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					            Module: Health Psychology

            Lecture: Stressful medicine

            Date:               09 March 2009

Chris Bridle, PhD, CPsychol
Associate Professor (Reader)
Warwick Medical School
University of Warwick

Tel: +44(24) 761 50222
                 Aims and Objectives
n   Aim: To provide an overview of the psychological
    aspects of stress and coping
n   Objectives: You should be able to describe …
    n   the psychological and physiological effects of stress and
        their underlying mechanisms of action
    n   the main perspectives on stress, i.e. response, stimulus
        and process
    n   the psychological antecedents of stress and stressors
        common to the clinical context
    n   ideas for removing or reducing the negative impact of
        stressors among patients
                Dual Pathway Model:
            From Psychology to Physiology

                   Acute & Chronic
Psychological          Stress           Physiological
  Appraisal           Direct Path        Reactivity

Factors:              Indirect Path
  Stable            Health-Related
  Situational         Behaviour
         What are the Effects of Stress?

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

                                                                         Up-regulation by stress
(Kiecolt-Glaser et al., 1984)

                                Down-regulation by stress

                                                                                                       (Kiecolt-Glaser et al., 1985)
                                                                          reduction intervention
                                n   Medical students, battery of
                                    measures obtained before,       n   Older population, protocol
                                    during and after exam               assessment schedule from
                                    period (+ 1 month)                  previous study
                                n   Higher pre-exam stress          n   2 hour imagery-based
                                    scores associated with              relaxation intervention
                                     n   lower post-exam NK cells   n   30% increase in NK cell
                                     n   higher urinary cortisol
                                                                        activity compared to control

                                      A psychological process (stress) can down-regulate
                                    immune response, and a psychological intervention can
                                                enhance immunocompetence
    Physiological Effect: Pharmacological Response

n   Stress alters response to viral and bacterial vaccines,
    including respiratory viruses, hepatitis-B, and influenza
n   An example:
     n   Adult participants provide a range of stress-related data, e.g.
         questionnaires and biological samples
     n   Baseline antibodies measured and influenza vaccine delivered
     n   Follow-up measures of antibodies at 1 and 4 months
     n   Does stress attenuate antibody response at follow-up?

         YES: stressed people had significantly fewer antibodies
     Interestingly, in this study perceived stress at baseline was
         a better predictor of subsequent antibody response!
                                                        (Miller et al., 2004)
     Physiological Effect: Stressed In-Patients

n   On the ward                   n   After discharge
    n   Slower wound healing          n   Longer recovery, e.g.
    n   More post-surgery                 return to work
        complications                 n   More service use, e.g.
    n   Longer in-patient stay            related symptoms
    n   More staff time per day       n   Less use of
    n   More analgesia use                rehabilitation services
    n   Less satisfaction with        n   Increased risk of co-
        treatment - associated            morbidity and early
        with poor adherence               mortality

 Stress not only increases risk of illness among the healthy,
but also impedes recovery / worsens prognosis among the ill
              Understanding Stress

n   Three perspectives to understand stress:

    n   Response:    Focus on the effect (physiological)

    n   Stimulus:    Focus on the cause (stressor)

    n   Process:     Focus on the person-environment
                     interaction (transaction)
           Physiological Response to Stress:
              Fight or Flight to Feed and Breed

                        Central Nervous
Sympathetic NS                                  Parasympathetic NS
Acute Stress Response       Biomarkers         Conservation Response

                 cardiac rate, BP, respiration rate,
  Increased          glycogenolysis, peripheral         Decreased
                         diversion of blood
                    catecholamines and cortisol

                     immune surveillance, gut
  Decreased        function, kidney function, fat       Increased
                        stores, sex steroids
                                                         (Cannon, 1914)
         General Adaptation Syndrome (GAS)

n   Stress is a non-specific physiological response to a
    threat to one’s physical or emotional well-being
n   Three stages of physiological response:
    •   Alarm: fight or flight response - nervous,
        endocrine and immune systems activated
        for defence against threat
    •   Resistance: conservation response initiated
        to return homeostasis, but becomes
        counterproductive if alarm continues
    •   Exhaustion: depletion of physiological
        resources - collapse of adaptive responses,
        immune failures and disease outcomes
                                                      (Hans Selye, 1956)
Acute Physiological Response to a Stressor
   … then a parasympathetic
         response to restore
                         What happens if the 'acute'
                         stress response continues?


Sympathetic                     Parasympathetic
 Slower recovery from sympathetic NS arousal, leads to the
             break down of adaptive systems:

GI: ulcers, IBS, esophageal reflux;   Drm: eczema, acne, psoriasis;
RS: amenorrhea, impotence;            IS: tissue rejection, infection;
ReS: asthma, hyperventilation;        Psy: cognitive impairment, low
CV: essential hypertension,                self-efficacy & self-esteem,
    migraine, Raynaud’s disease;           anxiety, learned helplessness

             Sympathetic                    Parasympathetic
      Stress as a Non-Specific Physiological

n   Focus on the physiological effects of stress helps us
    understand how stress influences health

n   Important starting point but an insufficient explanation
         i.e. tells us nothing about the cause of stress

         Should we focus on the threatening stimulus
             as a way of understanding stress?
        Stress as a Threatening Stimulus
n   Social Readjustment Rating Scale (SRRS)
    n   43 life events, e.g. divorce, marriage, job loss, etc.
    n   Each event ranked, relative to one another, on the
        degree of adjustment that would be required of the
        average person in order to adapt
    n   Rank used to quantify the degree of threat associated
        with each event, i.e. Life Change Units (LCUs)
    n   SRRS score is the LCU-total based on event exposure
        during past 12 months
    n   LCUs hypothesised to be positively related to illness
                                                   (Holmes & Rahe, 1967)
                                      Life Change Units and Disease
                                  n   SRRS scores associated with subsequent illness
% People with Illness (2 Years)

                                  n   Replicated many times – modest relationship
                                  n   Most prognostic value for SRRS scores >200

                                                                                   Score classification:
                                                                                     Low < 149
                                                                                     Mild = 150-200
                                                                                     Mod = 200-299
                                                                                     Major >300

                                                    Life Change Units (Baseline)

                                                                                   (Holmes & Rahe, 1967)
                                Top   10 Stressful Life Events     LCUs
         SRRS:                  1.    Death of a spouse             100
      Example life              2.    Divorce                        73
    events with LCUs            3.    Marital Separation             65
                                4.    Jail term                      63
                                5.    Death of close family member   63
n    What life event would
                                6.    Personal injury or illness     53
     top your list of
     stressors?                 7.    Marriage                       50
                                8.    Fired at work                  47
n    Is it in the SRRS?
                                9.    Marital reconciliation         45
n    Is any event ‘obviously’
     ranked incorrectly?
                                10.   Retirement                     45

n    Which one(s)?              Other SLEs
                                13. Sexual difficulties            39
n    What does that say
     about ‘stress as a         23. Son/daughter leaving home      29
     stimulus’?                 30. Trouble with boss              23
                                38. Change in sleeping habits      16
                                43. Minor violation of laws        11
                  Types of Stressor

n   Stressors differ along a range of dimensions:

    n   Chronicity: discrete sudden traumas to continuous
        chronic stressors, e.g. car accident and diabetes

    n   Magnitude: life changing events to daily hassles, e.g.
        getting married / divorced and car parking at WMS

    n   Inclusiveness: individuals to societies, e.g. driving
        test and 11 September
   Stress as a Threatening Stimulus

Focus on the stimuli neglects the individual, i.e. the same
   SLE will be equally stressful for different people and
      equally stressful for the same people across
               time and repeated exposure

Stress responses vary not only between people,
   but within people also, and in response to
      not only different events, but to the
               same event as well
  Is stress better understood as a subjective process?
Stress as a Subjective Process

Stimulus    A static, direct effect      Stress
 Event                                  Response

  Event              ?
                & Coping

     An indirect subjective process
            Transactional Model of Stress
 n   Causal chain of influence
 n   Stimulus events indirectly
     related to stress experience
 n   Processes of appraisal and
     coping intervene in the
     stressor-stress relationship
 n   Stress as a subjective post-
     appraisal outcome

Stimulus Event      Primary           Secondary                     Health-Related
  (a potential     Appraisal           Appraisal                      Outcome
   stressor)     (event demands)       (oneself)                       (Stress)

  Input                        Intervening Processes                   Output

                                                       (Lazarus & Folkman, 1984)
               Intervening Processes
n   Primary appraisal: Determines the adaptational significance
    of the event, i.e. is the event relevant and, if so, is it a
    challenge, harm or threat?
n   Secondary appraisal: Evaluates available response options
    and opportunities, i.e. am I able to cope adequately with
    the event's adaptational demands?
n   Coping: Cognitive and behavioural activities initiated in
    response to the appraisal process in order to manage the
    adaptational demands of the event

        What factors influence appraisal outcomes?
    You know the answer to this question already!
                  Appraisal Influences
n   Factors influencing appraisal:
    n   Background: historical and current life context, e.g.
        culture, S-E-S, housing, marital stability, general health
    n   Stable: relatively enduring individual differences, e.g.
        emotional disposition, expectancies, explanatory styles
    n   Social: perceptions of supporting relationships, e.g.
        social support, identification, integration
    n   Situational: characteristics of the event, e.g. control,
        predictability, time since onset, novelty
                Situational Characteristics

      Favourable              Hospitalisation*          Additional
    Controllability            Loss of control       Illness concerns
    Predictability               Uncertainty        Treatment worries
   Social Support                 Isolation        Uncertain Prognosis
 Peripheral Domain            Central Domain           Fear of pain
      Familiarity               Unfamiliarity      Worried about family
      Autonomy                  Dependence              Indignity
    Sense of Self                Compliance               Anger
* or treatment, becoming ill, seeking help, etc.

   From a psychological perspective, going to hospital*
                   is a huge stressor

n Coping can usefully be hierarchically ordered

   n   Activities: any and all cognitions and behaviours directed
       towards the management of stressor demands, e.g.
       Gathering relevant information, or Going to the pub
   n   Strategies: related coping activities clustered into
       meaningful groups, e.g. Planning, or Mental
   n   Dimensions: related strategies clustered into one of two
       inclusive dimensions according to focus, e.g. problem-
       focussed coping and emotion-focussed coping
                    Effects of Coping
n   Coping changes the situation
    n   Directly: alters concrete aspect of the stressor context
    n   Indirectly: alters the way the situation is perceived

n   Stimulates (re)appraisal of the ‘new’ situation
    n   Primary appraisal: challenge, harm or threat?
    n   Secondary appraisal: can I respond effectively?

n   Evaluation of coping based on relative demands
    n   Adaptive: contributes to resolving demands
    n   Maladaptive: may or may not be effective in the short
        term, but contributes to, or creates, future demands
               Coping Effectiveness
  Problem-focused coping:            Emotion-focused coping:
Attempts to manage or change        Attempts to remove or reduce
concrete aspects of the stressor   the stressor's emotional distress

            Flexible coping likely the most effective,
                  but often difficult in practice

             Effectiveness dependent on situational
                  characteristics of the stressor


 Problem-focussed coping most          Emotion-focussed coping
  effective when the stressor is       most effective when the
       amenable to change            stressor can not be changed
                 Transactional Model

 Potential       Primary            Secondary                       Health-Related
 Stressor       Appraisal            Appraisal                        Outcome

 Stimulus      Is the event
                                 Can I deal with   Problem- and /    Psychological
  Event       relevant to me
                                 the demands of      or Emotion-       and / or
              and, if so, what
                                   the event?          Focused         Physical
             are its demands?

Background      Stable             Situational
  Factors       Factors              Factors

                       Social Factors
                                                      (Lazarus & Folkman, 1984)

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

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

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

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