STRESS AND HEALTH Psikologi Abnormal Kuliah ke 3

DSM TERMS DSM II : Psychophysiological disorder DSM III : Psychological factors affecting physical disorder DSM IV : Psychological factors affecting medical conditions (other conditions that may be a focus of clinical attention) 2

Psychological Factors Affecting Medical Conditions DSM-IV-TR Criteria A medical illness is present. Psychological factors have influenced the course of the condition, interfered with treatment, increased health risks, or exacerbated symptoms. 3

Stress and Health Behavioral medicine Interdisciplinary approach involving medicine and behavioral science Goals To understand, prevent, and treat illnesses influenced by psychological factors Health psychology Branch of psychology concerned with role of psychological factors in health and illness Includes: Stress and stress management Prevention of disease Copyright 2009 John Wiley & Sons, NY 4

Konsep Stres/Apakah stres? Tidak ada definisi universal ttg stres. Definisi ttg stres berkaitan dgn bagaimana mengukurnya dan bagaimana men -treat stres tsb. - Response-based definitions - Situational definitions - Relational definitions

Response-based definitions The essence of stress is a particular pattern of behavioral, emotional or biological reactions to events. Tdk tgt pd peristiwanya, kalau responnya spt ini = stres, kalau tidak berespon spt itu = tdk stres Hans Selye (1936): best known response-based to stress GAS (General Adaptation Syndrome): o PHASE I : Alarm Reaction o PHASE II : Resistance o PHASE III : Exhaustion

Alarm reaction autonomic nervous system is activated by the stress Resistance organisms adapt to the stress through available coping mechanisms. Kalau stres terus berlanjut dan organisme tidak dapat berespon secara efektif Exhaustion organisms dies or suffer irreversible damage (Selye 1950)

What is stress? Selye’s General Adaptation Syndrome Stress as a response Problem with response -focused definitions: Based on physiological and psychological responses Similar responses can occur to non-stressful stimuli e. g. , pleasurable events 8

Utk membedakan stres sebagai respon terhadap peristiwa yang mungkin atau mungkin pula tidak menimbulkan respon stres, pendekatan response-based menggunakan istilah stresor untuk peristiwa yang dapat menimbulkan respon stres. Stressor: an event that leads to stress responses.

What is Stress? Situational-based definitions Stress as a stimulus Stressors include: Boredom, catastrophic life events, daily hassles, and sleep deprivation Problem with stimulus-focused definitions Based on nature of stimuli rather than response Differences as to what constitutes a stressor Major vs. daily hassles Acute vs. chronic events 10

Relational definitions: Stress lies neither entirely in the event nor entirely in the person’s response, but rather in the relation between the two. Lazarus (1966) “Stress is experienced when a situation is perceived or appraised as taxing or exceeding the person’s adaptive resources”

Definition of Stress Subjective experience of distress in response to perceived environmental problems (Lazarus, 1966) Whether event is stressful depends upon an individual’s perception or appraisal Emphasis on how we perceive or appraise the environment 12

Coping and Health Avoidance coping Involves aspects of both problem focused and emotion focused. The essence: Avoid acknowledging problem (e. g. denial) Neglecting to do anything to solve it (e. g. giving up or just wishing the problem would go away) The least effective way of coping 14

Coping and Health Effective coping varies by situation Distraction may be adaptive in some situations (chronic pain) and maladaptive in others (financial problems) 15

Coping and Health Positive emotions Provide some benefit Smiling, laughing, seeing the humor in things, finding ‘the silver lining’ Can buffer or blunt the effect of stress, e. g. fewer grief related symptoms, better relationship with others Better health, live longer 16

Assessment of Daily Experiences (ADE) Measures the relationship between stress & health Less reliance on retrospective reports than other measures Responses collected at the end of each day Results: Increases in undesirable events and decreases in desirable events precede onset of respiratory illness (Stone et al. , 1987) 17

Coping Orientations to Problems Experience (COPE) Scale Measures the types of coping used to handle recent stressors Coping methods of women with breast cancer (Carver et al. , 1993) Humor linked to less distress (women who accepted their diagnoses and used humor) Avoidant coping (I try not to think about it) linked to more distress and greater progression of the disease. 18

Social Support and Health Types of social support Structural Networks of social relationships Number of friends, marital status, etc Functional Quality of social relationships Friends, family supportive and there when needed 19

Theories of stress-illness link Developed to understand how psychological factors such as negative emotions impact health and disease Most involve psychological and biological factors Diathesis-stress models Individual vulnerability to stress Much research limited by self-report data Copyright 2009 John Wiley & Sons, NY 20

Theories of Stress-Illness Link Stress may lead to health changes that are not directly due to biological or psychological factors but to changes in in healthrelated behaviors. High stress may result in: Changes in health related behaviors e. g. , increased smoking, substance abuse (e. g. increased alcohol consumption) , lack of exercise, altered diet Changes in physiology e. g. , cardiovascular reactivity, reduced immune system functionings 21

Biologically Based Theories Allostatic Load price paid if body must constantly adapt to stress Damage caused by prolonged exposure to stress hormones (e. g. , cortisol) Impaired immune system functioning Increased susceptibility to disease Higher allostatic load effects predicted greater risk for cardiovascular disease 2 years later (Seeman et al. , 1997). Stress and the immune system Psychoneuroimmunology Study of how psychological factors impact immune system 22

Stress and the Immune System Natural immunity the body first and quickest line of defense against infectious microorganisms Consists of macrophages (sel lekosit besar) and natural killer cells which stimulates release of cytokines Cytokines Key elements in the immune system Trigger fatigue, fever and HPA axis activation to fight infection. (Fever though unpleasant a sign that the body is responding as it should to infection) Excessively high levels linked to diseases in older adults 23

Stress and the Immune System Specific immunity cells that respond more slowly to infection, e. g. Lymphocytes Respond more slowly Include T-helper and B cells. (T-helper release cytokines; B cells release antibodies that deals with specific patogens) 24

HPA axis (hypothalamus – pituitary– adrenal cortex) Salah satu sistem neuroendokrin yang sentral untuk respon tubuh terhadap stres Manifestasi stres di tubuh terlihat melalui kinerja aksis HPA Penelitian pada tikus dan primata yang mengalami trauma dini (dipisah dari ibu) menunjukkan peningkatan aksis HPA bila dihadapkan pada stres pada usia yang lebih dewasa Copyright 2009 John Wiley & Sons, NY 25

Stress and the Immune System Prenatal stress experienced by a mother can impact offspring behavior and immune system functioning (Coe & Lubach, 2005) Rhesus monkey infants, whose mothers were exposed to loud and unpredictable noise during pregnancy, showed emotion regulation difficulties. Also exhibited immune system disturbances Stress can trigger the release of cytokines such as interleukin-1 and interleukin-6, as if the body were fighting off an infection (Maier & Watkins, 1998). Inflammation and higher levels of IL-6 linked to coronary heart disease, arthritis, multiple myeloma, non-Hodgkin’s lymphoma, osteoporosis, and type 2 diabetes 26

Psychological Theories Psychodynamic Anger-in theory (Franz Alexander, 1950) Unexpressed hostility negative emotions which impact health “The various psychophysiological disorders are products of unconscious emotional states specific to each disorder” - Unexpressed anger/hostile impulses hipertension (anger-in theory) - Repressed dependency need ulcer Cognitive Appraisal of stressor is key Appraising life events and experiences as exceeding one’s resources may be at risk for adverse health effects 27

Psychological theories Personality personality traits have also been linked to immune system functioning Link between chronic negative emotion and cardiovascular disease Predisposition to negative emotions also linked to reduced immune system functioning Slowed antibody production following a flu vaccine (Rosenkranz et al. , 2003) Copyright 2009 John Wiley & Sons, NY 28

DSM IV-TR Psychological Factors Affecting Medical Conditions The presence of one or more specific psychological or behavioral factors that adversely affect a general medical condition (GMC)

Cardiovascular Disorders Diseases involving heart and blood circulation system Two cardiovascular disorders affected by stress: Essential hypertension Coronary heart disease 30

Essential Hypertension High blood pressure Increases risk for: Heart attack, stroke, atherosclerosis (clogged arteries) Tidak disadari silent killer Essential hypertension No evident biological cause 90% of all hypertension is essential 31

Tekanan darah diindikasikan: Systolic pressure Arterial pressure when the ventricles contract and the heart is pumping (jumlah tekanan pembuluh darah arteri ketika ventrikel berkontraksi dan jantung memompa darah) Diastolic pressure Normal levels 120 systolic 80 diastolic High levels 140 or higher systolic 90 or higher diastolic Arterial pressure when the ventricles relax and the heart is resting (jumlah tekanan pembuluh darah arteri ketika ventrikel rileks dan jantung tidak memompa darah) 32

Etiologi: risk factors Genes substantial role Obesity Excessive intake of alcohol Excessive salt consumption

Etiology: Role of Psychological Stress Real-world events (e. g. , stressful interviews, natural disasters, job stress) can increase BP Stressful lab tasks trigger BP increases Negative mood induction, cold pressor test (putting a hand in cold water), giving a speech, mental arithmetic, etc. Unethical to test whether short term lab induced BP increases lead to prolonged hypertension Ambulatory BP monitoring studies: (participants wear blood pressure cuff that takes reading as they go about their daily lives) Both positive and negative emotions linked to increases in BP Paramedics high in anger and defensiveness had higher BP during stressful calls. 34

Etiology: Role of Anger Inappropriate and excessive levels Angering easily most problematic, especially for men In women, anger suppression, problematic Type A behavior (Friedman and Rosenman) Three components 1. 2. 3. Achievement striving/competitiveness Urgency/impatience Hostility 35

Etiology: Role of Anger CARDIA (Coronary Artery Risk Development in Young Adults) study Urgency/impatience increased risk of developing hypertension Especially for men Hostility increased risk for both genders Achievement striving/competitiveness Predictor only for white men Copyright 2009 John Wiley & Sons, NY 36

Biological Risk Factors for Essential Hypertension Cardiovascular reactivity Extent to which BP and HR increase in response to stress Predicts later development of high blood pressure and increased risk of hypertension Influenced by heredity Genes linked to the neurotransmitter serotonin Especially one or two long alleles in the promoter region of the serotonin transporter gene 37

Coronary Heart Disease Two forms Angina pectoris Intermittent chest pain caused by insufficient oxygen to heart (ischemia) Silent ischemia Insufficient oxygen without pain Triggered by physical exertion or stress Myocardial infarction (heart attack) Also caused by insufficient oxygen to heart Total blockage of coronary artery Often results in permanent heart damage 38

Table 7. 2 Risk Factors for Coronary Heart Disease (CHD) Age Cigarette smoking Diabetes Elevated BP or serum cholesterol Alcohol Obesity Lack of exercise Sex (men more likely to have CHD) 39

Etiology: Stress and Mycardial Infarction Acute Physical exertion and episodes of anger Acute stress such as physical attack Chronic Marital conflict Financial worries Job strain Excessive work load, lack of control over decision making, no opportunity to fully use one’s skills 40

Etiology: Other Psychological Risk Factors Type A behavior Predicted CHD in some studies but not all Best type A predictors: Anger, hostility, cynicism Anger and hostility also related to other variables linked to CHD: Greater blood pressure reactivity to stress Higher levels of cholesterol Abnormal calcium deposits Cigarette smoking and alcohol use Metabolic syndrome among adolescents Greater activation of platelets Anxiety and depression also linked to CHD 41

Asthma Severe constriction of the airways Air passages narrow Wheezing (suara ngik-ngik) and labored breathing (sesak nafas) Rales Whistling sound (rhonchi – seperti udara yg keluar dari air) on exhalation Person feels as if they are suffocating Biological risk factors Respiratory infection Allergens (zat yang menyebabkan alergi e. g. serbuk bunga) Air pollution Exercise Stressful life event and negative emotions Stress and negative emotion linked to lower peak flow and more reports of asthma symptoms. 42

Figure 7. 7 Effect of Parenting Problems and Mothers’ Stress on Frequency of Asthma in Children 43

AIDS Acquired immunodeficiency syndrome More than 25 million people worldwide have died of AIDS In 2007, more than 33 million people are HIV-positive Worldwide, women now account for nearly 50 percent of people infected with HIV 44

AIDS Prevention through behavioral change Modifying sexual practices Condom use Encouraging monogamy or reducing number of sexual partners Abstinence only programs have not proven effective in decreasing risky behavior or reducing the risk of developing HIV. 45

AIDS Strategies for effective prevention Accurate information about HIV transmission Explain risk factors (e. g. , sharing needles) Identify cues to high-risk situations (e. g. , alcohol use) Provide instruction in condom use Teach sexual assertiveness skills How to resist pressure to have sex Community efforts to make safer sex the norm 46

Gender and Health Women live longer than men Women in poorer health than men Higher rates of diabetes, lupus, arthritis, anemia Formerly believed that estrogen protected women from cardiac disease Hormone replacement studies fail to find reduced risk Women less likely to exhibit Type A Behavior Not necessarily less likely to experience anger More likely to suppress 47

Gender and Health Gender differences in mortality decreasing. May be due to: Increasingly similar lifestyles More women smoke and drink Lung cancer leading cause of cancer death since 1987 In 2004, only one state earned a passing grade in efforts to curb smoking in women Differences in disease identification and treatment Little public awareness that cardiovascular disease is the main cause of death in women Stress test not a good predictor of heart disease risk in women, especially when no pain is present Women less likely to receive referral for cardiac rehab following heart attack. 48

Socioeconomic Status, Ethnicity, and Health Low SES linked to higher rates of health problems and mortality from all causes Differences attributed to: Greater stress associated with SES Environmental constraints Less access to healthy foods More liquor stores Less opportunity to exercise Limited access to health services Stress associated with discrimination and prejudice 49

Stress Management Techniques anyone can use to cope with stress Relaxation training Muscle relaxation Deep breathing Cognitive restructuring Modify maladaptive thoughts Enhance perception of control Behavioral-skills training Time management, prioritizing, assertiveness Environmental-change Workplace alterations, increase social support 50