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 Email: C.Bridle@warwick.ac.uk www.warwick.ac.uk/go/hpsych

Aims and Objectives

Aim: To provide an overview of the psychological aspects of stress and coping

Objectives: You should be able to describe … the psychological and physiological effects of stress and

their underlying mechanisms of action

the main perspectives on stress, i.e. response, stimulus and process

the psychological antecedents of stress and stressors common to the clinical context

ideas for removing or reducing the negative impact of stressors among patients

PsychologicalAppraisal

Health-RelatedBehaviour

PhysiologicalReactivity

Acute & ChronicStress

Indirect PathFactors: Background Stable Social Situational

Direct Path

Dual Pathway Model:From Psychology to Physiology

What are the Effects of Stress?

Four classes of effect Affective: shock, distress, anxiety, fear, depression,

anger, frustration, lowered self-esteem, learned helplessness, guilt

Behavioural: smoking, alcohol, helpseeking delay, poor adherence, relapse, social withdrawal, illicit drugs, risky sexual behaviours

Cognitive: poor attention, errors in decision-making, hypervigilance for threats, bias to interpret ambiguous events as threatening, mood-consistent memory

Physiological: activation of nervous system, hormone production, metabolic function, immune function, fatigue, disease and illness

Physiological Effect: Immune Dysregulation

Down-regulation by stress Medical students, battery of

measures obtained before, during and after exam period (+ 1 month)

Higher pre-exam stress scores associated with

lower post-exam NK cells higher urinary cortisol

Up-regulation by stress reduction intervention

Older population, protocol assessment schedule from previous study

2 hour imagery-based relaxation intervention

30% increase in NK cell activity compared to control (K

ieco

lt-G

lase

r et

al., 1

98

4)

(Kie

colt-G

lase

r et a

l., 19

85

)

A psychological process (stress) can down-regulate immune response, and a psychological intervention can

enhance immunocompetence

Physiological Effect: Pharmacological Response

Stress alters response to viral and bacterial vaccines, including respiratory viruses, hepatitis-B, and influenza

An example: Adult participants provide a range of stress-related data, e.g.

questionnaires and biological samples Baseline antibodies measured and influenza vaccine delivered Follow-up measures of antibodies at 1 and 4 months Does stress attenuate antibody response at follow-up?

(Miller et al., 2004)

YES: stressed people had significantly fewer antibodies

Interestingly, in this study perceived stress at baseline was a better predictor of subsequent antibody response!

Physiological Effect: Stressed In-Patients

On the ward Slower wound healing More post-surgery

complications Longer in-patient stay More staff time per day More analgesia use Less satisfaction with

treatment - associated with poor adherence

After discharge Longer recovery, e.g.

return to work More service use, e.g.

related symptoms Less use of

rehabilitation services Increased risk of co-

morbidity and early mortality

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

Understanding Stress

Three perspectives to understand stress:

Response: Focus on the effect (physiological)

Stimulus: Focus on the cause (stressor)

Process: Focus on the person-environment interaction (transaction)

Physiological Response to Stress:Fight or Flight to Feed and Breed

Sympathetic NSAcute Stress Response

Increased

Decreased

cardiac rate, BP, respiration rate, glycogenolysis, peripheral

diversion of blood catecholamines and cortisol

immune surveillance, gut function, kidney function, fat

stores, sex steroids

Parasympathetic NS

Conservation Response

Decreased

Increased

Central Nervous System

Biomarkers

(Cannon, 1914)

(Hans Selye, 1956)

Stress is a non-specific physiological response to a threat to one’s physical or emotional well-being

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

General Adaptation Syndrome (GAS)

Sympathetic Parasympathetic

STRESS

Acute Physiological Response to a Stressor

… then a parasympathetic response to restore

homeostasis

Homeostasis

What happens if the 'acute' stress response continues?

Sympathetic Parasympathetic

ChronicStress

GI: ulcers, IBS, esophageal reflux;RS: amenorrhea, impotence;ReS: asthma, hyperventilation;CV: essential hypertension, migraine, Raynaud’s disease;

Drm: eczema, acne, psoriasis; IS: tissue rejection, infection;Psy: cognitive impairment, low self-efficacy & self-esteem, anxiety, learned helplessness

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

Homeostasis

Stress as a Non-Specific Physiological Response

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

Important starting point but an insufficient explanation

i.e. tells us nothing about the cause of stress

Should we focus on the threatening stimulusas a way of understanding stress?

Stress as a Threatening Stimulus

Social Readjustment Rating Scale (SRRS)

43 life events, e.g. divorce, marriage, job loss, etc.

Each event ranked, relative to one another, on the degree of adjustment that would be required of the average person in order to adapt

Rank used to quantify the degree of threat associated with each event, i.e. Life Change Units (LCUs)

SRRS score is the LCU-total based on event exposure during past 12 months

LCUs hypothesised to be positively related to illness

(Holmes & Rahe, 1967)

0

10

20

30

40

50

60

70

80

90

0 50 100 150 200 250 300 350

Life Change Units and Disease

(Holmes & Rahe, 1967)

Life Change Units (Baseline)

% P

eople

wit

h Illn

ess

(2 Y

ears

) SRRS scores associated with subsequent illness Replicated many times – modest relationship Most prognostic value for SRRS scores >200

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

Top 10 Stressful Life Events LCUs1. Death of a spouse 1002. Divorce 733. Marital Separation 654. Jail term 635. Death of close family member 636. Personal injury or illness 537. Marriage 508. Fired at work 479. Marital reconciliation 4510. Retirement 45

Other SLEs13. Sexual difficulties 3923. Son/daughter leaving home 2930. Trouble with boss 2338. Change in sleeping habits 1643. Minor violation of laws 11

SRRS:Example life

events with LCUs

What life event would top your list of stressors?

Is it in the SRRS?

Is any event ‘obviously’ ranked incorrectly?

Which one(s)?

What does that say about ‘stress as a stimulus’?

Types of Stressor

Stressors differ along a range of dimensions:

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

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

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 acrosstime and repeated exposure

Stress responses vary not only between people, but within people also, and in response to

not only different events, but to thesame event as well

Is stress better understood as a subjective process?

Stress as a Subjective Process

StimulusEvent

StressResponse

StimulusEvent

StressResponse

Appraisal& Coping

A static, direct effect

?An indirect subjective process

Stimulus Event(a potential

stressor)

PrimaryAppraisal

(event demands)

SecondaryAppraisal(oneself)

Response(Coping)

Health-RelatedOutcome(Stress)

Transactional Model of Stress

(Lazarus & Folkman, 1984)

Causal chain of influence Stimulus events indirectly

related to stress experience Processes of appraisal and

coping intervene in the stressor-stress relationship

Stress as a subjective post-appraisal outcome

Input Intervening Processes Output

Intervening Processes

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?

Secondary appraisal: Evaluates available response options and opportunities, i.e. am I able to cope adequately with the event's adaptational demands?

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

Factors influencing appraisal:

Background: historical and current life context, e.g. culture, S-E-S, housing, marital stability, general health

Stable: relatively enduring individual differences, e.g. emotional disposition, expectancies, explanatory styles

Social: perceptions of supporting relationships, e.g. social support, identification, integration

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

Coping

Coping can usefully be hierarchically ordered

Activities: any and all cognitions and behaviours directed towards the management of stressor demands, e.g. Gathering relevant information, or Going to the pub

Strategies: related coping activities clustered into meaningful groups, e.g. Planning, or Mental disengagement

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

Coping changes the situation Directly: alters concrete aspect of the stressor context Indirectly: alters the way the situation is perceived

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

Evaluation of coping based on relative demands Adaptive: contributes to resolving demands Maladaptive: may or may not be effective in the short

term, but contributes to, or creates, future demands

Coping Effectiveness

Problem-focused coping:Attempts to manage or change

concrete aspects of the stressor

Emotion-focused coping:

Attempts to remove or reduce the stressor's emotional distress

Problem-focussed coping most effective when the stressor is

amenable to change

Emotion-focussed coping most effective when the

stressor can not be changed

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

Effectiveness dependent on situational characteristics of the stressor

Heuristic

Transactional Model

PotentialStressor

PrimaryAppraisal

SecondaryAppraisal

CopingHealth-Related

Outcome

Is the eventrelevant to meand, if so, what

are its demands?

Can I deal withthe demands of

the event?

Problem- and / or Emotion-

Focused

StableFactors

SituationalFactors

StimulusEvent

Psychologicaland / or Physical

Social Factors

BackgroundFactors

(Lazarus & Folkman, 1984)

Conclusions

Stress has negative implications for both psychological and physical health

Illness is inherently stressful, whilst treatment referral compounds the experience

The harmful effects of stress can be avoided, removed or reduced in advance

Transactional model provides an organising framework

Proactive early intervention will enhance clinical effectiveness and patient health outcomes

Summary

This session would have helped you to understand …

the psychological and physiological effects of stress and their underlying mechanisms of action

the main perspectives on stress, i.e. response, stimulus and process

the psychological antecedents of stress and stressors common to the clinical context

ideas for removing or reducing the negative impact of stressors among patients referred for treatment

Any questions?

What now?

Revision planning …

… if you haven’t started already

Before next week, let me know any broad areas of particular weakness / concern

Next week’s session will provide a framework for revision