Health Psychology: Stress, Behaviour And Disease

Douglas Carroll University of Glasgow., Douglas Carroll

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781135386344
• Topic: Psychology
• Subtopic: Education General
• Index: Psychology

This work, designed for A-Level and undergraduate students, describes how behaviour can interact with stress to produce ill-health and, conversely, how stress can be managed to avoid the dangers of heart disease and other illnesses.  Health psychology has a relatively short history, but the past decade has witnessed an explosion of interest in this topic.  It is designed to be accessible to the beginning psychology student but to take that student, or any other interested reader, to a depth sufficient to enable them to feel a sense of satisfaction in being able to co me to grips with the major theoretical and empirical perspectives that are influential in contemporary psychology. Professor Carroll has, himself, a distinguished record of research in health psychology and his own research and writing has substantially influenced the development of this field in Britain..

Chapter 1
Introduction: Stress, Behaviour, and Disease

Health psychology is a broad church, but one of fairly modern construction. According to Matarazzo (1980) health psychology encompasses the total sum of the contributions that the discipline of psychology, the science of human behaviour and experience, has to make to the matter of physical health and well-being. The areas of such contribution range from the aetiological to the therapeutic; health psychology is concerned with untangling the psychological factors that contribute to the onset and course of illness and disease, and also with the application of psychological knowledge and techniques to the prevention and amelioration of disease, and the promotion of health. In addition, it has a regard to people’s experience and behaviour in medical settings. Finally, health psychology is concerned with mental health and psychological disorders, such as depression, but only to the extent that these impinge on physical health. For the most part, though, mental health is the proper focus of clinical psychology.

Although the official delineation of these sorts of activities as health psychology is relatively new, the idea that psychological factors can contribute to physical illness and that essentially psychological techniques might be pressed into the treatment of illness and the promotion of physical well-being is far from new. The great physicians of antiquity realized that what might be manifest as physical illness and physical symptoms can often be traced to psychological antecedents.

By way of illustration consider a case reported by Galen from the first century AD (cited by Mesulam and Perry, 1972). The patient was an agitated and much troubled woman, complaining of a variety of physical symptoms. Examination revealed no apparent organic cause for the woman’s malaise. However, during the course of the clinical interview, a bystander happened to mention that he had seen a young dancer called Phylades performing at the theatre. Galen observed that at the mention of this name, the woman’s pulse became rapid and irregular. At subsequent consultations, Galen dropped the names of a number of dancers but without effect. Only the name of Phylades produced such turmoil. Galen deduced that it was unrequited love for this dancer which was the source of the woman’s emotional agitation, and this emotional distress that underlay her physical symptoms.

It is only really in the later part of this century that these early lessons started to take on renewed significance. The end of the nineteenth and the beginning of the twentieth centuries were periods of substantial medical advance. However, this progress was very much founded on the idea that disease was the product of specific pathogens: germs that invaded the body and disrupted some aspect of its functioning. The belief in specific and single pathogenic agents encouraged the search for specific antidotes. The discovery of effective antidotes, for example vaccines, in turn reinforced the germ model of disease and illness. This overall approach, coupled with changes in environmental infrastructure, such as the provision of clean water supplies and the introduction of efficient sewage systems, was enormously successful. Infectious diseases that had previously debilitated or killed substantial numbers of people were virtually eliminated.

Two consequences of this achievement were soon evident. First of all, people, at least those in western countries, were living longer. This century has witnessed a substantial increase in average life expectancy. Second, people were succumbing to different afflictions; cardiovascular disease and cancer supplanted the infectious diseases as the major causes of death. It was soon apparent that the medical model, which had previously served so well, was hopelessly inadequate in the face of these new challenges, for these were multiply determined disorders, the products of a variety of interacting factors. Most importantly for present purposes, some of these factors were psychological, i.e., they had to do with the way people conducted themselves, their life styles, the sort of social and psychological environments they inhabited, as much as they had to do with physically noxious agents. Accordingly, there was once more the need to appreciate that mind and body are intimately intertwined: not only that psychological factors can and do contribute to the onset and progress of disease, but also that health, in general, is a matter of the mind as well as the body. It is people who get ill and must be treated. To isolate disease and treatment as topics only for the attention of medicine and biology is to misunderstand the nature of most contemporary illness.

The insights of Galen and the other great physicians of the past, that, in matters of illness and health, people’s feelings, behaviour and social environment are important, are ignored at our peril. They are certainly at no time more pertinent than now. In one sense, health psychology can be considered an attempt to consolidate and build on these early insights, although, in another sense, it is very much a response to contemporary concerns. However, health psychology should not be seen as an attempt to supplant the biological focus of twentieth-century medicine, replacing it with a psychological focus. Rather, its orientation is interactive; its manifesto derives from the presumption that both biological and psychological processes contribute to illness and disease, and that biology and psychology, not to mention sociology and anthropology, have important contributions to make to understanding, remedy, and prevention.

Psychological Stress

A key concept in health psychology, and one that dominates much of this text, is psychological stress. In spite of this pivotal position, though, it has proved surprisingly difficult to obtain agreement among researchers as to the precise meaning of psychological stress. However, given the extent to which the term is now part of everyday vocabulary and that most people have some common understanding of what it signifies, issues of exact definition need not detain us overmuch.

The American physiologist, Walter Cannon (1935) was among the first to use the term stress in a non-engineering context, and clearly regarded it as a disturbing force, something which upset the person’s equilibrium, disrupted the usual balance. Cannon applied the term homeostasis when referring to this equilibrium or balance. From a perspective such as this, then, stress refers to those events or situations that challenge a person’s psychological and/or physiological homeostasis. Stressful circumstances are those which do not permit easy accommodation. Because of their meaning and the nature of the information they contain, individuals have to mobilize extensive psychological and/or physiological resources to deal with them; they cannot be handled ‘on automatic’. What sorts of circumstances, then, are stressful and pose a challenge to homeostasis? Lazarus and Cohen (1977) offered a helpful taxonomy. They suggested that there were three broad classes of stressors, varying in the magnitude of the challenge posed, varying also in their persistence, and, finally, varying in the number of people affected simultaneously.

The first class, Lazarus and Cohen called cataclysmic events. Included here are natural disasters, such as earthquakes and floods, and also manufactured disasters such as war. Cataclysmic events are powerful in their impact and pose an enormous challenge to individuals. It is hardly surprising to find that, as a consequence, they can have a substantial affect on health and well-being. However, two other characteristics of cataclysmic events may serve to mitigate the worst of such effects. They are often short-lived, and they usually affect whole communities, i.e., everybody is in the same boat. Thus, the stress effects are not necessarily protracted and the people involved can rally together, providing each other with mutual support and comfort. We shall see later that social support can act as an effective buffer against the impact of stress.

A second class of stressors is what Lazarus and Cohen called personal stressors, and others have called negative life events. These are such things as the death of a close relative, divorce, loss of job, etc. They, too, represent powerful challenges, and are also, thankfully, in most cases, relatively short-lived in their impact. However, unlike cataclysmic events, personal stressors happen to fewer people at any one time. While most of us will experience the death of a close relative, for example, the experience will be individual rather than collective in the sense that different people have to face the experience at different times. This can have important implications, for the personal nature of such stressors limits the possibilities for broad social support, and the benefits that brings. There is substantial evidence that negative life events are associated with physical illness. Both objective symptomatology and subjective ratings of illness closely follow clusters of person stressors (see, e.g., Rahe, 1975; Rahe, et al., 1970). Finally, while the occurrence of negative life events is clearly important, the absence of positive life events may also affect health in a deleterious fashion. For example, in a study of 18-year-old Swedes, those who exhibited high blood pressure reported significantly fewer positive life events in the previous two years than those who were not hypertensive (Svensson and Theorell, 1983).

The third class of stressors are what Lazarus and Cohen identified as daily hassles. These might be regarded as background stressors. While individually they are not nearly as powerful as cataclysmic events or personal stressors, they are omnipresent. What they lack in terms of magnitude of challenge, they make up for in terms of frequency and persistence. Thus, daily hassles are chronic rather than acute stressors, and it is this chronicity which makes them serious. In addition, daily hassles, like personal life events, are suffered individually. Although such hassles are undoubtedly the lot of almost everyone, each individual harbours the illusion that he or she is the sole victim. ‘Why me?’ is a common evocation. This presumption of personal victimization again reduces the likelihood of social support with its potential to buffer the effects of stress.

One common source of daily hassles is the work environment. A large body of research now attests to the pervasiveness of work stress and its impact on health. A few examples will serve to illustrate the association between stress at work and poor health. In a recent study of occupational stress among university employees, Carroll and Cross (1990) administered a battery of questionnaires to 1,000 academic and academically-related staff in seven British universities. In all, completed questionnaires were returned by 662 individuals, almost half of whom (49 per cent) indicated that they found their jobs stressful either often or almost always. Most importantly in the present context, job stress was found to have consequences for self-reported physical well-being. For example, of those who reported the poorest physical health (had scores in the highest third on a questionnaire measuring physical symptomatology), 81 per cent reported experiencing job stress often or almost always, whereas of those reporting the best physical health (having scores in the lowest third of possible scores on physical symptomatology), only 28 per cent reported experiencing stress often or almost always. In addition, of the various possible sources of occupational stress, it would seem that increased and conflicting job demands were the most reliable predictors of physical symptomatology.

Until recently occupational stress researchers have largely ignored university employees, presumably on the assumption that such occupations are relatively stress-free. The study reported above suggests that this is a highly questionable assumption. Frequent stress was reported by a substantial number of the respondents, and frequency of stress experience was found to have implications for self-reported health. In contrast, nursing has always been acknowledged to be a stressful profession. Gray-Toft and Anderson (1981) have identified seven major sources of stress within nursing: dealing with death and dying, conflict with doctors, lack of support, inadequate preparation, conflict with other nurses, workload, and uncertainty over treatment. In a recent study of nurses working in National Health Service and private hospitals in Britain, Tyler et al. (1991) confirmed that, irrespective of the sector in which they were employed, nurses reported high levels of job stress. There were, however, differences in the apparent source of these high stress levels between the two sectors. Whereas conflict with doctors and uncertainty over treatment were more commonly reported as sources of stress by nurses in the private sector, stress derived from high workloads was more frequently cited by National Health Service nurses. In general terms, then, it would appear that whereas the physical environment, i.e., sheer workload, is a greater source of stress in the National Health Service, social and psychological aspects of the work environment present more of a problem to private sector nurses. However, irrespective of sector, it would appear that stress takes its toll in terms of health and well-being. Nurses in both sectors registered worryingly high scores on a questionnaire measure of symptomatology, and there was a significant positive association between the overall level of stress experienced and reported levels of symptomatology.

Both of these examples have relied on questionnaire measures of health, with all the attendant drawbacks. For example, it could be that a generally negative orientation towards life underlies both reports of high levels of job stress and protestations of poor physical health. However, while general negativity may be a factor, it is unlikely to account fully for the relationship reported in studies of this sort. Occupational stress is not only associated with subjectively reported levels of ill-health and symptomatology, but is also a predictor of objectively diagnosed illness and disease. For example, Alfredsson et al. (1985) conducted an analysis of deaths from heart disease across all occupational groups in Sweden. Occupations were classified in terms of high and low demand, and also as high and low in terms of the control over the work environment they afforded employees. Deaths from heart disease were found to be far more common among groups of workers who had the least control over what they did at work and when they did it, and who, at the same time, were in occupations with the highest demands. Theorell et al. (1985) reported further evidence of an association between occupational demand and control on one hand and objective health indicators on the other. Young workers in a variety of occupations monitored their own blood pressures once every two hours during a typical working day. Systolic blood pressure elevations at work were greater among those who were in high-demand/low-control occupations (e.g., waiter, cook) than those in low-demand/high-control occupations.

All of these studies suggest that work can be a potent source of background stress, that it can impose on the individual conflicting and often excessive demands, and that it contributes substantially to the daily hassles that individuals encounter. In addition, as we have seen, work stress can have deleterious effects on individuals’ sense of physical well-being and objective indices of health.

Appraisal, Vulnerability and Coping

So far I have been talking about stress as if it is an objective characteristic of the environment. It is not. Stress, like beauty, lies in the eye of the beholder. The point is nowhere better illustrated that in the research and writings of Richard Lazarus and his colleagues. For us to experience an event or situation as stressful, according to Lazarus (1966), we have to perceive or appraise it as such. Other appraisals, i.e., non-threatening appraisals, would serve to diminish the disruptive impact of the event, short-circuit the stress. An experimental study reported by Lazarus et al. (1965) provides a neat illustration of the point. Subjects viewed a stressful film called Woodshop, which depicted a series of gruesome accidents at a sawmill, such as a worker severing a finger. One group of subjects was encouraged to adopt a denial appraisal, by informing them, prior to viewing the film, that the participants in it were actors, that the events were staged and that no one was really injured. A second group was encouraged to use an intellectualization appraisal, and study the film from the vantage of its likely impact as a vehicle for promoting safety at work. A third group viewed the film without prior instruction. Heart rate and skin conductance were monitored throughout to gauge the physiological impact of the film, and subjects were quizzed about how stressful they found it. Subjects who had received either denial or intellectualization instructions showed less physiological disruption during the film and reported that it was less stressful than subjects given no appraisal instructions.

Thus, particular appraisals can ameliorate the impact of a potentially stressful event. There is a lesson of general significance to be learnt from this demonstration; there are psychological mechanisms at our disposal which may serve to combat stress. The existence of such devices has been recognized for some time. Freud referred to them as defence mechanisms, although today they are generally called coping strategies, and, to an extent, they help us explain why, in the face of a potentially stressful situation, some people yield but others do not. Part of the explanation is that some individuals have a fuller repertoire of positive psychological coping strategies. However, this is far from a complete explanation. Most current models of stress and illness postulate that stress precipitates illness where there is an existing vulnerability, a diathesis as it is sometimes called.

It is possible to regard this vulnerability as operating at a number of levels. First of all, it can operate at a biological level. Some individuals may simply be predisposed to suffer disruption to specific biological systems in the face of stress. There is now substantial evidence, for example, that individuals vary markedly in the physiological reaction they show to stress. In Chapter 3 I shall present evidence which suggests that, at least as far as cardiac reactions are concerned, variability to an extent reflects genetic predisposition. For the moment, though, let me briefly illustrate the general proposition by taking another example: pepsinogen and its role in ulcers.

It is generally conceded that psychological stress contributes to the development of ulcers, but stress cannot by itself afford a full explanation. The suspected mechanism is that stress causes an increase in the secretion of pepsinogen. Pepsinogen is secreted by the stomach and converted into pepsin, an enzyme which digests protein. Together with hydrochloric acid, pepsin constitutes the main active agent in the stomach’s digestive juices. What is clear is that there are wide variations among individuals in the amount of pepsinogen they characteristically secrete. The research of Mirsky (1958) demonstrated that these individual differences showed familial aggregation, i.e., high levels of pepsinogen secretion ran in families. Additionally, identical twin pairs are far more similar in terms of pepsinogen secretion levels than are non-identical twin pairs. Because of the identical genetic profiles of identical twins, results such as this are generally taken to indicate a pronounced genetic influence, in this case on pepsinogen secretion levels. A study reported by Weiner et al. (1957) indicated just how stress and biological predisposition can interact to produce disease. The subjects were new recruits to the US army. Prior to their basic training, which is generally conceded to be extremely stressful, gastrointestinal examinations were undertaken. On the basis of the results, two groups of soldiers were selected, a group of oversecretors of pepsinogen and a group of undersecretors. None of the selected soldiers had ulcers at this stage. Approximately four months later, at the end of basic training, the soldiers were re-examined. Fourteen per cent of the oversecretors had now...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• Contents
• Acknowledgments
• Series Editor’s Preface
• Chapter 1 Introduction: Stress, Behaviour, and Disease
• Chapter 2 Type A Behaviour and Coronary Heart Disease
• Chapter 3 Hypertension and Cardiovascular Reactions to Stress
• Chapter 4 Cancer and the Immune System
• Chapter 5 The Challenge of AIDS
• Chapter 6 Stress Management: Reducing the Risk of Coronary Heart Disease
• Chapter 7 Exercise, Fitness, and Health
• Chapter 8 Taking One’s Medicine: Following Therapeutic Advice
• Chapter 9 Pain and Psychological Approaches to its Management
• Chapter 10 Final Comments: Gender, Race, Social Class, and Health
• Bibliography
• Note on the Author
• Index