"The health of nations is more important than the wealth of nations."

Will Durant.

Lecture 7

Physical Disorders and Health Psychology

Dale L. Johnson

Changes in Orientation of Psychologists

There continues to be a problem in the relation between psychology and physical health in Western cultures. It is the opinion of many that this problem can be attributed to the persisting influence of Rene Descartes (1637) whose philosophy argued for dualism, a split between body and mind. They were separate realms, and much discussion of how they could come together. There was speculation that the pineal gland might be the point of contact. Psychoanalytic theory tried to bridge this split with a new field, one called psychosomatic medicine. This field dealt with how experience has an effect on the development of physical symptoms. It was not a way of dismissing physical symptoms by saying, "Its all in your mind." There was an effort to discover how one's experience or personality give rise to certain physical symptoms. Symptoms had symbolic significance. Having a persistent back ache probably meant that one had sexual conflicts and a repressed desire to run away. Other symptom patterns represented other kinds of conflicts:

Asthma--over-dependent, infantile, wants to be care for, ambivalent feelings toward self or others.

Colitis--conforming and obsessive, depressed, conflicted, stingy.

Heart disease--hurried, competitive, impatient, success-oriented.

Hives--craving for affection, guilt-ridden, self-punishing.

Hypertension--high achievement needs, repressed anger, conforming.

Migraine--perfectionistic, rigid, competitive, envious.

Ulcer--longing for parental love, dependency needs, repressed hostility, ambitious.

The problem with these formulations, which are over-simplified above, is that they were difficult to test and the results were so often not supportive of the theory. Most often, however, the psychological explanation just did not explain the symptoms as well as a physiological explanation. For example, my father had hives for years. Was he "caving for affection, etc"? Perhaps, and who isn't, but not noticeably. He broke out with hives only on Sunday mornings. We in the family interpreted this as his not wanting to go to church and there was some truth in that. He finally went to a dermatologist who discovered that my father was sensitive to yeast. Did he drink beer on Saturday night? It has yeast in it. No, he didn't drink. But, my mother baked bread every Saturday and when my father came home from work he ate slice after slice of steaming, warm bread (loaded with yeast). When he reluctantly gave up eating fresh bread the hives no longer appeared. It was not a psychosomatic problem, it was an allergy problem.

Another example, is the person with stomach ulcers, or peptic ulcers. About 10% of the population have these (or "this," one is enough). For years the psychosomatic formulation was regarded as true and people spent thousands of dollars in psychoanalysis to get through their ulcers problem. Now, medical research has shown that stomach ulcers usually are caused by a bacteria, heliobacter pylori. It is a bacteria that can be treated effectively with antibiotics in 70% to90% of cases. Stress may be involved in exacerbating the condition.

Dissatisfaction with the psychosomatic explanations increased. For example, Vailant and MacArthur followed 199 men from 1940 to 1970. They had been interviewed and tested in their youth and periodically to age 50. None of the early personality types predicted later physical symptoms. In fact, the symptom pattern was likely to change over the years. There was also dissatisfaction with the failure of psychosomatic treatments. These disappointments paved the way for a search for alternative explanations.

One of the most important lines of work, if not the most important, was that of Hans Selye on stress and the breakdown of physiological functions. Selye worked with animals. One of his experimental designs called for holding rats by tail and dipping them into ice water. Rats find this stressful. Stressed rats developed changes in their sympathetic nervous system in a number of ways. The effects did not appear immediately, but did appear with persistent or excessive stress. Selye described his general adaptation syndrome as follows:

STRESSOR

ORGANISM'S RESPONSE

Alarm Resistance Exhaustion

Mobilization to Coping with and If resistance does

meet and resist resistance to terminate stressor

stressor stressor --coping exhausted

For example:

Aggression-provoking stimuli

leads to

increased adrenal activity

There are many diseases of adaptation (with exhaustion). These include prolonged elevated catecholamines which may lead to kidney disease, arthritis, cardiovascular disease, or elevated inflamatory corticosteroids which may lead to arthritis.

What are the stressors?

What is the response? Many, including emotional upset, worsening performance.

What is the stimuli? Again, many including environmental conditions: electric shock, boredom, daily hassles, major life events, and sleep deprivation.

Selye's work revolutionized the field. I was at the American Psychological Association meeting in Chicago when he first presented his research to psychologists. There were perhaps 4000 psychologists in the audience. It was fascinating. People left the session full of ideas and eager to extend Selye's research. The discussion was intense. Much of the discussion centered on the idea of stress. What is stress? How can we measure it? Doesn't stress mean something different for each person?

This discussion led to another major step forward. It is the research of Holmes and Rahe. They developed a way of measuring stress. They had subjects, in their case, sailors in the navy, review a checklist of possibly stressful items and check those that applied to them. The items included, "death of a spouse" which people agree is extremely stressful, and "loss of job" which is also stressful. Their sailors completed these checklists and went off to sea. The researcher kept track of them and noted when they became ill. The sailors who had high stress scores were more likely to develop symptoms of colds, flu, mononucleosis, and the like. They avoided the problem of identifying stress that has a personal meaning for an individual by assuming that it is the accumulation of many stressful experiences that is important for the person's physical well-being.

These developments, and many others, led to a new field called “behavioral medicine.” This new field deals with applications of behavioral science knowledge to the prevention, diagnosis, and treatment of medical problems. The field tends to be interdisciplinary, involving psychologists, physicians, nurses, and others.

Health Psychology has also arisen as a new field, mainly within psychology. As an example, one of my clinical psychology students, one who had always wanted to spend his life doing psychotherapy, came by my office last year to tell me what he is now doing and it is not psychotherapy. He is working with physiatrists (physical medicine specialists) and neurologists in the management of pain and other problems associated with physical rehabilitation. He has set up three offices in the Houston area, and is busy full-time.

The change from psychosomatic medicine as the orienting model to health psychology came about because psychologists abandoned authority-driven theories (e.g., Freud, Jung) and replaced them with theories that were built on scientifically-derived evidence. This change has been slow and difficult, but the result is a much better understanding of the mind/body relationship, and better treatment for people with illnesses. Part of the change was a recognition that there is no real distinction between "psychosomatic illnesses" and "real illnesses." All illness has a psychological component, which may be present in its cause, is surely present while the illness is active, and may be part of the recovery, or, if there is no recovery, in the patient's demise.

The relation of psychological and social factors to physical health

Two ways in which psychological and social factors affect physical health:

1) they might affect basic physiological processes that influence health.

2) as life styles, they might place the person at risk for some illnesses.

AIDS is an example in that the time from infection with the HIV and the development of AIDs is influenced by stress in the person's life. There are now medications that are quite effective in lengthening the life span of people with AIDs, but prevention is still the most practical intervention. It is best not to contract HIV. There has been an enormous amount of money spent on prevention, but only preliminary signs of effectiveness.

Risk Factors

These are behaviors, experiences or events that have effect on health. Identification of risk factors is essential for the development of ways preventing illnesses or disorders. As examples of this, research on health psychology has revealed that there are a number of major risk factors. The basic three that all doing research in the area agree upon are

• smoking
• lack of exercise
• not wear seat belts

After these come

• overweight
• use of alcohol in excess and/or use of illicit drugs

All of these involve psychological processes and are most affected by psychological interventions.

Psychological and social factors affecting biological processes in physical disorders and disease

Some concepts or ideas:

Lazarus: What is stressful depends on the perceiver. That is , it depends on how each person defines the situation. In other words, what is stressful for one person may not be for another.

The style of coping when stress occurs has implications for consequences. Taking direct action and information-seeking tend to reduce emotional stress and gaining comfort from others also has stress reduction effects.

What are the stress-related illnesses? Probably all illnesses are stress-related. "Our belief is that any severe illness is affected by how we think about it."

How long is the list? Not clear, but it is apparent that the list is longer each year.

Moderators and Mediators

In doing research in health psychology these are useful considerations.

Moderators

These include such things as social support which tends to minimize risk for illness or to reduce the severity of the symptoms.

Structural: The network of social relationships, including marital status, number of friends, and the like predicts mortality. Low support is associated with less recovery. However, there is another consideration. It is functional; that is, the quality of the support is what makes the difference. The best support is that which is provided by an intimate acquaintance, a person to whom one can tell everything, and who will listen. It is worth noting that this kind of support does not happen entirely by chance; one has to develop it.

Mediators

These are considerations of how stress actually affects the immune system?

Example: Stone (1987) found higher levels of negative mood were related to less resistance to infection.

Specific Illnesses

The textbook reviews a number of illnesses that are involved with stress and the like. I will not review them again. Read the book.

The Immune System

The relation of the psychological system to the immune system and to physical disorders has led to the new field of behavioral immunology.

Infectious disease is caused by exposure to identifiable pathogens, also called antigens, such as viruses, bacteria, prions and parasites. White blood cells are most involved. There are several types of cells.

One of the mysteries of infectious diseases is that only a fraction of those exposed to infectious agents actually become ill. Why? It is known that many people exposed to HIV do not develop HIV. Differences in genetics account for some of these differences, but not all. It is also clear that stress is involved in this, but perhaps in highly complex ways.

Psychoimmunology

This is the study of how psychological factors interact with the immune system. As an example, there is a longitudinal study by Kasl, Evans, and Neiderman with West Point Cadets. They studied mononucleosis which is caused by the Epstein-Barr virus (EBV). In their study the design was as follows. All cadets were examined for presence of the EBV antibodies. Cadets who had them were immune and were not studied further. Those who did not were susceptible and they were followed by the researchers. They found 20% were infected each year. They compared infected and non-infected cadets on a number of research variables. They found that the infected group was comprised of men who described their fathers as "overachievers," and who were not doing well in school. Imagine the fathers of West Point cadets, many of whom were military officers. They would have high expectations for their sons and this was communicated to the sons, but the sons were not doing well, not living up to paternal expectations. This led to high stress.

We might also note that the immune system tends to be suppressed with depression. Were these men depressed?

All Cadets

antibody group no antibodies

immune susceptible

20% infected each year

periodic blood tests

not affected affected

75% 25%

Modifying behaviors and life-styles to promote health

I came across the following in Medscape and report it, with the note that the copyright is by Medscape.

" An optimistic outlook on life could result in a longer and healthier life, (Medscape 2/24/00)

Mayo Clinic researchers found in a 30-year patient study.

The researchers found that the pessimistic group of patients had a 19% increase in the risk of death when comparing their expected life span with their actual life.

The results could lead to further advances that can help physicians working with patients to change and perhaps lengthen their lives and improve their health, says Toshihiko Maruta, MD, a Mayo Clinic psychiatrist and lead author of the study that appears in the February issue of Mayo Clinic Proceedings. "It confirmed our common-sense belief," says Dr. Maruta. "It tells us that mind and body are linked and that attitude has an impact on the final outcome, death."

Mayo Clinic researchers surveyed patients in 1994 who had taken the Minnesota Multiphasic Personality Inventory (MMPI) at Mayo Clinic between 1962 and 1965. The test has an Optimism-Pessimism scale that grades the explanatory style of the patients — how people habitually explain the causes of life's events — and categorizes them as either optimists, pessimists, or mixed based on how they answer certain questions.

By identifying which patients were alive 30 years later, the researchers were able to study explanatory style as a risk factor for early death. The final study group consisted of 839 patients who lived in Olmsted County, Minnesota, where the Mayo Clinic is located. The study patients (529 women and 310 men) were classified as 124 as optimistic, 518 as mixed, and 197 as pessimistic. Age and sex were factored into the results. The researchers compared the expected with actual survival rates and found that the optimistic group's observed survival was significantly better than expected. And they found a 19% increase in risk of death among the pessimistic group.

The researchers said they could not definitively explain how a pessimistic style acts as a risk factor for early death. It could be through the mind; optimists are less likely to develop depression and learned helplessness. "

It could be through the attitude toward medical care; optimists might be more positive in seeking and receiving medical help, with fewer tendencies to self-blame and catastrophic thinking.

In an accompanying editorial, Martin E. P. Seligman, of the

Department of Psychology at the University of Pennsylvania, says,

"Pessimism is identifiable early in life and changeable. So it is possible that individuals at specific physical risk might enter into brief programs that stably change their thinking about bad events and so lower their risk for physical illness and even death."

The researchers concur, saying in their article, "It would be an exciting clinical endeavor to see if certain clinical interventions can

meaningfully move a patient's explanatory style toward the optimistic pole with the goal of improving treatment response, as Seligman's work has done.

Anger/Hostility

Another emotion that is involved in health is anger, or its persistent form, hostility. Ernest Johnson, an African American psychologist who was on the UH faculty before moving back home to Florida, found that long-lasting, unexpressed, hostility was characteristic of many African Americans. Furthermore, this hostility was asssociated with high blood pressure. The more unexpressed hostility, the higher the blood pressure. It is possible that the hostility does not work alone, but interacts with a genetic predisposition in many African Americans to have an excess of endothelin which restricts blood vessels. Of course, hostility is a general problem, and is not limited to one ethnic group. Road rage is an example that has become apparent more recently. Road rage is thought to be the situational expression of otherwise unexpressed hostility. Where does the hostility come from? Many sources are possible. One is the feeling that one is not being treated well by other, not being appreciated.

Hostility or anger are also causally related to other cardiac problems such as angina and heart attacks, Hostility levels are not lowered by participating in aggressive sports or hitting punching bags. They can be lowered through cognitive behavior psychotherapy and/or by engaging in stress reducing behaviors, as in relaxation. Regular exercise is also helpful. Although research has shown that these methods are effective, they seem to be more effective if carried out over a longer period of time such as one year.

Specific Illnesses

The textbook reviews AIDs, cancer, cardiovascular problems, chronic pain and chronic fatigue syndrome. I will add a few more.

Headaches

There are many kinds of headaches. Some are fairly rare and easily managed. These include the Chinese restaurant headache caused by MSG in food, the hot dog headache caused by nitrites in food and alcohol. Don't eat the food or drink the alcohol.

There have been several formal attempts to classify headaches, but not of the categories is quite satisfactory for some people. There are 200 types of headache and one person may have more than one kind. Some people, for example, have headaches that seem to be both of the migraine and the cluster type.

Stress or tension headache. This is typically begins in the neck and moves up to the head, especially to the back of the head. It is readily treated with aspirin.

The migraine headache affects 18% of females and 6% of males. It is an extremely intense pain typically on one side of the head, but it may be on both. During the pain sufferers cannot tolerate light or noise. The pain can last from one hour to several days. Cranial blood vessels constrict and then dilate and pain results because they vessels are connected with sensitive nerves.

Among the famous sufferers of migraine have been Sigmund Freud, Princess Margaret, Charles Darwin, Thmas Jefferson, George Bernard Shaw, Lewis Carroll (Alice in Wonderland), Joan Didion, and Supreme Court Justice William Douglas.

Cluster headaches occur on one side of the head only and the pain is described as excruciating. The last from a few minutes to several hours. They are more common in men. They occur in cycles and may reappear for many days and then disappear for months.

Aspirin does not do much for migraine or cluster headaches, unless, of course, the headache is mild. The treatment of more severe forms calls for specialist advice and many different medications may have to be tried. Pharmacological treatment has advanced greatly in the past two decades and may include ergotamine ort selective serotonin receptor agonists such as sumatriptan. Medications may also be prescribed to prevent the onset of headaches. Treatment guidelines warn against the use of narcotics such as demerol because of the danger of addiction even though pain may be great. Nonpharmacologic treatments are also available. These include relaxation training, biofeedback and cognitive therapy. Alternative therapies have been advocated by some, and accupuncture is fairly popular, but there is little evidence to demonstrate efficacy.

Weblinks: American Headache Society www.ahsnet.org.

U.S. Headache Consortium guidelines. www.ahsnet.org/guidelines.php

American Council for Headache Education WWW.achenet.org.

Fibromyalgia

This illness involves musculotskeletal pain, fatique, and many tender spots on the body. These tender spots are localized and very painful. There may also be sleep disturbance, morning stiffness, irritable bowel syndrome and anxiety. In America about 3 to 6 million people have it. The cause is unknown. It may be a form of arthritis. Cortisol may be involved. It may be a sequel to Lyme Disease. Diagnosis is difficult and for the patient, frustrating.

Treatment consists of exercise like swimming or walking, use of heat or massage, relaxation, and anti-depressant medication to improve mood. Note that the psychological aspects of treatment probably involve enhancing motivation to exercise. If antidepressants help to improve mood, it is likely that cognitive therapy would have the same effect.

Website: Fibromyalgia Partnership www.fmpartnership.org

Idiopathic Environmental Intolerance (IEI)

In this disorder the person has an extreme aversion to and need to escape from chemicals such as perfumes or air pollutants. Its origins have been obscure, but now Binkley and Canadian associates have found it shares a neurogenetic basis with panic disorder. The gene is apparently associated with novelty-seeking, or the opposite, avoidance behavior and it is this that is associated with IEI. This finding, obtained with only 11 patients and 11 controls, could lead to new ways of treating the disorder. It might be treated as panic disorder is treated, but this has not ret been done.

Future Prospects

The field of health psychology is one of the fastest growing areas in psychology. Thirty years ago it was virtually unheard of. Today, it attracts many new Ph.D.s and there seem to be no end of jobs in this area.