INTRODUCTION AND HISTORY OF HEALTH PSYCHOLOGY

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Clinical Psychology (PSY401)

Lecture 39

INTRODUCTION AND HISTORY OF HEALTH PSYCHOLOGY

INTRODUCTION

Our lifestyle affects our health and sense of well-being. Most health problems in the United States are

related to chronic diseases (such as heart disease, cancer, and stroke), and these diseases are often associ-

ated with behavior or lifestyle choices (such as smoking or overeating) made by individuals . The costs

of medical care have skyrocketed to more than 14% of the gross domestic product (GDP), or more than

$898 billion annually. The potential financial burden associated with health problems has led many to

reevaluate their lifestyles and behavior. There has also been a shift in perception. Health has become

associated with positive well-being rather than simply the absence of disease. These trends, as well as

others, have led Americans to focus much more intensely on behaviors and lifestyles that promote health

and prevent disease.

Psychology, as a science of behavior, has much to contribute to the field of health, and health

psychology has become a fast-growing specialty in clinical psychology. One clue that an emerging field

has indeed been recognized is the appearance of textbooks and handbooks detailing that field. General

textbooks on health psychology are now prevalent (for example, Brannon & Feist, 2000; Rice, 1998;

S. E. Taylor. 1999), as are specialized textbooks on clinical health psychology (Belar & Deardorff, 1995;

Camic & Knight, 1998), women and health (Blechman & Brownell, 1998), and pediatric health

psychology (Goreczny & Hersen, 1999).

In addition, several specialty journals (including Health Psychology and Journal of Behavioral Medi-

c i n e ) report on research in these fields. Finally, a separate division of the American Psychological

Association (Division 38) has been established as a way to publicize and advance the contributions of

health psychologists.

DEFINITION

Although a variety of definitions have been offered over the years, behavioral medicine basically refers to

the integration of the behavioral sciences with the practice and science of medicine. Matarazzo 11980)

uses the term to refer to the broad interdisciplinary field of scientific investigation, education, and practice

that is concerned with health, illness, and related physiological dysfunctions

Health psychology is a specialty area within psychology. It is a more discipline-specific term. referring

to psychology's primary role as a science and profession in behavioral medicine. It includes health-

related practice, research, and reaching by many kinds of psychologists-social, industrial, physiological,

and others. Health psychology has been specifically defined as

The aggregate of the specific educational, scientific, and professional contributions of

the discipline of psychology to the promotion and maintenance of health, the preven-

tion and treatment of illness, and the identification of etiologic and diagnostic

correlates of health, illness and related dysfunction. (Matarazzo, 1980)

This definition was later amended to include psychologists' roles as formulators of health care policy

and contributors to the health care system. A recent definition of health psychology that

incorporates these new roles has been offered by Brannon and Feist (2000), who state that

Health psychology "includes psychology's contributions to the enhancement of

health. the prevention and treatment of illness, the identification of health risk

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factors, the improvement of the health care system, and shaping of public opinion

with regard to health"

HISTORY

As noted by Rice (1998), two major perspectives have influenced our views of health and illness. First is

the biomedical tradition, which developed over time as people sought to gain knowledge through

experience and observation. Early attempts were rather crude (for example, the discovery of the

benefits of acupuncture. Hippocrates' humoral theory of disease and treatment), but later biomedical

scientists focused on anatomy, "germ theory," and ultimately genetics in their attempt to define and

understand illness and disease. This Western tendency to focus solely on biological factors and to adopt a

reductionistic approach is not without its limitations, however (Rice, 1998). For example, critics argue

that we still do not know ,hat causes disease; rather, we have simply discovered another malfunction at a

smaller level of analysis (for example, at the DNA level).

Biomedical research may be so charmed with somatic correlates (such as abnormal physical processes

and biochemical imbalances) that psychosocial variables are often ignored. Finally this tradition

reinforces the mind-body dualism perspective, one that is both outdated and limed in its utility. This

is not to say that the biomedical tradition has been unimportant or irrelevant to medicine, science,

and psychology. Rather, a strict biomedical viewpoint is at times too narrow because it cannot

adequately account for widely encountered forms of illness and disease.

A second major influence on our views of health and illness is the psychosocial perspective .Rice, 1998).

For centuries, medical literature has recognized that psychological and social processes may either

cause or influence illness and disease. By the 1940s, this broad generalization had coalesced into the

field of psychosomatic medicine.

Psychosomatic medicine is based on he assumption that certain illnesses and disease states are caused by

psychological factors. Researchers (for example, Alexander, 1950) identified several "psychosomatic"

diseases, including peptic ulcers, essential hypertension, and bronchial asthma. All illnesses were

divided into those caused by "organic" or physical factors and those caused by psychological factors.

Some who adopted this perspective believed that each psychosomatic illness had a different, specific

underlying unconscious conflict predisposing the person to that disorder.

For example, repressed hostility was believed to result in rheumatoid arthritis. Although initially

appealing, these ideas.(and psychosomatic medicine in general) began to founder as it became apparent

that such specific psychogenic factors were not very predictive; most empirical studies did not support

the theories. In fact, psychosocial factors are involved in all diseases, but these factors may not necessarily

have a primary causal role.

Psychosomatic medicine was largely the province of psychiatrists and physicians. However,

behavioral psychologists began to extend the range of their therapy methods to the so called medical

disorders. Problems such as obesity and smoking came under the scrutiny of psychologists as well.

Then came a rapid increase in the use of biofeedback to help patients control or modify certain

physiological responses.

Another set of factors was slow to develop but ultimately had a strong impact. By the 1960s, many

major infectious diseases had been conquered. The helping professions began to turn their attention to

two of the biggest killers: cardiovascular diseases and cancer. Behaviors such as overeating, smoking,

and drinking were increasingly identified as major correlates of these diseases. The spotlight began

to shine not just on the disease process itself, but also on the associated behaviors whose reduction or

elimination might reduce individuals' vulnerability to disease.

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During the 1960s, stressful life events began to be implicated as specific risk factors for illness (for

example, Holmes & Rahe, 1967). The examination of how stressful major life events affect health led to an

examination of the health consequences of daily hassles, which can also prove stressful (for example, R. S.

Lazarus, 1984). A related line of research demonstrated how personality and behavioral style can influence

health. The impetus came from two cardiologists who were impressed with a common constellation of

traits and behaviors shared by many who suffered from coronary heart disease. The so-called Type A

personality (Friedman & Rosenman, 1974) is characterized by hostility, competitiveness, and being

time driven. Although subsequent research has failed to support a direct link between Type A personality

and heart disease (Brannon & Feist, 2000; Rice, 1998), the hypothesis stimulated research in health

psychology and served to focus attention on other behavioral risk factors for coronary heart disease (such

as smoking and lack of exercise), as well as on prevention efforts.

The recognition that both psychological and social factors influence illness and health is the basis

of an influential perspective known as the biopsychosocial model (Engel, 1977). In many ways, this

model can be viewed as an integration of the biomedical and psychosocial perspectives. As the name

implies, the biopsychosocial model holds that illness and health are a function of biological,

psychological, and social influences. Biological influences can include genetic predispositions,

nutritional deficiencies, and biochemical imbalances. Psychological influences can include the

individual's behaviors, emot i on s, and cog n it i ons.

Finally, soci al influences can include friends, family memb ers, home environment, and life

events. This biopsychosocial model represents how health psychologists conceptualize problems and plan

interventions.

Many other factors were important in the development of the field of health psychology. The tremendous

cost of health care has already been noted, along with the fact that infectious diseases were no longer

the principal culprits. A large portion of health care costs are directly traceable to human behaviors

and lifestyles that result in injuries, accidents, poisonings, or violence. Lifestyle choices such as alcohol and

drug abuse, smoking, and dietary patterns contribute to a variety of illnesses and diseases.

The foregoing are just a few of the more prominent factors in the development of the health psychology

field. We turn now to a discussion of how stress, lifestyle and behavior, personality, social support, and

health are linked. These links form the basis of the field of health psychology.

LINKING HEALTH WITH LIFESTYLE, BEHAVIOR, PERSONALITY, SOCIAL S UP P ORT,

AND STRESS

What are the processes by which psychological and social factors influence health and disease?

STRESS AND HEALTH:

Although the term stress is frequently used, it is not often precisely defined ( B r a n n o n & F e i s t , 2 0 0 0 ).

S o me u s e t h e t e r m t o refer to a quality of an external stimulus (such as a stressful interview), others to

refer to a response to a stimulus (the interview caused stress), and still others believe stress results from

an interaction between stimulus and response (stress resulted because the interview was challenging and

I was not prepared).

Most contemporary health psychologists adopt this third, interactionist viewpoint, seeing stress as a

process that involves an environmental event (a stressor), its appraisal by the individual (is it

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challenging or threatening?), the various responses of the organism (physiological, emotional,

cognitive, behavioral), and the reevaluations that occur as a result of these responses and changes in the

stressor (Rice, 1998). These and other psychosocial stimuli may contribute to a stress process that can

then directly affect the hormonal system, the autonomic system, and the immune system.

The physiological effect of stress on the body involves a complex chain of events (Brannon & Feist, 2000).

Stress causes the sympathetic nervous system, a system responsible for mobilizing body resources in ur-

gent situations, to stimulate the adrenal medulla of the adrenal gland. This results in the production of the

catecholamines epinephrine and nor epinephrine, whose effects on the body include increased heart

rate, respiration, blood flow, and muscle strength. Stress also causes the pituitary gland (a structure

connected to the hypothalamus in the forebrain) to release adrenocorticotropic hormone (ACTH), and

ACTH stimulates the adrenal' cortex of the adrenal gland to secrete glucocorticoids. The most im-

portant glucocorticoids where stress is concerned is cortisol. Cortisol is a hormone that, like epi-

nephrine and nor epinephrine, mobilizes the body's resources. Cortisol serves primarily to increase

energy level and decrease inflammation. The latter function is particularly useful if injuries are sustained in

an urgent situation.

Although responses of the body to stress can be helpful, severe stress and prolonged activation of these

systems can have adverse effects o body organs, mental functions, and the immune system. For example,

stress can affect the immune system so that it cannot effectively destroy viruses, bacteria, tumors,

and irregular cells. More than two decades ago, Ader and Cohen (1975) presented evidence

suggesting that the nervous system and the immune system interact and are interdependent by

demonstrating that immune system responses in rats could be classically conditioned. This initial

report eventually, led to a number of studies investigating the relationship between physiological fac-

tors (such as reactions to stress) and immune system response (Brannon & Feist, 2000). Currently it remains

unclear whether immunosuppression is a direct effect of stress or whether it is simply part of the body's

response to stressful events (Brannon & Feist, 2000). In any case, stress does appear to be an important

(though not the only)influence on health and illness.

BEHAVIOR AND HEALTH:

Behaviors, habits, and lifestyles can affect both health and disease. Everything from smoking, excessive

drinking, or poor diet to deficient hygiene practices have been implicated. Such behaviors are often deeply

rooted in cultural values or personal needs and expectations. In any event, they are not easily changed. We

will discuss in more detail several behaviors or lifestyle choices that have been linked to health. These

include cigarette smoking, alcohol abuse and dependence, and weight control.

Cognitive variables may influence our decisions about adopting healthy or unhealthy behaviors. To

cite one example, many health psychologists have focused on the variable self efficacy. Self-efficacy,

refers to "people's beliefs about their capabilities to exercise control over events that affect t h e i r l i v e s "

( B a n d u r a , 1 9 8 9 , ) S e l f - e f f i cacy is relevant to a number of topics addressed by health psychologists,

including major theories of health-related behavior change. This construct plays a major role in the most

prominent social cognitive models of health behavior, including the health belief model (Rosenstock,

1974: Rosenstock, Strecher, & Becker, 1988), protection motivation theory (R. WV. Rogers, 1975; Sturges

& Rogers, 1996), and the theory of planned behavior (Ajzen, 1985, 1988).

Protection motivation theory (PMT), for example, posits that behavior is a function of threat

appraisal (an evaluation of factors that will affect the likelihood of engaging in the behavior, such as

perceived vulnerability and perceived potential for harm) and coping appraisal (an evaluation of

one's ability to avoid or cope with negative outcome). Coping appraisal is influenced by one's self-

efficacy or belief that one can implement the appropriate coping behavior or strategy (Maddux et al.,

1995).

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An example that applies PMT to a real-life health decision may be instructive. Janey, an adolescent

girl faced with a decision about whether or not to start smoking cigarettes, according to PMT,

would engage in threat appraisal and coping appraisal. Threat appraisal might involve evaluating the

dangers of smoking (such as lung cancer) as well as the likelihood of her own vulnerability to this outcome.

To the extent that she does not perceive the danger to be severe or immediate to herself. Janey might be

more likely to start smoki n g . C o p i n g a p p r a i s al i s a l s o r e l ev a n t . T h i s p ro cess might involve

Janey's evaluation of how likely it is that she could refrain from smoking (the recommended coping

strategy). To the extent that Janey's believes she will not be able to refrain from smoking (for example,

because all her f ri e n d s smo k e s , i t b e c o me s mo r e l i k e l y t h a t s h e will engage in this behavior.

Thus, the cognitive variable self-efficacy can play a prominent role in behavior and lifestyle choices

that ultimat ely influence health.

Problems can also arise from the ways in which people respond to illness. Some people may be

unable or unwilling to appreciate the severity of their illness and fail to seek timely medical help.

When they do get medical advice, they may fail to heed it. All of these behaviors can indirectly foster

adverse outcomes.

PERSONALITY FACTORS:

Both directly and indirectly, personality characteristics can affect health and illness in many ways

(Friedman & Booth-Kewlev, 1987):

(1) personality features may result from disease processes;

(2) personality features may lead to unhealthy behaviors;

(3) personality may directly affect disease through p h y s i o l o g i c a l me c h a n i s ms : ( 4 ) a t h i r d ,

u n d e rl y ing biological variable may relate to both personality and disease; and

(5) several causes and feedback loops may affect the relationship between personality and disease.

Perhaps the most widely studied association between a personality trait and illness is that between Type

A behavior and coronary heart disease. As mentioned previously, the notion of a possible link between

personality or coping style and adverse health consequences, specifically coronary heart disease, was

proposed by two cardiologists (Friedman & Rosenman, 1974). They identified a set of discriminating

personality characteristics and behaviors and proposed that these constitute a Type A behavior

pattern. Glass (1977) describes Type A individuals as those who tend to:

Perceive time passing quickly,

Show a deteriorating performance on tasks that require delayed responding,

Work near maximum capacity even when there is no time deadline,

Arrive early for appointments,

Become aggressive and hostile when frustrated,

Report less fatigue and fewer physical symptoms,

Are intensely motivated to master their physical and social environments and to maintain control,

A number of early studies suggested a relationship between Type A behavior and coronary heart

disease. However, these findings were often misinterpreted as indicating that Type A individuals are

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likely to develop coronary heart disease (Davison & Neale, 1998). More recent studies do not show

as strong a relationship between Type A behavior and heart disease as was once thought (Smith,

1992), and it is clear that the vast majority of Type A individuals do not develop coronary heart

disease (CHD). However, Type A individuals are at relatively greater risk for CHD. More recent

studies suggest that the anger-hostility component of the Type A pattern does a better job of

predicting coronary heart disease than the more global Type A categorization.

SOCIAL SUPPORT AND HEALTH:

A topic attracting increased research interest is social support and its effects on health and well-being.

Social support refers not only to the number of social relationships, but also to the quality of those

relationships (can you confide in your friends and family members?) The basic idea is that interpersonal

ties can actually promote health. They insulate people from harm when they encounter stress, decrease

susceptibility to illness, and help people comply with and maintain treatment regimens. Social support is, in

many ways, a kind of coping assistance. A number of studies have indicated that better health outcomes are

positively related to social support. For example, Williams et al. (1992) followed approximately 1400

patients with coronary artery disease for an average of 9 years, and found that patients who rated higher

on measures of social support (for example, married, able to confide in spouses) exhibited significantly

lower rates of mortality over the follow-up period. This relation held even after controlling for demographic

variables and medical risk factors. This study and others suggest that social support may act as a type of

"buffer" against adverse health outcomes.

The relationships among social support stress, and health may depend on a number o factors,

including race, gender, and culture. For example, women (on average) seem to benefit more from social

support than do men; this may be because women tend to have more emotionally intimate relationships

(Brannon & Feist 2000). Preliminary data also suggest that white may benefit from social support more

than non whites (Brannon & Feist, 2000). However, the reason for this is not clear, and the possibility of

race and ethnic differences needs further study Clearly, the relationship between social support

and health is complex.

RANGE OF APPLICATIONS OF HEALTH PSYCHOLOGY

A full description of all the problems is hard to describe but a partial list culled from recent accounts

would include the following:

1. Smoking

2. Alcohol abuse Obesity

3. Type A personality

4. Hypertension

5. Alzheimer's disease

6. Acquired immune deficiency syndrome (AIDS)

7. Cystic fibrosis

8. Anorexia nervosa

9. Chronic vomiting

10. Ulcers

11. Irritable bowel syndrome

12. Tics

13. Cerebral palsy

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14. Cerebrovascular accidents

15. Epilepsy

16. Asthma

17. Neurodermatitis

18. Chronic pain

19. Headaches

20. Insomnia Diabetes

21. Dental disorders

22. Cancer

23. Spinal cord injuries

24. Sexual dysfunction

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