate immune
- T4 cells / Helper T cells = enhance immune response, signal B
calls to produce antibodies, tell T to destroy antigen
- Suppressor T Cells = suppress production of antibodies by B
cells when no longer needed
- 2x T4 cells > Suppressor T cells
- Too many T4 Cells: body attacks normal cells and not antigens
- Autoimmune disease (rheumatoid arthritis)
- HIV attacks helper T cells: lower immune response → AIDS

Psychoneuroimmunology (PNI) - psychological influences on neurological response of

immune response
Psychosocial Effects on Physical Disorders
AIDS
- Minority groups are disproportionately affected by deadly disease
- Perceived urgency of the US/world has decreased, despite clear concentration in
the US toward sexual minorities and communities of color
- Aids Related Complex (ARC); years of no symptoms, patients later develop minor
health problems: weight loss, fever, night sweats
- Stress related variables are clinically significant to immune response

- Diagnosis of AIDS: ONLY AFTER one serious disease appears

- Pneumocystis pneumonia, cancer, dementia, wasting syndrome
- Median time to AIDS — 7.3-10 years
- HAART (antiretroviral therapy): suppress virus in affected HIV patients
- Most AIDS patients die within 1 year without treatment
- With treatment: 2+ years (85% chance)
- Can have severe side effects (nausea and diarrhea)

- AIDS exposure + no disease — strong cellular branch of immune system

- May also be genetic factors, may be strong confidence in healthcare
provider, strong social supports
- Psychological factors (that impact immune system) prevent progression?

- CBT treatment: positive effects on immune systems of those symptomatic

Cancer
- Development of cancer can be due to psychosocial influences (psychoncology)
- Therapy group’s survival times were longer than those without
- Those with therapy lived 2x as long post cancer diagnosis
- Psychological treatment
- Reduce stress, improve quality of life = increase survival, reduce recurrence
- Better health habits, closer adherence to medical treatment, endocrine function
- Success: reduce stress, increase positive mood, healthy behavior
- Supportive relationships: buffers stress, slows disease progression
- Benefit finding: new emphasis on positives post cancer: purpose, spirituality, priorities

Cardiovascular Problems
- Cardiovascular disease — strokes, CVAs (cerebral vascular accidents)
- Hypertension - high blood pressure, risk factor: stroke and heart disease, kidney disease
- Heart muscles work harder to force the blood to all parts of the body
- Essential Hypertension: small percent of cases: abnormalities on adrenal gland
- African Americans 10x higher risk for hypertension
- Hypertension: biological, psychological and social contributions
- Can run in families, 2x likely if parents have it
- Can be due to eating too much salt
 - Psychological factors: social support, loneliness, depression can cause
- Anger and hostility = increase risk of hypertension

Coronary Heart Disease

- Blockage of arteries supplying blood to heart muscle (myocardium)
- Angina Pectoris (Angina) — chest pain due to obstruction
- Atherosclerosis — fatty substance/plaque builds in arteries
- Ischemia — deficiency of blood to body part (narrowing)
- Myocardial Infarction — Heart attack, death of heart tissue (clogged)

Type A Behavior Pattern — activities before Coronary Heart Disease — more likely
- Competitive drive, impatience, energetic, “pressured for time”
- Western Collaborative Group Study: 2x as likely to develop CHD
Type B Behavior Pattern — activities before Coronary Heart Disease — less likely
- Relaxed, less concern for deadlines, no pressure on life

Framingham Heart Study → CHD highest for those with a low level of education

Chronic Negative Emotions

- Increased heart rate when instructed those with Heart Disease to imagine anger
- Anger impaired the pumping efficiency of the heart → risk for arrhythmias

Type D Behavior Pattern — social inhibition, heightened negative emotions — no effect?

Psychosocial Factors to risk CHD

- Low socioeconomic status, low prestige
- Stressful life events
- Coping skills and social support

Chronic Pain
- Costliest medical problem in the United States
- Acute Pain — follows injury, disappears after injury healed/effectively treated
- Chronic Pain — begin with acute episode, does not decrease over time
- Tends to be muscles, joints, tendons, lower back
- Vascular pain - due to enlarged blood vessels — chronic
- Headaches - pain due to slow degeneration of tissues — chronic

Psychological and Social Aspects of Pain

- Severe chronic pain makes individuals give up on life, lose the fun on life → seek relief
- Severity of pain does not predict actions toward it
- Why do some people with intense chronic pain continue to work? — Psychosocial
Philips and Grant: experience of pain more related to personality and SES differences
- Plan to initiate lawsuit following injury?
- Not more on the level of disability
Phantom Limb Pain = people lost arm/leg feel pain in limb no longer there
- Sensory cortex of the brain contributes to phenomenon
Operant Control of Pain Behavior - critical family members → become caring/sympathetic
- Seems under the control of social consequences

→ Social networks can reduce pain

- Those without families — more emotional distress without rating pain

Biological Aspects of Pain

- Mechanisms of Pain Experience / Pain Control → Gate Control Theory of Pain
- Nerve impulses from painful stimuli → spinal column → brain
- Dorsal horns of SC = gate → open and transmit sensation of pain
- Small fibers determine pattern, intensity of pain ~ stimulation
- Small fibers open gate // large fibers close gate
Endogenous Opioids
- Neurochemical way brain inhibits pain
- Natural opioids exist within the body — endorphins, enkephalins (like NTs)
- “Runners high” — shut down marked tissue damage/injury
- Higher self efficacy/control = higher tolerance for pain
- Low self efficacy/ocontrol = more endogenous opioids = less tolerant of pain

Gender Differences in Pain

- Women suffer more from men: migraine, arthritis, carpal tunnel, TMJ, labor, periods
- Men have more cardiac pain and backache
- Both men and women have endogenous opioid systems: men more powerful
- Women: estrogen dependent neuronal signal= extra pain regulation
Placebo effect — very real in regards to pain

Chronic Fatigue Syndrome

- Suffer considerably, often give up on careers
- Chronic course

- Tend to have more early level stressful events

- Pre-existing stress and emotional instability

Psychosocial Treatment of Physical Disorders

 - Pain can be bad for you and kill you. → the feeling of pain (Rats) = cancer growth
- Pain may reduce natural killer cells in the immune system
→ Those who are reluctant to pain killers → may have worse treatment

Biofeedback
- Making patients away of physiological functions that they would not notice
- HR, BP, muscle tension, brain waves EKG, blood flow patterns
→ Therapist teaches patient how to control responses
- Goal: reduce tension in muscles → relieving headaches
- Biofeedback and relaxation more effective than placebo medication interventions

Relaxation and Meditation

- Progressive muscle relaxation — people tense different muscles in sequence
- Follow by relaxing each specific muscle group
- Learn to recognize tension in groups and how to reduce it

Relaxation Response (Benson) - repeat mantra (focus on syllable)

- Minimize distraction — close mind to intruding thoughts
- Feel calmer, more relaxed throughout the day
- Reduce flow of certain NTs and stress hormones, more sense of control

Stress and Pain Reduction Programs

- Practice variety of stress management techniques
1) Monitor stress closely, identify stressful events in daily life
2) Deep muscle relaxation, tensing to identify → relax beyond inactivity
- Identify unrealistic thoughts, develop new appraisals and attitudes

Time Management Training - prioritize activities, less attention to nonessential demands

Assertiveness Training - learn to stand up for themselves in appropriate ways

Drugs and Stress Reduction Programs

- Pain relief medications — lessen efficacy of comprehensive programs in treatment
- May have increased pain after medication wears off
- Instead → focus on avoiding triggers leading to headache

- Common and obvious practiced strategy to avoid pain (frequent overuse)

- Can lead to dependency

Denial as a Means of Coping

- Optimistic people more likely to recover sooner after diagnoses
- Optimistic people less likely to use denial as a coping to severe stressors
- Denial → may not notice variations in symptoms, avoid treatments/rehabilitations
- Denial may also help endure shock, → must have better coping mechanisms after
Modifying Behaviors to Promote Health
- Postponing or controlling diseases by making lifestyle changes
- Big 3 - Eating habits, lack of exercise, smoking
- Unprotected sex, avoid injury precaution, alcohol excesive, tanning

Injury Prevention
- Accidents — leading cause of death 45+ years, 5th overall cause of death
- Psychological variables: programs on protecting children from accidents
- Escape fires, prevent burns, etc. - taught safety skills

AIDS Prevention
- Changing high risk behavior is the most effective way to prevent AiDS
- Comprehensive Programs — educating at risk individuals in ineffective
- Successful: target those most likely to change behavior

Smoking in China
- Myths Chinese Smokers Follow
1) Smoking = symbol of personal freedom
2) Perception that tobacco is important in social and cultural interaction
3) Perception that health effects of smoking = controlled through reasonable/measured use
4) Importance of tobacco to the economy

Stanford Three Community Study

- Successful effort to reduce risk factors for disease in community
- 3 entire communities of California = reduce risk factors for CHD
Community 1 — no interventions, info to assess risk factors over time, risk assessment
Community 2 — Media blitz on dangers of CHD, hints to reduce factors
Community 3 — All of (2), with face to face intervention with behavioral counselors

→ Interventions were ALL successful in reducing risk factors

- Community 3 intensive instruction with counseling = most change in risk

Using the word psychosomatic to describe a disorder with an obvious physical component is
considered misleading because
- It gives the impression psychological disorders like anxiety or depression do not have a
biological component

Health psychology, a subfield of behavioral medicine, focuses on all of the following EXCEPT
- Psychological factors affecting health
- Health policy
- Healthcare systems
 - Interdisciplinary study of psychology and health

Research has shown that increased levels of cortisol in response to stress may cause damage
to parts of the
- Brain

Which of the following statements accurately describes a process in the activation of the HPA
axis?
- The hippocampus secretes corticotropin-releasing factor (CRF).
- CRF stimulates the thyroid gland
- The pituitary gland (via the parasympathetic nervous system) activates the adrenal
glands.
- The adrenal glands secrete the stress hormone cortisol.

Research has shown that excessive secretion of the stress hormone cortisol can result in cell
death in the hippocampal region of the brain in cases of
- Post traumatic stress disorder

All of the following are effects of chronic secretion of cortisol EXCEPT

- Increased testosterone
- Muscle atrophy
- Hypertension
- Immune system response impairment

Sapolsky and colleagues found that physical health in wild baboons was associated
- Social rank

Which of the following statements about AIDS is true?

- The death rate from AIDS declined 50% from 2002 to 2010.

The main function of neurohormones is to

- Carry the brain’s signals to the rest of the body

Psychosocial interventions such as stress reduction techniques for chronically ill individuals are
thought to affect the disease process via the immune system by
- Helping patients reduce depression, thus reducing cortisol

In trying to determine if the type A/type B classifications are reliable and valid as predictors of
heart disease, it becomes apparent that
- not every individual shows distinctively type A or type B characteristics.
Gregor just learned that his spouse of 28 years has died in an automobile accident. Upon
hearing the news, Gregor collapsed and was rushed to the hospital in apparent heart failure.
Gregor probably suffered
- Myocardial stunning

Which of the following is an example of the phenomenon known as “operant” control of pain
behavior?
- Kate’s family has always been critical and demanding. Since her accident, though, family
members have become caring and sympathetic.

In a comprehensive headache treatment program, people who were low users of analgesic
medications
- improved more than people who were using medication only.