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CHAPTER 7
Psychological Factors Affecting Medical Conditions
1. Case Studies
A. Psychological evaluation revealing distress over physical condition in the case of George.
B. Stress associated illness in the case of Sarah.
C. Diagnosis of a perforated ulcer in the case of Jack.
2. Historical Perspective
3. Diagnostic Issues
10. Treatment
12. Summary
A. George, a 32-year old high school teacher, consulted his doctor 37 times about chest
pains, which had caused him great anxiety because he was convinced he was having a
heart attack. Psychological evaluation revealed considerable distress and agitation
extending beyond concerns about physical health. He readily expressed complaints in
many areas of his life, and claimed that his achievements as a teacher gave him no
pleasure. He also reported going “all out” in his day-to-day life and routinely being on
the go from 5am until the evening. Of note, George smokes, abuses alcohol, and is not
physically active. The case suggests that behavioural and psychological factors will need
to be targeted to help George with his physical health.
B. Sarah is a student in her first year of medical school and is also an athlete. She had just
finished a gruelling set of exams when she noticed the first symptoms of what she
recognized as flu. By the start of the next day, she was experiencing full-blown
symptoms: high temperature, aches and pains, a deep cough, and a runny nose. This case
illustrates the role of stressors in infectious diseases, even in physically-fit people like
Sarah.
C. One Sunday morning, Jack awakened with a strange burning sensation in his stomach.
The burning pain came and went and Jack did not seek medical attention for it for some
time. Eventually, he was taken to the nearest hospital after vomiting blood, at which time
he was diagnosed with a perforated ulcer. He reported that at the onset of the burning
pain, he had been going through considerable stress in relation to his upcoming wedding,
about which he was ambivalent. This case illustrates the relationship between stress and
gut health.
D. The actor and comedian John Candy was a smoker and significantly overweight. There
was a history of heart disease in his family, and his father died of heart disease in his
thirties. He tried to lose weight and quit smoking but was unsuccessful, and he lived a
high-pressure life. At the age of 43, John Candy died suddenly from a myocardial
embolism (blood clot in his heart). This case illustrates the combination of biological,
behavioural and likely psychosocial factors in promoting cardiovascular risk.
2. Historical Perspective
The notion that psychological processes have an impact on bodily states, and can even produce
physical disease, has a long history in Western thought, and has also been prominent in other
cultures. Medical and psychological activities and interests converged in a branch of psychology
called psychosomatic medicine. However, there was an issue with this label because it implied a
dualistic view of the mind and of the body. Indeed, during the early to mid-1900s, the thinking
was that some but not all physical disorders were the direct expression of emotion or
psychological conflicts. Over several decades of research and clinical writings it became clear
that psychological factors play a role in all aspects of health and illness. This new understanding
led to a branch of psychology called behavioural medicine, which is contained within the
broader term, health psychology.
In the DSM-5, there is a new class of disorders called Somatic Symptom and Related Disorders
that has a specific diagnosis called psychological factors affecting a medical condition. An
example of when this would be assigned is in a case wherein it is clear that a psychological or
behavioural factor (e.g., overtly ignoring one’s symptoms) is directly correlated with worsening
or non-recovery from a medical disease. Those who work in the area of behavioural medicine do
not find this DSM diagnosis particularly helpful because it lacks specific information. An
alternative system, Diagnostic Criteria for Psychosomatic Research seems to provide more
information on the type of psychological factors that may adversely impact physical health e.g.,
“Type A Behaviour.”
One’s body tissues can be affected by certain behaviours, especially when they are recurrent. For
example, the act of smoking regularly exposes body tissues to toxins that in turn confer risk for
disease. In this example, smoking is not the direct cause of disease but rather serves as a vehicle
for transmission of nicotine, which is the more proximal cause of body tissue damage.
Psychosocial variables can also damage body tissues, again indirectly, via their effects on the
endocrine system, the autonomic nervous system, and the immune system.
The study of stress has provided answers to important questions regarding the pathways by
which psychosocial variables lead to, exacerbate, or maintain physical illness and disease. The
term “stress” has been interpreted and studied in three ways: (1) as a response (2) as a stimulus,
or a property of the external world, or (3) as a transaction that intervenes between stimulus and
response.
Selye proposed the first formal theory of stress called the general adaptation syndrome (GAS).
The first phase is alarm (adaptation challenge). If the challenge persists, then resistance
(fighting or coping) follows. With continued challenge comes exhaustion (resistance fails), and
the organism may succumb to disease.
This focus box highlights the usefulness of studying the way couples interact under stress.
Research has shown for example that hostile interactions are associated with greater release of
stress-relevant hormones.
A. Social Status
Social status “refers to an individual's relative position within a social hierarchy.” What
appears to be important is the extent to which individuals hold a more dominant versus a
more submissive position in their hierarchy. Individuals in a dominant position (like
bosses) show stress responses that are similar to those in a less dominant position,
however they appear to recover more quickly from stressors– that is, they do not show a
sustained stress response whereas those lower in dominance do.
B. Social Support
One of the most pervasive and consistent psychosocial variables that has been related to
health status is social support. Individuals who feel less connected to others are at higher
risk of mortality. Good social support is a potent protective factor in health; however the
exact mechanisms remain unclear.
C. Personality
Alexythymia refers to difficulty identifying and labeling internal experiences such as
emotions. Individuals high in alexithymia also do not view internal experiences as
important. Type A personality also plays a role in medical conditions.
A. Infectious Disease
The onset of infectious diseases such as colds or the flu has been shown to be associated
with the stressors and strains of daily life. The symptoms of some infectious diseases,
often seem to onset or become exacerbated during periods of emotional stress. Exam
stress, employment stress and marital difficulties have been linked to infectious disease
risk in some studies. It is likely that immune system mechanisms are involved, but these
are unclear at the moment.
B. Ulcer
Ulcers have long been considered a symptom of stress. Psychoanalysis was once the
treatment of choice for ulcers. Evidently, the conceptualization of ulcers has changed
over time and has become more complex. It is understood that exposure to stressors is
linked with increased secretion of gastric acids (i.e., digestive juices), which erodes the
stomach’s lining, giving way to the formation of ulcers. The unpredictability of the
stressor is a moderating factor. However, questions remain as to how chronic,
unpredictable stress creates these changes in the gut. Considerable excitement has been
aroused in the medical community by the discovery of a bacterium, H. pylori, that is
believed to play a primary role in the development of ulcers. However, it likely does not
act in isolation to cause ulcers. Some preliminary work indicates that exposure to stress
intensifies the harmful actions of this bacterium, possibly via cortisol relevant
mechanisms.
Numerous studies using the stress reactivity paradigm have shown that cardiovascular
functions are responsive to changing psychological conditions. It has been argued that the
risk of cardiovascular disease increases with heightened or exaggerated cardiovascular
reactivity. However, it has been shown that blunted or attenuated cardiovascular
reactivity is also associated with health risks, so over- and under-reactivity are both
problematic. In addition to reactivity, there also has been interest in the role of
cardiovascular recovery in health and illness—delayed return to a baseline state after a
stressor is over is indicative of poor adaptation.
Some psychological factors have been implicated in cardiovascular disease. In one study,
people identified as Type A (aggressively ambitious) were approximately twice as likely
to die from heart disease as those identified as Type B (calm and relaxed), and this was
independent of behaviours like smoking. Some studies found that hostility was the main
characteristic accounting for increased risk of heart disease. The Type A versus B
characterisations do not shed light on the specific features that confer risk for heart
disease. It turn out hostility is a key factor. It features prominently in at least five
theories: the psychophysiological reactivity model, the psychosocial vulnerability
model, the transactional model, the health behaviour model, and the constitutional
vulnerability model. Individuals who are high in hostility engage in more unhealthy,
heart-disease promoting behaviours and have difficulty regulating anger. Finally,
evidence has emerged for a connection between depression and cardiovascular risk and
mortality. Several explanations have been offered. One is reduced physical activity,
which coincides with depression and confers risk for cardiovascular events. A massive
Canadian study examining a large range of risk factors for a recurrence of heart attack
showed that psychosocial variables placed third in a list of 9 risk factors.
The longitudinal study, in which a large group of people are evaluated with respect to the
existence of psychological features and are then followed up to determine whether they have
developed the disease, can shed light on possible cause-effect relationships especially when they
span many years.
10. Treatment
There are two classes of intervention that are prescribed to manage/target psychosocial factors
within the context of physical illness. “Generic” approaches include basic stress management
principles and various type of relaxation. The more targeted interventions directly focus on
modifying known psychosocial factors. For example, programs have been developed to reduce
Type A behaviour and encourage social connection.
Dr. Lavoie is a health psychologist who studies the role of behavioural and psychological factors
in chronic diseases including asthma and cardiovascular diseases. She has developed and tested a
number of interventions designed to reduce health-compromising behaviours (e.g., increase
physical activity and reduce medication non-adherence). She also trains health professionals in
the use of motivational interviewing to help patients make positive health related changes.
12. Summary
1. Self-Awareness. Learning about your stressors and how the things you do affect
your stress levels. Learning what your strengths and weaknesses are and how to
cope with or improve upon those weaknesses.
5. Diet. While experts disagree on the exact role of diet in stress, eating a well-
balanced diet, as with exercise, is not only good for your overall health, but may
help you manage stress as well. In particular, avoiding excess caffeine and excess
sugar is important because they can make stressed people feel more “jittery” and
anxious.
7. Attitude. None of the above techniques will be very effective if you fill your head
with negative thoughts and regularly view the world with a pessimistic, fatalistic
attitude. Focusing on what you can do and on what you can control, and trying to
find the best in each situation, will make each of the above techniques work much
more effectively.
Dr. Gillian Booth at St. Michael’s Hospital in Toronto conducted a 5-year longitudinal
study with residents of Toronto. She identified 1.2 million Torontonians aged 30-64 who
did not have diabetes. The neighborhoods where these people lived were rated on the
degree to which they are conducive to walking. “Walkable” neighborhoods are highly
populated, have streets that connect to other streets, and are in close proximity to stores,
schools, and other destinations. The risk of developing diabetes in the 5 year follow-up
period was 32% higher for those living in the least walkable areas compared to those who
lived in the most walkable areas in Toronto. In a similar study conducted in Utah with a
sample of 650,000 residents, people who lived in older, more walkable neighborhoods
had lower BMIs (Body Mass Index), placing them at lower risk for obesity related
disorders. Some of these benefits are likely due to greater levels of physical activity, but
other factors, such as more interaction with neighbors and higher levels of community
involvement may also make people less susceptible to weight-related illnesses.
Mutta hän oli kyllä sitä ajatellut, ja vain Diana tiesi, kuinka syvästi.
Sheikin oma katse oli himmeä, kun hän hellästi silitti kumaraista
päätä. »Enkö?» mutisi hän hymyilevien huuliensa värähtäessä.
»Diane, olen tiennyt sen koko ajan. Mutta siitä puhuminen ei olisi
tehnyt sitä keveämmäksi. Se oli kovaa minullekin. Mutta niin täytyi
olla, ja lopputulos oli välttämätön. Aavistin, että lähettäessämme
hänet otaksuttavasti erosimme hänestä iäksi. Mutta mitä muuta olisi
voinut tehdä? Hänen oli mentävä.»
Neljäkolmatta tuntia sitten hän oli kysynyt itseltänsä sitä. Nyt hän
sen tiesi tai luuli tietävänsä. Ja se tieto pani hänet aprikoimaan,
millaiset suhteet hänellä tulisi vastaisuudessa olemaan tämän
ranskaa puhuvan, barbaarinnäköisen isän kanssa, jonka hänestä
näytti erottavan niin laaja ja ylipääsemätön kuilu.
Eilinen ilta oli tehnyt sen seikan ihan selväksi. Eikä hän ollut
tänään nähnyt mitään sellaista, mikä olisi kallistanut häntä
muuttamaan mielipidettään. Päinvastoin hän oli nähnyt sellaista,
mikä oli nostattanut hänen sisunsa miltei hillittömään vimmaan ja
mikä oli lujittanut hänen vihaansa ja vastahakoisuuttansa.
Eikö hän tiennyt siitä mitään vai oliko hän tahallansa näkemättä
tapausta, johon aika oli hänet totuttanut? Mutta tiesipä hän tai oli
tietämättä, yksi seikka oli eittämättömän selvä: hän palvoi sitä
miestä, joka suvaitsi tällaista raakuutta, ja oli onnellinen
ympäristössä, joka hänen pojastansa oli sanomattoman
kammottava. Caryllista oli varhaisen aamun välikohtaus antanut
värityksen sen päivän kaikille seuraaville tapahtumille. Hänessä oli
herännyt inho kaikkea hänen ympärillänsä olevaa ja tapahtuvaa
kohtaan. Nyt hänestä tuntui, että hänellä oli oikeutettu syy siihen
järjettömään vihaan, jota hän oli aina tuntenut isäänsä vastaan.
»Olen hyvilläni, että kerroit siitä minulle», alkoi hän vihdoin. »Sen
nojalla saatan ymmärtää sen, mikä on koko päivän ollut minusta
selittämätöntä. On — ikävää, että sinä näit sellaista», jatkoi hän
hitaasti, huolellisesti punniten jokaista sanaansa, »ennenkuin olet
ehtinyt oppia laajemmin ymmärtämään niitä olosuhteita, jotka
tekevät tällaiset kiusalliset tapahtumat välttämättömiksi. Sellaisenaan
sen täytyy näyttää sinusta barbaariselta ja hirveältä. Mutta sinä näit
vain rangaistuksen, sinun on mahdoton tietää, mistä se aiheutui.
Tämä on alkeellinen maa, mon ami, jossa intohimot lainehtivat rajusti
ja vallattomuus rehoittaa; ja on erinäisiä rikkomuksia, jotka vaativat
ankaria, pikaisia toimenpiteitä, jos mieli lainkaan säilyttää kuria. Ja
muista, että täällä olemme sovinnaisuuksien ulkopuolella ja etteivät
tänne ulotu lait, jotka ohjaavat sovinnaisia yhteiskuntia. Täällä
hallitsee vain voimakas käsi. Tasapuolisuutta ja oikeutta on
selitettävä eri luokkiin kuuluvien yhteiskuntien tarpeitten mukaan, ja
isäsi jakama oikeus on sellaista oikeutta; jonka hänen hallitsemansa
kansa tunnustaa oikeaksi ja jota se ymmärtää.