Module: Health Psychology Lecture: Stressful medicine Date: 09 March 2009

Module: Health PsychologyLecture: Stressful medicineDate: 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.ukwww.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

Dual Pathway Model:From Psychology to Physiology Psychological Appraisal Physiological Reactivity Acute & ChronicStress Direct Path Indirect Path Factors: Background Stable Social Situational Health-Related Behaviour

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

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 Physiological Effect: Immune Dysregulation (Kiecolt-Glaser et al., 1984) (Kiecolt-Glaser et al., 1985) 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? • 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 • 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 • 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 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 Central Nervous System Sympathetic NS Acute Stress Response Increased Decreased Parasympathetic NS Conservation Response Decreased Increased Biomarkers cardiac rate, BP, respiration rate, glycogenolysis, peripheral diversion of blood catecholamines and cortisol immune surveillance, gut function, kidney function, fat stores, sex steroids (Cannon, 1914)

(Hans Selye, 1956) General Adaptation Syndrome (GAS) • Stress is a non-specific physiologicalresponse 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

Acute Physiological Response to a Stressor … then a parasympathetic response to restore homeostasis What happens if the 'acute' stress response continues? STRESS Homeostasis Parasympathetic Sympathetic

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

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 stimulus as 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)

Life Change Units and Disease  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 % People with Illness (2 Years) Life Change Units (Baseline) (Holmes & Rahe, 1967)

SRRS:Example life events with LCUs Top 10 Stressful Life Events LCUs 1. Death of a spouse 100 2. Divorce 73 3. Marital Separation 65 4. Jail term 63 5. Death of close family member 63 6. Personal injury or illness 53 7. Marriage 50 8. Fired at work 47 9. Marital reconciliation 45 10. Retirement 45 Other SLEs 13. Sexual difficulties 39 23. Son/daughter leaving home 29 30. Trouble with boss 23 38. Change in sleeping habits 16 43. Minor violation of laws 11 • 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 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 Event Stress Response A static, direct effect Appraisal & Coping Stimulus Event Stress Response ? An indirect subjective process

Transactional Model of Stress • 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 Stimulus Event (a potential stressor) Primary Appraisal (event demands) Secondary Appraisal (oneself) Response (Coping) Health-Related Outcome (Stress) Input Intervening Processes Output (Lazarus & Folkman, 1984)

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 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 Emotion-focused coping: Attempts to remove or reduce the stressor's emotional distress Problem-focused coping: Attempts to manage or change concrete aspects of the stressor Flexible coping likely the most effective, but often difficult in practice Effectiveness dependent on situational characteristics of the stressor Heuristic Emotion-focussed coping most effective when the stressor can not be changed Problem-focussed coping most effective when the stressor is amenable to change

Transactional Model Potential Stressor Primary Appraisal Secondary Appraisal Coping Health-Related Outcome Stimulus Event Is the event relevant to me and, if so, what are its demands? Can I deal with the demands of the event? Problem- and / or Emotion- Focused Psychological and / or Physical Background Factors Stable Factors Situational Factors Social Factors (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

Module: Health Psychology Lecture: Stressful medicine Date: 09 March 2009