PSY467: Health Psychology Week 7-10 PDF

PSY467:Health Psychology Week VII: Changing Health Behaviors Dr. Zehra Merve Kaya Fall 2024 PSY467:Health Psychology Week VIII: Illness Cognitions Dr. Zehra Merve Kaya Fall 2024 PSY467:Health Psycho...

PSY467:Health Psychology Week VII: Changing Health Behaviors Dr. Zehra Merve Kaya Fall 2024 PSY467:Health Psychology Week VIII: Illness Cognitions Dr. Zehra Merve Kaya Fall 2024 PSY467:Health Psychology Week IX: Stress and Illness Dr. Zehra Merve Kaya Fall 2024 What is Stress? The term ‘stress’ means many things to many different people. A layperson may define stress in terms of pressure, tension, unpleasant external forces or an emotional response. Contemporary definitions regard stress from the external environmental as a stressor (e.g. problems at work), the response to the stressor as stress or distress (e.g. the feeling of tension), and the concept of stress as something that involves biochemical, physiological, behavioural and psychological changes. In addition, researchers differentiate between acute stress, such as an exam or having to give a public talk, and chronic stress, such as job stress and poverty.  The most commonly used definition of stress was developed by Lazarus and Launier (1978), who regarded stress as a transaction between people and the environment and described stress in terms of ‘person– environment fit’. If a person is faced with a potentially difficult stressor, such as an exam or having to give a public talk, the degree of stress they experience is determined first by their appraisal of the event (‘Is it stressful?’) and second by their appraisal of their own personal resources (‘Will I cope?). A good person–environment fit results in no or low stress and a poor fit results in higher stress. Measuring Stress Laboratory Setting Naturalistic Setting Costs and Benefits of Different Settings Physical Measures Self Report Costs of Benefits of Different Measures Early Stress Models Cannon’s Fight or Flight Model Selye’s General Adaptation Syndrome Life Events Theory Cannon’s Fight or Flight Model He suggested that these physiological changes enabled the individual to either escape from the source of stress or fight. Within Cannon’s model, stress was defined as a response to external stressors, which was predominantly seen as physiological. The initial stage was called the ‘alarm’ stage, which described an increase in activity, and occurred as soon as the individual was exposed to a stressful situation. The second stage was called ‘resistance’, which involved coping and attempts to reverse the effects of the alarm stage. The third stage was called ‘exhaustion’, which was reached when the individual had been repeatedly exposed to the stressful situation and was incapable of showing further resistance. Problems with the Cannon and Selye Models Both regarded the individual as automatically responding to an external stressor and described stress within a straightforward stimulus–response framework. They therefore did not address the issue of individual variability and psychological factors were given only a minimal role. Both also described the physiological response to stress as consistent. This response is seen as non-specific in that the changes in physiology are the same regardless of the nature of the stressor. Life Events Theory Life events theory was developed to examine stress and stress- related changes as a response to life experiences. Problems with Life Events Theory The individual’s own rating of the event is important. The problem of retrospective assessment. Life experiences may interact with each other. Stressors may be short term or ongoing. The Transactional Model of Stress This role for psychology took the form of his concept of appraisal. Lazarus argued that stress involved a transaction between the individual and their external world, and that a stress response was elicited if the individual appraised a potentially stressful event as actually being stressful.  Lazarus defined two forms of appraisal: primary and secondary. According to Lazarus, the individual initially appraises the event itself – defined as primary appraisal. There are four possible ways that the event can be appraised: (1) irrelevant; (2) benign and positive; (3) harmful and a threat; (4) harmful and a challenge.  Lazarus then described secondary appraisal, which involves the individual evaluating the pros and cons of their different coping strategies. Therefore primary appraisal involves an appraisal of the outside world and secondary appraisal involves an appraisal of the individual themselves. The form of the primary and secondary appraisals determines whether the individual shows a stress response or not.  According to Lazarus’s model this stress response can take different forms: (1) direct action; (2) seeking information; (3) doing nothing; or (4) developing a means of coping with the stress in terms of relaxation or defense mechanisms. Does Appraisal Influence the Stress Response? In condition 1, the trauma condition, the soundtrack emphasized the pain and the mutilation. In condition 2, the denial condition, the soundtrack showed the participants as being willing and happy. In condition 3, the intellectualization condition, the soundtrack gave an anthropological interpretation of the ceremony. The study therefore manipulated the subjects’ appraisal of the situation. The results showed that subjects reported that the trauma condition was most stressful. However, in contrast, some research indicates that appraisal may not always be necessary. Which Events are Appraised as Stressful? However, research shows that some types of event are more likely to result in a stress response than others. Salient events. Overload. Ambiguous events. Uncontrollable events. Stress and Changes in Physiology Stress causes changes in physiology and behavior which in turn can have an impact upon health and illness.  1 Sympathetic activation: when an event has been appraised as stressful it triggers responses in the sympathetic nervous system. This results in the production of stress hormones known as catecholamines (adrenalin and noradrenalin, also known as epinephrine and norepinephrine) which cause changes in factors such as blood pressure, heart rate, sweating and pupil dilation. This is experienced as a feeling of arousal 2 Hypothalamic-pituitary-adrenocortical (HPA) activation: in addition to sympathetic activation, stress also triggers changes in the HPA system. This results in the production of increased levels of corticosteroids, the most important of which is cortisol, which results in more diffuse changes, such as the management of carbohydrate stores and inflammation.  Stress has also been shown to cause changes in the immune system. Stress has an impact on wound healing. Research also indicates that stress may relate to illness progression. However, stress may also be a result of the illness itself, such as relationship breakdown, changes in occupation or simply the distress from a diagnosis. Therefore, if the illness is appraised as being stressful, this itself may be damaging to the chances of recovery. Changes in Behavior Stress also causes changes in behavior which in turn are linked with health Smoking Alcohol Eating Exercise Accidents In Class Activity Case 1: Mine is a graduate student juggling academic deadlines, part-time work, and family responsibilities. She’s been experiencing frequent headaches and stomach issues. Case 2: Levent is a caregiver for a chronically ill parent. Over time, he’s started to feel fatigued, and his immune system seems compromised—he catches colds often. Case 3: Maya is going through a high-conflict divorce and reports insomnia, weight loss, and chest pains. Discussion Questions for Each Group: Identify the primary stressors in the case. Discuss potential short-term and long-term health consequences of the stress. Propose strategies to manage the stress effectively (e.g., lifestyle changes, social support, relaxation techniques). Does Stress Cause Illness? One of the reasons that stress has been studied so consistently is because of its potential effect on the health of the individual. Research shows that hypertension rates are more common in those with high stress jobs. Both cross-sectional and longitudinal studies also show that stressful occupations are associated with an increased risk of coronary heart disease (CHD).  Researchers have identified two approaches to understanding the link between stress and illness. The first highlights the direct and indirect pathways and reflects the impact of stress on changes in physiology and behaviour. The second approach reflects the differential effects of chronic and acute stress. These two models will now be described. Direct and Indirect Pathways  Chronic and Acute Stress Model In particular, chronic stress is associated with atherosclerosis, which is a slow process of arterial damage that limits the supply of blood to the heart. Further, this damage might be greater in those individuals with a particular genetic tendency. This chronic process is supported by research indicating links between job stress and cardiovascular disease Physiological Moderators of the Stress-Illness Link Not everyone who experiences stress becomes ill. Research indicates that some of this variability is due to individual differences in physiological factor. Stress Reactivity: Research suggests that greater stress reactivity may make people more susceptible to stress-related illnesses. This means that when given the same level of stressor and regardless of their self-perceived stress, some people show greater sympathetic activation than others (e.g. Vitaliano et al. 1993). For example, individuals with both hypertension and heart disease have higher levels of stress reactivity Stress Recovery After reacting to stress the body recovers and levels of sympathetic and HPA activation return to baseline. However, some people recover more quickly than others and some research indicates that this rate of recovery may relate to a susceptibility to stress-related illness. Some research has focused particularly on changes in cortisol production, suggesting that slower recovery from raised cortisol levels could be related to immune function and a susceptibility to infection and illness Allostatic Load Researchers argued that the body’s physiological systems constantly fluctuate as the individual responds and recovers from stress – a state of allostasis – and that as time progresses, recovery is less and less complete and the body is left increasingly depleted. Therefore, if exposed to a new stressor the person is more likely to become ill if their allostatic load is quite high. Stress Resistence To reflect the observation that not all individuals react to stressors in the same way, researchers have developed the concept of stress resistance to emphasize how some people remain healthy even when stressors occur (e.g. Holahan and Moos 1990). Stress resistance includes adaptive coping strategies, certain personality characteristics and social support. Psychological Moderators of Stress There is also evidence that psychological factors moderate the link between stress and illness. Healthy Behaviors Coping Styles: Approach vs Avoidance; Problem focused vs Emotion focused Social Support: Esteem, Instrumental, companionship, support Actual or Perceived Control Personality Type A Hostility Conscientiousness  PSY467:Health Psychology Week X: Pain and the Placebo Effect Dr. Zehra Merve Kaya Fall 2024 What is Pain? Pain seems to have an obvious function. It provides constant feedback about the body, enabling us to make adjustments to how we sit or sleep and stops us from burning or cutting ourselves as we go about our daily lives. Pain is also a warning sign that something is wrong and results in protective behaviour, such as avoiding moving in a particular way or lifting heavy objects. Pain triggers help-seeking behaviour and is a common reason for patients visiting their doctor Chronic vs Acute Pain Researchers differentiate between acute pain and chronic pain. Acute pain is defined as pain that lasts for six months or less. It usually has a definable cause and is mostly treated with painkillers. A broken leg or a surgical wound is an example of acute pain. In contrast, chronic pain lasts for longer than six months and can be either benign, in that it varies in severity, or progressive, in that it gets gradually worse. Chronic low back pain is often described as chronic benign pain whereas illnesses such as rheumatoid arthritis result in chronic progressive pain. Pain as a Sensation Early models described pain within a biomedical framework as an automatic response to an external factor Descartes, perhaps the earliest writer on pain, regarded it as a response to a painful stimulus. Von Frey (1895) developed the specificity theory of pain, which again reflected this very simple stimulus–response model. He suggested that there were specific sensory receptors which transmit touch, warmth and pain, and that each receptor was sensitive to specific stimulation. In a similar vein, Goldschneider (1920) developed a further model of pain called the pattern theory. He suggested that nerve impulse patterns determined the degree of pain and that messages from the damaged area were sent directly to the brain via these nerve impulses. These three models of pain describe pain as a sensation as follows Tissue damage causes the sensation of pain. Psychology is involved in these models of pain only as a consequence of pain (e.g. anxiety, fear, depression). Psychology has no causal influence. Pain is an automatic response to an external stimulus. There is no place for interpretation or moderation. The pain sensation has a single cause. Pain was categorized into being either psychogenic pain or organic pain. Psychogenic pain was considered to be ‘all in the patient’s mind’ and was a label given to pain when no organic basis could be found. Organic pain was regarded as being ‘real pain’ and was the label given to pain when some clear injury could be seen. INCLUDING PSYCHOLOGY IN THEORIES OF PAIN These early models of pain had no role for psychology. First, it was observed that medical treatments for pain were mostly only useful for treating acute pain. Such treatments were fairly ineffective for treating chronic pain. This suggested that there must be something else involved in the pain sensation which was not included in the simple stimulus–response models. It was also observed that individuals with the same degree of tissue damage differed in their reports of the painful sensation and/or painful responses. The third observation was phantom limb pain. Measuring Pain This has raised several questions and problems. For example, ‘Are we interested in the individual’s own experience of the pain?’ (i.e. what someone says is all important), ‘What about denial or self-image?’ These questions have resulted in three different perspectives on pain measurement: self-reports, observational assessments physiological assessments, Pain as a Perception ? Gate Control Theory  Input to the Gate: Melzack and Wall suggested that a gate existed at the spinal cord level, which received input from the following sources: Peripheral nerve fibres: The site of injury (e.g. the hand) sends information about pain, pressure or heat to the gate. Descending central influences from the brain: The brain sends information related to the psychological state of the individual to the gate. Large and small fibres. Output from the Gate: This output from the gate sends information to an action system, which results in the perception of pain. How Does the GCT Differ from Earlier Models of Pain? Pain as a perception. The individual as active, not passive. The role for multiple causes. Is pain ever organic? Pain and dualism. Where is the gate? A Psychosocial Model of Pain Perception The Role of Learning Classical Conditioning: As described by theories of associative learning, an individual may associate a particular environment with the experience of pain. For example, if an individual associates the dentist with pain due to past experience Operant Conditioning :Research suggests that there is also a role for operant conditioning in pain perception and this can be moderated through positive or negative reinforcement. The Role of Affect Anxiety: Acute vs Chronic pain Fear: possibility of turning acute pain to chronic pain, fear avoidance The Role of Cognition Catastrophizing: Rumination, Magnification, Helplessness Meaning: Self Efficacy: self-efficacy in pain perception and reduction. Attention: attention to the pain can exacerbate it whereas distraction can reduce the pain experience. Behavioral Process Pain Behaviors: facial or audible expression (e.g. clenched teeth and moaning), distorted posture or movement (e.g. limping, protecting the pain area), negative affect (e.g. irritability, depression) or avoidance of activity (e.g. not going to work, lying down). Secondary Gains: miss work, adopt a sick role, generate empathy Experience of Pain What is missing in this research, however, is how pain is experienced. Why they had developed chronic pain Comparison Not believed by others When in public they had to hide their pain The Role of Psychology in Pain Treatment Acute pain is mostly treated with pharmacological interventions. Chronic pain has proved to be more resistant to such approaches and recently pain clinics have been set up that adopt a multidisciplinary approach to pain treatment. Current treatment philosophy also emphasizes early intervention to prevent the transition of acute pain to chronic pain.  Improving physical and lifestyle functioning. This involves improving muscle tone, self-esteem, self-efficacy and distraction, and decreasing boredom, pain behaviour and secondary gains. Decreasing reliance on drugs and medical services. This involves improving personal control, decreasing the sick role and increasing self-efficacy. Increasing social support and family life. This aims to increase optimism and distraction and decrease boredom, anxiety, sick role behaviour and secondary gains.  Respondent methods. Respondent methods are designed to modify the physiological system directly by reducing muscular tension. Cognitive methods. A cognitive approach to pain treatment focuses on the individual’s thoughts about pain and aims to modify cognitions that may be exacerbating their pain experience. Behavioural methods. Some treatment approaches draw upon the basic principles of operant conditioning and use reinforcement to encourage the individual to change their behaviour. A ROLE FOR PAIN ACCEPTANCE? The psychological treatment of pain includes respondent, cognitive and behavioral methods. These are mostly used in conjunction with pharmacological treatments involving analgesics or anesthetics. The outcome of such interventions has traditionally been assessed in terms of a reduction in pain intensity and pain perception. Recently, however, some researchers have been calling for a shift in focus towards pain acceptance. The Placebo Effect Inert substances that cause symptom relief (e.g. ‘My headache went away after having a pill’). Substances that cause changes in a symptom not directly attributable to specific or real pharmacological actions of a drug or operation (e.g. ‘After I had my hip operation I stopped getting headaches’). Any therapy that is deliberately used for its non-specific psychological or physiological effects (e.g. ‘I had a bath and my headache went away’). These definitions illustrate some of the problems with understanding placebos. For example: What are specific/real versus non-specific/unreal effects? For example, ‘My headaches went after the operation’: is this an unreal effect (it was not predicted) or a real effect (it definitely happened)? Why are psychological effects non-specific? (e.g. ‘I feel more relaxed after my operation’: is this a non-specific effect?). Are there placebo effects in psychological treatments? For example, ‘I specifically went for cognitive restructuring therapy and ended up simply feeling less tired’: is this a placebo effect or a real effect? How do placebos work?  Characteristics of the individual: emotional dependency, extroversion, neurosis and being highly suggestible. Characteristics of the treatment: if a treatment is perceived as being serious Characteristics of the health professional: higher professional status has been shown to increase the placebo effect. THE ROLE OF PLACEBOS IN HEALTH PSYCHOLOGY Health Beliefs: A placebo in the form of herbal tea may only be effective if the individual believes in alternative medicines and is open to non- traditional forms of intervention. Illness Cognitions: For example, if an illness is seen as long-lasting without episodes of remission, times of spontaneous recovery may not happen, which therefore cannot be explained in terms of the effectiveness of the treatment. Health Professionals’ Health Beliefs: Placebos may also be related to the beliefs of the health professional. For example, a doctor may need to believe in the intervention for it to have an effect. Health Related Behaviors: A placebo may function via changes in health- related behaviour. Stress: Placebos also have implications for understanding responses to stress. PSY467:Health Psychology Week XI: HIV and Cancer Dr. Zehra Merve Kaya Fall 2024 THE HISTORY OF HIV AIDS (acquired immune deficiency syndrome) was identified as a new syndrome in 1981. At that time, it was regarded as specific to homosexuality and was known as GRIDS (gay-related immune deficiency syndrome). As a result of this belief, a number of theories were developed to try to explain the occurrence of this new illness among homosexuals In 1984, the human immunodeficiency virus type 1 (HIV 1) was identified and, in 1985, HIV 2 was identified in Africa. The Structure of HIV The HIV virus is a retrovirus, a type of virus containing RNA. There are three types of retrovirus: Oncogenic retroviruses which cause cancer, Foamy retroviruses which have no effect at all on the health status of the individual, Lentiviruses, or slow viruses, which have slow long-term effects. HIV is a lentivirus. The progression from HIV to AIDS THE PREVALENCE OF HIV AND AIDS In 2015 there were an estimated 36.7 million people worldwide infected with the HIV virus. Generally, the incidence of HIV peaked in the late 1990s and has now mostly stabilized. However, the numbers of people living with HIV has increased due to population growth as have the numbers of people now taking antiretroviral therapy which has significantly improved the life expectancy of those infected with the HIV virus The epicenter of the global epidemic is in sub-Saharan Africa. THE ROLE OF PSYCHOLOGY IN THE STUDY OF HIV Some HIV transmission is through blood transfusions or from mother to child during birth. Most transmission, however, is through human behavior involving sexual intercourse or shared needle use. Health psychology has studied HIV in terms of attitudes to HIV and safe sex, changing these attitudes, examining predictors of behaviour and the development of interventions to change behaviour.  Not everyone exposed to the HIV virus becomes HIV-positive. This suggests that psychological factors may influence an individual’s susceptibility to the HIV virus. The time for progression from HIV to AIDS is variable Psychological factors may have a role in promoting the replication of the HIV virus and the progression from being HIV-positive to having AIDS. Not everyone with HIV dies from AIDS. Psychological factors have a role to play in determining the longevity of the individual. PSYCHOLOGY AND THE PROGRESSION FROM HIV TO AIDS Minority Stress and Stigma: HIV and AIDS remain stigmatized conditions. Adherence to Medication: Many people who are offered HAART, however, do not take the treatment. Comorbidities: general health status and the existence of other illnesses could promote the progression from HIV to AIDS. Lifestyle: injecting drugs further stimulates the immune system, which may well influence replication, and thereby points to a role for drug use not only in contracting the virus but also for its replication. Cognitive Adjustment Type C Coping Style PSYCHOLOGY AND LONGEVITY WITH HIV In the 1980s HIV/AIDS was an acute terminal illness with life expectancy post diagnosis ranging from days up to about 18 months. Nowadays, fortunately, in most countries it is seen as a chronic condition with the life expectancy of those who are HIV positive almost matching those who are not. PSYCHONEUROIMMUNOLOGY (PNI) Measuring Immune Changes: (1) tumour growth, which is mainly used in animal research; (2) wound healing, which can be used in human research by way of a removal of a small section of the skin and can be monitored to follow the healing process; (3) secretory immunoglobulin A (sIgA), which is found in saliva and can be accessed easily and without pain or discomfort to the subject (4) natural killer cell : cytoxicity (NKCC), T lymphocytes and T helper lymphocytes, which are found in the blood. Psychological State and Immunity Research has focused on the capacity of psychological factors to change immune functioning. Mood: Studies indicate that positive mood is associated with better immune functioning (as measured by sIgA), that negative mood is associated with poorer functioning. Beliefs: It has also been suggested that beliefs may themselves have a direct effect on the immune system. In particular, some research has explored the impact of how pessimism, attributional style, fighting spirit, hopelessness and helplessness may all impact upon immune function. Emotional expression: Some evidence also suggests that certain coping styles and the ways in which emotions are expressed may change immune function. In particular, research highlights that suppression, denial, Type C coping and repressive coping may be harmful for health.  https://www.youtube.com/watch?v=17pfZUlAqow PSY467:Health Psychology Week XI: Cancer Dr. Zehra Merve Kaya Fall 2024 What is Cancer? Cancer is defined as an uncontrolled growth of abnormal cells, which produces tumors called neoplasms. There are two types of tumor: benign tumors, which do not spread throughout the body, and malignant tumors, which show metastasis. There are three types of cancer cell: carcinomas, which constitute 90 per cent of all cancer cells and which originate in tissue cells; sarcomas, which originate in connective tissue; and leukemias, which originate in the blood. THE PREVALENCE OF CANCER In 2015, cancer was responsible for 8.8 million deaths globally. It was the leading cause of death and nearly 1 in 6 deaths was due to cancer. The most common causes of cancer death are: lung cancer (1.69 million deaths); liver cancer (788,000 deaths); colorectal cancer (774,000 deaths); stomach cancer (754,000 deaths) breast cancer (571,000 deaths).  Deaths from cancer worldwide are projected to continue to rise to over 11 million in 2030. In 2012, the highest cancer rates were found in Denmark, France, Australia, Belgium, Norway and the USA, with the lowest rates reported in Japan, Argentina and Puerto Rico. THE ROLE OF PSYCHOLOGY IN THE STUDY OF CANCER A role for psychology in cancer was first suggested by Galen in AD 200– 300, who argued for an association between melancholia and cancer. First, psychological factors are important in terms of cancer onset and a discussion of health and illness beliefs, health behaviours and behaviour change interventions. Second, psychology is involved in factors such as screening, help-seeking, delay and adherence. Further, sufferers of cancer report psychological consequences, which have implications for coping, adjustment, pain and a person’s quality of life.  The role of psychology in cancer is also illustrated by the following observations: Cancer cells are present in most people but not everybody gets cancer. All those who have cancer do not always show progression towards death at the same rate. Not all cancer sufferers die of cancer. 1) PSYCHOLOGY AND THE INITIATION AND PROMOTION OF CANCER 1 Behavioural factors. 2 Stress. 3 Life events. 4 Control. 5 Coping styles. 6 Depression. 7 Personality. 2) PSYCHOLOGICAL CONSEQUENCES OF CANCER Psychology also has a role to play in cancer in terms of how people respond to their diagnosis. Lowered Mood: Up to 20 per cent of cancer patients may show severe depression, grief, lack of control, personality change, anger and anxiety. Body Image: Women with breast cancer often report changes in their sense of femininity, attractiveness and body image. Cognitive Adaptation: a search for meaning, believing that they could control their cancer and any relapses, a process of self-enhancement (social comparison). Benefit Finding: stress-related growth, post-traumatic growth, benefit- finding, meaning-making and existential growth 3) DEALING WITH THE SYMPTOMS OF CANCER Psychology has a role to play in the alleviation of symptoms of cancer, and in promoting quality of life. 1 Pain management. 2 Social support interventions. 3 Treating nausea and vomiting: Respondent conditioning and visual imagery, relaxation, hypnosis and desensitization 4 Body image counselling. 5 Sense-making strategies. 6 Fear reduction: AFTER (Adjustment for the Fear, Threat or Expectation of Recurrence) 4) PSYCHOLOGY AND LONGEVITY WITH CANCER Cognitive Responses and Longevity: (‘fighting spirit’, those who showed denial of the implications of their disease and those who showed a hopeless/helpless response.) Life Stress and Disease Free Interval: The results showed that life events rated as severe were related to first recurrence of breast cancer. No Relationship between longevity and psychological factors.  PSY467:Health Psychology Week XII: Obesity and Heart Disease Dr. Zehra Merve Kaya Fall 2024 What is Obesity? Population means: Population means involve exploring mean weights, given a specific population, and deciding whether someone is below average weight, average or above average in terms of percentage overweight. Body mass index (BMI) is calculated using the equation weight (kg)/ height (m2). This produces a figure that has been categorized as normal weight (20–24.9); overweight (25–29.9); clinical obesity (30– 39.9); and severe obesity (40+).  Waist circumference. Researchers originally used waist:hip ratios to assess obesity but recently waist circumference on its own has become the preferred approach. For men, low waist circumference is < 94 cm; high is 94–102 cm and very high is > 102 cm. For women, low waist circumference is < 80 cm; high is 80–88 cm and very high is > 88 cm. Weight reduction is recommended when waist circumference is greater than 102 cm in men and 88 cm in women Percentage body fat. How Common Is Obesity? Since 1975, rates of obesity worldwide have nearly tripled. In 2016 it was estimated that 39 per cent of adults were overweight and 13 per cent were obese, while 41 million children under the age of 5 and 340 million children aged 5–19 years were overweight or obese. The Role of Psychology In The Study Of Obesity Psychology has a role to play in obesity in terms of the beliefs people hold about obesity, the role of beliefs and behaviours in its onset, how people cope with and adjust to this condition, how obesity is managed and the consequences on an individual’s physical and psychological well-being. THE CONSEQUENCES OF OBESITY Obesity is associated with both physical and mental health problems. Physical Health Problems: Obesity has been associated with cardiovascular disease, diabetes, joint trauma, back pain, cancer, hypertension and mortality. The effects of obesity are related to where the excess weight is carried; weight stored in the upper body, particularly in the abdomen, is more detrimental to health than weight carried in the lower body Direct linear relationship between BMI and risk factors for heart disease including blood pressure, cholesterol and blood glucose.  Psychological Problems: The contemporary cultural obsession with thinness, the aversion to fat found in both adults and children and the attribution of blame to people living with obesity may promote low self- esteem and poor self-image in those individuals who do not conform to the stereotypically attractive thin image. Further, those who are depressed or anxious may eat more as a means to manage their mood. Accordingly, psychological problems may be either a consequence or a cause of weight problems but much research shows that they are associated. For example, research indicates that adults who are obese also tend to show depression, anxiety, low self-esteem and high levels of body dissatisfaction WHAT CAUSES OBESITY ? Genetic Theories: Size appears to run in families and the probability that a child will be overweight is related to the parents’ weight. For example, having one parent with obesity results in a 40 per cent chance of producing a child with obesity, and having two parents with obesity results in an 80 per cent chance. In contrast, the probability that thin parents will produce overweight children is very small, about 7 per cent Twin studies. Studies have examined the weights of non-identical twins reared together, who have different genes but similar environments. The results show that the identical twins reared apart are more similar in weight than non-identical twins reared together.  Adoptee studies. The results showed a strong relationship between the weight class of the adoptee (thin, median weight, overweight, obese) and their biological parents’ weight class but no relationship with their adoptee parents’ weight class. Genetic analysis: Obesity is found in some syndromes which are caused by individual genes such as Bardet-Biedl syndrome and Prader-Willi syndrome. These are known as monogenic types of obesity and are caused by genetic mutations. The Obesogenic Environment To address the dramatic increase in obesity since the 1970s, researchers have turned their attention to the role of the external world which has been labelled an obesogenic environment For example, they have highlighted the impact of the food industry with its food advertising, food labelling and the easy availability of energy-dense foods such as fast foods and takeaways. They have identified environmental factors which encourage us to live an increasingly sedentary lifestyle, such as a reduction in manual labour, the use of cars, computers and television and the design of towns whereby walking is prohibited through the absence of streetlights, pavements and large distances between residential areas and places of entertainment or shops, and they have focused on factors which make it more and more difficult to eat well and be active, such as the presence of lifts and escalators which detract from stair use and the cheapness of prepared foods which discourages food shopping and cooking. Behavioral Theories Physical Activity Increases in the prevalence of obesity coincide with decreases in daily energy expenditure due to improvements in transport systems, and a shift from an agricultural society to an industrial and increasingly information-based one. Eating Behaviour These perspectives emphasize mechanisms such as exposure, modelling and associative learning, beliefs and emotions, body dissatisfaction and dieting, all of which can help explain obesity. For example, it is possible that those living with obesity have childhoods in which food is used to reward good behaviour, or have parents who overeat, or hold cognitions about food which drive eating behaviour. Are Changes in Obesity Related to Changes in Activity? Epidemiological data: The results from this study suggested a strong association between an increase in both car ownership and TV viewing and an increase in obesity. However, this data was only correlational so it remains unclear whether obesity and physical activity. Prospective data: The results showed that lower levels of activity were a greater risk factor for weight gain than any other baseline measures. Do those who are Living with Obesity Eat for Different Reasons than those of Healthier Weight? External eating: In the 1960s Schachter developed his externality theory of obesity which suggested that, although all people were responsive to environmental stimuli such as the sight, taste and smell of food, and that such stimuli might cause overeating, those with obesity were highly and sometimes uncontrollably responsive to external cues. It was argued that normal-weight individuals mainly ate as a response to internal cues (e.g. hunger, satiety) and those with obesity tended to be under-responsive to their internal cues and over-responsive to external cues. Emotional eating: Research has also addressed the emotionality theory of eating behaviour. For example, Bruch (e.g. 1974) developed a psychosomatic theory of eating behaviour and eating disorders which argued that some people interpret the sensations of such emotions as emptiness as similar to hunger and that food is used as a substitute for other forms of emotional comfort. Do those who are living with Obesity Eat more than those of Healthier Weight? The Amount Eaten: Increased body weight seems to be associated with increased food intake. Further, if overeating is defined as ‘compared with what the body needs’, it could be argued that those living with obesity overeat because they have excess body fat. Eating Differently: more likely to skip breakfast, skip lunch and eat at night and reported larger portion sizes at meal times, eat fast, smaller feeding window. Type of Food: they may eat proportionally more fat, more processed foods. Obesity Treatment Dieting: The failure of traditional treatment packages for obesity resulted in psychologists, nutritionists, dieticians and endocrinologists taking a more multidimensional approach to obesity treatment. Success of Dieting: Modern-day weight loss programmes often include self- monitoring, reinforcement, information, exercise, cognitive restructuring, motivational interviewing, attitude change and relapse prevention and encourage people with obesity to eat less than they do usually rather than encouraging them to eat less than those of a healthier weight. Consequences of Dieting: Some research suggests that having periods of time in your life when you weigh less, even if this weight is regained, may be healthier in the same way that stopping smoking for the odd month or even year gives the lungs time to recover (Blackburn 1995). In contrast, other research indicates that yo-yo dieting or weight cycling (i.e. showing large fluctuations in weight) may be harmful – even more harmful than remaining at a more stable higher weight (Lissner et al. 1991).  Medication: When dieting alone has failed, people who are overweight or living with obesity can turn to medication. There are currently three groups of anti-obesity drugs offered in conjunction with dietary and exercise programmes. Those in the first group work on the central nervous system and suppress appetite. The second group of drugs reduce fat absorption The third group of drugs is new and show promise. These drugs were originally developed for treating diabetes and increase insulin secretion, thereby increasing sugar metabolism. Success of Medication  Surgery: Although there are a multitude of different surgical procedures for obesity (Kral 1995), the most popular are the vertical banded bypass, gastric bypass and gastric banding often known as bariatric surgery, metabolic surgery or weight loss surgery (WLS). The results showed an average weight loss of 28 kg in the surgical group after two years compared to only 0.5 kg in the behavioural group. WHAT IS CORONARY HEART DISEASE? (CHD) They include coronary heart disease (CHD; disease of the blood vessels supplying the heart muscle) Most research in health psychology has focused on CHD and cerebrovascular disease THE PREVALENCE OF CVD In 2017, CVD was the highest cause of death globally. In 2015, it was estimated that 31 per cent of all global deaths were due to CVD (about 17.7 million people) and, of these deaths, 7.4 million were due to coronary heart disease (CHD) and 6.7 million were due to stroke. Deaths from CHD have declined in recent years in North America and across Europe mainly due to the decline in smoking and other lifestyle factors. In middle age, the death rate is up to five times higher for men than for women; this evens out, however, in old age when CHD is the leading cause of death for both men and women. THE ROLE OF PSYCHOLOGY IN THE STUDY OF CHD The risk factors for CHD, Beliefs about CHD, The psychological impact of CHD, Rehabilitation and the modification of risk factors, The predictors of patient health outcomes. Many risk factors for CHD have been identified, such as educational status, social mobility, social class, age, gender, stress reactivity, family history, ethnicity, smoking, diet, obesity, sedentary lifestyle, perceived work stress and personality. RISK FACTORS FOR CHD 1) Smoking. One in four deaths from CHD is thought to be caused by smoking. Smoking more than 20 cigarettes a day increases the risk of CHD in middle age threefold. In addition, stopping smoking can halve the risk of another heart attack in those who have already had one. 2) Diet. Diet, in particular cholesterol levels, has also been implicated in CHD. It has been suggested that the 20 per cent of a population with the highest cholesterol levels are three times more likely to die of heart disease than the 20 per cent with the lowest levels. Cholesterol reduction can be achieved through a reduction in total fats and saturated fats, an increase in polyunsaturated fats and an increase in dietary fiber.  3) Obesity. Obesity is a clear risk factor for CHD and stroke. This is in part through high blood pressure and cholesterol, which has generated a debate about whether healthy obesity exists if those who are obese take their medication to reduce these factors. The research indicates, however, that even if these factors are medically managed and levels normalized, obesity remains an independent risk factor for CHD and stroke 4) High blood pressure. High blood pressure is also a risk factor for CHD – the higher the blood pressure, the greater the risk.  5) Type A behavior and hostility. Type A behavior and its associated characteristic, hostility, are probably the most extensively studied risk factor for CHD. 6) Stress. Stress has also been studied extensively as a predictor of CHD and research has shown links between stress reactivity and CHD, life events and CHD, and job stress. BELIEFS ABOUT CHD Gudmundsdottir et al. (2001) also explored people’s beliefs about CHD but examined the beliefs of people who had had an MI in the past year. Using a longitudinal design they assessed the patients’ beliefs within 72 hours of admission into hospital and interviewed the patients about the causes of their MI. Patients were then followed up three times over the next year. The results showed that the most common causes derived from all methods were ‘smoking’, ‘stress’, ‘it’s in the family’, ‘working’ and ‘eating fatty foods’. People therefore have beliefs about CHD which might influence their subsequent risky behaviour and reflect a process of adjustment once they have become ill. THE PSYCHOLOGICAL IMPACT OF CHD Anxiety and Depression: Negative mood is very common in patients with CHD, particularly after a heart attack or stroke. The results showed that during hospitalization 30.9 per cent of patients reported elevated depression scores and 26.1 per cent reported elevated anxiety scores. Counselling seemed to minimize this increase. In contrast to the patients, the partners did show very high levels of anxiety and depression while the patients were still in hospital. This dropped to normal levels in those who received counselling  PTSD: Research has also explored the prevalence and predictors of PTSD following either stroke or MI and indicates rates of about 17 per cent, with people experiencing intrusive thoughts, elevated levels of arousal, psychological numbing and avoidance of reminders of the trauma Finding Meaning: Bury (1982) argued that illness can be seen as a form of biographical disruption which requires people to question ‘what is going on here?’ and results in a sense of uncertainty. Radley (1984, 1989) has drawn upon this perspective to explore how people adjust and respond to CHD. In particular, Radley argues that patients diagnosed with CHD try to resolve the dual demands of symptoms and society. He suggests that people with a chronic illness such as CHD need to establish a new identity as someone who has been ill but can be well again. This need occurs against a backdrop of family and friends who are worried about their health and often results in the ill person persistently acting in a ‘healthy way’ as a means to communicate that things are ‘back to normal’. REHABILITATION FOR PATIENTS WITH CHD Rehabilitation programmes use a range of techniques including health education, relaxation training and counselling, and have been developed to encourage CHD sufferers to modify their risk factors. Although MI is the primary cause of premature mortality in many western countries, over 60 per cent of patients will survive their MI. Furthermore, if risk factors can be modified then the likelihood of a further MI is greatly reduced. Rehabilitation programmes are therefore designed to reduce these risk factors. MODIFYING RISK FACTORS Exercise: Meta-analyses of these exercise-based programmes have suggested that they may have favourable effects on cardiovascular mortality and hospital admissions (e.g. Anderson et al. 2016). Type A Behaviour: The Recurrent Coronary Prevention project was developed by Friedman et al. (1986) in an attempt to modify type A behaviour. This programme was based on the following questions: can type A behavior be modified? If so, can such modification reduce the chances of a recurrence of a heart attack?  General Lifestyle Factors: Rehabilitation programmes have been developed which focus on modifying other risk factors such as smoking and diet Overall, all patients improved their lifestyle during the first 3 months and showed extra improvement in their eating habits over the next 9 months. However, by one-year follow-up many patients had increased their smoking again and returned to their sedentary lifestyles.  Illness Cognitions: Research illustrates that patients’ beliefs about their MI may relate to health outcomes in terms of attendance at rehabilitation, return to work and adjustment Stress Management: Stress management involves teaching individuals about the theories of stress, encouraging them to be aware of the factors that can trigger stress, and teaching them a range of strategies to reduce stress, such as ‘self-talk’, relaxation techniques and general life management approaches, such as time management and problem-solving. Stress management has been used successfully to reduce some of the risk factors for CHD, including raised blood pressure (Johnston et al. 1993), blood cholesterol (Gill et al. 1985) and type A behaviour (Roskies et al. 1986). PREDICTING PATIENT HEALTH OUTCOMES Patients Demographgic: being female, older age, having obesity, smoking and having spent fewer years in education. Perceptions of Control Goal Disturbance Social Support Illness Cognition: In particular, studies indicate that those with more negative beliefs about their work capacity (Maeland and Havik 1987), a greater perception of helplessness towards future MIs (called ‘cardiac invalidism’; Riegel 1993) and beliefs that their MI has more serious consequences and will last a longer time at baseline (Petrie et al. 1996) show poorer outcomes.  This chapter examines what it means to be ‘healthy’ and what it means to be ‘sick’, and reviews these meanings in the context of how individuals cognitively represent illness (their illness cognitions). What is health? Who’s healthy? Physiological/physical, for example, good condition, have energy Psychological, for example, happy, energetic, feel good psychologically Behavioural, for example, eat, sleep properly Future consequences, for example, live longer The absence of illness, for example, not sick, no disease, no symptoms. What does it mean to be ill? Not feeling normal, for example, ‘I don’t feel right’ Specific symptoms, for example, physiological/psychological Specific illnesses, for example, cancer, cold, depression Consequences of illness, for example, ‘I can’t do what I usually do’ Time line, for example, how long the symptoms last The absence of health, for example, not being healthy. Illness Cognitions A patient’s own implicit common sense beliefs about their illness’. Cognitions provide patients with a framework or a schema for coping with and understanding their illness, and telling them what to look out for if they are becoming ill.  1 Identity: this refers to the label given to the illness (the medical diagnosis) and the symptoms experienced (e.g. I have a cold – ‘the diagnosis’, with a runny nose – ‘the symptoms’). 2 The perceived cause of the illness: these causes may be biological, such as a virus or a lesion, or psychosocial, such as stress- or health-related behaviour. In addition, patients may hold representations of illness that reflect a variety of different causal models (e.g. ‘My cold was caused by a virus’, ‘My cold was caused by feeling run down’). 3 Time line: this refers to the patient’s beliefs about how long the illness will last, whether it is acute (short term) or chronic (long term) (e.g. ‘My cold will be over in a few days’). 4 Consequences: this refers to the patient’s perceptions of the possible effects of the illness on their life. Such consequences may be physical (e.g. pain, lack of mobility), emotional (e.g. loss of social contact, loneliness) or a combination of factors (e.g. ‘My cold will prevent me from playing football, which will prevent me from seeing my friends’). 5 Curability and controllability: patients also represent illnesses in terms of whether they believe that the illness can be treated and cured and the extent to which the outcome of their illness is controllable either by themselves or by powerful others (e.g. ‘If I rest, my cold will go away’, ‘If I get medicine from my doctor, my cold will go away’). The Self Regulatory Model Leventhal incorporated his description of illness cognitions into his self- regulatory model (SRM) of illness behaviour (e.g. Leventhal et al. 1980; 2007a). This model is based on approaches to problem solving and suggests that illness/symptoms are dealt with by individuals in the same way as other problems Traditional models describe problem-solving in three stages: (1) interpretation (making sense of the problem); (2) coping (dealing with the problem in order to regain a state of equilibrium); and (3) appraisal (assessing how successful the coping stage has been). In terms of health and illness, if healthiness is an individual’s normal state, then any onset of illness will be interpreted as a problem and the individual will be motivated to re-establish their state of health Stage 1: Interpretation An individual may be confronted with the problem of a potential illness through two channels: symptom perception (‘I have a pain in my chest’) or social messages (‘the doctor has diagnosed this pain as angina’). Once the individual has received information about the possibility of illness through these channels, according to theories of problem- solving, the individual is then motivated to return to a state of ‘problem-free’ normality. This involves assigning meaning to the problem. According to Leventhal, the problem can be given meaning by accessing the individual’s illness cognitions. Symptom Perception It is often assumed that we experience symptoms in response to some underlying physical problem. Individual Differences in Symptom Perception Internal/External Focus: Slower recovery, overestimation of sxs Demographics: women reported more, sxs reported more on weekdays, mornings and evenings Attachment Style: more secure you are less somatic sxs you have  Mood: Placebo pain reduction, pain lowers mood, lowered mood leads GI issues, loneliness and cold sxs Cognition: menstruation study, boredom overreporting, distraction underreporting Social Context: Cross cultural perception Stage 2: Coping Two broad categories of coping have been defined that incorporate the multitude of other coping strategies: approach coping (e.g. taking pills, going to the doctor, resting, talking to friends about emotions) and avoidance coping (e.g. denial, wishful thinking). When faced with the problem of illness, the individual will therefore develop coping strategies in an attempt to return to a state of healthy normality Approaches to coping with illness: (1) coping with the crisis of illness; (2) adjustment to physical illness and the theory of cognitive adaptation; (3) benefit-finding and post-traumatic growth. 1) The Crisis of Illness Changes in identity: illness can create a shift in identity, such as from care giver to patient, or from breadwinner to person with an illness. Changes in location: illness may result in a move to a new environment such as becoming bed-ridden or hospitalized. Changes in role: a change from independent adult to passive dependent may occur following illness, resulting in a changed role. Changes in social support: illness may produce isolation from friends and family, effecting changes in social support. Changes in the future: a future involving children, career or travel can become uncertain. Crisis of an Illness can be increased by.. Illness is often unpredicted: if an illness is not expected then the individual will not have had the opportunity to consider possible coping strategies. Information about the illness is unclear: much of the information about illness is ambiguous and unclear, particularly in terms of causality and outcome. A decision is needed quickly: illness frequently requires decisions about action to be made quickly (e.g. should we operate? Should we take medicines? Should we take time off from work? Should we tell our friends?). Ambiguous meaning: because of uncertainties about causality and outcome, the meaning of the illness for an individual will often be ambiguous (e.g. is it serious? How long will it affect me?). Limited prior experience: most individuals are healthy most of the time. Therefore illness is infrequent and may occur to individuals with limited prior experience. (e.g. I’ve never had cancer before, what should I do next?). 2) Adjustment to Illness (1) a search for meaning; (2) a search for mastery; and (3) a process of self-enhancement. 3) Benefit Finding and Post Traumatic Growth Stage 3: Appraisal This involves individuals evaluating the effectiveness of the coping strategy and determining whether to continue with this strategy or whether to opt for an alternative one. PSY467:Health Psychology Week VIII: Accessing Health Care Dr. Zehra Merve Kaya Fall 2024 The Role of Medical Interventions Research indicates wide variations in health care provision and access in terms of the types and costs of medicines, the training and expertise of health care professionals, the distances needed to travel to access health care and the availability of free health care versus the need for health insurance.  New Medicines Availability of Vaccinations Availability of Skilled Health Professionals Role of the Environment : Such environmental factors include food availability, food hygiene, sanitation and sewage facilities, and clean water. Health Care Systems Level I: Self Care Level II: Primary Care Level III: Secondary Care Self Care Many symptoms and illnesses are managed through self-care with no need for professional input. In addition, the internet and self-help books provide photographs and descriptions of symptoms to aid self-diagnosis and self- medication, and alternative and complementary practitioners offer a range of herbal, nutritional and homeopathic cures. Primary Care Primary care is the first contact with the health service and the patient is free to make an appointment whenever they feel they need one. The role of the primary care team is to diagnose and manage whatever problems fall within its range of expertise or to refer patients on to the hospital specialists in secondary care for a second opinion and further tests. Those in the primary care team are therefore the gatekeepers into secondary care. This process prevents secondary care being inundated with less serious medical problems, but errors inevitably occur as minor problems are referred on and serious problems are missed. Secondary Care If referred by their GP, a patient is then permitted to see a specialist in secondary care. In most countries access to secondary care can only occur via a referral letter from the GP, Secondary care tends to be based in a hospital to provide access to beds and operates with an outpatient system (for check-ups, tests and follow-up consultations) and an inpatient system (having an operation, staying overnight). Help Seeking and Delay Symptoms: the patient has a headache, back problem or change in bowel habits that indicates that something is wrong. Signs: on examination the doctor identifies signs such as raised blood pressure, a lump in the bowel or hears rattling when listening to a patient’s chest which indicates that there is a problem. Symptom Perception Bodily data Mood Cognitions Social Context Before this leads to help-seeking, however, the individual also has to decide whether the symptom is abnormal and whether it requires formal help from a doctor. This is influenced by the development of illness cognitions. Illness Cognitions Once a symptom has been perceived as such, a person then forms a mental representation of the problem. This has been called their ‘illness cognitions’ which are described in detail in Chapter 8. Research indicates that illness cognitions often consist of the same dimensions relating to identity (‘What is it?’), time line (‘How long will it last?’), causes (‘What caused it?’), consequences (‘Will it have a serious effect on my life?’) and control/cure (‘Can I manage it or do I need treatment?’). Social Triggers These triggers relate less to the individual’s perception of the symptom itself and more the impact that the symptom will have on their daily lives. Perceived interference with work or physical activity: work and physical activity are core to most people’s daily lives. A symptom that disrupts this will be identified as abnormal. Perceived interference with social relations: similarly, a symptom will also be perceived as abnormal if it interferes with our ability to interact with others. An interpersonal crisis: people have symptoms all the time that they normalize and habituate to. A sudden crisis such as an argument, divorce, change of job or retirement may trigger increased attention to a long-standing symptom leading to help-seeking for something that the patient appears to have had for a while. Sanctioning: the notion of sanctioning is similar to social messages as it involves other people encouraging a visit to the doctor so that patients often start a consultation saying, ‘Sorry to botheryou but my mother insisted I come to see you.’ Costs and Benefits of Seeing a Doctor Therapeutic Practical Emotional The sick role: benefits and obligations DELAY Symptom perception ‘I am too busy at work to think about my symptoms.’ ‘I am happy and not stressed.’ Illness cognitions ‘It will go away soon.’ ‘It must be that big meal I ate last night.’ Social triggers ‘My friends have reassured me that this is normal.’ ‘My chest pain hasn’t interfered with my work or relationships.’ ‘People in my family get a lot of indigestion.’ Costs and benefits of going to the doctor ‘Doctors can’t do much for indigestion.’ ‘I don’t want to bother a busy doctor with my problems.’ SCREENING Most people choose to come into contact with health care when they detect a symptom and seek help. This process relies upon two factors. First, patients need to identify that they have a symptom and conclude that health professionals will be able to help. Second, this process relies upon an illness having symptoms that can be detected. Many health problems, however, such as cancer, hypertension and genetic disorders are asymptomatic in the early stages but are sometimes too far advanced for successful treatment once symptoms are severe enough to be noticeable. Health care has therefore introduced screening programmes as a means to pick up problems at a time when they cannot be detected by the patient on the premise that early detection leads to better treatment success.  Primary prevention: Cholesterol Testing Secondary prevention: Mammograms Tertiary prevention: HbA1c Testing in Diabetic Patients Types of screening: Opportunistic screening Population screening Self screening In Class Activity Brainstorm examples of screenings under the three care levels and match them to the corresponding prevention strategy (primary, secondary, or tertiary prevention). The Need to Change Behavior To prevent illness: Behaviour change is key to preventing chronic conditions. For example, stopping smoking can prevent lung cancer. This is sometimes called primary prevention. To manage illness: Once diagnosed with a chronic condition, behaviour change is also key to illness management. For example, encouraging medication adherence is important for many illnesses such as asthma and those with high blood pressure. This is sometimes known as secondary prevention. To reduce physical symptoms: Chronic conditions can result in a multitude of physical symptoms such as fatigue, pain, nausea and bowel problems. For example, dietary change may reduce nausea or bowel problems and exercise may reduce fatigue and pain. To improve well-being: Having cancer, being diagnosed with heart disease or living with MS can be miserable and reduce a person’s sense of well-being and quality of life. Behaviour change can also help to improve well-being. Further, eating a healthier diet may or may not improve physical health outcomes for cancer but it can help people feel more in control of their lives and that they can make a difference in a small way.  Most psychology-based interventions fall within the framework of four main theoretical perspectives: 1) learning and cognitive theory; 2) social cognition theory; 3) stage models; 4) the role of affect. These are explored together with attempts to integrate these approaches and generate integrated models of behaviour change. Learning and Cognitive Theory Learning theory forms the basis of much psychological work with its emphasis on associative learning, reinforcement and modelling. From this perspective we eat chocolate when we are feeling fed up because we associate chocolate with feeling special from when we were children (associative learning), because our parents commented how lucky we were when they gave it to us (reinforcement) and because we saw them eat it (modelling). Cognitive theory then adds to this approach by exploring how people think as well as how they behave. Learning Theory Approaches Reinforcement: One way to change behaviour is to positively reinforce the desired behaviour and ignore or punish the less desired behaviour. Ex. pairing food with emotion Incentives: Research has also explored the impact of financial incentives as a means to change behavior. For example, increased taxes on both alcohol and cigarettes over the past few decades have been linked with a reduction in drinking and alcohol. Modelling: Modelling healthy behaviour can also change behaviour: a child is more likely to smoke if their parents smoke  Associative Learning: Associative learning involves pairing two variables together so that one variable acquires the value or meaning of the other. Classical conditioning. Exposure: One of the best predictors of future behaviour is past behavior as having already performed a behaviour makes that behaviour seem familiar and can increase an individual’s confidence that they can carry out the behaviour again Cognitive Theory Approaches Cognitive Behavioural Therapy (CBT) Freeman (1995) describes how CBT emphasizes the following: The link between thoughts and feelings. Therapy as a collaboration between patient and therapist. The patient as scientist and the role of experimentation. The importance of self-monitoring. The importance of regular measurement. The idea of an agenda for each session set by both patient and therapist. The idea that treatment is about learning a set of skills. The idea that the therapist is not the expert who will teach the patient how to get better. The importance of regular feedback by both patient and therapist. Some CBT Startegies Keeping a diary: many behaviours and thoughts occur without people being fully aware of them. For CBT, clients are asked to keep a diary of significant events and associated feelings, thoughts and behaviours. Gradually trying out new behaviours: For CBT, clients are asked either on their own or with the therapist to try out new behaviours or face activities that have been avoided. Cue exposure: many people find that unhealthy behaviours can be triggered by certain situations. For CBT, clients are sometimes exposed to such situations when with the therapist in order to help them learn new coping responses and extinguish the old unhealthy reactions to these situations.  Relaxation techniques: clients may use music, repeated clenching and relaxing of muscles, recordings of soothing voices or as a means to aid relaxation. Distraction techniques: distraction can be a powerful method for managing anxiety or preventing unhealthy responses to certain situations. Cognitive restructuring: central to CBT is the notion that behaviour is maintained through a series of distorted cognitions and a vicious cycle between thoughts and behaviours which is perpetuated by irrational self-talk. Cognitive Distortions Selective abstraction, which involves focusing on selected evidence (e.g. ‘drinking alcohol is the only way I can unwind after work’). Dichotomous reasoning, which involves thinking in terms of extremes (e.g. ‘If I am not in complete control, I will lose all control’). Overgeneralization, which involves making conclusions from single events and then generalizing to all others (e.g. ‘I failed last night so I will fail today as well’). Magnification, which involves exaggeration (e.g. ‘Stopping smoking will push me over the brink’). Superstitious thinking, which involves making connections between unconnected things (e.g. ‘If I do exercise, I will have another heart attack’). Personalization, which involves making sense of events in a self-centred fashion (e.g. ‘They were laughing, they must be laughing at me’). CBT and Chronic Illness Antoni and colleagues (Antoni et al. 2001, 2002) have developed structured guidelines for using CBT with patients with a range of chronic illnesses including those with HIV and cancer as a means to change cognitions and promote behaviour change. They outline a detailed system for changing irrational thoughts using rational thought replacement, which they call the ABCDE system.  This is as follows: Awareness: because much of our self-talk is automatic, the first step is to become aware of the cognitions we hold and the ways in which these impact upon emotional and physical responses. This awareness process can involve diary-keeping, reflection and talking to a therapist. Beliefs: clients are then asked to rate their beliefs about each of the self-talk processes they hold to identify how strong their cognitions are. They should ask themselves ‘How much do I believe that each of these cognitions is true?’. Challenge: clients challenge their thoughts through questions which ask for evidence or encourage the client to think through what other people would think or do in the same situation. Delete: Antoni and colleagues then argue that clients need to delete these self- statements and replace them with constructive cognitions. This can involve thinking through alternative explanations and different ways of making sense of what happens to them. Evaluate: the final stage is for the client to evaluate how they feel after the cognitions have been deleted and whether they feel the process has been successful. Case Study Case Study: Jamie’s Journey with Breast Cancer and CBT Background: Jamie is a 35-year-old woman recently diagnosed with early-stage breast cancer. Since receiving the diagnosis, Jamie has felt a persistent sense of despair, believing that her future is bleak and that her life will never return to normal. She often thinks, “This is the end of the life I knew,” and “There’s no point in making plans now.” These beliefs have impacted Jamie’s daily life, making her reluctant to seek treatment options and limiting her interactions with friends and family. She feels increasingly isolated, anxious, and hopeless. Jamie’s healthcare team suggests CBT to help her reframe her beliefs and manage her emotional responses to her diagnosis. Questions Identify Jamie’s initial beliefs: What core irrational beliefs does Jamie hold about her breast cancer diagnosis? Rate Jamie’s beliefs: How might Jamie assess the strength of these beliefs? Challenge the beliefs: What specific questions might Jamie ask herself to challenge her beliefs? Replace with constructive thoughts: Suggest additional balanced or positive thoughts Jamie might use. Evaluate the impact: How could Jamie assess the effectiveness of the ABCDE process in managing her thoughts and emotions over time? ABCDE Process Awareness Jamie begins keeping a daily journal, noting her thoughts, feelings, and physical reactions to situations connected to her diagnosis, such as medical appointments or seeing reminders of her illness at home. She notices that her thoughts are consistently negative and automatic, with common patterns like “I’ll never recover fully,” or “Nothing I do will change this outcome.” Beliefs Jamie rates the belief “I’ll never be able to have a normal life again” as a 9 out of 10 in terms of strength. When asked to evaluate her belief with questions like, “How much do I believe that each of these cognitions is true?” she recognizes that she feels strongly that her illness has stolen any hope for a fulfilling future.  Challenge Working with her therapist, Jamie challenges her thoughts by asking questions like, “What evidence supports or contradicts this belief?” and “What would my loved ones say about my situation?” Jamie realizes that although breast cancer is a serious diagnosis, treatments are available, and many people with similar diagnoses go on to live meaningful, fulfilling lives. This insight begins to shift her perspective. Delete (or Replace) Jamie then focuses on replacing the thought “I’ll never be able to have a normal life again” with a more balanced thought, such as, “While this diagnosis is life-changing, there are treatments that can help me regain a sense of normalcy.” Jamie also practices alternative statements like, “I can still find joy and meaning in my life, even during this journey.” Evaluate After practicing the ABCDE steps over time, Jamie reflects on the impact of this process. She finds that she is beginning to feel less anxious and more hopeful, experiencing fewer moments of despair. Jamie is also more open to discussing treatment options and feels more in control of her response to the diagnosis. The ABCDE model has helped Jamie cultivate a sense of resilience and optimism as she faces her treatment. Relapse Prevention CBT describes a number of cognitive and behavioural strategies to help people change their behaviour. Marlatt and Gordon (1985) developed a relapse prevention model to explore the processes that occur when a change in behaviour fails to last and people relapse. The relapse prevention model was based on the following concept of addictive behaviours: Addictive behaviours are learned and therefore can be unlearned; they are reversible. Addictions are not ‘all or nothing’ but exist on a continuum. Lapses from abstinence are likely and acceptable. Believing that ‘one drink = a drunk’ is a self-fulfilling prophecy.  Base Line State: Abstinence Pre-Lapse State: High risk situation, coping, positive outcome expectancies No Lapse: good coping strategies Lapse: This lapse will either remain an isolated event and the individual will return to abstinence, or will become a full-blown relapse. Abstinence Violation Affect: Having lapsed, the individual is motivated to understand the cause of the lapse. If this lapse is attributed to the self, this may create guilt and self-blame. This internal attribution may lower self-efficacy, thereby increasing the chances of a full-blown relapse. However, if the lapse is attributed to the external world, guilt and self-blame will be reduced and the chances of the lapse remaining a lapse will be increased.  Marlatt and Gordon developed a relapse prevention programme based on cognitive behavioural techniques to help prevent lapses turning into full- blown relapses. This programme involved the following procedures: Self-monitoring (what do I do in high-risk situations?). Relapse fantasies (what would it be like to relapse?). Relaxation training/stress management. Skills training (‘How will I say “No” to a drink?’). Contingency contracts (‘When offered a cigarette I will...’). Cognitive restructuring (learning not to make internal attributions for lapses). Case Study: Alex’s Smoking Cessation Journey Background: Alex is a 30-year-old who has smoked cigarettes for over a decade. After developing respiratory issues and wanting to improve their health, Alex has decided to quit smoking entirely. For the first few weeks, Alex maintained abstinence, but lately has been struggling with cravings, especially in social situations and during stressful times. Alex’s goal is to avoid smoking altogether, but they are concerned about experiencing lapses and falling back into old patterns. Alex’s counselor introduces them to a relapse prevention program to manage high-risk situations and build resilience against potential lapses. Questions Identify High-Risk Situations: What situations triggered Alex’s cravings to smoke? Can you suggest additional behavioral or cognitive coping strategies? Outcome Expectancies: How might Alex further strengthen negative outcome expectancies for smoking? Abstinence Violation Effect (AVE): How can Alex reduce the likelihood of AVE following a lapse? Preventing Relapse: Using the techniques above, what additional steps could Alex take to strengthen their relapse prevention plan? Relapse Prevention Process Baseline State: Abstinence Alex initially commits to total abstinence from smoking, setting this as their target behavior. For the first few weeks, they experience a sense of control over their behavior, successfully avoiding cigarettes. Pre-Lapse State: High-Risk Situation Alex encounters high-risk situations that challenge their abstinence. Some common situations include attending social gatherings where others are smoking, experiencing work-related stress, and feeling anxious during difficult conversations. Alex notes that their cravings are strongest during times of negative emotion, interpersonal conflict, and when exposed to social pressure from peers who smoke.  Coping Behavior In therapy, Alex identifies coping strategies to manage these high-risk situations. They plan to: Avoid certain social settings temporarily, where they feel tempted. Use substitute behaviors like chewing gum when they feel the urge to smoke. Practice cognitive coping by reminding themselves of the health benefits they’ve noticed since quitting smoking. Outcome Expectancies Alex discusses their positive outcome expectancies for smoking, such as “smoking will help me relax,” and contrasts these with negative outcome expectancies like “if I smoke, I’ll feel guilty and it may worsen my health.” By focusing on the negative consequences, Alex strengthens their commitment to staying abstinent.  No Lapse or Lapse? One day, Alex has a particularly challenging day at work and ends up having a cigarette, resulting in a lapse. They experience regret and worry that this slip will undo all their progress. Alex’s counselor reminds them that lapses are part of the process and do not have to lead to a full relapse. No Lapse Outcome: If Alex uses effective coping strategies and remembers the negative outcome expectancies, they may increase their self-efficacy and return to abstinence. Lapse Outcome: However, if Alex feels overwhelmed and unable to resist, they may risk a full relapse by continuing to smoke in the following days. Abstinence Violation Effect (AVE) Following the lapse, Alex feels dissonance between their goal to quit smoking and their current behavior. Initially, Alex blames themselves, thinking, “I’m weak; I can’t stick to my goals,” which lowers their self-efficacy and increases the risk of full relapse. Alex’s counselor works on reframing these thoughts, helping Alex attribute the lapse to external factors (stress and social pressure) rather than internalizing blame. By understanding that the lapse does not define them, Alex starts to regain confidence. Relapse Prevention Program Techniques To strengthen Alex’s ability to manage future situations, the counselor implements several techniques: Self-Monitoring: Alex keeps a journal, documenting the triggers and feelings associated with smoking urges. Relapse Fantasies: Alex imagines what it would be like to resume regular smoking, visualizing both the immediate relief and the long-term consequences (worsening health and disappointment). Relaxation Training: Alex learns relaxation and breathing exercises to manage stress, a key trigger for smoking. Skills Training: Alex practices assertive responses for when friends offer them cigarettes, like saying, “No thanks, I’m working on my health goals.” Contingency Contracts: Alex commits to a personal contract stating, “If I am offered a cigarette, I will remind myself of my reasons for quitting and choose an alternative, like going for a quick walk.” Cognitive Restructuring: Alex challenges self-blaming thoughts, learning to view lapses as learning opportunities rather than personal failures.