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: [email protected] 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
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