Health Psychology Biopsychosocial Interactions, 8th Edition Sarafino, Smith Solution Manual with Tes

Health Psychology Biopsychosocial Interactions, 8th Edition By Sarafino, Smith

Email: Richard@qwconsultancy.com

CHAPTER 1 AN OVERVIEW OF PSYCHOLOGY AND HEALTH CHAPTER OUTLINE I. What is Health?

A. Section Introduction 1. Common definitions of health focus on lack of: a. objective signs of illness - e.g., high blood pressure b. subjective symptoms of illness - e.g., pain or nausea B. An Illness/Wellness Continuum 1. The concepts of health and sickness overlap 2. Antonovsky proposes an illness/wellness continuum with polar ends of death/illness/disability v. optimal wellness a. need to change focus from what makes people sick to what keeps people well 3. Health = the positive state of physical, mental and social well-being that varies over time along a continuum C. Illness Today and in the Past 1. In industrialized nations, people live longer than in past and suffer from different patterns of illnesses 2. Until this century, people in North America died from mainly dietary and infectious diseases a. dietary illnesses: illnesses resulting from malnutrition such as beriberi (lack of vitamin B1) b. infectious diseases: acute illnesses caused by harmful matter or microorganisms (bacteria or viruses); main cause of death in most of world today 3. History of diseases in US a. 18th century: epidemics of smallpox, diphtheria, yellow fever, measles and influenza killed thousands, esp. children i. infectious diseases such as malaria and dysentery weakened victims and made them susceptible to other fatal diseases ii. such diseases were introduced to America by European settlers 1) Native Americans died at high rates due to lack of previous exposure and natural immunity; lack of immunity probably due to low degree of genetic variation

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b. 19th century: new infectious disease beginning to emerge (e.g., tuberculosis) i. decrease in deaths from infectious diseases by end of 19 th century ii. cause of decline 1) improved personal hygiene 2) better nutrition resulting in greater resistance to disease 3) public health innovation (e.g., water purification and sewage treatment facilities) 4) increased personal concern about health and following advice of health reformers c. 20th century: death rate due to infectious disease declined and average life expectancy increased i. increase in infant life expectancy from 48 years to 77 years ii. chronic disease leading cause of health problems and half of all deaths in developed countries 1) definition = degenerative illnesses that develop or persist over long period of time 2) examples = heart disease, cancer, stroke 3) reasons = increase in industrialization increases stress and exposure to harmful chemicals; longer life span places people at higher risk for chronic disease 4. Main causes of death across the life span a. children – accidental injury, cancer, & congenital abnormalities b. adolescents – accidental injury, homicide, suicide II. Viewpoints from History: Physiology, Disease Processes, and the Mind A. Early Cultures 1. Belief that physical and mental illness caused by mystical forces (e.g., evil spirits) a. speculative evidence - use of trephination to allow spirits to escape B. Ancient Greece and Rome 1. Hippocrates’ humoral theory a. health was due to harmony or balance of four humors whereas illness was the result of an imbalance of bodily fluids b. health recommendations included good diet, avoiding excesses to keeps humors in balance 2. Introduction of the mind/body problem a. Greek philosophers, including Plato, argued that the mind and body are separate entities (mind has little impact on the body and its state of health)

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3. Influence of Galen a. believed in humoral theory and mind-body split b. innovations attributed to Galen - animal dissections to discover how systems work, localization of illness, and belief that different disease have different effects C. The Middle Ages 1. With collapse of Roman Empire, advancement of knowledge and culture slowed dramatically 2. Impact of the Church on slowing development of medical knowledge a. prohibition on human and animal dissection b. belief that creatures with a soul were set apart from ordinary laws of the universe 3. Illness was believed to be a punishment for sin a. medical treatments involving use of torture to drive evil spirits out of body were done by clergy under this belief 4. Influence of St. Thomas Aquinas a. church scholar who saw the mind and body as interrelated unit that forms whole person D. The Renaissance and After 1. Period witnessed rebirth of inquiry, culture, politics, belief in “humancentered” focus; set stage for changes in philosophy once scientific revolution began 2. Influence of Descartes a. advanced notion of "body as machine" and described mechanics of body action and sensation b. believed the mind and body, although separate entities, communicated through pineal gland c. argued soul left humans at death; therefore dissection on humans acceptable 3. Changes in science & medicine a. knowledge increased due to technological improvements (e.g., microscope) and use of dissection b. rejection of humoral theory and development of new theories due to increased knowledge of body functions and discovery of microorganisms c. surgical practice improved by antiseptics & anesthesia d. status of hospital changed to "place of healing" along with more respect for ability of doctors to heal 4. Biomedical model a. new approach to conceptualizing health/illness that proposes physiological problems cause afflictions of the body b. health/illness of body separated from psychological/social experience of the mind c. dominant perspective in medicine since 19th century

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III. Seeing a Need: Psychology’s Role in Health A. Section Introduction 1. Biomedical model led to: a. development of vaccines and reduction in infectious disease b. development of antibiotics and cures to illnesses from bacterial infection 2. Despite advances, biomedical model needs improvement B. Problems in the Health Care System 1. Health care costs comprise an increasing percentage of the GDP 2. Chronic diseases are now the main health problems a. improvements in treatments have been modest 3. People have changed a. higher levels of knowledge, more motivation, better able to afford medical care b. “the person” still left out of biomedical model C. “The Person” in Health and Illness 1. Section introduction a. individual differences in tendency toward illness due to: i. biomedical sources such as physiological processes or exposure to microorganisms ii. psychological and social factors 2. Lifestyle and illness a. lifestyle modifications (changes in everyday patterns of behavior) may affect characteristics associated with health problems b. risk factors = biological or behavioral characteristics/conditions associated with development of a disease or injury i. biological risk factor example: inherited genes ii. behavioral risk factor examples: smoking, eating high saturated fat diet iii. having more risk factors are associated with (but don’t necessarily cause) higher likelihood of developing disease c. behavioral risk factors associated with five leading causes of death: i. heart disease = smoking, high dietary cholesterol, obesity, lack of exercise ii. cancer = smoking, high alcohol use, diet iii. stroke = smoking, high dietary cholesterol, lack of exercise iv. Chronic Obstructive Pulmonary Disease (COPD) = smoking v. accidents = alcohol/drug use, not using seat belts d. lifestyle contributes to health problems and high medical costs i. society bears burden of medical costs through public and private insurance programs

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e. influence of lifestyle factors on health i. seven lifestyle practices related to current and future health 1) practicing all seven practices resulted in health similar to younger persons 2) incidence of death decreased as number of health practices increased, esp. for older persons f. why people persist in unhealthy behaviors i. immediate pleasures of less healthful behavior ii. remote negative consequences iii. social pressures to engage in unhealthful practice iv. strong habit of behavior (e.g., addiction or dependency) v. lack of awareness of dangers associated with health behaviors or how to change behavior 3. Personality and illness a. personality = person’s cognitive, affective, or behavioral tendencies that are fairly stable across time/situation b. evidence linking personality traits to health i. low levels of conscientiousness and poor mental health linked to heart disease ii. anxiety, depression, anger/hostility or pessimism linked to variety of diseases, esp. heart disease iii. negative emotions linked to reaction to stress 1) positive emotions (e.g., optimism, hopefulness) linked to lower illness rates, quicker recovery when ill c. illness may affect personality and emotional states i. reaction to serious illness/disability may be anxiety, depression, anger and hopelessness ii. overcoming negative thoughts/feelings may increase recovery D. How the Role of Psychology Emerged 1. Section introduction a. ancient Greeks connected medicine and psychology b. Freud felt physical symptoms could be an expression of unconscious conflicts i. evidence - conversion hysteria c. need for explanation led to development of field of psychosomatic medicine 2. Psychosomatic medicine a. field, formed in 1930s, concerned with the interrelationships among the psychological and social factors, the biological and physiological functions of illness, and the development & course of illness b. theoretical foundation is psychoanalytic with a focus on psychoanalytic interpretation of specific, real health problems

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3. Behavioral medicine and health psychology a. fields emerged in 1970s to study role of psychology in illness b. behavioral medicine: an interdisciplinary field involving psychology, sociology, medicine & others i. theoretical foundations in classical and operant conditioning ii. evidence that psychological events influence bodily functions and that people can learn to control physiological systems supported the link between mind and body 1) conditioning methods important in therapeutic approaches (e.g., biofeedback) used to modify behaviors and emotions c. health psychology: recently developed sub-discipline in psychology also emphasizing behaviorism i. primary goals of health psychology 1) promote and maintain health by studying factors involved unhealthy behaviors 2) prevent illness by reducing risk factors, and to treat those with illnesses 3) identify the causes and diagnostic correlates of health, illness, and related dysfunction 4) analyze and improve health care systems and health policy 4. An integration a. general similarity: all have similar goals, study similar topics, & share same knowledge; shared belief that health & illness results from biological, psychological and social forces b. how they differ: separate organizations; varying emphasis on specific topics/viewpoints i. psychosomatic medicine – continued close ties to medicine and application of psychiatry ii. behavioral medicine – focus on interventions that do not use drugs or surgery iii. health psychology – relies on information from other subdisciplines in psychology to identify/alter lifestyle and emotional processes related to illness E. Health Psychology: The Profession 1. Work locations and primary activities a. clinics and hospitals – providing direct help to patients b. academic departments – indirect help through research, teaching and consulting 2. Nature of clinic/hospital work a. promoting emotional & social adjustment to illness or disability b. helping patients manage health problems by teaching psychological methods of intervention (e.g., controlling pain)

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3. Research and teaching a. providing information from research about lifestyle & personality factors that contribute to health and illness b. designing interventions to promote health c. educating medical personnel about psychosocial needs of patients 4. Educational/training requirements a. doctoral degree in psychology b. clinical health psychology = APA accredited specialty c. state licensing & board certification available IV. Current Perspectives on Health and Illness A. Section Introduction 1. The biopsychosocial model expands on the biomedical model and involves the interplay of biological, psychological, and social aspects of a person’s life 2. Model assumes 3 factors affect and are affected by health/illness.

B. The Biopsychosocial Perspective 1. The role of biological factors a. involves the study of inherited genetic materials and processes as well as physiologic functioning including structural defects and immuniological activity b. healthful functioning of body depends on how component physical systems in body operate and interact with each other 2. The role of psychological factors a. role of lifestyle and personality involves describing behavior and mental processes – the focus of psychology i. cognition - mental activities of perception, thought, belief systems, decision-making influence health/illness experience ii. emotions - positive & negative emotional states influence and are influenced by health/illness 1) influence decisions to seek treatment iii. motivation - defined as why people do what they do 1) part of explanation for adaptive and maladaptive health behaviors, participation in health intervention programs 3. The role of social factors a. peer pressure related to adolescents engaging in smoking and drinking b. society establishes health values resulting in both positive and negative behaviors (e.g., mass media promotions) c. community values and community’s environmental characteristics influence extent to which its members engage in health-related behaviors d. family - socialization provides strong influence on the healthrelated behaviors, attitudes, and beliefs of its members

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4. The concept of “systems” a. addressing the “whole person” acknowledges that people and reasons for their behavior are complex b. a holistic approach considers all aspects of a person’s life as a total entity and is consistent with the biopsychosocial approach c. system = a dynamic entity of continuously interrelated components with smaller components nested within larger components (i.e., levels) i. events in one system influences events in other systems C. Life-Span and Gender Perspective 1. Life-span perspective - an approach in which a person is considered in the context of their prior development, current development, and likely future development a. illnesses experienced vary with age b. pediatrics and geriatrics = branches of medicine dedicated to health/illness of children and elderly c. biopsychosocial systems change as we age i. biological - e.g., physiological growth & decline ii. psychological - e.g., cognitive changes influence knowledge, ability to think, accepting responsibility for change, understanding implications of illness & rationale for changing health-related behaviors iii. social - e.g., shift in health care-giving responsibilities from care-givers to self ; influences of peers or important others on behavior 2. Gender perspective – an approach that looks at how males and females differ in terms of biological functioning, health-related behaviors, social relationships, and risk for specific illnesses.

V. Relating Health Psychology to Other Science Fields A. Related Fields 1. Epidemiology - scientific study of the distribution and frequency of disease and injury a. investigate occurrence of illness and attempt to determine why it was distributed among the people it affected b. epidemiological terminology used to describe findings i. mortality - number of deaths, usually on a large scale ii. morbidity - any illness, injury, or disability iii. prevalence - the number of cases including both continuing and new cases at a given time iv. incidence - the number of new cases of illness, infection, or disability in a period of time v. epidemic - the rapid increase in incidence c. use of term “rate” adds relativity to meaning (e.g., mortality rate = number of deaths per number of people in a given population during specified period of time)

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2. Public health - field concerned with protecting, maintaining and improving health in the community through organizes effort. a. engaged in conducting research and establishing programs to promote and provide health-related services b. studies health/illness in context of the community as a social system 3. Sociology - evaluates the impact of social factors on groups or communities of people. a. medical sociology is concerned with social factors involved with distribution of illness, social reactions to illness, socioeconomic factors of health care use, ways in which hospital services/medical practices are organized 4. Anthropology - the study of cultures a. medical anthropology - study of cross-cultural differences in health, illness and health care.

5. Impact of other disciplines on health psychology a. the perspectives from other fields provide a broad perspective on health/illness and are incorporated into the discipline for explaining influences on health and illness B. Health and Psychology Across Cultures 1. Health and illness vary across history since, over time, lifestyles in cultures change 2. Sociocultural differences in health a. “sociocultural” refers to social and cultural factors, such as ethnic and income variations within and across nations b. sociocultural differences have been observed in illness patterns, diets, and health-related beliefs and values 3. Sociocultural differences in health beliefs and behavior a. ideas about cause of illness vary across time and culture i. affects beliefs about appropriate treatment approaches ii. example: beliefs about balance of yin and yang and the use of acupuncture to correct their balance b. religious beliefs affect health practices i. example: Jehovah’s Witnesses reject use of blood; Christian Scientists reject use of medicine entirely; Seventh Day Adventists view body as “temple” and urge followers to take care of their bodies VII. Research Methods A. Section Introduction 1. Theory = tentative explanation of why and under what circumstances certain phenomena occur a. characteristics of a "useful" theory i. clearly stated ii. brings together or organizes known facts iii. relates information that previously seemed unrelated iv. enables us to make predictions

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b. role of theory i. guides research by providing a "roadmap" of relationships to study 2. Variables - characteristics of people, events, or objects that may change a. independent variable - the variable manipulated directly and independently of variables not in the study b. dependent variable - some outcome that is measured and is dependent on the effects of the manipulated independent variable B. Experiments 1. Experiment: a controlled study in which the researcher manipulates a variable to study its effects on another variable 2. The experimental method: a hypothetical example a. a prediction or hypothesis of a theory is developed and tested b. participants are assigned randomly to groups in order to distribute characteristics equally across the groups c. experimental group receives the treatment or procedure being tested d. control group does not receive the treatment or procedure being tested e. placebo, an inert substance, may be given to a third group to test for the effects of expectations f. double-blind approach, where neither subject nor experimenter know assignment to condition, may be used to control for experimenter demand 3. Criteria for cause-effect conclusion a. levels of independent and dependent variables corresponded or varied together b. cause preceded the effect c. other plausible causes ruled out 4. Comparing experimental and nonexperimental methods a. determining causation i. in experiments, causation may be tested because an IV is manipulated ii. in nonexperimental methods, causation may not be tested because an IV is not manipulated b. nonexperimental methods are useful when it is not possible, feasible, or ethical to manipulate a variable of interest, or when an association between variables is to be demonstrated C. Correlational Studies 1. When aim of research requires only that association between variables be shown, correlational research used a. example: research on risk factors

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2. “Correlation” refers to the joint relation that exists between variables. a. correlation coefficient can range from +1.00 to -1.00 i. absolute value of coefficient indicates strength of the association b. positive correlation indicates that high scores on one variable are associated with high scores on another c. negative correlation indicates that high scores on one variable tend to be associated with low scores on the other variable d. because one can’t manipulate the variables of interest, causal statement can’t be made 3. Correlational studies are useful for a. examining existing relationships and variables that cannot be manipulated b. developing hypotheses c. generating predictive information D. Quasi-Experimental Studies 1. Quasi-experimental studies are similar to experiments except a. variables that define the group are not manipulated (e.g., gender) b. participants cannot be randomly assigned to the groups c. conclusions from quasi-experimental studies are correlational and not causal 2. Retrospective and prospective approaches a. retrospective – look back at past history of people who have developed a particular illness is compared to that of members of a control group i. purpose - to find commonalities in people's histories that may suggest why they developed a disease ii. shortcoming – faulty memory may contribute to inaccurate reports b. prospective – look forward in lives of individuals to determine if differences in variable at one point in time are related to differences in another variable at a later time i. more plausible causal connection ii. is potentially costly and time-consuming approach c. approaches developed by epidemiologists and used to identify risk factors for specific illnesses 3. Developmental approaches a. approaches designed to study differences between people of different ages or of the same people across time i. cross-sectional approach - individuals at different ages are observed at about the same time ii. longitudinal approach - the repeated observation of the same individuals over time 1) like prospective approach, potentially costly and time-consuming 2) subject to loss of participants over time 3) valuable approach to examine change and stability in lives of participants 11

b. cohort effect - generational effect due to historical experiences of a group of subjects 4. Single-subject approaches a. case study - in-depth examination of an individual from a person’s history, interviews, and current observation i. useful for describing development and treatment of an unusual problem b. single-subject design – a single participant study i. initial assessment is made before and after some intervention is made ii. useful in determining effectiveness of new treatment method c. disadvantages of single-subject approaches i. low generalizability d. advantages i. stimulates development of new treatments ii. suggests new topics for research E. Genetics Research 1. Genetic materials and transmission a. chromosomes – threadlike structures that contain genes b. genes – contain discrete particles of DNA i. genetic information is transmitted from parent to child ii. dominant genes – single gene of a gene pair that contributes to the presence of a trait iii. recessive genes – when two identical genes in a gene pair contribute to the presence of a trait c. DNA – basic substance of all genetic material that determines growth pattern and physical structures.

2. Twin and adoption studies a. types of twins i. monozygotic (MZ) twins – twins conceived together who have identical genetic material ii. dizygotic (DZ) twins – twins conceived separately and have no more genetically similar than singly born siblings b. twin studies – research on hereditary factors that focuses on differences in MZ twins compared to differences in DZ twins i. since MZ twins share same genetic material, differences between them are assumed due to environmental factors ii. differences observed in DZ twins assumed to be due to both genetic and environmental factors iii. if assume MZ and same-sexed DZ twins have equal environmental experience, can measure genetic influence by subtracting differences from MZ pair from differences from DZ pair

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c. adoption studies – research in compare traits of adopted children with those of both natural and adoptive parents i. if children are more similar to their natural parents than to adoptive, assume this is due to genetic influence d. conclusions observed from twin and adoption studies i. heredity affects physical characteristics & physiological functioning ii. genetic disorders affect levels of cholesterol & thus heart disease iii. heredity has greatest impact early in life; lifestyle & habits affects health in later life iv. environmental factors play a greater role than genetics in cancer development 3. Linking specific genes and diseases a. examples of genes related to disease i. sickle-cell anemia – sickle-shaped red blood cells due to presence of recessive gene in some African Americans ii. phenylketonuria – inherited disease in which baby’s body fails to produce enzyme necessary for metabolizing the toxic amino acid phenylalanine iii. oncogenes – genes related to development of cancer 4. Epigenetic Effects a. epigenetics – process in which chemical structures within or around DNA govern how, when, and how much a gene acts i. can be passed on to offspring ii. environmental events can change epigenetic process iii. epigenetic changes can influence response to stress, ability to learn and remember, and development of health problems F. Deciding which method is best 1. Each method has disadvantages and advantages a. experiments: can uncover cause-effect relationships but done in artificial conditions (not like real-world settings) i. ecological momentary assessment - a procedural method, using pagers to cue and collect data from individuals periodically during the day, that might help correct artificiality problem 2. Combining experimental and nonexperimental methods in same study may be possible and desirable a. example: does reading information on health effects of excessive cholesterol induce people to change their diets i. experimental manipulation = reading cholesterol information in experimental group v. reading other literature in control group ii. quasi-experimental measure = age of participants

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DISCUSSION TOPICS 1. Cultural Differences in Defining Health The introductory topic in Chapter 1 centers on developing a definition for health.

Sarafino places common beliefs in the absence of illness as indicators of health in contrast with Antonovsky's illness/wellness continuum. David Matsumoto (2000) expands on these themes to the extent that he sees them as being embedded in a cultural context. For example, Matsumoto notes that the medical model, the traditionally popular view of illness in the US, focuses on disease that results from some "specific, identifiable cause originating inside the body" and treatment of disease then requires eliminating the pathogens that "exist within a person's body." Health is therefore the lack of disease within the body. Matsumoto goes on the describe definitions of health as they occur in other cultures. In Asian cultures, he suggests, health is defined as the "balance between self and nature and across the individual's various roles in life." The synergy between nature, self, and others can result in a positive state called health.

Matsumoto connects this vision with current definitional debates occurring in the US and ties it to the emergence of biobehavioral medicine and health psychology.

As part of a discussion session, have students consider the theme of "residing within the body". How have we seen similar explanations in mental health? How is it more generally linked to causal explanations that are common in our culture?

Source: Matsumoto, D. (2000). Culture and psychology: People around the world. (2nd ed.). (pg.

230). Stamford, CT: Wadsworth.

2. Sex and Gender Bias in Animal and Human Research.

Since Chapter 1 introduces research methodologies to the student, this would seem to be an appropriate section to discuss the claims of sex and gender bias in clinical research using animal and human participants. Reviews on the topic by Rodin and Ickovics (1990) and Sechzer and colleagues (1994) might serve as the basis for the presentation. While they both highlight the efforts to change requirements for participant inclusion in human research, Sechzer and her colleagues note particular problems in animal research with respect to the under-representation of female animal subjects in studies, lack of information regarding the sex/gender of participants in studies, and overgeneralization of findings drawn from male samples to females.

Standards for reporting of findings are presented.

Sources: Rodin, J., & Ickovics, J.R. (1990). Women's health: Review and research agenda as we approach the 21st century. American Psychologist, 45(9), 1018-1034.

Sechzer, J.A., Rabinowitz, V.C., Denmark, F.L., McGinn, M.F., Weeks, B.M., and Wilkens, C.L. (1994). Sex and gender bias in animal research and in clinical studies of cancer, cardiovascular disease and depression. In J.A. Sechzer, A. Griffin, and S. Pfafflin (Eds.), Forging a women's health research agenda: Policy issues for the 1990s. New York: New York Academy of Sciences.

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3. Introducing Alternative and Complementary Medicines.

With the growing use of alternative and complementary medicines by health consumers, some discussion of the types of careers available in these fields may expand the discussion introduced by Sarafino in this chapter. One source of information is Dianne Lyons' book on careers in alternative medicine in which she provides an overview of various fields of alternative medicines and profiles schools providing training in these various specialties. She also provides information regarding accreditation, licensure and certification, and professional associations specific to alternative medicine specialties.

Source: Lyons, D.J.B. (1997). Planning your career in alternative medicine: A guide to degree and certificate programs in alternative health care. Garden City Park, NY: Avery.

4. Cultural Differences in Health Care and Medical Delivery Systems.

The "social" in the biopsychosocial perspective also includes institutionalized forms of health care delivery. Matsumoto contends that health care delivery systems are products of many factors including the country's level of social and economic development, the nature of technological advances and their availability to people, the level of urbanization and industrialization within the country, governmental structure, international trade laws and practices, and demands for privatization and public expenditures. He describes the United States as "an example of a country with a relatively high economic level that uses an entrepreneurial system of health care, characterized by a substantial private industry covering individuals as well as groups."

He goes on to attest that "it makes sense that an entrepreneurial system is used in the United States, for example, because of the highly individualistic nature of the American culture." This observation makes for an interesting starting point in a discussion with students regarding the influence that culture has with their health and illness experiences.

Source: Matsumoto, D. (2000). Culture and psychology: People around the world. (2nd ed.). (pp.

246-247). Stamford, CT: Wadsworth.

5. Stem Cell Research Debate.

The public and scientific debate regarding the use of stem cell derived human embryos highlights the ethical problems in the genetic chase to find solutions for diseases such as diabetes, Parkinson's disease, and spinal cord injuries. An article in Newsweek magazine (2004) can be used as a starting point for the discussion of genetic processes in health. The political, scientific, and social aspects of the debate are highlighted.

Source: Kalb, C., Rosenburg, D., & Ulick, J. (2004). Stem cell division, Newsweek, 144(17) 42-48.

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More information for this discussion can be found by going to: http://stemcells.nih.gov/info/ethics.asp - stem cell information from NIH http://www.time.com/time/2001/stemcells/ - Time magazine series on stem cell research

ACTIVITY SUGGESTIONS 1. Assess Yourself: What's Your Lifestyle Like? Have students complete Handout #1: What's Your Lifestyle Like? Discuss whether there are points of ambiguity or potential weaknesses in these questions.

2. Health Risk Appraisal. A generous number of health risk appraisals can now be completed on-line. HRAs can be easily found by entering the key phrase "Health Risk Appraisal" on most major search engines. Have students complete one and then compare its format to the Assess Yourself exercise above. To extend this exercise, have students pick one or two identified risk areas and develop a plan to improve their functioning on those areas.

3. Journal Comparison. Obtain copies of Psychosomatic Medicine, Journal of Behavioral Medicine, and Health Psychology. Compare and contrast the types of problems studied and the approaches taken. Have the students find at least one example of an experiment, a quasi-experimental study, a retrospective study, a prospective study, and a case study. In particular, have students report on the gender/sex bias argument presented in Discussion item 2.

4. Health Psychology and Health Care Professions. Students may be interested in finding out more information about Health Psychology and the other health care professions described in the chapter. Have students go to the Division 38 - Health Psychology webpage (http://www.health-psych.org/) and explore the educational and training programs for becoming a health psychologist. Another resource that students may consult is the book Career Paths in Psychology: Where your degree can take you by R.J. Sternberg (2006, American Psychological Association). The following chapter provides an overview of the work done by clinical psychologists employed in hospital settings: Daly, B.P., & Brown, R.T. Clinical psychologists in hospitals, pp.

179-200. For other health care professions, the book Career Opportunities in Healthcare by S. Field (2002, New York: Facts on File), has salary, skill requirement, and advancement opportunity information on 70 careers in health including art therapy, athletic training, dance therapy, music therapy, occupational therapy, prosthetistics, physical therapy, rehabilitation counseling, social work, speech pathology and audiology, and therapeutic recreation specialist. Students might find information regarding education and training programs for specific areas of interest on-line using sites such as:

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www.bls.gov/oco/oco1002.htm - U.S. Department of Labor – Bureau of Labor Statistics, Occupational Outlook Handbook of Professional and related occupations 5. The Evolution of Health Psychology as a Field. Have students read each of the four articles below that demonstrate the changing views within the field of health psychology. Starting with the earliest article by Matarazzo in 1980 introducing the field and the concept of the biopsychosocial model of medicine, each article is an example of how the field has grown in scope and ambition. After students have read each article, discuss in class the implications of each article in terms of what is emphasized and the influence each may have had on the field. An alternative may be to have the students read different articles and discuss as a class what stood out about the article they read.

Johnson, N.G. (2003). Psychology and health: Research, practice, and policy.

American Psychologist, 58(8), 670-677.

Matarazzo, J.D. (1980). Behavioral health and behavioral medicine: Frontiers for a new health psychology. American Psychologist, 35(9), 807-817.

Taylor, S.E. (1990). Health psychology: The science and the field. American Psychologist, 45(1), 40-50.

Taylor, S.E. (1987). The progress and prospects of health psychology: Tasks of a maturing discipline. Health Psychology, 6(1), 73-87.

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Handout #1

Assess Yourself: What's Your Lifestyle Like?

This survey assesses seven aspects of your usual lifestyle. For each of the listed practices, put a check mark in the preceding space if it describes your usual situation. _____ I sleep 7 or 8 hours a day. _____ I eat breakfast almost every day. _____ I rarely eat between meals. _____ I am at or near the appropriate weight. _____ I never smoke cigarettes. _____ I drink alcohol rarely or moderately. _____ I regularly get vigorous physical activity. _____ Total number of check marks.

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RESOURCES Suggested Readings: Culture, gender, age and health Aboud, F.E. (1998). Health psychology in global perspective. Thousand Oaks: Sage.

Alexander, L. L. (2007). New dimensions in women’s health. Sudbury, MA: Jones and Bartlett.

Ammer, C. (2005). The encyclopedia of women’s health. New York: Facts on File.

Helman, C. (2007). Culture, health, and illness. New York: Oxford University Press.

Jacobsen, K.H. (2008). Introduction to global health. Sudbury, MA: Jones and Bartlett.

Loue, S. (1999). Gender, ethnicity, and health research. New York: Kluwer Academic/Plenum Publ.

Loustaunau, M.O., & Sobo, E.J. (1997). The cultural context of health, illness, and medicine. Westport, CN: Bergin & Garvey.

MacLachlan, M. (2001). Cultivating health: Cultural perspectives on promoting health. New York, NY: John Wiley & Sons Ltd. Marmot, M., & Wilkinson, R.G. (2006). Social determinants of health. Oxford: Oxford University Press.

Maxwell, J., Belser, J., & David, D. (2007). A health handbook for women with disabilities. Berkeley, CA: Hesperian.

Meyer, I. & Northridge, M.E. (2007). The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual and transgender populations. New York;London: Springer.

National Institutes of Health (2006). Women of color health data book: adolescents to seniors. Bethesda, MD: Office of Research on Women’s Health.

Niven, C.A. & Carroll, D. (1993). The health psychology of women. Chur, Switzerland: Harwood Academic.

Seear, M. (2007). An introduction to international health. Toronto: Canadian Scholars’ Press.

Shankle, M. (2007). The handbook of lesbian, gay, bisexual, and transgender public health. Binghampton, NY: Haworth Press.

Sheikh, A. & Sheikh, K. (1989). Eastern and western approaches to healing: ancient wisdom and modern knowledge. New York: Wiley.

US Dept. of Health and Human Services (2005). The health and well-being of children in rural areas: a portrait of the nation, 2005. Rockville, MD: US Dept. of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Psychology’s role in health Adler, N., & Matthews, K. (1994). Health psychology: Why do some people get sick and some stay well? In L.W. Porter & M.R. Rosenzweig (Eds.). Annual Review of Psychology. (Vol. 45, pp. 229-259). Palo Alto, CA: Annual Reviews.

Boll, T.J., Frank, R.G., Baum, A. et al. (2004) Handbook of clinical health psychology: Volume 3. Models and perspectives in health psychology. Washington D.C.: American Psychological Association.

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Boyer, B.A. & Paharia, M. I. (2008). Comprehensive handbook of clinical health psychology. Hoboken, NJ: Wiley & Sons.

Freidman, H.S. & Silver, R. (2007). Foundations of health psychology. New York: Oxford University Press.

Johnson, N.G. (2003). Psychology and health: Research, practice, and policy.

American Psychologist, 58(8), 670-677.

Karoly, P. (1985). Measurement strategies in health psychology. New York: Wiley.

Luecken, L.J. & Gallo, L.C. (2008). Handbook of physiological research methods in health psychology. Los Angeles: Sage Publ.

Smith, T.W., Orleans, T.C., & Jenkins, D.C. (2004) Prevention and health promotion: Decades of progress, new challenges, and an emerging agenda. Health Psychology, 23(2) 126-131.

Suls, J. & Wallston, K.A. (2003). Social psychological foundations of health and illness. Malden, MA: Blackwell Publishers Taylor, S.E. (1990). Health psychology: The science and the field. American Psychologist, 45, 40-50.

Current perspectives on health and illness Cook, A.R. (1999). Alternative medicine sourcebook: Basic consumer health information. Detroit, MI: Omnigraphics.

Fontanarosa, P.B. (Ed.) (2000). Alternative medicine: An objective assessment.

Chicago, IL: American Medical Association.

Gesler, W.M. (1991). The cultural geography of health care. Pittsburgh, PA: University of Pittsburgh Press.

Gordon, J.S. (1996). Manifesto for a new medicine: Your guide to healing partnerships and the wise use of alternative therapies. Reading, MA: AddisonWesley.

Hafferty, F.W., & McKinlay, J.B. (1993). The changing medical profession: An international perspective. New York: Oxford University Press.

Haugen, D. (2008). Alternative medicine. Detroit: Greenhaven Press.

Jonas, W.B. & Levin, J.S. (Eds.) (1999). Essentials of complementary and alternative medicine. Philadelphia: Williams & Wilkins.

Kutner, M. et al (2006). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. Washington, D.C.: U.S. Dept. of Education, National Center for Education Statistics.

Lyons, D. (1997). Planning your career in alternative medicine. Garden City Park, NY: Avery.

Mijares, S.G. (2003). Modern psychology and ancient wisdom: Psychological healing practices from the world’s religious traditions. New York: Haworth Press Inc. Pelletier, K.R. (2000). The best alternative medicine: What works? What does not? New York: Simon & Schuster.

Shorter, E. (1992). From paralysis to fatigue: A history of psychosomatic illness in the modern era. New York: Free Press.

Relating health psychology to other fields de La Cancela, V., Chin, J., & Jenkins, Y. (1998). Community health psychology: Empowerment for diverse communities. New York: Routledge.

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Kazarian, S.S. & Evans, D.R. (2001). Handbook of cultural health psychology. San Diego, CA: Academic Press.

Herman, C.E. (Ed.). (1997). Special issue: Psychological aspects of genetic testing.

Health Psychology, 16.

Lopez-Casasnovas, G., Rivera, B., & Currais, L. (2005). Health and economic growth: findings and policy implications. Cambridge: MIT Press.

Sahler, O.J. & Carr, J.E. (2007). The behavioral sciences and health care. Cambridge, MA: Hogrefe.

Journals related to health psychology • Journal of Behavioral Medicine • Journal of Clinical Psychology in Medical Settings • Journal of Health Psychology • Journal of Immigrant Health • Journal of Immigrant and Minority Health • Journal of Psychosomatic Medicine

21

Suggested Films and Videos: Psychology’s role in health 1. Achieving Psychosocial Health. (2001, Films for the Humanities and Sciences, 29 min). Explains the elements of psychosocial health.

2. Discovering Psychology (Program 23-24) (2001, WGBH Educational Foundation, 60 min). Program 23 examines psychological research related to the bio-psychosocial model of medicine.

3. Emotion and illness (1995, Films for the Humanities and Sciences, 30 min).

Discusses the role that emotions play on physical health.

Current Perspectives on health and illness 4. Alternative Medicine. (2002, Films for the Humanities and Sciences, 52 min). A look at alternative medicine techniques from practitioners and respected critics.

5. Alternative medicine: Expanding your horizons in healthcare choices. (1995, Aquarius Productions, 29 min). Reviews alternative or complementary health systems, such as naturopathy, homeopathy, Chinese & Indian medicine, and others.

6. Medicine at the Crossroads: The Magic Bullet. (1993, WNET/BBC-TV, 57 min).

Looks at the expectation that medicine can provide "a pill" to solve all health problems.

7. Medicine at the Crossroads: Code of Silence. (1993, WNET/BBC-TV, 57 min).

Takes the viewer into the world of medical training, cross-cultural experiences with disease, and the patient interface with medical systems.

8. Medicine at the Crossroads: Temple of Science. (1993, WNET/BBC-TV, 57 min). The world of the teaching hospital is highlighted using Johns Hopkins as an example. Sophisticated technological successes and production of leading doctors/scientists are placed in contrast with primary care provision.

Internet sites of interest: Psychology and Health 1. http://www.apa.org - The American Psychological Association 2. http://www.psychologicalscience.org - American Psychological Society 3. http://www.sbm.org/ -The Society of Behavioral Medicine 4. http://www.apm.org/ - The Academy of Psychosomatic Medicine 5. http://sosig.esrc.bris.ac.uk - Social Science Information Gateway Women and Minority Health 6. http://www.4women.gov – The National Women’s Health Information Center 7. http://www.pitt.edu/~ejb4/min/ - The Minority Health Network 8. http://www.omhrc.gov/OMHRC/index.htm - Office of Minority Health Resource Center

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Professional Organizations 9. http://www.aapa.org - The American Academy of Physician Assistants 10. http://www.aanp.org - The American Academy of Nurse Practitioners 11. http://www.aota.org - The American Occupational Therapy Association 12. http://www.apta.org - The American Physical Therapy Association 13. http://www.naswdc.org - The National Association of Social Workers 14. http://www.nln.org - The National League for Nursing 15. http://www.who.int - World Health Organization 16. http://www.cdc.gov/nchs- National Center for Health Statistics 17. http://www.census.gov - United States Census Bureau Alternative Medicine 18. http://www.pitt.edu/~cbw/internet.html - Alternative Medicine Resources Index 19. http://www.altmedicine.com/ - Alternative Health News Online 20. http://www.amfoundation.org/ - Alternative Medicine Foundation

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TEST QUESTIONS True or False F

1.

Advances in medical treatment were responsible for a sharp decrease in infectious diseases at the turn of the 20th century.

2.

Today, accidental injury is the leading cause of death in children and adolescents in the United States.

3.

During the Middle Ages, the influence of the Church resulted in many major advancements in medical knowledge.

4.

“Risk factors” are those biological or behavioral characteristics that are known to cause a disease.

5.

In the past, practitioners of psychosomatic medicine generally used a psychoanalytic model to explain a physical symptom.

6.

One of the goals of health psychology is to have an effect on public policy.

7.

The biopsychosocial model of health and illness is actually an extension of the biomedical model.

8.

The "systems" approach assumes simple systems are embedded within complex systems.

9.

Although sociocultural research has found differences in health beliefs across cultures, disease patterns themselves do not differ.

10.

Quasi-experimental designs allow us to make causal conclusions from existing groups.

(4)

T (5)

F (6)

F (9)

T (10)

T (11)

T (13)

T (15)

F (20)

F (25)

24

Matching Match one of the following with descriptions given in questions one to five. a. Hippocrates b. Plato c. Galen d. St. Thomas Aquinas e. Descartes c (6)

1. From his work, which included dissection, this second century physician felt that pathologies could be localized in parts of the body.

d

2. An Italian philosopher, he saw the mind and body as an interrelated unit.

(6)

b (5)

a (5)

e (6)

3. He was among the Greek philosophers to propose that the mind and body are separate entities.

4. Called "the father of medicine," his humoral theory for the origin of disease was influential for centuries.

5. He described in mechanical terms the functioning of the body's actions and sensations such as pain.

Match the following with descriptions given in questions 6 through 10 a. epidemiology b. public health c. medical sociology d. medical anthropology e. health psychology e (12)

6. Provides direct service to patients in the management of their illnesses or engages in research and teaching.

a

7. Concerned with the incidence and prevalence of illnesses.

(17)

b

8. Organizes health education or provides community health services.

(18)

c

9. May conduct studies of health care services and how they are organized.

(18)

d

10. May conduct studies on the medical practices in different cultures.

(18)

25

Multiple Choice c 1. Claudia goes to the university health center complaining of a sore throat and (2) headache. A blood test reveals that her white blood cell count is high, and a throat culture reveals a streptococcus infection. Which of the following is true? a. Claudia’s high white blood cell count is a symptom of illness. b. Her sore throat is a sign of illness. c. The results of the blood test and throat culture are signs of illness. d. Her headache and high white blood count are symptoms of illness. d (2)

c (2)

b (2)

a (2)

d (3-4)

d (4)

2. Common definitions of health include a. optimal weight and endurance. b. absence of signs of malfunctioning. c. absence of subjective symptoms of disease. d. both b and c.

3. In his continuum of illness and health, Aaron Antonovsky suggested that a. wellness and illness are independent concepts. b. medical treatment affects only the wellness side of the continuum. c. his model represents differing health statuses. d. lifestyle has little impact on health or illness.

4. In discussing the illness and health continuum, Antonovsky emphasizes a. illness more than health. b. a revised focus toward what helps people stay healthy. c. the psychosocial factors that contribute to illness. d. the role of poverty in health care.

5. The term "health", as used by the author of the textbook, is best described as a. a positive state of mental, social, and physical well-being. b. the absence of illness. c. the absence of disease risks. d. lack of a terminal condition.

6. Infectious diseases were: a. more frequently fatal in the past than they are now. b. brought over to North America by European settlers. c. the greatest threat to American health in the 19th century. d. all of the above 7. The decline in the death rate from infectious diseases by the end of the 19 th century was largely the result of a. the development of antibiotics. b. advances in medical treatment. c. changing definitions of disease states in the medical community. d. preventive measures.

26

a (4)

b (5)

d (5)

c (5)

a (6)

c (6)

8. A person living in the United States today a. is more likely to die of a chronic disease than any other cause of mortality. b. has a shorter life span than someone who lived in the 19th Century. c. is likely to be at high risk of dying of infections. d. has an average life expectancy over 90 years.

9. The procedure referred to as trephination a. is effective in the treatment of chronic disease. b. is believed to have been done in the past for superstitious reasons. c. is frequently used today in the treatment of infectious diseases. d. was based on the humoral theory of illness.

10. Hippocrates, the "Father of Medicine" a. suggested that eating a good diet would promote good health. b. proposed the humoral theory of illness and wellness. c. defined health as a balance of humors. d. all of the above.

11. A "humor" is a a. type of emotional response. b. spiritual state. c. a bodily fluid. d. all of the above 12. A main contribution of Galen to knowledge about illness a. was to discover that illness can be localized in specific parts of the body. b. was to reject the humoral theory of Hippocrates. c. was not appreciated until the 20th century. d. was to reject the mind/body split.

13. The position of Rene Descartes on the mind/body problem can best be described as: a. agreeing with both Aquinas and Plato that the mind and body are unitary. b. agreeing with Aquinas and disagreeing with Plato that the mind and body are unitary. c. agreeing with Plato and disagreeing with Aquinas on the unitary nature of mind and body. d. placing little to no emphasis on the mind.

27

b (7)

a (7)

c (7)

b (8)

d (9)

b (9)

14. Which of the following was NOT an advance in science and medicine in the 18th and 19th centuries? a. The growing use of dissection in autopsies to aid in the acquisition of knowledge. b. The rejection of the belief that the mind and body are separate. c. The discovery that microorganisms cause certain diseases d. New surgical and anesthetic techniques.

15. The proposition that all diseases can be explained by disturbances in physiological processes a. is the basis of the biomedical model. b. is no longer the dominant view in the field of medicine. c. has never been widely accepted. d. is consistent with an emphasis on psychosocial factors.

16. Dr. Lee believes that disease occurs independently from our psychological and social experience. Dr. Lee believes in the _____ theory. a. humoral b. biopsychosocial c. biomedical d. trephination 17. Which of the following statements about chronic disease is true? a. Significant advances have been made in their treatment, to the point where they are no longer dangerous. b. Although we know more about the causes of chronic diseases, advances in their treatment have been modest. c. Psychological and social factors have little to do with these diseases. d. Gains and survival rates from cancer between 1950 and 1987 are due to improved medical techniques.

18. Which of the following is NOT a risk factor for an individual developing cancer? a. high alcohol use b. high fat diet c. cigarette smoking d. all of the above are risk factors 19. Risk factors for a health problem a. directly cause diseases. b. are associated with diseases. c. are largely unknown today. d. are usually easily cured with medication.

28

d (9)

d (9)

b (9)

c (9)

d (10)

d (10)

20. Melody has been having a great deal of difficulty in her attempt to quit smoking. Which of the following might be reasons for her lack of success? a. She thinks getting cancer is not likely. b. Her friends all smoke and don't think it’s such a big problem. c. She is addicted to nicotine. d. all of the above 21. Smoking has been identified as a risk factor in each of the following health problems except a. stroke. b. cancer. c. chronic lung disease. d. obesity.

22. In Belloc and Breslow's study of longevity and health practices a. longevity was not statistically related to most health behaviors. b. the health of older participants who practiced all seven health habits was similar to that of much younger participants. c. maintaining an appropriate weight was the best predictor of health. d. eating multiple small meals was important.

23. Which of the following is NOT one of the healthful behaviors studied by Belloc and Breslow (1972)? a. never smoking cigarettes b. never or only occasionally eating between meals c. taking one aspirin per day d. sleeping 7 to 8 hours a day 24. People whose personalities include high levels of _____ seem to be "disease-prone." a. anger & hostility b. depression c. anxiety d. all of the above 25. Considering the psychosocial characteristics of the following people, which one is most likely to develop an illness? a. Fernando, a banker who works long hours. b. Linda, a student who occasionally feels a bit sad and homesick. c. Ling, an athlete who experiences mild levels of anxiety before her competitions. d. John, an anxious and pessimistic news director who frequently "blows up" at his staff.

29

c (10)

a (10)

c (11)

a (11)

d (11)

b (11)

26. Jane feels a numbness in her hand and has been to several doctors, who have found no organic cause for her problem. She might be suffering from a. trephination. b. behavioral modification. c. conversion hysteria. d. psychoanalysis.

27. Medical history notes for a young woman with a skin rash refers to her "conflicting feelings about being physically close to her husband". Her physician seems to accept a _____ explanation for her illness. a. psychosomatic b. behavioristic c. public health d. humoral 28. Which of the following approaches would a specialist in behavioral medicine be most likely to use in treating a chronic headache? a. medicine b. psychoanalysis c. biofeedback d. psychotherapy 29. The work on biofeedback by physiological psychologists has shown us that a. even internal functions like heart rate and blood pressure can be controlled with psychological methods. b. the mind/body dichotomy really exists and can be measured. c. psychoanalysis is effective in the treatment of high blood pressure. d. biofeedback is an ineffective method of therapy.

30. Which of the following is the least likely to be studied by a modern health psychologist? a. why people do not use seat belts b. how to design a media campaign to encourage healthful lifestyles c. how patients are affected by characteristics of hospitals and nursing homes d. how to differentiate organic symptoms from conversion hysteria 31. Which of the following is not an example of an indirect way that health psychologists help patients? a. Conducting research to discover information about lifestyles that affect health. b. Providing therapy to a patient to assist in adjustment to a chronic illness. c. Holding a training workshop for medical professionals regarding psychosocial characteristics of patients. d. Designing new behavior change programs that will affect people’s health.

30

b (12)

d (13)

d (13)

a (15)

b (17)

c (17)

32. Mei-Lin has lost the use of her legs after being in a biking accident. Her health psychologist is working with her to cognitively redefine the experience as a challenge rather than a disaster. This technique is classified as a(n) _____ method. a. ineffective b. cognitive c. behavioral d. psychoanalytic 33. A biopsychosocial approach to dealing with an adolescent girl's weight problem would be likely to consider a. her family history. b. how her weight problem affects her friendships. c. how she feels emotionally about her weight problem. d. all of these 34. Which of the following is true regarding the role of emotions in health and illness? a. People with positive emotions take better care of their health. b. Fear prevents some people from obtaining medical care. c. Recovery from illness can be affected by emotions. d. all of the above 35. Which of the following is NOT true of the systems concept in health psychology? a. It takes into account an unchanging, interrelated group of parts. b. By definition, a person qualifies as a system. c. It is consistent with the biopsychosocial model. d. Events in one system affect events in other systems.

36. Compared with older individuals, children a. experience the same number of chronic diseases as adults. b. suffer from relatively few chronic diseases. c. are more responsible for their own health. d. have cognitive skills similar to those of adolescents and adults.

37. The life-span perspective in health psychology reveals that adolescents a. will be healthier than children because they are exposed to fewer infectious diseases. b. typically follow the example of their parents more than their friends. c. are powerfully influenced by peer pressure, often leading to poorer health practices. d. respond to illnesses much like the elderly do.

31

c (17)

b (17)

a (18)

c (18)

d (18)

a (19)

38. Greg is a 15 year old who was diagnosed as a diabetic at age 4. For the first time, he now is not following his health regimen. The most probable explanation is a. he doesn't understand what he should do. b. he secretly doesn't want to be healthy. c. social pressures to avoid being "different" prevent him from taking proper care of himself. d. he may be forgetting what to do and should have a neuropsychological examination.

39. When reporting the decrease in deaths from AIDS, an epidemiologist is discussing AIDS’ a. morbidity. b. mortality. c. incidence. d. prevalence.

40. An epidemiologist writes a report discussing the total number of previously reported and new cases of AIDS for the past 5 years. He is reporting on the disease's a. prevalence. b. morbidity. c. incidence. d. mortality.

41. Dr. Yi is collecting data on the number of new cases of cholera in Beijing during the summer of 1997. Dr. Yi is studying the __________ of cholera. a. prevalence. b. morbidity. c. incidence. d. epidemic.

42. An epidemic usually refers to a situation in which a. many people die from a disease. b. a disease receives greater publicity. c. the mortality rate of a disease increases. d. the incidence rate of a disease has increased rapidly.

43. Wilbur has had a stroke and is now undergoing treatment by exercising and receiving electrical stimulation to his severely weakened muscles. The professional performing this treatment is most likely a a. physical therapist. b. licensed practical nurse. c. doctor. d. medical anthropologist.

32

a (20)

44. Cultural differences in illness patterns have been reflected by a. higher prevalence of stomach cancer in Japan than in the USA. b. uniform cancer rates across the USA. c. the devaluation of the importance of good health in the USA. d. the universality of illnesses.

d

45. According to the textbook author, culture influences (20-21) a. beliefs regarding the causes of health and illness. b. accepted practices for curing illness. c. norms or expectations on what to do when one is ill. d. all of the above. b (21)

c (21-22)

d (22)

b (23)

46. Religious beliefs and practices in the USA a. invariably lead to poorer health. b. may either promote healthful living, or deter it, depending on the religion. c. invariably promote good health. d. have declined with the rise of health psychology.

47. Which of the following is not necessarily a component of a useful theory? a. It relates previously seemingly unrelated information. b. It enables us to make predictions. c. It has been proven to be correct. d. It organizes known facts.

48. In a study of the effects of an anti-inflammatory drug on chronic jaw pain, one group receives an inactive substance in the form of a pill. This group receives a. the independent variable. b. the dependent variable. c. a control. d. a placebo.

50. The method of experimental design in which the subject and the experimenter are unaware of which group they are assigned is called the a. experimental control. b. double-blind procedure. c. nonexperimental method. d. quasi-experimental approach.

33

a (23)

a (24)

b (24)

d (24)

51. Which of the following illustrates a difference between experimental and non-experimental approaches to research? a. Only experimental methods can imply causation. b. In nonexperimental methods, the researcher manipulates an independent variable. c. Only experimental methods measure dependent variables d. Nonexperimental methods test cause and effect relationships.

52. Nonexperimental or correlational studies a. can generate predictive information. b. are not usually useful because they can't lead to causal inferences. c. are not usually done anymore. d. involve the manipulation of independent variables.

53. Researchers reported that there is a strong relationship between height and IQ: as height goes up, IQ goes up. They are reporting a. a negative correlation. b. a positive correlation c. a non-linear relationship. d. no correlation.

54. A student researcher writes in his report that his statistical analysis revealed a correlation coefficient of +2.13 between the two variables in his study.

His reported correlation coefficient a. indicates a negative correlation. b. indicates a positive correlation. c. is a significant result. d. is an error.

d

55. A _____ study would NOT be an example of a quasi-experimental study.

(24 - 26) a. retrospective b. prospective c. longitudinal d. correlational a (25)

56. To study the effects of cigarette smoking on breast cancer, 500 healthy teenaged girls were recruited to participate in a study that tracked their smoking (or nonsmoking) behavior and cancer incidence for five decades. This is an example of a. a prospective study. b. an experiment. c. a retrospective study. d. a single-subject approach.

34

c (26)

c (27)

b (28)

d (29)

57. Suppose that a recent study found an increase in heart and lung disease among people aged 50-60. Further study revealed that, compared to people 20 years younger, these individuals tended to smoke more during their young adulthood, because they were not aware of the health effects of smoking at that time. This difference between individuals raised at different times is an example of a. the placebo effect b. a cross-sectional approach c. a cohort effect d. a prospective study 58. Dr. Martinez is conducting an in-depth study of a patient exposed to farm pesticides. Dr. Martinez is probably using a a. cross-sectional design. b. experimental design. c. single-subject design. d. twin study.

59. A reasonable assumption that can be made about monozygotic twins is a. they are likely to have many genetic differences. b. differences between them are environmentally determined. c. they will be reared in identical environments. d. they are always same sexed.

60. In deciding which research methods to use, a researcher might keep in mind that a. it is never appropriate to use experimental and nonexperimental methods in the same study. b. nonexperimental methods can still support causal explanations. c. nonexperimental methods are rarely helpful in science. d. experimental and nonexperimental methods can be effectively combined in the same study.

35

Short Answer Questions 1. Provide a brief summary of Antonovsky's illness-wellness continuum. How does it differ from traditional definitions of health?

2. Review the two primary perspectives of the mind-body problem. How is the debate relevant to a discussion of health and illness?

3. Your job is to work with pediatric cancer patients. What developmental factors must you keep in mind as you proceed with your work?

Essay Questions 1. Ten-year-old Juan has been diagnosed with diabetes. Describe his likely experience living with the disease from a biopsychosocial perspective.

2. Compare and contrast the disciplines of psychosomatic medicine, behavioral medicine, and health psychology.

3. You are interested in testing the effectiveness of a newly developed treatment for back pain. Outline your approach to your research project.

36

CHAPTER 2 THE BODY'S PHYSICAL SYSTEMS CHAPTER OUTLINE Module 1. The Nervous System A. How the Nervous System Works 1. General function of nervous system a. integrate actions of internal organs 2. Features of neurons a. cell body - location of cell nucleus and site of cell metabolism b. dendrites - projections that receive excitation/inhibition from other neurons c. axon - long projection from cell body through which messages are sent d. synaptic knobs - at end of axon; contain neurotransmitter messengers e. synapse – fluid-filled gap between the dendrites of different neurons 3. Neuronal transmission a. an electrochemical process that involves: i. stimulation at the dendrites ii. propogation of ion exchange along the axon iii. release of neurotransmitters at the synapse b. possible effects of different neurotransmitters i. excitation of receiving neuron – increases likelihood of electrical impulse being generated ii. inhibition of receiving neuron – decreases likelihood of electrical impulse being generated iii. either excitation or inhibition depending on characteristics of receiving neuron 4. Developmental changes in the nervous system a. nervous system is immature at birth – has almost all neurons person will have in life but brain only weighs 25% of adult weight b. growth in brain is due to increase in glial cells and myelin i. function of glial cells = service & maintain neurons ii. function of myelin = present on some axons; increases speed of nerve impulses and prevents activity in a neuron from being interfered with by activity in neighboring neurons 1) multiple sclerosis - a disorder that occurs when myelin sheath degenerates resulting in loss of muscle coordination and increasing spasticity in movement

37

c. during childhood, development of dendritic system and growth of myelin sheath increases significantly i. myelin growth progresses from head to feet and mirrors motor development ii. chronic poor nutrition early in life affects this development. d. in early adulthood, number of brain cells doesn’t change much but synaptic functioning starts to decrease leading to decline in ability to send nerve impulses 5. Divisions of the nervous system a. central nervous system – consists of brain and spinal cord b. peripheral nervous system – remaining network of neurons throughout the body B. The Central Nervous System 1. Section introduction a. brain weight increases to 75% of final weight at age 2 to 95% at age 10 b. divisions of the brain i. forebrain – uppermost part of brain ii. cerebellum – located at back of brain iii. brainstem – lowest portion of the brain 2. The forebrain a. two main subdivisions i. telencephalon - includes cerebrum and limbic system ii. diencephalon - includes thalamus and hypothalamus b. cerebrum i. largest portion of brain ii. cerebral cortex – outermost layer of cerebrum iii. controls complex motor and mental activity 1) motor control is organized contralaterally (cortex on one side of brain controls motor activity on opposite side of body) iv. hemispheres of the cerebrum and their functions 1) left hemisphere – reasoning, spoken/written language processes, numerical skills 2) right hemisphere - visual imagery, emotions, perceptions of patterns v. lobes of the cerebral cortex and their functions 1) frontal lobe - motor activity, mental activity, personality and emotion 2) temporal lobe - hearing, vision, memory 3) occipital lobe - principal visual cortex 4) parietal lobe - body sensations & movement c. limbic system i. inner edge of cerebrum ii. controls expression of emotions 38

d. thalamus i. chief relay station for incoming sensory and outgoing motor information e. hypothalamus i. involved in expression of emotions ii. controls motivation activities such as eating, drinking, sexual activity iii. involved in process of homeostatis (balance of body systems) 3. The cerebellum a. cauliflower-shaped portion of brain located below the cerebrum b. maintains body balance & coordinates movement i. has nerve connections to motor cortex of cerebrum and sense organs of body c. how cerebellum initiates movements and makes actions precise and well coordinated i. compares intent with performance ii. smooths movement by dampening tendency of motions to go quickly back and forth d. ataxia - a condition that results from damage to cerebellum characterized by jerky, uncoordinated movements 4. The brainstem a. located at the top of the spinal cord b. four portions of brainstem i. midbrain 1) connected to the thalamus 2) receives information from visual & auditory systems; important in muscle movement 3) Parkinson's disease – degeneration in midbrain that results in motor tremors & rigidity in posture ii. reticular system 1) extends from top to bottom of brain stem and into the thalamus 2) controls states of sleep, arousal, & attention 3) coma & epilepsy are linked to disrupted activity in this system iii. pons 1) bulge at front of brainstem 2) involved in eye movements, facial expression, & chewing

39

iv. medulla 1) located at bottom of brainstem 2) controls vital functions (breathing, heart rate, diameter of blood vessels) 3) damage due to accident or disease (e.g., polio) can be life threatening 5. The spinal cord a. transmits efferent impulses from the cortex to the body and afferent impulses toward the brain b. damage to the upper spinal cord may cause quadriplegia / tetraplegia (paralysis of four limbs) and damage lower may cause paraplegia (paralysis of the legs) C. The PeripheraI Nervous System 1. Parts of the peripheral nervous system a. somatic nervous system i. involved in sensory and motor functions 1) afferent neurons - carry messages from sense organs to the spinal cord 2) efferent neurons - carry messages to striated skeletal muscles ii. myasthenia gravis – disorder involving weakening of muscle/nerve function of head & neck b. autonomic nervous system i. activates internal organs & provides feedback on activity to the brain ii. two subdivisions of the ANS 1) sympathetic nervous system - mobilizing energy for action 2) parasympathetic nervous system - regulates calming processes 2. Nerves of the peripheral nervous system a. cranial nerves b. vagus nerve – regulates sympathetic and parasympathetic activity Module 2. The Endocrine System A. Section Introduction 1. Glands in this system are associated with activity in the autonomic nervous system 2. Modes of communication a. nervous system – electrochemical process of communication i. ion transfer within neuron ii. neurotransmitter activity between neurons b. endocrine system – chemical process of communication i. hormones carried in the blood throughout the body

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3. Some chemicals are produced by both systems and function as both hormones and neurotransmitters B. The Endocrine and Nervous Systems Working Together 1. Pituitary gland a. master gland linking endocrine system to nervous system b. hypothalamus stimulates pituitary hormone release c. pituitary hormones stimulate activity of other endocrine glands 2. Hormone specificity a. each hormone has its own specific effect on cells and organs i. examples: estrogens and testosterone 3. Hypothalamus-pituitary-adrenal axis a. in an emergency situation, the hypothalamus releases corticotropin-releasing factor to pituitary b. pituitary releases ACTH, which stimulates adrenal glands C. Adrenal Glands 1. Located on top of the kidneys 2. Release of hormones in response to stress and emergencies a. cortisol helps control swelling when injured b. epinephrine and norepinephrine (also called adrenalin and noradrenalin) work in conjunction with the sympathetic nervous system 3. Nervous system neurotransmitters have instantaneous, localized effect whereas endocrine system hormones have a slow, broad and long-lasting effect D. Other Glands 1. Thymus gland a. located behind the sternum b. plays a role in development of antibodies and immunities against disease 2. Thyroid gland a. regulates general activity level and body growth b. disorders of thyroid production i. hypothyroidism – insufficient secretion of thyroid hormones may lead to low activity levels and weight gain or even dwarfism and mental retardation ii. hyperthyroidism - excessive thyroid secretion may lead to high activity levels, short attention span, tremors, insomnia, weight loss 1) Graves' disease, in which individuals are irritable, restless and confused, may result

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3. Pancreas a. located below the stomach b. regulates the blood sugar level by secreting glucagon, which raises the blood sugar level, and insulin, which lowers it c. insufficient production of insulin causes diabetes mellitus, which results in hyperglycemia, or excessive blood sugar Module 3. The Digestive System A. Food's Journey Through Digestive Organs 1. Section introduction a. digestive system is a 20-foot pathway beginning in mouth and ending at the rectum whose primary function is to break down food, absorb nutrients, and excrete waste 2. Digesting food a. processes for breaking down food i. mechanical - chewing in the mouth; churning in the stomach ii. chemical - enzymes throughout the entire system 1) enzyme names reflect substance upon which it acts b. digestive processes at various locations in the system i. mouth - chewing and enzymes in saliva begin the digestive process ii. esophagus - moves food from mouth to stomach via peristalsis iii. stomach - churning action and gastric juices (hydrochloric acid & pepsin) break down proteins iv. small intestine 1) alkalinity increases to protect lining of small intestine 2) enzymes secreted by pancreas into duodenum cause carbohydrates, proteins, fats to be broken down 3) absorption significantly increased 4) capillaries absorb amino acids, simple sugars, water, fatty acids, vitamins & minerals 5) lacteals accept glycerol and fatty acids/minerals v. large intestine (colon) 1) absorption of water 2) production of feces 3. Disorders of the digestive system a. peptic ulcers - open sores in the digestive system lining particularly in the duodenum i. caused by bacterial infection and chronic excess gastric juices ii. characterized by abdominal pain iii. people who experience high levels of stress are more prone to developing peptic ulcers

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b. hepatitis - viral inflammation of the liver that may lead to permanent liver damage i. characterized by flu symptoms, jaundice & liver damage ii. types of hepatitis 1) Hepatitis A - transmitted through contaminated food, utensils, and water 2) Hepatitis B & C - transmitted through exposure to infected blood & sexual contact c. cirrhosis – condition where liver cells die and are replaced with scar tissue i. impairs liver functioning involved in digestion and cleansing and regulating of blood composition ii. disease process can result from hepatitis or alcohol abuse d. cancer of digestive tract i. may occur in any part of the digestive tract, especially colon and rectum ii. higher prevalence in people over 40 years of age iii. early detection possible and improves chances of recovery B. Using Nutrients in Metabolism 1. Metabolism - all the chemical reactions in body's cells 2. Outcomes of metabolism a. synthesis of new cell materials b. regulation of body processes c. energy for heat & fuel 3. Focus on energy production a. all body systems require metabolism of carbohydrates and fats to produce energy necessary to maintain body functions and physical action b. calories - unit measure of energy in food i. 1 calorie = amount of heat needed to raise 1 gram of water 1 degree Celsius c. energy needed to support basic bodily function i. basal metabolic rate = number of calories burned when body is at rest expressed in terms of calories per area of body surface per hour 1) BMR varies with size of body, age, gender, stress, climate, and thyroid activity 4. Relationship between weight, activity level, and basal rate a. activity raises metabolism above basal rate b. overweight generally due to consuming more calories than body uses

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Module 4. The Respiratory System A. Section Introduction 1. Functions of breathing a. supplies the body with oxygen needed for metabolism b. removes the carbon dioxide formed as a waste product of metabolism B. The Respiratory Tract 1. Path of air into the lungs a. air enters through the nose or mouth and is conducted through, in order, the larynx, trachea, bronchial tubes, bronchioles and alveoli. b. oxygen and CO2 transfer occurs at the alveoli 2. Mechanical process of respiration a. inhalation i. diaphragm contracts and the ribs move up and out to enlarge the lung chambers b. exhalation i. diaphragm relaxes and the lung elasticity forces the air out C. Respiratory Function and Disorders 1. Regulation of respiration a. medulla controls rate of respiration based on blood CO2 concentration as measured by sensors in blood vessels i. high CO2 increases breathing rate ii. low CO2 decreases breathing rate 2. Protective mechanisms of the lungs a. reflexes i. sneezing and coughing clear irritation in nasal passages and in lower portions of respiratory system b. mucociliary escalator i. cilia and mucus, which line the respiratory passages, move debris toward back of mouth 3. Disorders of the lungs a. cystic fibrosis – chronic, progressive and eventually fatal respiratory disease b. pneumonia – inflammation and development of fluid in alveoli caused by either viral or bacterial infection c. emphysema - disease in which the walls between alveoli are destroyed d. pneumoconiosis - damage of the alveoli and bronchioles due to chronic inhalation of dust e. disorders affecting the bronchial tubes i. asthma - narrowing of bronchial airways with accompanying bronchial spasms & excessive mucous ii. chronic bronchitis - inflammation & excess mucous in bronchial tubes

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f. lung cancer - unrestrained growth of cells in the lungs which may spread to other parts of the body 4. Most lung disorders/diseases are caused and/or worsened by smoking Module 5. The Cardiovascular System A. Section Introduction 1. Human body needs system to deliver nutrients to cells for metabolism and remove waste products of metabolism a. cardiovascular system, comprised of the heart and blood vessels, transports oxygen, nutrients, waste products, and other substances in blood B. The Heart and Blood Vessels 1. Heart - muscular pump which circulates the body's blood a. myocardium - the heart muscle b. atria - upper chambers of the heart c. ventricles - lower chambers of the heart d. coronary arteries and veins – blood vessels that service the myocardium 2. Arteries carry blood from the heart and veins to the heart 3. Path of blood through the body a. blood low in O2 and high in C02 enters the right atrium and then the right ventricle b. from right ventricle, blood then goes to the lungs to pick up 02 and then to the left atrium and into the left ventricle c. left ventricle pumps blood out the aorta to the rest of the body and then back 4. Kidneys receive blood from general circulation system and remove waste into the urine 5. Liver receives blood from intestinal tract and systemic circulation and performs two functions: a. harmful bacteria and debris are removed b. nutrients are stored until needed C. Blood Pressure 1. Blood pressure - measured force exerted by blood on the artery walls a. systolic pressure - maximum force in arteries with each heart contraction b. diastolic pressure - resting pressure between myocardial contractions 2. Five aspects of fluid dynamics that affect blood pressure a. cardiac output - blood volume pumped per minute i. as cardiac output increases, blood pressure increases b. blood volume - amount of blood in the system i. as blood volume increases, blood pressure increases

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c. peripheral resistance – difficulty encountered moving through narrowing tubes in system i. resistance increases in small-diameter arteries d. elasticity of the blood vessels – ease in blood vessels ability to expand and contract i. as blood vessels lose elasticity, blood pressure increases e. viscosity - blood thickness dependent on blood composition i. thicker viscosity results in higher blood pressure 3. Additional factors affecting blood pressure a. environmental temperature – high temperature results in blood vessel dilation and decreases in cardiac output and diastolic pressure b. activity level – exercise increases blood pressure c. body position – changing body position (e.g., from reclining to standing) is affected by impact of gravity resulting in decrease in cardiac output and blood pressure d. emotional experience – when sympathetic nervous system is activated due to stress or negative emotions, cardiac output and systolic/diastolic blood pressure increases 4. Measuring blood pressure a. hypertension (high blood pressure) - clinically defined as being at or above 140 systolic and 90 diastolic pressures i. impact of hypertension – strains and damages heart and arteries ii. risk factors for hypertension include body weight, age (as it connects to weight gain), gender, race, and family history b. optimal blood pressure – below 120/80 D. Blood Composition 1. Section introduction a. blood referred to as "liquid tissue" - cells suspended in a liquid i. adult body containing 4 to 6 liters of blood b. blood composition (formed elements plus plasma) affects blood pressure 2. Components of blood a. formed elements i. cells and cell-like structures that comprise 45% of the blood ii. types of formed elements 1) red blood cells - contain hemoglobin, which transports oxygen to the cells of the body a) formed in bone marrow b) most abundant cells in blood c) anemia = condition in which level of red blood cells or hemoglobin below normal

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2) Ieukocytes, or white blood cells - serve protective functions by engulfing or destroying bacteria a) produced in bone marrow and organs in the body b) leukemia = disease in which abnormal white cells produced in high quantities and crowd out normal leukocytes and red blood cells 3) platelets - granular fragments that prevent blood loss a) functions by plugging wounds or helping blood to clot b) hemophilia = disease in which clotting is impaired because platelets do not function properly due to a lack of a critical protein in the blood b. plasma i. liquid that comprises 55% of the blood.

1) 90% of the plasma is water 2) contains various organic and inorganic elements a) plasma protein - increases blood thickness b) other elements – hormones, enzymes and waste products plus products of digestion (vitamins, minerals, simple sugars, amino acids, and lipids) ii. lipids 1) triglycerides a) most abundant lipid b) saturated fat = fully hydrogenated triglycerides c) unsaturated/polyunsaturated fat = fatty acids not fully hydrogenated; derived from plants 2) cholesterol a) a fatty substance produced by the body b) diets containing highly saturated fats can result in build up in patches on artery walls E. Cardiovascular Disorders 1. Atherosclerosis a. process of accumulation of fatty patches, or plaques, on artery walls 2. Arteriosclerosis a. hardening and narrowing of the arteries 3. Myocardial infarction (heart attack) a. death of heart muscle tissue due to arterial blockage 4. Angina pectoris a. pain in the chest caused by an obstruction in an artery

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5. Aneurysm a. weakened area in a blood vessel which may result from hypertension and atherosclerosis 6. Stroke a. disruption of blood to the brain which may be caused by a blood vessel which ruptures or by a blood clot (thrombosis) Module 6. The Immune System A. Section Introduction 1. Immune system fights to defend the body against foreign invaders a. has the ability to distinguish between "self" and "not self" B. Antigens 1. Antigen a. any substance that can trigger an immune response i. bacteria – microorganisms that grow rapidly, compete with cells for nutrients, excrete toxins that destroy cells or impair metabolic processes ii. fungi – organisms that attach to organic host and absorb nutrients from it; some cause skin or internal diseases but others are beneficial iii. protozoa – one-celled animals that live in water or animals iv. viruses – particles of protein and nucleic acid containing genetic information that allow them to reproduce 1) function by causing cell to abandon own metabolic activity and becoming a “factory” for making the virus b. transplanted organs may be treated by the body as an antigen i. ways to encourage transplant acceptance 1) selecting organ donor with close genetic match to recipient 2) use drugs to suppress immune system 2. Allergens - harmless substances, such as pollen, that produce an immune system response (i.e., allergies) a. allergy treatments may consist of injections of regular, small doses of the allergen.

C. The Organs of the Immune System 1. Lymphatic or lymphoid organs a. role - develop and deploy lymphocytes (white blood cells) b. main lymphatic organs i. bone marrow - origin of lymphocytes ii. thymus – one of the maturation sites for lymphocytes iii. lymph nodes - contain filters that capture antigens and provides a home base for lymphocytes iv. lymph vessels - connect lymph node and contain lymph iv. spleen - filters out antigens, serves as a home base for lymphocytes, and removes ineffective/worn-out red blood cells 48

D. Soldiers of the Immune System 1. Two types of white blood cells a. phagocytes i. as part of nonspecific immunity process, engulf and ingest any kind of antigen ii. types of phagocytes 1) macrophages - phagocytes that are fixed at a particular site 2) neutophils - circulate in the blood b. lymphocytes - respond to presence of specific antigens via specific immunity processes 2. Types of specific immunity processes a. cell-mediated immunity i. immune process that operates at the level of the cell ii. T cells - the soldiers in this process, named for their maturation site (thymus) iii. types of T cells 1) killer T cell – target and kill transplanted tissue, cancerous cells, cells invaded by antigens 2) memory T cell - remember previous invaders and allow more rapid future defense from same invaders 3) delayed-hypersensitivity T cell - involved in delayed immune reactions such as some allergies and produce lymphokines that stimulate other T cells to grow, reproduce and attack invaders 4) helper T (CD4) cells - stimulate lymphocytes to reproduce and attack antigens.

5) suppressor T cell - slow down or stop cell-mediated and antibody-mediated immunity processes b. antibody-mediated "humoral" immunity i. immune process where antigens are attacked directly while still in body fluids, before they have entered cells ii. B cells, the soldiers of this process, give rise to plasma cells that produce antibodies iii. role of antibodies (immunoglobulins) - protein molecules that attach to antigens 1) slow down invader so phagocytes can destroy 2) attract other substances that puncture antigen 3) form memory B cells to remember antigen and function like memory T cells

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E. Defending the Body with an Immune Response 1. Lines of defense a. first line i. skin – acts as barrier ii. mucous membranes of respiratory and digestive tracts – contain antibodies and antimicrobial substances b. second line i. non-specific and specific immune processes 1) phagocytes attack invaders and signal B cells and helper T cells 2) B cells stimulate production of plasma cells that produce antibodies 3) antibodies attach to invaders thus aiding phagocytes and other protein substance to kill invader c. third line i. killer T-cells destroy invaded cells ii. suppressor T cells slow down cell-mediated and antibodymediated immune responses iii. memory B and T cells left in blood and lymph to initiate future immune response 2. Immune response and cancer a. cancer cells have antigens on surface that cause T cell response b. some cancer cells release substances that suppress immune response or antigen may not be easy for immune system to recognize F. Less than Optimal Defenses 1. Developmental changes a. effectiveness increases in childhood, declines with old age i. most children born with only 1 type of antibody; may gain others if breastfed b. childhood vaccinations stimulate the production of memory lymphocytes c. in old age, T-cells, B-cells, and antibodies respond weakly 2. Lifestyle, stress and immune function a. unhealthy lifestyle (e.g., smoking, sedentary activity level, poor nutrition) affects immune function and production of lymphocytes/antibodies b. stress suppresses immune function 3. Autoimmune diseases a. diseases in which immune system attacks the body caused by heredity or prior infections b. types of autoimmune diseases and areas of body affected i. rheumatoid arthritis - tissues & joints ii. rheumatic fever - heart muscles iii. multiple sclerosis – myelin iv. lupus erythematosus - skin and kidneys 50

DISCUSSION TOPICS 1. Culture and Its Relationship to Disease.

Matsumoto raises some interesting issues regarding the relationship between culture and mortality rates for various diseases. In his review of the topic, he notes that Triandis and colleagues (1988) found a significant positive relationship between heart attacks and individualism. It was suggested that social support networks, a variable frequently linked to disease rates, vary along the individualism-collectivism continuum with collectivistic cultures emphasizing stronger and deeper social ties. Matsumoto reviews some of his own research that explores other cultural tendencies found in 28 different countries around the world, including individualism-collectivism, power distance, uncertainty avoidance, and masculinity, as they relate to various medical diseases. He found significant predictive relationships between these cultural dimensions and mortality rates for these diseases. He concludes that these cultural characteristics affect social support and/or the expression of negative affect and thus contribute to cross-cultural differences in disease rates.

Source: Matsumoto, D. (2000). Culture and psychology: People around the world. (2nd ed.). (pp.

246-247). Stamford, CT: Wadsworth.

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ACTIVITIES 1. Assess Yourself: How Many Calories Do You Burn While Resting? Have students complete Handout #1: How Many Calories Do You Burn While Resting? This activity can be extended by having students chart their calorie intake and exercise levels for a day so they can see the relationship between these variables and discuss various ways they could affect weight gain/loss.

2. Indicators of Optimal/Illness Functioning. In Chapter 1, some time was given to indicators of health (i.e., physical measurements of the presence of illness). This exercise can be linked to that topic by suggesting that laboratory tests act as indicators of normal, optimal, or disrupted functioning in the various systems of the body. For example, a hematocrit measures the proportion of the blood made up of red blood cells.

Have students explore various forms of laboratory tests used to produce indicators of system functioning and report on the nature of these tests (i.e., how are they conducted, "normal" range of scores). Information on medical tests can be found at http://www.labtestsonline.org , a site that contains a wealth of information about medical tests (e.g., how they are conducted, what results mean.)

3. Medical Library Search for Treatments. Have students select one or two diseases of interest and then, using the Medem medical library found at: http://www.medem.com/medlb/medlib_entry.cfm, explore the types of treatments typically used for these diseases. This website includes information on the types of a disease class, symptoms, general procedures in diagnosis, and treatment. Students can report to the class the information they have gathered.

4. Search for Archaic Medical Terminology. One rather fun exercise is to have students log on to the following website which contains information on archaic medical terms: http://www.paul_smith.doctors.org.uk/ArchaicMedicalTerms.htm. The terminology used to describe some of these diseases/disease states can be used in a "stump your neighbor" activity during class. You could also extend this activity into a discussion of how we react to the various names given to different disease states. If you have shown the video Medicine at the Crossroads: Code of Silence, this ties in to the observation that the word "cancer" is synonymous to death to many Japanese people.

5. Cross-word puzzles. Handouts 2 through 7 pertain to terms used in the six modules of this chapter. Students may find them handy in their efforts to learn these terms and the processes/functions they describe.

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Handout #1

Assess Yourself: How Many Calories Do You Burn While Resting?

1. Determining basal metabolic rate (BMR): a. Using Figure 2-11 in the Sarafino text, estimate your BMR by • finding your age along the horizontal axis.

• drawing a vertical line from your age point to the graph for your gender • drawing a horizontal line from the point where this vertical line intersects with the gender graph to the left vertical axis. b. The resulting number on the vertical axis is your estimated BMR. 2. Calculating body surface area (BSA): a. Start with a BSA score of 1.540 b. Adjust the base BSA for height by adding .035 for every inch taller than 60 inches or subtracting .035 for every inch shorter than 60 inches. c. Adjust the base BSA for weight using the following rules: • subtract .08 if your body is small frame and you are slim • do nothing if you are medium frame and average weight • add .08 if you are large frame or moderately heavy • add .15 if you are 20 pounds or more overweight

Base BSA BSA (height adjustment) BAS (weight adjustment) Final calculated BSA

1.540 +/-_____ +/-_____ _____

3. Calculating calories burned per hour while sleeping or lying down: _____ (BMR) x _____ (BSA) = _____ calories/hour

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Handout #2

Module 1: The Nervous System Across 4 - site for association of ideas 9 - home of visual imagery 12 - home of emotions 13 - increasing likelihood electrical impulse will occur 14 – receivers 17 - vision and memory processed here 19 - increase message speed 20 - messages travel along 21 - chief relay station 22 - important in emotions and motivations 23 - site of metabolism 24 - controls vital functions 25 - controls arousal

Down 1 - central nervous system 2 - home of language 3 - emergency responses 5 - body sensations 6 - thalamus and hypothalamus 7 - service neurons 8 - chemical messenger 10 - junction 11 - cerebrum & limbic system 15 - principal visual area 16 - body balance and coordination of movement 18 - paralysis of lower part of body

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Module 2: The Endocrine System 1

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Handout #3

Module 2: The Endocrine System - Solution 1

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Handout #4

Module 3: The Digestive System - Solution 1

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B A S A L M E T A B O L I C R A T E Y V 4 N S E 5 T A C I R R H O S I S 6 7 H L D W P 8 9 P E P T I C U L C E R E N Z Y M E 10 C S V O I R A I A D G I 11 N S E H E P A T I T I S A 12 C L N T T 13 14 E S O P H A G U S P A 15 R C M E C O L O N T P S 16 H E P A T I T I S B O R C I A I S 17 C A L O R I E N

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Module 4: The Respiratory System - Solution 1

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Module 6: The Immune System - Solution

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M U L T 7 M I E P M L G O C Y T E S R S Y C T L E R O T I G E N S I H R I T I S

RESOURCES Suggested Readings: Useful in teaching the systems of the body are slides based on the CIBA collection of medical illustrations by Frank Netterp M.D. The slides are extremely reasonable in price. A catalogue may be obtained by referring to the projection slides from The CIBA Collection of Medical Illustrations from: CIBA Medical Education Division CIBA GEIGY Corporation Post Office Box 18060 Newark, NJ 07191 Disease Boik, J. (1995). Cancer & natural medicine: A textbook of basic science and clinical research. Princeton, MN: Oregon Medical Press.

Davey, B., & Seale, C. (1996). Experiencing and explaining disease. Buckingham, PA: Open University Press.

Desnick, R.J. (1991). Treatment of genetic diseases. New York: Churchill Livingston.

Hatty, S.E. & Hatty, J. (1999). The disordered body: Epidemic disease and cultural transformation. Albany: SUNY Press.

Koenig, H.G. & Cohen, H.J. (2002). The link between religion and health: Psychoneuroimmunology and the faith factor. London: Oxford University Press Lorber, J. (1997). Gender and the social construction of illness. Thousand Oaks, CA: Sage.

Lippincott, W. (2008). Understanding diseases. Philadelphia: Wolters Kluwer Skelton, J.A., & Croyle, R.T. (1991). Mental representations in health and illness. New York: Springer-Verlag.

Medicine and the Body Albrecht, G.L., Fitzpatrick, R., & Scrimshaw, S.C. (2000). Handbook of social studies in health and medicine. Thousand Oaks, CA: Sage.

Memmler, R.L., Cohen, B.J., & Wood, D. (1996). Structure & function of the human body. Philadelphia: Lippincott.

Moore, S. B. (1996). Everything you need to know about medical tests. Springhouse, PA: Springhouse Corp.

Tarter, R.E., Butters, M., & Beers, S.R. (2001). Medical neuropsychology (2nd ed.).

Dordecht, Netherlands: Kluwer Academic Publishers.

Nicoll, D. (1997). Pocket guide to diagnostic tests. Stamford, CN: Appleton & Lange.

Wasson, J.H. (1997). The common symptom guide: A guide to the evaluation of common adult and pediatric symptoms. New York: McGraw-Hill.

Zaret, B.L. (1997). The patient's guide to medical tests. Boston: Houghton Mifflin.

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Suggested Films and Videos: Disease 1. Body Wars: Disease and the Hygiene Hypothesis. (2001, Films for the Humanities and Sciences, 51 min). Explores how our ultra-hygienic culture may be contributing to higher levels of certain diseases.

2. Medicine at the Crossroads: Pandemic (1993, WNET/BBC-TV, 57 min). Discusses progress in the scientific understanding of AIDS and attempts to prevent the disease.

Medicine 3. Human Genome Education Model Video Series (1995-98, HGE video series, 19-45 min). A 5 video series discussing ethical, legal and social issues of the Human Genome Project.

4. Medicine at the Crossroads: Conceiving the future. (1993, WNET/BBC-TV, 57 min). Based on the premise that genetics provides a powerful way to predict health and determine the future of every embryo; explores medical practice in different societies is dealing with these capabilities.

5. Medicine at the Crossroads: Random Cuts (1993, WNET/BBC-TV, 57 min).

Discusses the continued use of medical procedures even after they have been demonstrated to be ineffective.

6. Medicine at the Crossroads: The Magic Bullet. (1993, WNET/BBC-TV, 57 min).

Looks at the expectation that medicine can provide "a pill" to solve all health problems.

7. Medicine, how do you feel, Mr. Jacobs? (1995, PBS Video, 57 min). Reviews advances in medicine from the Black Plague to genetic technologies.

8. Molecular Medicine: Human Gene Therapy & the Future of Modern Medicne.

(1993, Caroline Biological Supply Company, 47 min). Gene therapy researchers describe events leading to the first human gene therapy treatments in 1990.

9. Reproduction: Designer Babies. (1995, Films for the Humanities, 20 min).

Examines issues raised by potential uses and misuses of genetic technology.

Internet sites of interest: Professional Organizations 1. http://www.alzheimers.org - Alzheimer's Disease Education and Referral Center 2. http://www.cancer.org - American Cancer Society 3. http://www.diabetes.org - American Diabetes Association 4. http://www.eatright.org - American Dietetic Association 5. http://www.americanheart.org - American Heart Association 6. http://www.lungusa.org - American Lung Association 7. http://www.arthritis.org - Arthritis Foundation 8. http://www.aafa.org - Asthma and Allergy Foundation of America 9. http://www.cdc.gov - Centers for Disease Control and Prevention 10. http://www.epilepsyfoundation.org - Epilepsy Foundation of America 11. http://www.modimes.org - March of Dimes Birth Defects Foundation 12. http://www.aidsinfo.nih.gov - HIV/AIDS Treatment Information Service 67

13. http://www.kidney.org - National Kidney Foundation 14. http://www.spinalcord.org - National Spinal Cord Injury Association 15. http://www.nsgc.org/ - National Society of Genetic Counselors, Inc. 16. http://www.ama-assn.org/ -American Medical Association Medical Resources 17. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi - PubMed (a publications index on medicine).

18. http://www.ornl.gov/sci/techresources/Human_Genome/medicine/medicine.shtml information on the Human Genome Project 19. http://www.nlm.nih.gov - US National Library of Medicine 20. http://education.yahoo.com/reference/gray/ - online version of Gray’s Anatomy of the Human Body 21. http://www.innerbody.com/htm/body.html - Human Anatomy Online 22. http://www.bbc.co.uk/science/humanbody/index.shtml - BBC Science and Nature – Human Body & Mind.

68

TEST QUESTIONS True or False F

1.

The transmission of messages through the axon ordinarily follow the order from axon, to cell body, to dendrite.

2.

Damage to the myelin sheath tends to produce little noticeable effect in motor functioning.

3.

The thalamus is known as the chief relay station in the brain because it directs sensory information to various parts of the brain and motor information to the skeletal muscles.

4.

Insufficient production of insulin results in diabetes mellitus.

5.

In the digestive system, enzymes are active only in the small intestine.

(32)

F (33)

T (35)

T (42)

F

(42 - 44)

F

6.

The basal metabolic rate is the number of calories burned when our bodies are at rest and is higher in males than females.

7.

The chemical processes in metabolism require oxygen.

8.

Blood pressure is a phenomenon that results from the fact that the circulatory system is a closed system.

9.

Organ transplants fail because the immune system identifies the transplanted tissue as an antigen.

10.

The thalamus is the maturation site for white blood (T) cells.

(46)

T (47)

T (53)

T (54)

F (58)

69

Matching Match one of the following with descriptions given in questions one to five. a. frontal lobe b. temporal lobe c. parietal lobe d. occipital lobe e. thalamus e (35)

1. Serves as the chief relay station for sensory messages coming in and for motor commands out to the skeletal muscles

b

2. Involved in hearing and memory

(35)

a

3. Contains the motor cortex

(34)

d

4. The primary visual cortex

(35)

c

5. Involved in body sensations such as of pain, cold, heat, and touch

(35)

Match one of the following with the descriptions given in questions six to ten. a. killer T cells b. memory T cells c. delayed-hypersensitivity T cells d. helper T cells e. suppressor T cells e

6. Operate to slow down or stop immunity processes.

(58)

a (57)

d

7. Directly attack cancerous cells, transplanted tissue and cells invaded by antigens.

(58)

8. Report invasions and stimulate lymphocyte production in the spleen and lymph nodes.

c

9. Produce lymphokines, which stimulates other T-cells to grow.

(57)

b (57)

10. The fact that one usually has mumps only once in life is the result of these cells.

70

Multiple Choice d (32)

a (32)

c (32)

b (33)

d (33)

b (33)

1. Which of the following is NOT a part of a neuron? a. axon b. dendrite c. synaptic knob d. septum 2. Specialized nerve cells called _____ are responsible for communication in the nervous system. a. neurons b. glial cells c. transmitter cells d. C cells 3. Chemical messengers called neurotransmitters a. transmit messages along the axon. b. may inhibit, but not excite a neuron. c. may either inhibit or excite a neuron. d. are found only in the dendrite.

4. The neurological disease called multiple sclerosis a. results from the deterioration of the myelin sheath. b. produces a lack of motor coordination. c. is caused by neural tangles. d. both a and b 5. Which of the following occurs to the brain as we age? a. New neurons continue to form. b. Glial cells increase in number. c. Myelination increases. d. both b and c 6. Chronic poor nutrition early in life does which of the following? a. It has little to no long lasting effects on motor and intellectual performance. b. It results in impaired development of myelin, glial cells, and dendrites. c. It affects adult brain deterioration but not childhood motor and mental functioning. d. It affects only motor functioning in young children.

71

c (34)

d (35)

c (36)

d (36)

b (37)

7. Which of the statements below accurately describes the roles of the right and left hemispheres of the brain in most people? a. They perform essentially the same functions. b. The left hemisphere controls vision and the right hemisphere controls body balance. c. The left hemisphere controls language whereas the right controls emotions. d. In adults the functions of each hemisphere are interchangeable.

8. Following a sharp blow to the back of her head, Shelley developed partial blindness. Which part of her brain was most likely injured? a. cerebellum b. frontal lobe c. parietal lobe d. occipital lobe 9. Marty's neurologist suspects his obesity might be due to damage in his brain. Which structure does he suspect is damaged? a. parietal lobe b. thalamus c. hypothalamus d. brain stem 10. Michael J. Fox and Mohammed Ali are two famous persons with Parkinson's disease. They very likely experience _____ due to damage to their _____. a. seizures; reticular system b. trouble breathing; medulla c. ataxia; cerebellum d. tremors; midbrain 11. Alice, a childhood victim of polio, requires an artificial breathing device due to damage to her _____. a. pons b. medulla c. hypothalamus d. midbrain

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c (38)

b (38)

c (40)

d (40)

a (41)

c (41)

12. Results of studies on biofeedback treatment for paralysis due to stroke indicate a. psychotherapy is a more effective intervention than biofeedback. b. biofeedback works only if conducted daily. c. as few as two biofeedback sessions per week improved muscle function in a 6 week trial. d. surgery combined with biofeedback is necessary for successful treatment.

13. Teddy is afraid of needles and injections. Whenever the nurse attempts to give him an injection, he screams and flails his arms and legs wildly. His heart rate increases, and he begins to sweat profusely, which indicates activation of the a. cerebral cortex. b. sympathetic nervous system. c. parasympathetic nervous system. d. pituitary gland.

14. The endocrine system is to _____ communication as the nervous system is to _____ communication. a. chemical; mechanical b. cellular; systemic c. chemical; electrochemical d. local; global 15. The "master gland" of the endocrine system, the pituitary gland: a. controls the secretion of other glands. b. releases hormones into the blood. c. releases ACTH, which affects emergency reactions. d. all of the above 16. Which pituitary hormone is released during an emergency? a. ACTH (adrenocorticotropic hormone) b. cortisol c. epinephrine d. norepinephrine 17. When you leap out of the path of a speeding car, the adrenal hormone _________ is released, causing an increase in respiration and heart rate. a. insulin b. ACTH c. epinephrine d. thyroxine

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a (42)

b (42)

d (42)

c (43)

c (44)

d (44)

d (44)

18. Dwarfism and intellectual deficiency are often the result of a. hypothyroidism. b. high levels of cortisol in the blood. c. a diseased pancreas. d. excessive secretion of adrenal hormones.

19. A co-worker has recently behaved in a restless and irritable manner and seems confused. A possible physical cause for such behavior is a. a diseased thymus gland. b. excessive thyroid secretion. c. too little thyroid secretion. d. none of the above 20. The actual digestive process begins in the a. liver. b. esophagus with the secretion of certain enzymes. c. duodenum. d. mouth.

21. Research on sex differences in the organ systems and glands indicates that a. differences between males and females are learned and not physiological. b. females do not exhibit the symptoms of Grave's disease. c. males actually secrete more hormones under stress than females do. d. there are no statistically significant differences in these systems.

22. The major gastric juices produced in the stomach are a. pepto and bismol. b. hydrochloric acid and peristalase. c. hydrochloric acid and pepsin. d. insulin and bile.

23. In the small intestine, which does NOT occur? a. The food mixture becomes alkaline. b. Enzymes are received from the pancreas. c. Most ingested materials the body uses are absorbed into the bloodstream. d. Storage of feces takes place.

24. Most of the ingested substances our bodies use are absorbed into the bloodstream through the lining of the a. colon. b. stomach. c. esophagus. d. small intestine.

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a (45)

a (45)

b (45)

d (46)

d (46)

d (46)

d (47)

25. Which of the following is not typically a disease of the liver? a. ulcers b. cirrhosis c. hepatitis d. anemia 26. Which of the following diseases of the liver is not transmitted by sexual contact? a. hepatitis A b. hepatitis B c. hepatitis C d. All the above diseases are transmitted by sexual contact.

27. Serum hepatitis, or hepatitis B, is often transmitted through a. stress or poor diet. b. transfusion of infected blood or using contaminated needles. c. handling or eating contaminated food. d. kissing and fondling.

28. The basal metabolic rate is a. not affected by the size of the body. b. exactly the same regardless of gender. c. constant across the life span. d. none of the above 29. Lower basal metabolic rates are associated with a. males more than females. b. those who live in cold climates. c. individuals under stress. d. increasing age.

30. Bearing in mind the factors that affect metabolism, the best advice for an individual desiring to lose weight would be a. to eat more food so as to stimulate your digestive system and therefore increase your BMR. b. eat less. c. exercise more to raise metabolism above basal rate. d. both b and c.

31. The act of breathing (respiration) does which of the following? a. Supplies the body with oxygen. b. Supplies a necessary component for metabolism. c. Helps us get rid of a specific waste product. d. all of the above

75

a (47)

b (48)

b (48)

b (49)

c (50)

a (50)

c (51)

32. Select the correct sequence of the passage of air in the respiratory system. a. trachea, bronchial tubes, bronchioles, alveoli b. trachea, bronchial tubes, alveoli, broncioles c. trachea, bronchioles, bronchial tubes, alveoli d. bronchial tubes, trachea, broncioles, alveoli 33. Breathing rate is controlled by the a. lungs. b. medulla. c. bronchioles. d. hypothalamus.

34. Which bodily action(s) do not serve to protect the respiratory system? a. sneezing b. hiccuping c. coughing d. mucociliary escalation and swallowing 35. Which of the following is not a disease or disorder of the respiratory system? a. cystic fibrosis b. hypertension c. pneumoconiosis d. asthma 36. The oxygenation of blood takes place in the a. atriums b. ventricles c. lungs d. aorta 37. Which bodily organs cleanse the blood of impurities? a. kidneys and liver b. liver and gall bladder c. gall bladder and lungs d. right atrium and right ventricle 38. Taking into account the laws of fluid dynamics, which of the conditions below would not typically result in increased blood pressure? a. decreasing blood vessel elasticity b. thinner blood vessels c. thinner blood d. all of these would result in increased blood pressure

76

b (51)

b (51)

d (52)

b (52)

c (52)

a (53)

39. Which of the following results in an immediate decrease in blood pressure? a. exercise b. standing up quickly c. cold weather d. emotional arousal 40. After a recent physical, your physician tells you that your blood pressure is 120/80. You are a. hypertensive. b. normotensive (normal). c. hypotensive. d. just nervous because you're at the doctor's office.

41. Which of the following is not a risk factor for hypertension? a. race b. gender c. age d. all of these are risk factors 42. Which of the following statements about red blood cells is not true? a. They are formed in the bone marrow. b. Their primary function is to fight infection. c. They are carriers of hemoglobin. d. They live for about 3 months.

43. Which of the following is true regarding leukocytes? a. They contain hemoglobin. b. They assist in the clotting process. c. Their primary function is to help fight infection. d. They are actually red blood cells damaged by anemia.

44. The most abundant lipid in the body is a material formed of glycerol and fatty acid called a. triglyceride. b. cholesterol. c. thrombosis. d. glycid.

77

d (54)

c (54)

c (55)

d (56)

b (56)

a (56)

45. John stepped on a nail a few days ago and has developed a bacterial infection that his immune system is fighting. The bacteria in his body that triggered an immune response are called a. allergens. b. enzymes. c. white blood cells. d. antigens.

46. Which of the following are not antigens? a. viruses b. bacteria c. leukocytes d. protozoa 47. The "home base" organ for white blood cells is the a. lymph nodes. b. heart. c. spleen. d. thymus.

48. Macrophages and neutrophils are a. specialized T cells. b. involved in cell-mediated immunity. c. lymphocytes. d. involved in non-specific immunity.

49. Which of the following statements regarding AIDS is not true? a. It does not kill directly. b. Although millions of people have the disease worldwide, most of the deaths have occurred in the United States. c. It is caused by a virus. d. It affects T cells.

50. The key distinction between phagocytes and lymphocytes is a. phagocytes are involved in nonspecific immunity and lymphocytes in specific immunity. b. phagocytes are red blood cells. c. lymphocytes do not attack specific antigens. d. phagocytes cannot be replenished.

78

a (57)

d (58)

d (58)

b (59)

c (59)

d (59)

51. The "t" in T cells refers to their site of maturation, the ______. a. thymus b. thyroid c. tongue d. tonsils 52. One of your body's first lines of defense against infection is a. good hygiene. b. antiseptics. c. antibiotics. d. your skin.

53. Antibody-mediated immunity differs from cell-mediated immunity a. in no significant way. b. because of its use of T cells. c. because antibody-mediated immunity attacks antibodies within the body's cells. d. because antibody-mediated immunity attacks antigens in bodily fluids rather than infected body cells.

53. Evidence indicates that stress and illness are related because stress a. suppresses the respiratory system. b. suppresses the immune system. c. leads to increased damage to the hypothalamus. d. increases our basal metabolism rate which makes us age faster.

55. Kiecolt-Glaser and her colleagues found that killer T cell activity a. was unrelated to stress. b. was directly related to the presence of antigens. c. was low in highly stressed individuals. d. was higher in highly stressed individuals.

56. Studies have shown immunosuppression in which of the following conditions? a. Following stressful final exams. b. Immediately after the death of a spouse. c. Among women unsatisfied in their marriage. d. all of the above

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Short Answer Questions 1. Compare and contrast the communication systems in the endocrine system versus the nervous system.

2. Discuss the issue of individual variability in internal systems between people. Provide evidence to support your answer.

3. Compare and contrast cell-mediated immunity and antibody-mediated immunity.

Essay Questions 1. Derek has just been bitten by a dog. Explain what is happening within two of the systems of his body as a result.

2. This chapter describes a number of diseases or disorders that can occur in the six systems reviewed. What linkages exist between the discussion in this chapter and the discussion of common definitions of health and illness in Chapter 1?

3. Leanne has high blood pressure. Discuss the mechanical, psychological, environmental, and demographic factors that may be an influence on her condition.

Additional Multiple Choice Questions (Answers are Highlighted): The _______________ nervous system controls the activities of the visceral organs under normal conditions; the __________________nervous system mobilizes the body in response to stress.

A. parasympathetic; sympathetic B. sympathetic; parasympathetic C. somatic; autonomic D. autonomic; somatic Parkinson’s disease is associated with which of the body’s physical systems?

A. endocrine system B. immune system C. cardiovascular system D. respiratory system E. central nervous system Cirrhosis is associated with which of the body’s physical systems?

A. endocrine system B. immune system C. cardiovascular system D. digestive system E. central nervous system 80

Kidney failure would be attributed to which system of the body?

A. immune system B. limbic system C. central nervous system D. renal system E. reproductive system Which of the below choices is NOT one of the common disorders of the nervous system?

A. Epilepsy B. Cerebral Palsy C. Paraplegia D. Huntington’s E. Myocardial infarction This bodily system is responsible for interpreting incoming sensory information, then sending out instructions on how the body should react: a.

Renal system b.

Cardiovascular system c.

Endocrine system d.

Central Nervous system e.

Digestive system

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CHAPTER 3 STRESS: ITS MEANING, IMPACT, AND SOURCES CHAPTER OUTLINE I. Experiencing Stress in Our Lives A. What is Stress?

1. Components of stress a. physical – direct material or bodily challenge b. psychological – how individuals perceive circumstances in their lives 2. Approaches to examining components of stress a. stress as a stimulus i. focus is on stressors in the environment ii. stressors = physically or psychologically challenging events or circumstances b. stress as a response i. focus is on the reaction to stressors 1) psychological responses -- behaviors, thoughts and emotions to stressors 2) physiological responses - heightened bodily arousal to stressors 3) strain - the sum of psychological and physiological responses c. stress as a process i. focus includes stressors and strains but adds transactions between the person and environment 1) stress = a process in which person is an active agent who can influence impact of stressor through behavioral, cognitive, and emotional strategies 3. Text's definition of stress a. stress = the circumstance in which person-environment transactions lead to a perceived discrepancy between the physical or psychological demands of a situation and the resources of the individual's biological, psychological, or social systems i. stress taxes person's biopsychosocial resources - stressor may produce strain on any one or all 3 systems of resources ii. perceived or actual demands of a situation - amount of resources required by stressor iii. perceived or actual discrepancy between demands and resources – assessment of whether resources will be over- or underutilized 81

iv. assessment of discrepancies occurs through transactions with the environment - assessing current demand on basis of nature of similar prior transactions B. Appraising Events as Stressful 1. Lazarus’ concept of cognitive appraisal a. evaluation of threat from stressor and resources available 2. Stages of cognitive appraisal a. primary appraisal i. assessing the meaning of the situation for our well-being 1) relevant - does this mean something to me? have I experienced something similar before that didn’t affect me?

2) good - is this something I want?

3) stressful - this is serious! ii. events judged to be stressful are further evaluated for following three implications: 1) harm-loss - amount of damage already occurred 2) threat - expectation of future harm 3) challenge - opportunity for growth, mastery or profit by using more than routine resources iii. stress produced by vicarious transactions 1) seeing other people in stressful situations 2) may produce stress depending on the primary appraisal b. secondary appraisal i. the ongoing assessment of available resources for coping to determine if resources are sufficient ii. significant discrepancy between demand and resource leads to stress c. stress may occur without cognitive appraisal i. example: in emergency situations, stress may occur before person has had time to engage in appraisal 1) when person is in shock, cognitive functioning is impaired ii. cognitive appraisal most likely in non-emergency situations 3. Factors leading to stressful appraisals a. personal factors - intellectual, motivational and personality characteristics such as self-esteem level, importance of threatened goal, or irrational beliefs b. situational factors - situations that involve strong demands and are imminent are more stressful i. life transitions – moving from one life condition or phase to another 82

ii. timing of situations - those that deviate from expected timetables ii. ambiguous situations – lack of clarity in a situation iii. desirability of situation - undesirable events tend to experienced as more stressful than desirable ones iv. controllability of situation - can the event be controlled?

1) behavioral control - affecting the event through some action 2) cognitive control - affecting the experience of the event by using some mental strategy C. Dimensions of Stress 1. Researchers assume amount of stress experienced related to stressor frequency, intensity, and duration a. findings suggest that stronger stressors produce greater physiological strain b. chronic stress - stressors that occur extremely often or last a long time and make people more susceptible to illness II. Biopsychosocial Reactions to Stress A. Biological Aspects of Stress 1. Reactivity a. physiological response to stressor produced by the sympathetic nervous system and endocrine system b. measured by comparison against baseline level of arousal c. influenced by genetic factors 2. Fight-or-flight response a. proposed by Walter Cannon (1929) b. perception of danger causes sympathetic nervous system stimulation of adrenal glands to secrete epinephrine which arouses the body c. effects of fight-or-flight i. positive - mobilizes organism to respond quickly to danger ii. negative - prolonged high arousal can be harmful to health 3. General adaptation syndrome a. Selye subjected laboratory animal to various stressors over a long period of time i. discovered that fight-or-flight only first in series of bodily reactions to prolonged stress b. general adaptation syndrome stages: i. alarm reaction - intense arousal to mobilize the body's resources to resist the stressor ii. stage of resistance - adaptation to the stressor, continuous physiological arousal with increased vulnerability to diseases of adaptation 83

iii. stage of exhaustion - limited ability to resist after prolonged arousal, disease likely and death possible c. evidence supporting GAS i. persons exposed to chronic stress have greater reactivity to stressors ii. linkage between high levels of allostatic load and chronic stress - adapting repeatedly to intense stressors takes high physiologic toll that accumulates over time 3. Do all stressors produce the same physical reactions? a. research indicates that stressors of many types increase adrenal gland hormone secretion b. Selye proposed nonspecific response in GAS i. same physiological reactions occur regardless of stressor ii. doesn't take into consideration psychosocial factors in stress response. c. evidence that psychosocial processes important to consider i. Mason concludes there is no evidence that any single hormone responds to all stimuli in absolutely nonspecific manner 1) some stressors involve release of epinephrine, norepinephrine and cortisol but others only 2 of these 2) other research finds that all 3 released only when stressor evokes strong emotion ii. Frankenhaeuser suggests pattern of arousal depends on effort and distress 1) effort involves interest, striving, determination 2) distress involves anxiety, uncertainty, boredom, dissatisfaction 3) combinations of effort and distress a) effort with distress – reaction to daily hassles elevates catecholamine and cortisol b) effort without distress – reaction to joyous events elevates catecholamine but suppresses cortisol c) distress without effort - reactions to helplessness, loss of control elevates cortisol and catecholamines – same endocrine profile as in depression iii. physiological response to stress is affected by cognitive appraisal 1) example: children’s reactions to achievement tests

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d. overall evaluation of GAS model i. basic structure of GAS model is valid but incorrect assumption regarding nonspecificity and model fails to consider psychosocial factors in stress B. Psychosocial Aspects of Stress 1. Cognition and stress a. stress affects cognition i. stress may impair memory and attention during cognitive tasks 1) example: attempts to tune out chronically noisy environments may result in generalized cognitive deficits. ii. stress may also enhance attention, especially regarding memories of the stressor b. cognition affects stress i. repetitive thoughts can perpetuate stress and make it chronic 2. Emotions and stress a. development of emotional expressions i. infants capable of expressing emotions via motor, vocal, and facial expressions b. emotions accompany stress i. emotional state aides in evaluation of stress ii. cognitive appraisal processes affect stress and associated emotional experiences c. common emotions related to stress i. fear - a common emotional response to threat 1) phobias: intense and irrational fears that are directly associated with specific events and situations 2) anxiety: vague feeling of uneasiness or doom involving relatively uncertain or unspecific threat which may result from health events such as surgery or waiting for test results, appraisals of low self-worth, or anticipation of loss ii. depression 1) difference between normal and clinical depression include frequency/duration, disruption of energy/sleep, negative thoughts (i.e., suicide, low self-esteem) 2) disabling health problems often lead to depression iii. anger 1) common reaction to harmful or frustrating events a) important because anger may lead to aggressive behavior 85

3. Social behavior and stress a. some stressful situations (e.g., emergencies) facilitate cooperation whereas others cause people to be less sociable or caring b. stress accompanied by anger may increase aggression i. child abuse is frequently preceded by a stressful experience for parent c. stress may decrease helping behaviors i. example: shopping center study 4. Gender and sociocultural differences in stress a. differences in frequency of stressors i. women report having experienced more major & minor stressors than men do 1) finding may be due to women being more willing to report stress 2) real gender variations in experience may produce finding a) heavier daily workloads b) greater physiological strain ii. members of minority groups or individuals who are poor report more stress b. differences in reactivity and physiological recovery i. in many studies, men show greater reactivity and longer physiological arousal than women 1) recent research indicates this gender difference depends on relevance of stressor to gender role ii. some research shows African Americans so greater reactivity than European Americans 1) may depend on nature of stressor and gender III. Sources of Stress Throughout Life A. Sources Within the Person 1. Illness places demands as psychological and biological systems a. degree of stress depends on seriousness of illness and age of person i. ability of body to fight disease improves in childhood and declines in old age ii. as we age, implications of disease become more apparent to us due to increased cognitive abilities 2. Choice conflicts a. appraising opposing motivational forces can produce stress b. types of choice conflicts i. approach/approach conflicts - two attractive yet incompatible goals 86

1) usually resolution is done easily, but if decision is perceived to be important, stress may arise ii. avoidance/avoidance - two undesirable alternatives 1) usually people try to postpone or escape the decision 2) if postponing/escaping not possible, people vacillate between alternative 3) this type of conflict usually difficult to resolve and very stressful iii. approach/avoidance - attractive and unattractive features for a single goal 1) can be stressful and difficult to resolve c. conflicts may be more complicated than above and stress is more likely when: 1) choice may be between two or more alternatives 2) choices involve many features 3) opposing features are fairly equal in strength 4) “wrong” choice could lead to negative or permanent consequences B. Sources in the Family 1. Section introduction a. in accordance with “systems” concept, experiences of one family member affects experiences of rest of family, potentially resulting in stress b. three sources of stress within a family i. a new addition to the family ii. divorce iii. illness, disability and death 2. Addition to the family a. new baby brings stress during the pregnancy and after due to new responsibilities and changes in family relationships i. baby's temperament may be easy or difficult 3. Marital strain and divorce a. may produce stressful transitions in social, residential, and financial circumstances for all members of the family i. custodial parent preoccupied and often not available for children ii. adjustment may take time or may not occur at all b. steps to enhance children's adjustment to divorce i. maintain loving, secure home life ii. tell children in advance iii. encourage open, truthful, sensitive communication iv. give explanations at level child can understand v. recruit help/advice from others vi. encourage contact with both parents 87

4. Family illness, disability and death a. sources of family stress: short-term or chronic illness of a child, adult illness or disability or loss of a spouse or child b. types of stress stemming from illness in child i. time needed for care giving ii. reduced personal freedom for family members iii. difficult treatment decisions iv. learning about illness v. expenses vi. reduction of time for other family members c. types of stress stemming from illness in adult i. strain on financial resources if illness affects family income ii. reduced personal freedom and time iii. may affect spousal sexual relationship iv. may change family role for healthy spouse and older children in family d. age of sick person influences stress experience in family i. being ill may be inconsistent with the person’s roles in family esp. if person is younger 1) may produce frustration, distress or anger ii. intense caregiving needs may result in increased family stress e. impact of age on reaction to death i. children’s reaction to death of parent – child’s reaction depends on cognitive understanding of meaning of death 1) younger children grieve less strongly and for shorter time because they don’t understand the permanence of death ii. parent’s reaction to death of child – parents may experience loss of hopes and expectations for future as well as identity as parent iii. adult’s reaction to death of spouse – spouses may lose hopes, expectations and roles as well as important source of companionship C. Sources in the Community and Society 1. Section introduction a. interpersonal and situational events outside the family are sources of stress for both children and adults i. children: school and competitive events ii. adults: occupations and environmental situations 2. Jobs and stress a. stress associated with occupations may range from minor and brief to intense and prolonged

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b. factors of jobs that make them stressful and have been related to high blood pressure and heart rate, risk factors for heart disease i. demands of the task 1) excessive workload or long work hours ii. nature of work activity 1) repetitive manual activity 2) underutilization of worker’s abilities 3) evaluation of job performance iii. responsibility for people's lives 1) e.g., medical personal and other health personnel iv. physical environment of the job 1) presence of noise, temperature, humidity or illumination v. perceived insufficient control 1) feeling that one has little opportunity to learn new skills or make decisions on their own vi. poor interpersonal relationships 1) having to work with others who are abusive or unpleasant vii. perceived inadequate recognition or advancement 1) not getting acknowledged or promoted when person thinks he or she deserves it viii. actual job loss or insecurity about job security 1) associated with depression and health problems c. stress associated with retirement i. losses associated with retirement 1) decreased opportunity for social interactions 2) loss in identity 3) loss in feelings of power or influence 4) loss in structure and routine associated with having a job 5) decreased feelings of usefulness and competence 6) loss of income ii. losses not only affect retiree but also spouse 2. Environmental stress a. noise and crowding i. reduces control over interpersonal interactions ii. restricts ability to move about freely or obtain resources b. environmental hazards & natural disasters i. exposure to hazard substances linked to long-term worry over what may happen to health 1) example: Love Canal

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IV. Measuring Stress A. Section Introduction 1. Common research methods for measuring stress a. physiological arousal b. life events measurement c. daily hassle measurement B. Physiological Arousal 1. Aspects of physiological arousal typically measured a. blood pressure b. heart rate c. respiration rate d. galvanic skin response (GSR) 2. How measured through electrical/mechanical equipment a. through individual measurement devices b. through use of polygraph – combines measure of all 4 3. Chemical assays of blood, urine, or saliva a. measure levels of corticosteroids and catecholamines as indicators of arousal 4. Advantages to physiological measurement for stress a. measures are direct and objective b. reliable nature of measurement c. outcomes are quantifiable 5. Disadvantages of physiological measures a. measure techniques are expensive b. person may have stress to the test itself c. outcomes can be affected by gender, body weight, level of prior activity, consumption of stimulants C. Life Events 1. Section introduction a. scales measuring self-report of stress have been developed b. one approach has been to measure frequency of life events that require some kind of psychological adjustment as measure of stress 2. The Social Readjustment Rating Scale (Holmes & Rahe, 1967) a. measure consists of list of life events derived from clinical observation and validated by a sample's rating of the adjustment necessary for a list of needs b. findings associated with SRRS i. number of events reported decreases with age and increases with education ii. single, separated, and divorced people reported more events than married and widowed persons

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c. strengths, results and weaknesses of the SRRS i. strengths of scale: 1) wide range of events are represented 2) values of items reflect relative impact of events assessed 3) quick and easy to administer ii. results of studies using SRRS 1) find illness and accident rate follow increases in stress 2) correlation between SRRS and illness is only .3 indicating stress not only factor associated with illness and accidents iii. weaknesses of scale: 1) some items vague 2) subjective appraisals, or personal meaning for event, not taken into account 3) no distinction between desirable and undesirable events a) subsequent studies find its undesirable events that are associated with illness 3. Other life events scales (from Table 3.5) a. Life Experience Survey i. 57-item scale that rates items along extremely positive to extremely negative continuum ii. advantage - positive or negative items can be examined separately b. PERI Life Events Scale i. 102-item scale that describes events involving gain, loss, or ambiguous outcome c. Unpleasant Events Schedule i. 320-item scale with multiple events categories where events are rated both in terms of frequency and aversiveness D. Daily Hassles 1. Defined as stressful, lesser events that do not come from major life events 2. Kanner et al’s Hassles Scale and Uplifts Scale a. Hassles scale = 117-item scale that measures events that range from minor annoyances to major problems i. research found a weak correlation with health status but was more strongly related to health status than was a life events scale

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b. Uplifts Scale = 135 positive events that bring peace, satisfaction, or joy i. findings indicate scores were not associated with health status E. Chronic Stressors in Specific Domains 1. General position on use self-report measures a. shortcomings: scales may be unreliable because stress is difficult concept to define and measure b. strength: overall findings suggest that stress is moderately related to health

V. Can Stress Be Good for You? A. Section Introduction 1. Reason why stress-illness correlation is low may be because not all stress is unhealthy B. Support for position that not all stress is unhealthy 1. Theories of motivation and arousal contend that people function best at an optimal level of arousal given situation a. individual differences in optimal level of arousal exist C. Researchers’ positions on good v. bad types of stress 1. Selye a. claims “distress” is the harmful, damaging type of stress and “eustress” is the constructive, beneficial type of stress 2. Frankenhaeuser a. differentiates between combinations of “distress” and “effort” i. distress with or without effort is more damaging than effort without distress 3. Lazarus a. identified 3 kinds of stress appraisals: harm-loss, threat, challenge b. suggested challenged persons more likely to have better morale and higher quality of functioning due to more confidence, less emotional involvement, and more capability to draw on available resources c. also suggested that physiological stress response to challenge is different than from threat so diseases of adaptation are less likely to occur D. Mason suggests that individuals differ in their susceptibility to the effects of stress due to differences in biological variation and psychosocial variations

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DISCUSSION TOPICS 1. Acculturative Stress.

Although a number of life changes that can contribute to the experience of stress are noted in this chapter, moving to another culture is not noted as one of them. The term “acculturation” has been defined as the changes that occur both to immigrating groups and to the culture into which they enter. John Berry has found that differences emerge in how people attempt to deal with acculturative change and stress due to acculturation is not always inevitable. Personal beliefs regarding acculturation, including the importance of maintaining one's cultural identity as well as relationships with others in the new culture, have an impact on the stress experienced. Any number of stressors may arise from an acculturation situation.

Persons who are marginalized (i.e., neither their original or new cultural groups are any longer valued as important) experience the most stress whereas those people who adopt an integration orientation (i.e., bringing his/her cultural group into an integrated part of the larger, coordinated social group) experience the least stress.

The posture regarding acculturation adopted by acculturative society contributes to the stress experienced. For example, societies that hold beliefs in pluralism are more likely to create supportive networks for acculturating individuals and demonstrate more tolerance of diversity. As a result, the experience of acculturative stress results from a combination of belief systems found in the emigrating person and the acculturative society to which he or she moves. Negative consequences of acculturative stress for the individual include “reduced health, lowered levels of motivation, a sense of alienation, and increased social deviance”. He argues, however, that acculturative stress can be largely avoided or reduced “if both participation in the larger society and maintenance of one’s heritage culture are welcomed by policy and practice of the larger society” (pg. 215).

Source: Berry, J. (1994). Acculturative stress. In W. Lonner & R. Malpass (Eds.), Psychology and culture (pg. 211-215). Boston: Allyn and Bacon.

2. Reconceptualizing Trauma: Sarafino introduces the concept of posttraumatic stress disorder in the highlight box on page 66. It should be noted that, traditionally, theories concerning the impact of trauma focused on psychological disruptions in men as a result of war time experiences. Maria Root, a feminist author, has offered a new conceptualization of trauma founded on greater inclusion of negative experiences based on issues of gender, race, class, sexual orientation, and ability. In her writing, she argues that the definition trauma has come more from the clinician's perspective than that of the experiencing individual. Moreover, she believes the emphasis has been on individual distress, ignoring traumatic events to whole groups of people such as the Holocaust, internment of Japanese Americans, dislocation and decimation of Native American peoples, etc.--thus providing only a minimal understanding of the role of trauma in the lives of women, children, and minority groups. Her approach “depathologizes” what 93

might be thought of as normal responses to horrible experiences and considers behaviors that follow trauma as specialized coping behaviors for survival As a result, a broader range of traumatic events are considered from this perspective including direct traumas (maliciously perpetrated violence, war, accidents, disasters), indirect traumas (being traumatized by the trauma sustained by another, witnessing trauma such as battering, receiving continual news reports of violence), and insidious traumas (having one's social status devalued by racism, sexism, ageism, poverty, heterosexism, anti-Semitism, the results of direct trauma on an ancestor, the effects of significantly declining health due to AIDS, diabetes, multiple sclerosis, etc.). Such trauma may have the impact of shattering one's beliefs about security and result in a permanent effect on personality and survival behaviors that represent efforts to cope with these experiences.

Source: Root, M. (1992). Reconstructing the impact of trauma on personality. In L. Brown, & M. Ballou (Eds.), Personality and psychopathology (pg. 229-265). New York: Guilford.

3. Cultural Discrepancies and Stress.

In 1997, Matsumoto and his colleagues conducted research on college students to determine if the discrepancy between personal cultural values and the perceived values of society are related to stress experiences. Participants reported their own personal cultural values and their perceptions of the values of the society in which they lived. Perceptions of ideal values were also gathered. Additional information was gathered regarding coping strategies, mood, and physical well being.

Results of the study indicated that greater discrepancies between self values and perceived values of one's culture were positively correlated with more distress and health problems. Use of a greater number of coping strategies was related to these higher levels of distress. Although the author suggests more research is required, he suggests that cultural discrepancies may mediate health outcomes and be related to our stress experiences.

Source: Matsumoto, D. (2000). Culture and psychology: People around the world. (2nd ed.). (pg. 238). Stamford, CT: Wadsworth.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Hassles in Your Life. The Hassles Survey on pages 82-83 of the textbook, developed by Sarafino & Ewing (1999), has been reproduced in Handout #1. Have students complete the scale and then look for trends across most frequent hassles for students at your institution. An extension of this activity might be to have students add local hassles that aren't addressed on this scale.

2. How Stressed Are You? Stress "tests" abound in popular newstand magazines.

One example, developed by Tamata Eberlein and reprinted from the original version in Redbook magazine, can be found in the 1999 version of Perspectives: Stress management (pg. 73-77). Have students complete and then critique this "scale". They should be able to find a number of biases in the scale. One part of the exercise might be to have them edit and revise this scale. One interesting part of the included article is a ranking of life stressors ala Holmes & Rahe by 750 Redbook survey participants.

Source: Eberlein, T. (1999). How stressed are you? A personalized test: A two-minute quiz. In D. Corbin (Ed.), Perspectives: Stress management. St. Paul, MN: Houghton Mifflin.

3. Social Readjustment Rating Scale. Have the students take the Holmes and Rahe Social Readjustment Rating Scale on page 80 of your text using the time frame of the last twelve months. How might they best test the hypothesis that social changes affect health? Have them suggest health variables they might look at, such as number of illnesses or doctor's visits. Are these adequate? Depending on class size divide the class in half based on SRRS score and compare the halves on criterion scores. Be sensitive to the fact that some of the information may be personally embarrassing or emotionally charged. Have the class suggest ways of protecting confidentiality.

Discuss the experimental design used.

4. Adolescent Perceived Events Scale. Obtain a copy of the Adolescent Perceived Events Scale (Compas, Davis, Forsythe, & Wagner, 1987). Compare with the Social Readjustment Scale. Students should critically evaluate the nature of questions and comparative advantages v. disadvantages of these scales.

5. Disasters and Stress. Unfortunately, a number of natural disasters have occurred within the past 5 years. Have the students find articles and each present a report on a specific disaster and victims' reactions to the particular disaster. A good resource to assign for required reading in conjunction with this project is Ursano (1997).

Source: Ursano, R.J. (1997). Disaster: Stress, immunologic function, and health behavior.

Psychosomatic Medicine, 59, 142-143.

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Handout #1

Assess Yourself: Hassles in Your Life.

Instructions: Rate the frequencies of each of the following events using the following scale 0 = never 3 = often 1 = rarely 4 = very often 2 = occasionally 5 = extremely often

___ annoying social behavior of self ___ accidents/clumsiness/mistakes of self ___ annoying social behavior of others ___ appearance of self ___ athletic activities of self ___ bills/overspending ___ boredom (few or uninteresting activities) ___ car problems ___ crowds/large social groups ___ dating (lack of or uninteresting partners) ___ environment ___ exams (preparing for, taking) ___ exercising ___ extracurricular groups ___ facilities/resources unavailable ___ family obligations or activities ___ family relationships ___ fears for physical safety ___ fitness (inadequate physical condition) ___ food (unappealing/unhealthy meals) ___ forgetting to do things ___ friends/peers: relationship issues ___ future plans (e.g., career or martial decisions) ___ getting up early for class/work ___ girl/boyfriend: relationship issues ___ goals/talks: not completing enough ___ grades (getting low grades) ___ health/physical symptoms of self

___ housing (finding or moving) ___ Injustice ___ job seeking/ interviews ___ job/work issues ___ lateness of self ___ losing or misplacing things ___ medical/dental treatment ___ money (lack of) ___ new experiences or challenges ___ noise of other people/animals ___ public speaking/oral presentations ___ parking problems ___ lack of privacy ___ professors/coaches ___ registering for/selecting classes ___ roommates/housemates: relationships ___ schoolwork (working on/hard) ___ sexually transmitted diseases ___ sports team/celebrity performance ___ tedious everyday chores ___ time demands/deadlines ___ traffic problems (other drivers) ___ traffic tickets ___ waiting ___ weather problems ___ weight/dietary management

Total score: _____ Compared to the stress other college students have for hassles, a score of: 105, about average. above 135, much more stress below 75, much less stress

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RESOURCES Suggested Readings: Experiencing Stress Brett, J.F., Brief, A.P., Burke, M.J., George, J.M., & Webster, J. (1990). Negative affectivity and the reporting of stressful life events. Health Psychology, 9, 57-68.

Cooper, C.L. & Dewe. P. (2004). Stress: a brief history. Malden, MA: Blackwell Publ.

Goldberger, L., & Breznitz, S. (Eds.). (1993). Handbook of stress: Theoretical and clinical aspects. New York: Free Press.

Kopin, I.J. (1995). Definitions of stress and sympathetic neuronal responses.

Annals of the New York Academy of Sciences, 771, 19-30.

Lazarus, R.S.(1998). The life and work of an eminent psychologist: Autobiography of Richard S. Lazarus. New York: Springer.

Lazarus, R.S. (1999). Stress and emotion: A new synthesis. New York: Springer.

Oxington, K.V. (2005). Psychology of stress. New York: Nova Biomedical Books.

Perrez, M. & Reicherts, M. (1992). Stress, coping, and health: a situation-behavior approach. Seattle: Hogrefe & Huber.

Slavin, L.A., Rainer, K.L., McCreasry, M.L. & Gowda, K.K. (1991). Toward a multicultural model of the stress process. Journal of Counseling & Development, 70, 156-163.

Reactions to Stress Bremner, J.D. (2002). Does stress damage the brain?: Understanding traumarelated disorders from a mind-body perspective. New York, NY: W.W. Norton & Co, Inc. Chizea, D. (2004). Growing up in the digital age: how stress impacts our younger generation. Ebensburg, PA: Chizea Productions.

Clark, D.D. (2007). They can’t find anything wrong!: 7 keys to understanding, treating, and healing stress illness. Boulder, CO: Sentient Publ.

Friedman, M.J., Charnery, D.S., & Deutch, A.Y. (Eds.). (1995). Neurobiological and clinical consequences of stress: From normal adaptation to PTSD. Philadelphia: Lippincott-Raven.

Matthews, K, et al. (1986). Handbook of stress, reactivity, and cardiovascular disease.

New York: Wiley.

Ng, D.M. & Jeffery, R.W. (2003). Relationships between perceived stress and health behaviors in a sample of working adults. Health Psychology, 22(6) 638-642.

Smith, J.C. (1993). Understanding stress and coping. New York: Macmillan.

Wykle, M., Kahana, E., & Kowal, J. (Eds.). (1992). Stress and health among the elderly. New York: Springer.

Sources of Stress Amato, P.R., & Keith, B. (1991). Parental divorce and the well-being of children: A meta-analysis. Psychological Bulletin, 110, 26-46.

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Aneshensel, C.S. (1992). Social stress: Theory and research. Annual Review of Sociology, 18, 15-38.

Cooper, C.L., Dewe, P.J. & O’Driscoll, M.P. (2001). Organizational stress: A review and critique of theory, research, and applications. Thousand Oaks, CA: Sage Publications, Inc. Dressler, W.W. (1994). Social status and the health of families: A model. Social Science & Medicine, 39, 1605-1613.

Hardy, R.E. (2001). Woodpeckers don’t get headaches: the psychology of stress, addiction, and relationships. Laredo, TX: we-publish.com O’Connor, R. (2005). Undoing perpetual stress: the missing connection between depression, anxiety, and 21st century illness. New York: Berkley Books.

Sapolsky, R.M. (2004). Why zebras don’t get ulcers. New York: Holt.

Ursano, R.J. (1997). Disaster: Stress, immunologic function, and health behavior.

Psychosomatic Medicine, 59, 142-143.

Measuring Stress Cohen, S., Kessler, R.C., & Gordon, L.U. (Eds.). (1995). Measuring stress: A guide for health and social scientists. New York: Oxford University Press.

Neufeld, R. (1989). Advances in the investigation of psychological stress. New York: Wiley.

Suggested Films and Videos: Experiencing Stress 1. Biological Mind: Seriously stressed. (2006, Films for the Humanities & Sciences, 46 min.). An immunologist, psychiatrist, and mental skills coach present the symptoms of chronic stress. Case studies are presented.

2. Scientific American Frontiers: Worried Sick. (2003, PBS Home Video, 60 min).

Explores stress, its modern sources, contributions to illness, and relaxation techniques to cope.

3. Stress Hurts! A wake-up call for women. (2000, Films for the Humanities & Sciences, 46 min). Dr. Nancy Snyderman reports on the unique stress experience of women.

4. Stressed to the limit. (2006, Intelecom, 27 min.). Explores various topics of health psychology, including the fight-or-flight response, lymphocytes, cytokines, heart disease, and the psychosocial lure of cigarette smoking.

5. The nature of stress. (1992, Annenberg/CPB Collection, 60 min). Explores the psychological and biological factors that contribute to stress.

Reactions to Stress 6. Accepting Life’s Transitions. (1998, Films for the Humanities & Sciences, 29 min.). Focuses on aging and how people cope with this life transition.

7. Coping with stress. (2001, Films for the Humanities & Science, 30 min).

Analyzes sources of stress and techniques for managing stress.

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8. Caught in the speed trap: Information age overload. (2000, Films for the Humanities & Science, 43 min). A look at techno-stress and its relationship to illness.

9. Post-Traumatic Stress Disorder. (1996, Films for the Humanities & Sciences, 15 min.). Examines the disorder associated with anxiety symptoms experienced following the witnessing of a traumatic event.

10. Stress: Keeping your cool. (1995, Films for the Humanities, 20 min) Experts explore the causes of stress and the relationship between stress and health.

Sources of Stress 11. Job stress. (1991, Whole Person Associates, 20 min). A look at occupational stressors with a focus on job stress management.

12. Running out of time: Time pressure, overtime, and overwork. (1995, Films for the Humanities & Science, 57 min). Explores the impact of time pressure and overwork with cross-cultural comparisons.

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Internet sites of interest: Stress Organizations 1. http://www.stress.org - The American Institute of Stress 2. http://www.ncptsd.org - National Center for PTSD Stress Information Resources 3. http://www.clas.ufl.edu/users/gthursby/stress- a virtual library on stress.

4. http://healthfinder.gov - search engine with links to the topic of stress.

5. http://www.apahelpcenter.org/articles/article.php?id=21 - APA site that discusses types of stress.

Online Stress Tests 6. http://www.internethealthlibrary.com/sq/stress/stress-assess.htm - Internet Health Library - How Vulnerable Are You to Stress?

7. http://health.discovery.com/centers/stress/balancing/stress/assessment.html - Discovery Health - Online Holmes & Rahe stress test.

8. http://www.jsearch.com/jshome2b.html- Job burnout test.

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TEST QUESTIONS True or False T

1.

Threat is the expectation of future harm.

2.

The assessment of our resources available for coping with an event is called primary appraisal.

3.

A cognitive appraisal is necessary in order for stress to occur.

4.

Albert Ellis believes that a person's irrational beliefs increase their stress.

5.

As a rule, life transitions are not stressful.

6.

The first stage of the General Adaptation Syndrome is the stage of resistance.

7.

Selye believed that the physiological pattern of response to different types of stress was the same.

8.

The three types of conflict are approach/approach, approach/avoidance and avoidance/avoidance.

9.

Children under five tend to grieve less over the loss of a parent than an adolescent.

10.

A near perfect positive correlation exists between social readjustment and illness.

(64)

F (64)

F (65)

T (65)

F (65)

F (67)

T (68)

T (73)

T (75)

F (81)

In general, men report experiencing more major and minor stressors than women.

A. True B. False

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Matching.

Match the following people with the descriptions in one through five a. Walter Cannon b. Hans Selye c. Holmes and Rahe d. Marianne Frankenhaeuser e. Richard Lazarus b

1. Described the General Adaptation Syndrome to chronic stress.

(67)

d

2. Examined the effects of effort and distress on stress.

(69)

a

3. In 1929, described the body's reaction to emergencies.

(67)

e

4. Related stress to cognitive appraisal.

(63)

c

5. Related illness to social readjustment.

(79)

Match the following with the descriptions in questions six through ten. a. Polygraph b. Social Readjustment Scale c. Corticosteroids and catecholamines d. Daily Hassles scale e. Uplifts scale d

6. Measures day-to-day unpleasant or potentially harmful events.

(82)

a

7. An electronic/mechanical measure of physiological changes.

(78)

e (82)

8. Was developed in the belief that pleasant events might lessen the effects of hassles on health.

c

9. Indicates the results of stress as expressed by the adrenal glands.

(78)

b

10. Provide the relative weighting of the stressfulness of different life changes.

(80)

102

Multiple Choice b (62)

a (62)

b (62)

c (62)

c (63)

1. Which of the following statements about stress is true? a. Stress is an uncommon experience. b. Stress may be only a mild condition. c. All individuals experience stress equally. d. Stress is always of short duration.

2. A stressor may be correctly defined as a. an event that is physically or psychologically challenging. b. a person under stress. c. a medication taken to relieve stress. d. none of the above 3. Marianne is preparing to give an oral report for her psychology class. Her stomach is tight and she perspires when she thinks about giving the report.

She describes these feelings as stress. This description focuses on stress as a. stimulus. b. response. c. transaction. d. chemical reaction.

4. A person's psychological and physiological response to a stressor is called a. a transaction. b. discrepant behavior. c. strain. d. avoidance 5. The process approach to stress includes what component in addition to stressors and strains? a. the environment only b. chronic living circumstances c. the relationship between the person and environment d. major life events

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c (62)

d (63)

b (63)

b (63)

c (64)

a (64)

6. The continuous interactions and adjustments between a person and the environment are called a. stressors b. strains c. transactions d. appraisals 7. Which is not one of the four components of the definition of stress? a. person-environment transaction b. perception of a discrepancy c. biopsychosocial resources d. biological markers of stress 8. David complains that he has "too much to do and not enough time to do it."

His experience of stress represents the discrepancy between a. stressors and strains. b. demands and resources. c. heredity and environment. d. biological and psychological systems.

9. Alice is a highly skilled computer specialist but spends the majority of her time conducting minor systems checks. The resulting boredom she experiences is stressful because a. it creates an overutilization of available resources. b. it creates an underutilization of available resources. c. a lack of activity always creates stress. d. she will soon forget about her available resources.

10. Richard Lazarus' cognitive appraisal model of stress is important because of its emphasis on a. changing actual environmental stressors. b. identifying physiological effects of stress. c. the role of perception in stress. d. the role of praise in reducing stress.

11. As you drive to school, the radio informs you that there is a traffic accident on an expressway near you. You determine that you will not be affected since you will exit well before any traffic jam will occur. The thought process in which you are engaging is called a. primary appraisal. b. secondary appraisal. c. final appraisal. d. a and c only

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a (64)

c (64)

b (64)

d (64)

b (64)

c (65)

12. Assessing a potentially stressful event in comparison to previous personal situations is called a. primary appraisal. b. secondary appraisal. c. threat impact analysis. d. rational emotion.

13. Manuel has been accepted to medical school, which he sees as a real opportunity to use his knowledge in biology and his skills with people. This situation represents the concept of _____ in the cognitive appraisal process. a. threat b. harm-loss c. challenge d. transaction 14. One example of a vicarious transaction that might cause stress would be a. fighting in a boxing match. b. watching a couple argue at a party. c. arguing with a bank teller over the balance of your checking account. d. failing a midterm exam.

15. Which of the following conclusions has been reached by studies of people’s empathizing with other individuals in stressful situations? a. People can experience stress vicariously. b. Empathic stress reactions depend on primary appraisal. c. Vicarious stress is unaffected by appraisal processes. d. Both a and b.

16. Ongoing assessment of available coping resources is called a. primary appraisal. b. secondary appraisal. c. cope-threat analysis. d. biofeedback.

17. Which of the following statements about cognitive appraisal and stress is NOT true? a. Primary and secondary appraisals are highly interrelated. b. Secondary appraisal doesn't always follow primary appraisal in time. c. Stress cannot be experienced unless cognitive appraisal occurs. d. Stress conditions often depend upon the outcome of our appraisals.

105

a (65)

b (65)

a (66)

c (66)

d (66)

18. People with positive self-esteem may experience less stress because a. demands are perceived as challenges rather than threats. b. threatening situations are more highly motivating to these individuals. c. people with good self-esteem have slower physiological responses to stressful situations. d. they have an overly inflated sense of self-confidence.

19. When Paul's girlfriend breaks up with him he reacts by saying "I'll never be happy. No one will ever love me!" According to Albert Ellis, Paul's _____ beliefs are increasing his stress. a. negative b. irrational c. transactional d. self-pitying 20. Janelle is fired from her job. Which of the following characteristics of stressful situations, as described in the text, does her situation reflect? a. low desirability b. ambiguity c. difficult timing d. posttraumatic stress disorder 21. In his new job, Harold has been given very unclear guidelines about his responsibilities. The stress he feels is probably related to a. low controllability. b. secondary appraisal. c. situation ambiguity. d. social readjustment.

22. Kevin was one of the few survivors of Hurricane Katrina in his New Orleans neighborhood. Since the hurricane he has had difficulty sleeping, gets extremely anxious when hurricane warnings are issued and keeps reliving memories of his escape during Katrina. Kevin is likely to be suffering from a. a malfunctioning hypothalamus-pituitary adrenal axis. b. harm ambiguity. c. a disease of adaptation. d. posttraumatic stress disorder.

106

b (67)

d (67)

b (67)

23. Walter Cannon's description of the body's reaction to emergencies has been called the a. parasympathetic response. b. fight-or-flight response. c. general adaptation syndrome. d. cognitive appraisal approach.

24. Walter Cannon proposed that the fight-or-flight response a. is related to epinephrine secretion. b. is preparatory in nature. c. may be harmful if prolonged. d. all of the above 25. The sympathetic nervous system and the endocrine system directly mediate a. only a few of our noticeable stress reactions. b. physiological reactions to stress. c. cognitive stress reactions. d. primary but not secondary appraisals.

a

26. The correct sequence of stages in the general adaptation syndrome is (67-68) a. alarm, resistance, exhaustion. b. resistance, alarm, exhaustion. c. alarm, exhaustion, resistance. d. exhaustion, resistance, alarm. a (67)

c (67)

27. Which general adaptation syndrome stage is most like the fight-or-flight response? a. alarm b. secondary appraisal c. exhaustion d. adaptation 28. Selye called the series of physiological reactions the body makes under long-lasting stress (the) _____ syndrome. a. fight-or-flight b. secondary appraisal c. general adaptation d. alarm

107

b (68)

c (69)

a (69)

b (69)

b (69)

29. Which of the following statements about the general adaptation syndrome is correct? a. It includes the role of psychosocial factors. b. It assumes that all stressors produce the same physiological reactions. c. It largely ignores biological responses to stress. d. It assumes that children do not go through the same stages as adults.

30. Mason's work with stressors and hormones showing the sensitivity of hormonal secretions to psychological influences is evidence against Selye's notion of a. the general adaptation syndrome. b. the alarm stage. c. the nonspecificity of the GAS. d. the resistance stage.

31. According to the research by Frankenhaeuser and her colleagues, increased catecholamine and cortial secretion is usually associated with experiences involving a. effort with distress. b. effort without distress. c. distress without effort. d. neither effort or distress.

32. According to the research by Frankenhaeuser and her colleagues, increased catecholamine secretion only may be associated with experiences involving a. effort with distress. b. effort without distress. c. distress without effort. d. both effort and distress.

33. In their study of the relationship of achievement tests in elementary school to stress, Tennes and Kreye found that stress significantly increased for a. all children on test days. b. children with above average intelligence but not for those with low intelligence. c. children with low intelligence but not for those with above average intelligence. d. none of the children showed increased stress on test days.

108

b (69)

d (70)

a (70)

d (70)

b (70)

34. Research on the influence of intelligence on the stress experienced by children taking achievement tests showed a. it has no effect. b. more intelligent children were more stressed than less intelligent children. c. less intelligent children were more stressed than more intelligent children. d. males were more stressed than females regardless of intelligence.

35. Research on children exposed to chronic noise levels at home showed that they had a. difficulty knowing which sounds to tune out. b. increased ability to discriminate between words. c. difficulty knowing which sounds to attend to. d. both a and c 36. Cohen and his colleagues concluded that children who live in noisy environments may a. develop generalized cognitive deficits. b. increase their ability to distinguish sounds. c. suffer physiologically but not cognitive deficits. d. learn to ignore relevant information.

37. What is one effect of epinephrine and norepinephrine on memory? a. They impair all types of memory. b. They enhance memories of neutral events. c. They interfere with memories of neutral events. d. They enhance memories of stressors.

38. Which statement regarding stress and cognition is NOT true? a. Cognitions can affect the experience of stress. b. Thinking about the stressful incident constantly reduces the stress. c. Stress can affect cognitions. d. Chronic stress can result from cognitive processes.

d

39. Two babies, one 2 months old and the other 19 months old, are stung by (70-71) bees. The older baby's emotional response is likely to be _____ whereas the younger baby is likely to show _____. a. distress; anger b. distress; distress c. anger; anger d. anger; distress

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b (71)

d (72)

c (73)

b.

(73)

b (73)

d (73)

40. Negative social behaviors tend to increase when stress is accompanied by a. depression. b. anger. c. resistance. d. poor impulse control.

41. Frank just received a reprimand at work for sloppy performance whereas Nancy had a terrible argument with her best friend. Research supports which of the following statements regarding their likely stress levels? a. Frank is probably experiencing much more stress than Nancy. b. Nancy is probably experiencing much more stress than Frank. c. Neither is likely to experience stress. d. Frank and Nancy are likely to have similarly high stress levels.

42. A medieval knight met a dragon while he was crossing a bridge over a huge chasm. He perceived that his only options were to charge into battle with the deadly beast or leap from the bridge. He was experiencing a(n) a. approach-approach conflict. b. approach-avoidance conflict. c. avoidance-avoidance conflict. d. knightmare.

43. Krystal has learned that she has a carcinoma that is best treated by a radical surgery that involves removal of her right eye and cheekbone, which would be quite disfiguring. However, if she doesn't undergo surgery, her chances of survival are quite poor. Krystal is experiencing a. an approach/approach conflict. b. an approach/avoidance conflict. c. an avoidance/avoidance conflict. d. harm ambiguity.

44. Which of the following statements about "temperamentally difficult" children is NOT true? a. Only about 10% of children are classified as "temperamentally difficult." b. They show predictable sleep patterns. c. They resist new foods. d. They react negatively to new people.

45. The Davises are getting a divorce. Which of the following is the best strategy for helping their children cope with the situation? a. Move to a new area so the children can "start over." b. Tell the children every detail of the situation no matter how painful to them. c. Keep the impending divorce from the children for as long as possible. d. Make sure the children have regular contact with both parents.

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d (74)

c (75)

d (75)

b (75)

a (75)

d (77)

46. The stress experienced by a family when an adult is ill a. may result from a strain on finances. b. diminishes with recovery. c. may restrict the family's time. d. all of the above.

47. Which of the following statements about a child's grief at the loss of a loved one is true? a. Adolescents seem to grieve the least. b. All age levels of children seem to grieve with equal intensity. c. Children under age 5 seem to grieve the least. d. A child's concept of death remains the same from age 4 to 8.

48. Which of the following statements regarding bereavement is true? a. Young children grieve longer and more intensely than older children. b. Parents with more children grieve the loss of a child more than parents with a single child who can regain their pre-parenting freedoms. c. Older couples grieve spousal loss more than younger couples because they have lived with each other longer. d. None of these statements is supported by the research in the text.

49. According to the research cited in the text, the loss of one’s spouse would be most stressful for which of the following age groups? a. An adult at any age. b. People approaching or in early adulthood. c. People in mid-life. d. People in old age.

50. Research has found that excessive workloads are associated with a. increased accidents and health problems. b. high unemployment and absenteeism. c. greater cognitive appraisal. d. happier marriages.

51. Research has found that retirement is associated with a. loss of identity. b. higher spousal stress. c. expectations of freedom and leisure d. all of the above

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c (77)

b (78)

b (78)

c (80)

d (81)

d (82)

52. The effects of local environmental hazards such as Three Mile Island have a. little effect on stress levels of local residents. b. created greater stress in those who hear about the event than in those who actually experience it. c. lasting, long-term negative effects on those who experience it. d. intense short-term but no long-term negative effects on local residents.

53. You are a researcher and need to include a physiological measure of stress in your next experiment. Which of the following could you use? a. an SRRS b. polygraph c. the GAS scale d. the Daily Hassles scale 54. Advantages of measuring physiological arousal to assess stress include all of the following except a. reliable measures. b. low cost. c. objective measures. d. easily quantifiable measures.

56. According to the findings on life events and age by Goldberg and Comstock, which of the following people would have been likely to report the fewest stressful life events in the year prior to the study? a. Ann, a single person in her 20s b. Bob, recently divorced in his 40s c. Wayne, a married person in his 60s d. all of the above were likely to have a very small number of stressful life events 56. Subjects' scores on the SRRS and illness do not correlate very highly. The best explanation for this finding is a. stress and illness actually are unrelated. b. some of the questions on the SRRS are vaguely worded. c. illness may occur for many reasons other than stress. d. both b and c 57. The most frequent daily hassles found by Lazarus and his coworkers included all of the following except a. rising prices. b. home maintenance. c. too many things to do. d. getting a task completed.

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b (82)

c (82)

b (84)

58. Research on the relationship of hassles and uplifts to health has shown a. no real relationship of either factor to health. b. some relationship of hassles to health. c. some relationship of uplifts to health. d. uplifts help protect from the effects of hassles.

59. The best way of summarizing the relationship of stress to health is a. stress and health are consistently and strongly related b. stress and health are unrelated. c. stress and health are consistently and moderately related. d. stress is the primary component in the development of illness.

60. Taking into account only the relationship between stress and performance, on which test are you most likely to perform the best? a. A practice exam which has no bearing on your grade. b. A mid-term which counts 25% of your grade. c. A final exam which is 100% of your grade. d. Stress and performance have been proven to be unrelated.

Which of the below is NOT one of the 3 Theories for stress? a. Fight or Flight b. Tend and Befriend c. Adjust or Exhaust d. General Adaptation Syndrome

Short Answer Questions 1. Discuss the relationship between primary and secondary appraisal.

2. Compare and contrast Cannon's fight-or-flight response with Selye's general adaptation syndrome.

3. Using concepts from the text to answer this question, what stress factors might be affecting your performance on this exam?

Essay Questions 1. Angelina and Warren, college juniors in their early 20s, unexpectedly find that they are about to become parents for the first time. Angelina is ecstatic about the situation whereas Warren is pretty distressed. Using the cognitive appraisal approach, describe some of the factors that might be contributing to their varying experiences.

2. Michael has started a new job and is experiencing a great deal of stress. What are 113

some of the situational and personal factors that might be affecting him physically, psychologically, and emotionally?

3. Consider that you are a consultant to a stress researcher. She is beginning a new study and wants to incorporate some measures of stress. What advice would you give her?

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CHAPTER 4 STRESS, BIOPSYCHOSOCIAL FACTORS, AND ILLNESS CHAPTER OUTLINE I. Psychosocial Modifiers of Stress A. Section Introduction 1. Individual differences in reactions to stress often result of psychological and social factors that modify impact of stressors on individual B. Social Support 1. Definition = perceived comfort, caring, esteem or help received from others 2. Types/functions of social support a. emotional or esteem support i. expression of empathy, caring, concern, positive regard, encouragement toward person that provides comfort and reassurance with sense of belongingness and love during times of stress b. tangible or instrumental support i. direct assistance such as lending money or helping with chores c. informational support i. giving advice, directions, suggestions, or feedback about how person is doing d. companionship i. availability of others to spend time with person providing feeling of membership to a group that shares interest and social activities 3. Social support needed and received a. type of support needed and received depends on the circumstances. i. example: cancer patients find emotional and esteem support helpful whereas patients with less serious chronic illness report different types of support equally helpful b. research shows students received more forms of social support following stressful situations i. emotional/esteem and informational support occurred more frequently than tangible support ii. emotional/esteem support protects people from negative emotional consequences of stress 4. Who gets social support? a. factors that determine receiving support i. qualities of recipients of support 1) sociability towards others 114

2) whether they help others 3) whether they let others know help is needed ii. qualities of support providers 1) less likely to give support if don't have needed resources 2) under stress or need help themselves 3) are insensitive to need of others iii. social support in old age 1) elderly may exchange less support due to loss of spouse or inability to reciprocate iv. composition and structure of social network 1) receiving social support depends on size, composition, intimacy and frequency of contact with social network b. assessing social support i. Social Support Questionnaire 1) 27-item questionnaire that measures sources of and satisfaction with support.

5. Gender and sociocultural differences in receiving support a. gender and social support i. women receive less support from spouses than men do and rely on women friends for social support 1) differences may be due to greater intimacy in women’s friendships and differences in seeking and providing emotional/esteem support b. sociocultural groups and social support i. African Americans have smaller social networks than European Americans or Hispanics. ii. minority men's networks are larger than women's. iii. for different race/ethnic groups, support networks include: 1) Hispanics: family 2) European American: friends/coworkers 3) African American: family and church 6. Social support, stress and health a. greater social support leads to less stress i. example: lower psychological strain, blood pressure in employees with more available social support b. cardiovascular reactivity lower in stressful situations for individuals with supportive friend present i. may depend on person's gender and type of support given c. is relationship between social support and health purely correlational? i. Berkman & Syme research equated participants on health dimensions and later found people with less social support had higher mortality rates.

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d. other research found social support has been linked to lower mortality rates, less illness, faster recovery from illness i. may depend on beliefs that one can cope with demands of illness 7. How social support affects health? a. two theories on how social support influences health i. buffering hypothesis - support protects during times of high stress 1) effective only or mainly when person encounters strong stressor; under low-stress, buffering doesn’t occur 2) buffering works in two ways a) person less likely to appraise situation as stressful b) social support modifies response to stress after initial appraisal ii. direct effects hypothesis - support is beneficial to health regardless of stress level 1) how direct effects works a) social support increases feelings of belongingness and self-esteem b) social contacts encourage us to lead healthier lifestyles 8. Does social support always help? a. may not be perceived as supportive or match needs i. instrumental support = valuable for stress that is controllable ii. emotional support = important for stress that is uncontrollable b. impact of marriage i. protective health benefits = married people live longer ii. marriage itself may not protect health 1) differences in death rates may depend on personality and satisfaction level with marriage c. circumstances in which social ties harm health i. frequent social contacts exposes people to infectious illness ii. family and friends may set bad examples or interfere with healthy behavior B. A Sense of Personal Control 1. People strive for personal control a. definition: feeling that they can make effective decisions and take actions to produce positive outcomes and avoid negative

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2. Types of control a. behavioral = concrete action(s) to reduce stress i. reduces intensity or shortens duration of event b. cognitive = using thought processes or strategies to reduce stress i. appears to have most consistent effect of reducing stress c. decisional = choice of a course of action d. informational = getting knowledge about stressful event 3. Beliefs about oneself and control a. section introduction i. people differ in degree to which they believe they have control over their lives b. types of locus of control i. internal = control of events lies within us ii. external = situations/others control what happens c. assessing locus of control i. I-E Scale by Rotter = scale used to measure the degree of internality or externality of beliefs about personal control d. how self-efficacy affects sense of control i. self-efficacy involves the estimate of chances of success based on: 1) belief that behavior would produce positive outcome 2) we are capable of producing the behavior properly ii. strong self-efficacy is linked to lower psychological and physiological strain 4. Determinants and development of personal control a. assessed through our past success/failure performances and social learning b. information used to determine personal control is usually retrospective, complex, not clear-cut i. result is that feelings of personal control are often not based on fact or particularly objective ii. illusion of control – Langer’s notion that we think we have control over otherwise chance events 5. Gender and sociocultural differences in personal control a. gender and sociocultural differences in personal control depend on social experience i. teachers and parents can foster beliefs in external control and low self-efficacy in girls ii. for people of color and the poor, limited access to power and economic development can also foster external locus of control beliefs

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6. When people lack personal control a. section introduction i. under high stress over long periods of time when nothing one does seem to matter, feelings of helplessness and apathy may develop b. Seligman’s theory of learned helplessness i. learning that actions don't result in expected outcomes ii. a principal characteristic of depression c. extension of theory i. observations that influenced extension of theory 1) exposure to uncontrollable negative events doesn’t always result in learned helplessness 2) depressed people report loss of self-esteem ii. revision of theory included attribution for cause of event iii. attributions for uncontrollable events judged on 3 dimensions 1) internal-external - are events due to personal inability or external causes? a) internal attribution connected to loss of selfesteem 2) stable-unstable - are events long-lasting or temporary? a) stable attribution connected to helplessness and depression 3) global-specific - are effects of events wide-ranging or narrow? a) global attribution connected to helplessness and depression iv. pessimistic world view consists of an internal-stableglobal attribution style 7. Personal control and health a. relationship between personal control and health i. strong sense of personal control may be related to: 1) maintaining health and preventing illness 2) adjusting to illness and promoting rehabilitation b. measuring personal control i. Multidimensional Health Locus of Control scales 1) 18 items on three subscales measuring the following beliefs: a) internal health locus of control: control for one’s health lies within oneself b) powerful other’s health locus of control: one’s health is controlled by other people c) chance locus of control: luck or fate controls health 118

c. beliefs of personal control influence health in various ways i. pessimism: poorer health habits, contract more illness, less likely to take active steps to treat illness ii. internal/powerful other’s control beliefs: related to less depression and increases hopefulness iii. internal control beliefs: influences realization that have effective ways to control stress iv. use of cognitive control: influenced adjustment in women with breast cancer v. self-efficacy beliefs: increased adherence to rehabilitation efforts 8. Health and personal control in old age a. section introduction i. declines in health and opportunities for responsibility observed in elderly in nursing or retirement homes 1) Langer and Rodin nursing home study found increasing responsibility related to better health and increased longevity 2) Schulz and other’s studies found withdrawing personal control had negative effects on health b. overall conclusions i. even minor levels of personal control have positive impact on health ii. facility staff need to carefully consider what kind of responsibility to introduce and what will happen if it is removed C. Personality as Resilience and Vulnerability 1. Hardiness a. personality style Kobasa says differentiates between people who do and do not get sick under stress i. differences in personal control only part of reason people vary in odds of getting sick b. characteristics of hardiness i. control = belief that one can influence events ii. commitment = sense of purpose or involvement iii. challenge = viewing changes as opportunities for growth 2. Sense of coherence, mastery, optimism, and resilience a. relationship between these conceptually similar terms i. sense of coherence - when the world is seen as comprehensible, manageable, meaningful 1) low sense of coherence related to more stress and illness symptoms ii. sense of mastery – belief that individuals can effectively deal with the events of life iii. optimism – point of view that good things are likely to 119

happen 1) higher optimism related to less distress, better health habits, better mental and physical health and faster recovery from illness iv. resiliency - having high levels of self-esteem, personal control, and optimism 1) characterized by appraising negative events as less stressful, using positive emotions in face of distress and finding meaning from negative experiences 2) etiology of resilience: genetics and compensating life experiences 3. Personality strengths and health a. retrospective and prospective studies found hardy people have fewer illnesses and deal with stress more effectively b. status as research/theoretical concept uncertain i. may actually be measuring negative affect, not hardiness 4. Personality strengths and health in old age a. stamina - a triumphant, positive outlook during adversity i. low stamina related to negative outlook, feelings of helplessness and hopelessness regarding life events of old age 5. The five-factor model of personality a. neuroticism vs. emotional stability b. extraversion vs. introversion c. openness vs. closed mindedness d. agreeableness vs. antagonism e. conscientiousness vs. unreliability D. Type A Behavior and Beyond 1. Defining and Measuring behavior patterns a. Type A behavior pattern characteristics i. competitive achievement orientation 1). includes being self-critical and striving towards goals with joy in efforts or achievements ii. time urgency 1). includes impatience with delays/unproductive use of time, over-scheduling of commitments, multitasking iii. anger/hostility 1). heightened tendency toward anger or hostility iv. vigorous vocal style 1) speak loudly and control conversation 2. Type B behavior pattern is characterized by low levels of above plus more easygoing and “philosophical” about life 3. Types of measures a. Structured Interview 120

i. face-to-face interview conducted by trained interviewer 1). yields information historical behavioral responses as well as reactions during interview d. strength/weakness of measure i. structured interview 1) strengths a) assesses all three major components of Type A b) classification of Type A with this method is consistent with health outcomes 2) weaknesses a) time-consuming b) expensive to use c) procedure may affect outcome 4. Behavior patterns and stress a. Type A individuals respond more quickly, rapidly to stressors, seeing them as threats and show greater reactivity 5. Age and developmental differences in Type A behavior a. Type A behavior pattern remains from childhood to middle age and then tends to decline in prevalence i. part of decline may be due to early death b. origins of Type A linked to early temperament and heredity 6. Type A behavior and health a. two methods of study and their findings i. looking at differences between Type A/Type B persons for risk of getting sick 1) relationship between Type A and general illnesses is weak ii. studying relationship between Type A and heart disease 1) Western Collaborative Group Study found Type A’s twice as likely to develop CHD and to have died from CHD 2) link esp. clear when structured interview used as measure for Type A 3) survey data helpful when predicting timing of heart attack

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7. Type A's "deadly emotion" a. what difference between structured interview and survey results reveals about the relationship between Type A and CHD i. SI measures all three components of Type A well whereas surveys don’t capture anger/hostility component well 1) observation led researchers to focus on anger/hostility as main component linking Type A to CHD b. research supporting relationship i. Barefoot et al study of physicians 1) high scores on Cook-Medley Hostility Scale were prospectively related to CHD and death ii. other findings linking anger/hostility to CHD 1) chronically very high/very low anger expression damaging to cardiovascular health 2) hostility esp. damaging when expressed outwardly and involves cynical or suspicious mistrust of others c. physiological explanations for relationship i. chronically high levels of stress hormones injure heart ii. high blood pressure strains heart d. cynical/suspicious beliefs and behaviors provokes and worsens social conflicts and undermines social support 8. Are there other dangerous aspects of the Type A pattern? a. social dominance is associated with coronary atherosclerosis and CHD b. Type A associated with greater physiological reactivity and strain II. How Stress Affects Health A. Introductory Section 1. Diathesis-stress model a. viewpoint that a person’s vulnerability to a physical or psychological disorder depends on interplay between predisposition to disorder and amount of stress they experience b. findings of common cold experiment i. people under high stress more likely to develop cold when exposed to virus ii. people experiencing positive emotion less likely to develop cold 2. Causal sequence of stress to illness a. direct route i. changes that stress produces in body’s physiology b. indirect route ii. impact of person’s behaviors when under stress B. Stress, Behavior, and Illness 1. Under high stress conditions, changes in behaviors are likely to 122

increase risk of illness a. more likely to consume high fat diets, engage in less exercise, consume more alcohol, smoke cigarettes b. also impairs sleep which leads to inattention and carelessness and probably more accidents C. Stress, Physiology, and Illness 1. Section introduction a. increase in allostatic load when stress is chronic and severe is linked to wear and tear on body that accumulates over time and leads to illness 2. Cardiovascular system reactivity and illness a. cardiovascular reactivity = any change in the heart, blood vessels or blood in response to stress i. levels of reactivity have been found to be stable throughout life ii. link found between high cardiovascular reactivity and development of CHD, hypertension and stroke. iii. levels laboratory reactivity assumed to reflect reactivity in daily life b. cardiovascular changes related to CHD development i. under stress, there are more activated platelets and lipids which hastens atherosclerosis 3. Endocrine system reactivity and illness a. catecholamines and corticosteroids are released due to activation of hypothalamus-pituitary-adrenal axis during stress i. may increase atherosclerosis and irregular heartbeat b. high levels of social support reduces endocrine reactivity 4. Immune system reactivity and illness a. as result of stress, increases in cortisol and epinephrine associated with decreases in : i. activity of T and B cells against antigens which increases development and progression of infectious disease ii. the production of anti-carcinogen enzymes involved in repair of damaged DNA in body cells D. Psychoneuroimmunology 1. Section introduction a. psychoneuroimmunology = field of study that focuses on the relationship between psychosocial processes and the activities of the nervous, endocrine, and immune system i. feedback loop exists between nervous and endocrine systems and the immune system 1) too little activity results in infection/disease 2) too much activity results in autoimmune disease 2. Emotions and immune function a. negative emotions such as pessimism, depression and stress 123

impair immune function i. research on caregivers of Alzheimer’s patients show lowered immune function and more days of illness ii. less stress associated with increased flu antibodies after vaccination b. Stone’s research shows positive emotions give immune function a boost i. positive events enhance antibody content for several days ii. negative events reduce antibody content only for day of event c. long-lasting, intense interpersonal events produce large immune reductions d. individual’s reaction to specific stressor stable over time 3. Psychosocial modifiers of immune system reactivity a. social support/hardiness can reduce stress and strengthen immune system b. verbally expressing feelings about an event improves immune function, esp. among the cynically hostile c. optimism interacts with length of stressor in reduction of immune function i. for short-term stressors, immune function declines among pessimists ii. for chronic stressors, immune function declines among optimists 4. Lifestyle and immune function a. people with healthy lifestyles (getting exercise, enough sleep, balanced meals, not smoking) show stronger immune functioning 5. Conditioning immune function a. immunosuppression and immuno-enhancement may be conditioned i. process involves both antibody-mediated and cellmediated immune processes III. Psychophysiological Disorders A. Section Introduction 1. Psychosomatic = symptoms or illnesses caused or aggravated by psychological factors 2. Psychophysiological disorders = physical symptoms or illnesses that result from interplay of psychosocial and physiological processes B. Digestive System Diseases 1. Types of diseases a. ulcers i. wounds found in the stomach and duodenum ii. causal processes includes combination gastric juices eroding stomach lining/duodenum that has been 124

weakened by bacterial infection b. inflammatory bowel disease i. wounds in the small and large intestine that cause pain and bleeding c. irritable bowel syndrome i. pain, diarrhea, and constipation without organic evidence of disease 2. Specific role of stress in these diseases is unclear but is related to flareups C. Asthma 1. Asthma = respiratory disorder in which inflammation, spasms and mucous obstruct bronchial tubes resulting in breathing difficulties 2. Three factors appear related to the development of asthma a. specific allergies b. respiratory infections c. biopsychosocial arousal from stress or exercising 3. Attacks appear to be triggered by a combination of allergic and psychosocial processes D. Recurrent Headache 1. Types of recurrent headache a. tension-type (or muscle contraction) headaches i. caused by combination of CNS dysfunction and persistent contraction of head and neck muscles ii. symptoms include dull, steady ache that feels like band of pressure around head b. migraine headaches i. result from dysfunction in brainstem and dilation of blood vessels ii. headache may be preceded by an aura accompanied by dizziness, nausea, and vomiting iii. higher prevalence in women 2. Headache triggers may include hormonal changes, diet, lack of sleep and environmental factors including sunlight and stress E. Other Disorders 1. Other diseases in which stress is a trigger or aggravates episodes a. rheumatoid arthritis i. pain and inflammation of joints b. dysmenorrhea i. painful menstruation accompanied by nausea, headache, dizziness c. skin disorders such as hives, eczema, and psoriasis 2. Although stress appears related to onset and course of these disorders, exact mechanisms remain unclear

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IV. Stress and Cardiovascular Disorders A. Section Introduction 1. Research supports idea that stress is related to development of CHD B. Hypertension 1. Clinical definitions a. hypertension = elevated blood pressure of over 140 systolic and 90 diastolic consistently over several weeks or more b. normal blood pressure = 120 systolic and 80 diastolic 2. Prevalence a. hypertension rates increase after age of 40 3. Classifications of hypertension a. secondary hypertension – caused by medical disorder of body systems or organs (e.g., kidneys) b. primary or essential hypertension - causal mechanism is unknown i. accounts for 90% of cases 4. Risk factors associated with hypertension a. obesity b. diet, including salt, fats, and cholesterol c. excessive alcohol use d. physical inactivity e. family history of hypertension f. psychosocial factors such as stress, anger and hostility 5. Stress, emotions, and hypertension a. situational correlates to hypertension i. stressful occupations (e.g., traffic controllers) ii. crowded, aggressive environments iii. high cardiovascular reactivity also linked to chronic stressors 1) heart rate and blood pressure reactivity linked to stressors that require active involvement 2) persons with severe hypertension show reactivity to all types of stressors b. psychosocial correlates to hypertension i. negative emotions esp. pessimism, anger, and hostility 1) blood pressure higher in pessimists 2) persons with hypertension more likely to be chronically hostile and resentful 3) resting blood pressure higher among persons that dwell on anger-provoking events 6. Stress and sociocultural differences in hypertension a. an interaction between race and environmental stressors is linked to hypertension i. example: African American men in high-stress areas of city were more likely to be hypertensive 126

ii. experiences of racism influence both blood pressure and blood pressure reactivity to stressors C. Coronary Heart Disease 1. CHD incidence is higher in technologically advanced countries a. people live longer and thus have more years to develop disease b. people have more risk factors including obesity and less physical activity c. psychosocial stressors may be different in advanced countries d. people in less advanced countries may have more social support and/or perceive less reason for anger/hostility.

2. Example research supporting link between stress and CHD a. occupational stressors such as heavy workload, increased job responsibility, job dissatisfaction are related to higher levels of CHD b. higher levels of atherosclerosis associated with perceived high levels of stress, unfair treatment, racial discrimination c. using prospective studies, positive relationship between CHD and major life stressors has been determined 3. Physical processes that link stress to CHD a. chronically high levels in catecholamine and corticosteroid damage arteries and heart b. stress elicits cardiac arrhythmia c. stress associated with smoking and high alcohol use d. development of metabolic syndrome i. condition of being over-weight, having hypertension, high cholesterol, poor insulin level control which follows after progression through chronic stress to poor health habits V. Stress and Cancer A. Personality has been linked to cancer since the time of Galen B. Common characteristic of cancers 1. Definition = broad class of disease in which cells multiply and grow in an unrestrained manner 2. Dozens of diseases share this characteristic a. complicates finding causal mechanisms and treatments b. examples i. leukemias - excess production of white blood cells by bone marrow ii. carcinomas - growth of a tumor in tissue C. Attempts to link cancer and stress have included retrospective studies 1. Cancer patients report having had high levels of stress 2. Problems with this approach a. cancer diagnosis made years after disease started b. perceptions may be distorted by the diagnosis 127

3. Research conclusions a. little connection between moderate stress and developing cancer later has been found b. relapses tend to be accompanied by stress or low social support c. high levels of stress after diagnosis is linked to lower immune functioning 4. Concluding thoughts a. influence of stress on cancer probably due to i. severity of stress ii. whether stress is chronic iii. how person reacts to stress iv. whether stress is encountered before or after cancer development b. causal role of stress likely due to i. impairment of immune system ii. increase in behavioral risk factors for cancer due to stress

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DISCUSSION TOPICS 1. Male Role Stereotype and Stress: The topic of stereotypes as a source of stress has received little discussion in the chapters on stress to this point. To the extent that roles and adoption of stereotypes becomes part of one's personality, the following topic may be a starting point for in-class discussion. Dale Cooper Thompson, in his book The Male Role Stereotype, describes the roles males have traditionally been expected to play in society and elaborates on these roles as a source of stress. He identifies six "codes of conduct" for men.

• Acting tough: Being strong and tough, boys & men should be able to "take it"; violence or physical force may be more acceptable means for settling issues.

• Hiding emotions: Bottling up "unacceptable" emotions has been linked to illnesses ranging from hypertension to depression.

• Earning "big bucks": Career choices may be shifted in the direction of bringing in a large income, to be the "breadwinner" and contributes to working at jobs one doesn't necessarily like and overwork.

• Getting the "right" kind of job: Boys are socialized early to see some jobs as not what men do and therefore may forego more rewarding areas of work.

• Competing intensely: Boys learn early to be intense competitors in all spheres of life with little "down time" for relaxation.

• Winning: Getting ahead, winning is an important end goal that can affect work and family relationships and reduce negotiation and compromise.

Students might be asked to express their views on the extent to which these or other stereotypes still serve as pressures in our society.

Source: Thompson, D.C. (1993). The male role stereotype. In Experiencing race, class, and gender in the United States (pp. 146-148). Mountain View, CA: Mayfield Publishers.

2. Eunichs, Testosterone and Longevity.

It has been suggested that testosterone contributes to men's greater vulnerability to some diseases, especially heart disease, whereas estrogen affords a buffering effect for women. Kilmartin reports that HDL levels tend to drop for boys but remain steady for girls during puberty. LDL increases for both males and females but does so more rapidly for males after puberty and not until menopause for females. The basic assumption is that estrogen provides a buffering effect for women. Studies conducted on neutered v. nonneutered cats found that the latter tended to die earlier than the former. Some have suggested this may be due to the link between testosterone and aggression but, even after aggression levels were controlled for statistically, large differences in life span were noted. Kilmartin reminds us of the ethical difficulties with human studies since it would be impossible to randomly assign men to castration/no castration conditions in an experimental design. He notes, however, that historical 129

circumstances have provided anecdotal evidence regarding life spans of men and boys who were castrated (eunichs) to serve as palace harem guards, to maintain singing voices in prepubescent ranges, or to reduce aggression levels while institutionalized in mental health hospitals. One study of the latter group of individuals found that they had a life span on average 14 years longer than a matched group of institutionalized noncastrated individuals. These reports represent an intriguing twist to the search for links between testosterone and heart disease.

Source: Kilmartin, C.T. (1994). The masculine self. (pp.156-157). New York: Macmillan Publishing.

3. Attributional style, culture, and depression.

Sarafino discusses the triad of internal-stable-global thinking as it relates to pessimism. Cross cultural researchers have attempted to test this pattern outside of the United States. In one study, Crittenden & Lamug (1988) found that Filipino and Amercian depressives did not differ in terms of their explanations for negative events: they both endorsed the internal-stable-global triad. Interestingly, however, while the triad pattern did not predict somatic complaints in American participants it did predict them in Filipino participants. These authors argue that Filipinos learn to express somatic complaints as part of their socialization as an expression of depression whereas Americans learn to express depression through indecisiveness, emptiness, and hopelessness. The key idea here is that cultural influences contribute to symptom expression and reporting.

Source: Crittenden, K., & Lamug, C. (1988). Causal attribution and depression: A friendly refinement based on Philippine data. Journal of Cross-Cultural Psychology, 19, 216-231.

4. Autoimmune disease and women.

In reviewing the apparent "gender bias" for disease, Dr. Denise Faustman, director of the Immunolbiology Laboratory at Massachusetts General Hospital and associate profess of medicine at Harvard Medical School, notes that women are 10 times more likely than men to experience autoimmune diseases. In her early research, she found that patients with type I diabetes have T cells that appear to have not been "educated" during their development about the differences between self and nonself.

Specifically, antigen-presenting cells fail to present protein fragments to the T cells properly. Autoimmune disorders may result, then, from faulty teachers, not faulty T cell activity. Since these early findings, similar defects in antigen presentation have been found in patients with lupus, MS, and rheumatoid arthritis. Noting that her early work found that 80-90% of nonobese diabetic (NOD) female mice subjects had this defect in antigen-processing pathways and thus went on to develop diabetes, only 10-15% of male NOD mice subjects did. Similar trends are noted in female v. male human patients with autoimmune disease. Investigating scientists suspected that hormones 130

(estrogen v. testosterone) might be involved in this disease process. This suspicion was heightened when scientists gave testosterone injections to female mice decreased their development of disease and castration of male mice increased their incidence of autoimmune disease. In humans, autoimmune diseases have been studied regarding their relationships to puberty, menstruation, and pregnancy - periods of hormonal fluctuations - with findings varying depending on specific autoimmune disorder. In some cases, high estrogen levels appear to alleviate symptoms whereas, in others, flareups of symptoms are observed. Dr. Faustman draws our attention to the practice of HRT in treatment of post-menopausal women and estrogen therapy in men at risk for heart disease when she asks if it might be possible someday to produce a pharmacological treatment that carries the apparent protective mechanisms of testosterone without its masculinizing effects.

This line of research illuminates the importance of gender/sex differences in the area of health research and ties in with the chapter discussion of immune system functioning.

Source: Faustman, D. (1999) When the body attacks itself. In C.J. Sample (Ed.), Perspectives: Women's health. (pp.125-128). St. Paul, MN: Houghton Mifflin.

5. Stress and Mental Health.

The American Psychiatric Association's Diagnostic and.Statistical Manual of Mental Disorders (4th ed.) presents in its multiaxial diagnostic system the Severity of Psychosocial Stressors Scales for both adults and children. In both cases the stressors are rated as being either "predominantly acute, that is with a duration of less than 6 months, or predominantly enduring, those events enduring more than 6 months." The stressors are then coded as being from I - None or 2 -Mild; through 3 - Moderate, and 4 - Severe; to 5 - Extreme and 6 - Catastrophic. The clinician is advised to rate the stressor itself, not the person's reaction to it. In terms of the different ways stress may be defined, which approach does the DSM-IV take? What are the advantages and disadvantages of such an approach?

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ACTIVITY SUGGESTIONS 1. Assess Yourself: How Much Emotional Support Do You Get? The “Assess Yourself” activity for this chapter has been reproduced in Handout #1. If possible, compare class responses based on the text's discussion of gender. Note that an additional question has been added to assess students' overall level of satisfaction with the support available to them.

2. Social Networks. Have the students examine their own social network (perhaps the same people identified in the Assess Yourself exercise if you wish to extend that activity). Identify how many people with whom they have regular contact. How often are these people seen? What is the nature of their relationship to these people?

Now consider an adverse situation. Which of these people could be asked for a loan of less than five dollars? Which could be asked for a hundred dollars? Who could be asked to turn in a term paper if you were ill? Who could be asked to take you to the emergency room? At 2:00 a.m.? Who would take care of you if you were seriously ill?

Discuss their responses in terms of the buffering effect a good social network has on limiting the effects of large stressors.

3. Learned Helplessness and Attributions. In order to help students appreciate the process of attribution, have the students examine their own cognitive processes. Ask them to write down an example of a recent positive and a recent negative event in their lives. For each event, have them answer the questions: 1. Was the cause of the event under your control or due to circumstances beyond your control?

2. Was the event due to relatively temporary or long-lasting factors?

3. Was the event due to a narrow or wide-acting cause?

After these questions have been answered, have the students identify whether they responded to question #1 in more of the internal vs. external direction, #2 in the stable or unstable direction, and #3 in the global or specific direction. Do the answers they gave differ for the positive and negative events?

4. Locus of Control. Rotter's Locus of Control Scale is accessible on the Web at http://www.ballarat.edu.au/ard/bssh/psych/rot.htm. Students can complete the survey online, have their score calculated, and receive feedback about how their score reveals the internal or external locus of control. Have students print their results for an in-class discussion on the usefulness and connection of locus of control to health issues.

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Handout #1

Assess Yourself: How Much Emotional Support Do You Get? Instructions: Think of the ten people to whom you feel closest. For some of them, you may not feel a strong bond -- but they are still among the closest ten people in your life.

Write their initials in the ten spaces below. ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ In the corresponding space below each of the following questions, rate each person on a 5-point scale where 1 = "not at all" and 5 = "extremely" 1. How reliable is this person: is this person there when you need him or her? ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

2. How much does this person boost your spirits when you feel low? ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

3. How much does this person make you feel he or she cares about you? ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

4. How much do you feel you can confide in this person? ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Add together all of the ratings you gave across all of the people and questions. A total score between 12 and 15 is fairly typical and suggests that you can get a reasonably good level of emotional support when you need it.

Now thinking about the support available to you from these 10 people, how satisfied are you with the support you receive?

1 not at all satisfied

2

3

4

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5 extremely satisfied

RESOURCES Suggested Readings: Psychosocial Modifiers of Stress Bolger, N., & Zuckerman, A. (1995). A framework for studying personality in the stress process. Journal of Personality and Social Psychology, 69, 890-902.

Friedman, H.S. (Ed.). (1992). Hostility, coping, and health. Washington, DC: American Psychological Association.

Houston, B.K. & Snyder, C.R. (1988). Type A behavior pattern: research, theory, and intervention. New York: Wiley.

Lynes, S.A. (1993). Predictors of differences between Type A and B individuals in heart rate and blood pressure reactivity. Psychological Bulletin, 114, 266-295.

Schaufeli, W.B., Maslach, C., & Marek, T. (Eds.) (1993). Professional burnout: Recent developments in theory and research. Washington, DC: Taylor & Francis.

Shumaker, S.A., & Hill, D.R. (1991). Gender differences in social support and physical health. Health Psychology, 10, 102-111.

How Stress Affects Health Blanchflower, D.G. & Oswald, A.J. (2007). Hypertension and happiness across nations.

Cambridge, MA: National Bureau of Economic Research.

Friedman, M.J., Charnery, D.S., & Deutch, A.U. (Eds.). (1995). Neurobiological and clinical consequences of stress: From normal adaptation to PTSD. Philadelphia: Lippincott-Raven.

Nelson, R.J., Demas, G.E., Klein, S.L., et al. (2002). Seasonal patterns of stress, immune function, and disease. New York: Cambridge University Press.

O'Leary, A. (1990). Stress, emotion, and human immune function. Psychological Bulletin, 108, 363-382.

Perrez, M., & Reicherts, M. (1992). Stress, coping, and health. Lewiston, NY: Hogrefe & Huber.

Rice, P.L. (1999). Stress and health (3rd ed.). Pacific Grove, CA: Brooks/Cole.

Smith, T.W., Ruiz, J.M., & Uchino, B.N. (2004). Mental Activation of Supportive Ties, Hostility, and Cardiovascular Reactivity to Laboratory Stress in Young Men and Women. Health Psychology, 23(5) 476-485.

Williams, R.B. (1995). Somatic consequences of stress. In M.J. Friedman, D.S. Charnery, & A.Y. Deutch (Eds.), Neurobiological and clinical consequences of stress: From normal adaptation to PTSD (pp. 403-412). Philadelphia: LippincottRaven.

Zatura, A.J. (2003). Emotions, stress, and health. London: Oxford University Press.

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Suggested Films and Videos: 1. Stress and immune function. (Films for the Humanities & Sciences, 26 min). An in-depth look at the relationship between stress and immune function.

2. The healing mind. (1993, Lucerne Media, 53 min). Explores psychoneuroimmunology.

Internet sites of interest: 1. http://www.msnbc.com/onair/nbc/nightlynews/stress/stresstypea.asp?cp1=1. - online printable type A personality quiz 2. http://workhealth.org/risk/rfbtypea.html - describes Type A Behavior Pattern.

3. http://www.teachhealth.com - explores the medical basis for stress 4. http://www.pnirs.org - Psychoneuroimmunology Research Society

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TEST QUESTIONS True or False F

1.

Informational support includes direct assistance such as when people lend money.

2.

If individuals believe that they are capable of coping with an illness, their recovery is not statistically affected by the addition of social support.

3.

Cognitive control strategies involve taking concrete actions to reduce the impact of a stressor.

(89)

T (92)

F (94)

T

4.

Pessimists are likely to adopt a set of internal-stable-global attributions (96) to explain negative life events.

F

5.

At the present time, all the research evidence indicates that hardiness is linked to good health.

6.

The Structured Interview for assessing Type A behavior is widely used because of its ease of administration and low cost.

7.

Release of hormones such as the catecholamines and corticosteroids appear related to atherosclerosis as well as diminished immune system functioning.

8.

Essential or primary hypertension is the result of a disorder in a body system such as the kidneys.

9.

Obesity, alcohol use, low levels of physical activity and a positive family history of hypertension are all related to the development of hypertension.

10.

(114)

Current research suggests there is little connection between moderate stress and later development of cancer.

T

Tension headaches are muscular in origin and involve a slow progression.

(99)

F (100)

T (104)

F (111)

T (112)

T

The gender differences in receiving social support have concluded that men receive social support from their friends, while women receive social support from their children.

A. True B. False In general, men report experiencing more major and minor stressors than women.

A. True B. False

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Matching Match the concept with the characteristics listed in questions one to five. a. Type A behavior b. hardiness c. resilience d. stamina e. internal locus of control b (98)

d (99)

a (100)

c

1. The belief that one can influence events in their lives and have a sense of purpose or involvement in the events of their lives.

2. In old age, has been characterized as "a triumphant positive outlook during periods of adversity".

3. A behavior pattern marked by a sense of time urgency, hostility and selfcritical competitiveness.

(98)

4. Children with these characteristics are able to resist the adversities of life and grow up well-adjusted even in extreme conditions.

e

5. Marked by believing one is responsible for successes and failures.

(94)

Match the disorder with the characteristics in questions six through ten a. atherosclerosis b. cardiac arrhythmia c. migraine d. essential hypertension e. leukemia c (110)

6. Results from the constriction and dilation of blood vessels, and may be preceded by an aura.

d

7. Medically defined as blood pressure exceeding 140/90.

(111)

b

8. Heart flutters or fibrillation.

(105)

a (104)

9. May result in a "heart attack" due to the narrowing of the coronary arteries by fatty plaques.

e

10. A type of cancer in which white blood cells proliferate rapidly.

(114)

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Multiple Choice b (88)

1. The perceived comfort and caring a person receives from other people or groups is referred to as a. eustress. b. social support. c. social network. d. self-esteem.

c

2. Which of the following is NOT one of the four basic types of social support?

(88-89) a. emotional b. informational c. attitudinal d. tangible a (89)

a (89)

d (89)

d (89)

3. When Joe's teacher unexpectedly required him to take on an extra project for a class that requires him to do additional work in the library at nights, his family agreed to provide child care for his 6-year-old. In doing so, they were offering a. tangible or instrumental support. b. attitudinal support. c. esteem support. d. informational support.

4. Janet was recently diagnosed as having leukemia. Research indicates that she might be in particular need of a. emotional and esteem support. b. cognitive expressive support. c. esteem support. d. esteem and informational support.

5. Cutrona's study of college students indicated that the LEAST frequently offered type of support was a. emotional. b. informational. c. esteem. d. tangible.

6. Which of the following is NOT a frequently suggested factor in whether people receive social support? a. their own assertiveness b. a need for independence c. discomfort in confiding in others d. educational background

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d (89)

d (90)

d (90)

c (91)

b (92)

7. Which of the following are factors that influence providing support? a. having appropriate resources or skills to help b. having too much stress of one’s own to deal with c. insensitivity to the needs of others d. all of the above 8. Which of the following statements about receiving support is true? a. Women receive more support from their spouses than men do. b. Black Americans have the largest social networks of any sociocultural groups. c. The composition of social networks does not vary much across sociocultural groups. d. In minority groups, men's networks are larger than are women's.

9. Which group tends to focus on extended families as their social network? a. European American women b. African American men c. Asians d. Hispanics

10. The best way of expressing the relationship between social support and mortality rate is that a. they have no relationship. b. social support increases mortality rate. c. high social support is correlated with a lower mortality rate. d. social support definitely causes lower mortality.

11. Deanna is convinced that she can cope on her own with the emotional demands of her illness. What is true about the value for social support for Deanna? a. She would benefit most from the support of her spouse. b. She is unlikely to benefit from social support. c. She would benefit most from the support of hospital staff. d. She would benefit most from the support of female friends.

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a (92)

b (92)

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a (93)

12. Cynthia believes that, while having a good social support network helps her a great deal in times of stress, it really doesn't affect her well-being during other less stressful times of her life. She seems to be endorsing the _____ hypothesis regarding social support and health. a. buffering b. direct effects c. stress reduction d. tangible 13. According to the buffering hypothesis, the protective effect of social support occurs a. in low stress situations. b. in high stress situations. c. in moderate stress situations. d. without regard for level of stress.

14. The notion that social support is beneficial to health regardless of the level stress experienced is called the _____ hypothesis. a. buffering b. social network c. direct effects d. social support 15. For social support to reduce stress most effectively, which of the following conditions needs to be met? a. We need to notice that it is being given. b. We need to perceive that it is supportive. c. It needs to match the demands of the situation. d. All of the above.

16. According to recent research, which of the following statements is true regarding the relationship between marriage and health? a. Being married definitely carries health benefits. b. Being divorced or single increases the likelihood of heart disease due to loneliness. c. Being married, in and of itself, does not produce a health benefit. d. Being married actually produces higher levels of stress and therefore is less beneficial to one's health.

17. When are social ties detrimental to our health? a. When other people interfere with our efforts to engage in healthful activities. b. When others encourage our own healthy behaviors. c. When others engage in healthy behaviors themselves. d. When our social network overprotects us.

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b (94)

b (94)

c (94)

b (94)

d (94)

d (95)

18. Throughout her pregnancy, Karla has taken natural childbirth classes where she has learned breathing techniques to use during labor. She has engaged in _____ control. a. cognitive b. behavioral c. informational d. decisional 19. Al-omari deals with the stress of his daily painful skin medical treatments, by imagining himself walking across campus again with his friends, laughing and joking with them. Al-omari is using which type of control? a. decisional b. cognitive c. behavioral d. informational 20. The type of personal control which leads to the most consistently beneficial effect on reducing stress is _____ control. a. social support b. behavioral c. cognitive d. emotional 21. Which of the following attributions concerning one's failure on an exam is representative of internal locus of control? a. "The teacher hates me." b. ''I didn't study enough.'' c. " I guess it just wasn't my lucky day." d. ''Those exam questions were just too difficult.''

22. Which of the following is necessary to develop high levels of self-efficacy? a. A high level of internal control. b. A belief that a behavior will be effective. c. Believing that one has the skills and resources available to perform the behavior well. d. Both b and c are necessary.

23. Across the life span, our sense of personal control a. changes as we age. b. is affected by the process of social learning. c. becomes more external as we reach older age. d. all of the above

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c (94)

d (95)

a (95)

d (96)

a (96)

c (97)

24. Pennebaker’s research on the impact of disclosure has found that having people talk or write about negative events a. increases stress significantly. b. is more effective than relaxation in reducing stress. c. has a modest but positive effect on reducing stress. d. has no effect on stress reduction.

25. Which of the following statements about personal control is true? a. Locus of control has relatively little impact on rehabilitative behaviors. b. Boys and girls tend to have the same levels of external locus of control. c. Minority and economic status are not related to locus of control. d. Limited access to power and financial advancement is linked to an external locus of control.

26. According to Seligman, learned helplessness is a principal characteristic of a. depression. b. anxiety. c. schizophrenia. d. internal locus of control.

27. Which combination of attribution types is most likely to result in an individual becoming depressed, feeling helpless, and losing self-esteem? a. external, unstable, specific b. external stable, specific c. internal, unstable, global d. internal, stable, global 28. Pessimistic people who believe that they have little personal control a. have more illnesses. b. have better health habits c. are more likely to seek a doctor's care for treatment of hypertension. d. do a good job in controlling their own stress.

29. Suppose for a moment that "George" was one of the older adults in the Langer & Rodin (1976) study on nursing homes and was assigned to the experimental group (i.e., he had a plant he cared for). On the basis of the research findings, a year and a half later, he was more likely to be _____ than control condition participants. a. deceased. b. a member of the gardening team. c. alive and healthier than control condition participants. d. alive but no healthier than control condition participants.

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c (98)

b (98)

d (99)

d (99)

a (100)

c (100)

30. Kobasa and Maddi proposed that hardiness includes the three characteristics of a. coherence, commitment, and resilience. b. control, coherence, and commitment. c. control, commitment, and challenge. d. love, honor, and truth.

31. Children who thrive in spite of terrible conditions are said to have a. depression. b. resilience. c. sociability. d. tolerance for ambiguity.

32. Research has revealed that the concept of hardiness a. has received consistent research support. b. has received inconsistent support. c. is assessed with tests that may actually measure negative affect. d. both b and c 33. Harold is competitive, self-critical, easily angered, and very impatient.

He could be described as having a(n) a. external locus of control. b. hardy personality. c. internal locus of control. d. Type A behavior pattern.

34. A trained interviewer who intentionally annoys and interrupts her clients is probably looking for signs of a. Type A behavior. b. coherence. c. internal locus of control. d. external locus of control.

35. The Jenkins Activity Survey is a self-report instrument used to measure a. resilience in children. b. locus of control. c. Type A behavior. d. self-efficacy.

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d (100)

c (100)

d (100)

c (101)

d (101)

d (101)

36. Evidence on the relationship of stress to Type A behavior suggests that a. Type A people interpret stressors as threats to personal control. b. Type A people experience stress quickly and strongly. c. Type A people show greater reactivity to stressors compared to Type B individuals. d. all of the above 37. The physiological portion of the response to stress is called a. hypertension. b. hardiness. c. reactivity. d. resilience.

38. Which of the following statements best reflects the findings from studies of reactivity during stress? a. The Type A reactivity pattern does not appear until the adult years. b. There is no correlation between reactivity and income or education level. c. There are no reactivity differences between Type A and Type B people. d. Reactivity differences between Type A and Type B participants depend on gender.

39. The decline researchers have found in Type A behaviors in old age is most likely due to a. Type A people learning more Type B behaviors as they age. b. social disapproval for this behavior pattern and thus change due to social pressures to do so. c. the earlier ages of death for Type A individuals. d. all of the above 40. Which statement best expresses the findings on the relationship between Type A behavior and health? a. No relationship has emerged in the best research. b. There is a strong link between Type A behavior and all kinds of illness. c. Only a few studies have been done so its best to conclude that there is no evidence available. d. There is a link between Type A behavior, as it is measured by the Structured Interview, and coronary heart disease.

41. Which of the following factors is related to the development of Type A behavior pattern? a. early temperament b. noncompetitive situations c. genetics d. both a and c 144

b (102)

c (103)

b (103)

d (104)

c (105)

d (106)

42. Which of the following has been described as the "deadly emotion" for Type A people? a. competitiveness b. hostility c. jealousy d. impatience 43. In the study where subjects with high and low stress received nasal drops containing the common cold virus, results indicated a. no consistent relationship between catching a cold and stress level. b. both groups were likely to develop a cold. c. subjects in the high stress group were much more likely to catch a cold than those in the low stress group. d. placebos were able to produce cold symptoms.

44. Regarding the relationship between stress and illness, the _____ is to body physiology as _____ is to individual behavior. a. indirect route; direct route b. direct route; indirect route c. direct route; direct route d. indirect route; indirect route 45. The link between stress and cardiovascular disease may be the result of the greater _____ when people are under chronic, severe stress. a. wear and tear on body systems b. concentrations of activated platelets in the blood c. progression of atherosclerosis. d. all of the above 46. Sudden death (voodoo death) usually involves a. a history of malnutrition. b. intense religious beliefs. c. cardiac failure with an underlying cardiovascular disorder. d. the presence of an extreme stressor regardless of the person's cardiac health.

47. Which of the following statements reflects how stress affects the immune system? a. Stress has no influence on the immune system. b. Increased cortisol and epinephrine actually improve T cell functioning. c. Because of the presence of cortisol, T cells confuse mutant cancer cells with healthy cells and ignore them. d. High levels of stress reduce the production of the enzymes that repair damaged DNA. 145

c (106)

a (108)

d (108)

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b (110)

48. Positive emotions have been found to ____ immune function whereas negative emotions have been found to ____ immune function. a. improve; improve b. reduce; reduce c. improve; reduce d. reduce; improve 49. In studies investigating the impact of optimism on immune function, findings indicate that: a. the influence of optimism depends on whether the stressor is short-term or chronic. b. optimism always increases immune function. c. optimism is not related to immune function. d. none of the above were found.

50. Research findings that immune function can be conditioned suggests that: a. immune function can be impaired via conditioning. b. immune function can be boosted via conditioning. c. conditioning affects immune functioning only for chronic stressors. d. both a and b.

51. When investigators filtered house dust into asthmatic children's hospital rooms they discovered that a. it triggered asthmatic attacks in almost all of the children. b. none of the children had asthmatic attacks. c. many children had asthmatic attacks but most didn't. d. the children weren't allergic to house dust after all.

52. Which statement best describes the relationship between stress and headache? a. All headaches have been found to be stress-related. b. All headaches are caused by some organic problem. c. Intense stress will always produce headaches. d. Stress is only one factor in headaches.

53. Research on the relationship between stress and psychophysiological disorders has found a. a definite and strong causal relationship for most disorders. b. that the nature of the relationship is unclear. c. that stress has no relationship with these disorders. d. that these disorders are caused solely by organic dysfunction.

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a (111)

d (110)

c (112)

c (112)

d (113)

54. When people receive a diagnosis of essential or primary hypertension it means that a. the mechanisms that cause their hypertension are unknown. b. their hypertension is caused by disorders in essential body systems. c. there are identifiable biomedical causes for their disease. d. they have heart disease.

55. Cases of high blood pressure that are caused by disorders of other body systems are called a. hypertensive defects. b. primary hypertension. c. atherosclerosis. d. secondary hypertension.

56. Studies comparing individuals from crowded versus uncrowded neighborhoods found a. no real differences in hypertension levels. b. no similarity to findings from animal studies on crowding. c. residents from crowded neighborhoods had higher heart rate and blood pressure increases during stressful tasks than did residents from uncrowded neighborhoods. d. residents from uncrowded neighborhoods had higher heart rate and blood pressure increases during stressful tasks than did residents from crowded neighborhoods.

57. Fredrikson & Matthews (1990) found some trends in their metaanalysis of studies on reactivity and hypertension. Which of the following was among their findings? a. Gender is not related to reactivity. b. Ethnicity is not related to reactivity but is related to hypertension. c. Patients with mild hypertension respond differently to psychological stressors than patients with severe hypertension. d. Regardless of hypertension severity, reactivity has its strongest relationship with passive psychological stressors.

58. Which of the following findings support the idea that CHD is a “disease of modernized societies”? a. People live longer in advanced societies and thus have a higher likelihood of developing CHD. b. People in advanced societies probably have higher levels of the risk factors for CHD. c. People in advanced societies probably have less social support networks than do people in less advanced societies. d. all of the above 147

b (114)

59. The significance of the observation that dozens of disease forms share the basic characteristic of unrestrained cell growth which we refer to as cancer is that a. stress can't possibly be related to all these diseases. b. the search for causes of these diseases is difficult. c. the medical community has a hard time communicating due to a lack of common terminology. d. all of the above

d 60. Research on cancer and high levels of stress leads to which of the following conclusions?

(115) a. There is a clear link between stress and the later development of cancer. b. Retrospective studies are the best methods for investigating the link between stress and cancer. c. Stress reduction interventions have little effect on cancer patients. d. Stress is most likely linked to cancer because of its effect on the immune system.

The most important of all psychosocial resources that contributes to resiliency is: a. Economic stability b. Education c. Social support d. Job stability

Short Answer Questions 1. Your Aunt Yvonne has to give a presentation to her boss and is very nervous about doing so. In what ways might you give her social support that could help to reduce her stress?

2. Compare and contrast the buffering and direct effects hypotheses.

3. Discuss the sub-scales of the Multidimensional Health Locus of Control scale from the standpoint of internal/external LOC.

Essay Questions 1. This chapter focuses on a variety of personal characteristics that contribute to the experience of health. If you were a parent, which characteristics would you seek to develop in your children and why? In what ways would you foster this development?

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2. Your friend has just been told that he has Type A behavior pattern. Help him understand the concept and the various factors that contribute to its development and maintenance.

3. If you were asked to arrive at a general conclusion regarding the relationship between stress and illness, what would it be? Support your answer with evidence.

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CHAPTER 5 COPING WITH AND REDUCING STRESS CHAPTER OUTLINE I. Coping With Stress A. What is Coping?

1. Definition a. process by which people try to manage the perceived discrepancy between the demands and resources they appraise in a situation i. may manage by correcting or mastering the problem, or by changing perception of it ii. involves transactions with the environment 2. Coping process not a single event a. involves a dynamic series of appraisals and reappraisals of the person and the environment b. reevaluation influenced by transactions that preceded it and affect subsequent coping efforts B. Functions and Methods of Coping 1. Section introduction a. two main functions of coping i. altering the problem ii. regulating emotional response to problem 2. Functions of coping a. emotion-focused coping i. aim is to control emotional response to stress ii. two types of techniques 1) behavioral – using drugs/alcohol, seeking assistance, engaging in distracting activities 2) cognitive – changing how one thinks about the event through redefinition a) noting that things could be worse b) making comparisons with worse off others c) finding something positive in the situation iii. Freud’s defense mechanisms 1) involve distorting memory or reality in some way 2) example: denial a) denying the existence of the problem iv. avoidance strategies 1) most effective during first few weeks of prolonged stress experience

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v. situations promoting the use of emotion-focused coping 1) situations that people believe there is little they can do to change 2) use of emotion-focused coping may interfere with seeking medical attention or promote unhealthy behaviors b. problem-focused coping i. used to reduce demands of stressful situation or expand resources for dealing with it ii. tend to be used when situations are perceived as changeable c. research on use of emotion-focused and problem-focused coping i. findings from Billings & Moos’ study on married couples 1) husbands & wives both use problem-focused coping more than emotion-focused coping 2) wives use emotion-focused coping more than husbands do 3) those with higher income and education use problem-focused coping more 4) persons use problem-focused coping less when stressful situation involves a death d. combining emotion-focused and problem-focused coping i. coping with stressful situations often involves using both types of coping strategies ii. if only one coping strategy used, it tends to be problemfocused coping 3. Coping methods and measurement a. over 400 coping methods have been identified by researchers b. efforts to develop instruments for measuring coping have not be successful so far i. often designed to correlate coping with mental or physical health which hasn’t been productive ii. tend to use retrospective methods which have been ineffective due to poor memory problem c. 4 promising directions of research on most important coping methods i. role of positive emotions 1) Folkman reports that positive emotions may sustain coping efforts ii. finding benefits or meaning 1) meta-analytic research indicates that finding benefits is associated with less depression, greater feelings of well-being

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iii. engaging in emotional approach 1) involves emotional processing and expression iv. accommodating to a stressor 1) adapt or adjust to presence of stressor 2) Folkman & Moskowitz findings a) high levels of expression linked to improved perceived health, more vigor, fewer medical visits, and less distress b) high levels of processing linked to increased distress, poor health habits and health due to rumination that perpetuates stress 4. Using and developing methods of coping a. four issues about patterns in using different coping methods i. people tend to be consistent in coping method they use for a particular stressor ii. seldom use just one type of coping method with a stressor iii. coping methods used for short-term stressors tend to be different than those used for long-term stressors iv. both genetics and transactions influence coping styles b. coping probably changes over the lifespan, but the mechanism for how that occurs is unclear i. in children, coping depends on cognitive and language skills 1) learn to develop emotion-focused, cognitive strategies ii. middle-aged people tend to use problem-focused coping, whereas the elderly use more emotion-focused 1) differences probably influenced by what people must cope with 2) older people tend to view problems as less changeable 5. Gender and sociocultural differences in coping a. societal sex roles play important role in coping patterns of men and women i. men report using problem-focused and women report using emotion-focused coping 1) if statistically control for occupation and education, these differences disappear b. people with higher incomes and educational level report using problem-focused coping c. disadvantaged people more likely to experience stressful events and less likely to cope with stress effectively

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II. Reducing the Potential for Stress A. Enhancing Social Support 1. Social support is helpful after stressors appear and may even avert stress 2. Some segments of the population have less support a. men have larger social networks but women use theirs more effectively b. many elderly live in isolated conditions with few people to count on for support c. social network size is related to person’s prestige, income and education d. for people from lower socioeconomic classes, social networks tend to be less diverse, mostly kin e. greater reliance on social and helping organizations since family members have different roles and live further away 3. Needs for giving and receiving social support change over time a. high stress and deteriorating health may occur together at same time that social support may be dwindling 4. Receiving support from community organizations a. bring together people with similar problems and interests, which may be a new source for sharing, help, and friendship b. unknown which types of organizations work best for support c. people most likely to join a group for serious illness if it involves embarrassment or stigma 5. Community role in enhancing social support networks a. creating programs to help people develop social networks b. providing facilities for meetings, recreation, fitness c. arranging social events d. providing counseling services 6. Factors that contribute to ineffective social support a. recipient interprets support as sign of personal inadequacy b. recipient believes that personal control is limited by support B. Improving One's Personal Control 1. Developing a "what's the use" attitude a. seen in people with chronic illnesses who stop trying to improve situation b. a signal that they need help to bolster sense of self-efficacy and reduce feelings of passivity/helplessness 2. Enhancing personal control a. in children i. provide a stimulating environment, encouragement and praise, reasonable standards of conduct and performance. b. in adults i. employees having more control over some aspects of their jobs 152

ii. elderly people doing more things for themselves c. assisting chronically ill persons by training them in effective ways to cope C. Organizing One's World Better 1. Organization reduces frustration, wasted time, and stress 2. Three elements of time management a. setting goals b. making daily "to do" lists c. making daily schedules D. Exercising: Links to Stress and Health 1. Correlational evidence relates fitness to decreases in depression, anxiety and tension a. problems in interpreting the correlation i. reduction may be due to placebo effect ii. correlation doesn't clarify causal pattern 2. Research providing evidence of benefits a. comparing moderate v. vigorous exercise found that young men who vigorously exercise show reduction in anxiety b. regular exercise lowers cardiovascular reactivity and decreases likelihood of hypertension c. experimental research provides evidence of exercise reducing heart rate and blood pressure 3. Protective effects of exercise a. less illness noted in those who exercised more b. stress has less impact on the health of fit people E. Preparing for Stressful Events 1. Enhancing feelings of control is an effective preparation for surgery a. behavioral control methods teach patients how to reduce discomfort or promotes rehabilitation by learning specific actions b. cognitive control helps patient concentrate on beneficial aspects of surgery c. informational control involves details about procedures or sensations they’ll experience i. too much information may increase stress unless focus is on what sensory experiences to expect III. Reducing Stress Reactions: Stress Management A. Section Introduction 1. Definition of stress management a. any program of behavioral and cognitive techniques that is designed to reduce psychological and physical reactions to stress 2. Pharmacological approaches a. use of medications to reduce emotions accompanying stress 153

B. Medication 1. Drugs used to reduce physiological arousal and anxiety a. benzodiazepines (e.g., Valium, Librium) i. decrease central nervous system transmission b. beta-blockers (e.g., Inderol) i. block sympathetic activity in the peripheral nervous system ii. may cause less drowsiness than benzodiazepines 2. Using drugs for stress should be on temporary basis a. used following acute crisis b. also may be used while person is learning new psychological methods for coping C. Behavioral and Cognitive Methods 1. Section introduction a. methods for coping with stress developed by psychologists focus on changing behavior or thinking processes 2. Relaxation a. since relaxation is opposite of arousal, relaxation techniques should be good way to reduce stress b. progressive muscle relaxation i. proposed by Jacobson (1938) ii. works by getting people to pay attention to how their muscles feel when tense and relaxed iii. involves a sequence of tightening and relaxing muscles while directing person to pay attention to how sensation feels 1) tensing technique used training and eliminated once person has mastered the process iv. sessions last 20-30 minute and work best in quiet, nondistracting setting with person lying down or sitting in comfortable furniture c. relaxation process used mostly with adults but may be taught to children i. problems in using technique with children 1) may not actually relax muscles when told to do so 2) may tense more muscles than told to do d. quick version i. once full version mastered, shortened form may be used in stressful situations 1) involves deep breathing, relaxing self-talk, thinking about something pleasant e. effects of relaxation on stress reduction i. people who receive training show less cardiovascular reactivity to stress & stronger immune functioning

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3. Systematic desensitization a. process pairs a stimulus hierarchy with relaxation b. assumes that fears are acquired by classical conditioning and this relationship may be counterconditioned with a calm response c. systematic desensitization may use in vivo, imagined, or symbolic stimuli d. effects of systematic desensitization on stress reduction i. one study found fear in adults was reduced in six 1 1/2 hr. sessions ii. technique may be used with children but may need to shorten session length 4. Biofeedback a. electromechanical device monitors physiological processes and reports the information i. process allows person to gain voluntary control over arousal level via operant conditioning b. effectiveness of biofeedback i. has been found as effective as progressive muscle relaxation treatment of stress-related headaches ii. no more effective than progressive muscle relaxation for reducing stress itself and is more costly c. children may be better candidates for biofeedback than adults. i. more enthusiastic, regarding it as a game ii. less skeptical that intervention will work iii. more likely to practice iv. problems = may have shorter attention span or be disruptive during session 5. Modeling a. modeling (also called social or observational learning) involves learning by observing the behaviors and consequences of that behavior of a model b. stress and fears may be acquired and reduced by modeling i. symbolic or in vivo models may be used c. method used similar to that in systematic desensitization i. person relaxes while watching calm model, either in vivo or symbolically d. research on effects of modeling in children i. depending on child's age and previous surgical experiences, stress/anxiety related to surgery may be reduced 1) anxiety may actually increase in younger children a) may need to use distraction techniques to reduce stress in these children 155

6. Approaches focusing on cognitive processes a. stress results from cognitive appraisals based on lack of information, misinformation or irrational belief b. cognitive restructuring i. involves replacing stressful thoughts with more constructive or realistic thoughts that reduce appraisals of threat or harm c. types of irrational beliefs related to stress i. Ellis' common irrational beliefs 1) can't-stand-itis 2) musterbating ii. Beck’s beliefs 1) arbitrary inference = drawing a specific conclusion from insufficient, ambiguous, or contrary evidence 2) magnification = greatly exaggerating the meaning or impact of an event iii. these kinds of irrational thinking affect cognitive appraisal of threat or harm due extreme perspective-taking d. use of cognitive therapy to change maladaptive thinking patterns i. therapy originally developed by Beck for treating depression ii. emphasis is on changing maladaptive thought pattern iii. helps clients see 1) they are not responsible for all the problems they encounter 2) negative events are not necessarily catastrophes 3) maladaptive beliefs are not logically valid iv. uses hypothesis testing strategy e. problem-solving training i. clients learn strategies for identifying, discovering, or inventing effective/adaptive ways to address problems 1) watch for problems that arise 2) define problem clearly 3) generate variety of possible solutions 4) decide on best course of action f. stress-inoculation training i. developed by Meichenbaum, involves variety of methods designed to teach skills to alleviate stress ii. three phases of training 1) learning about stress and how it affects people 2) acquiring behavioral and cognitive skills to fight stress 3) practicing skills with real or imagined stressors iii. training program is well thought out using well established techniques against stress 156

7. Multidimensional approaches a. assumes both problems and solutions are multifaceted; therefore require multi-faceted intervention i. effective approaches incorporate many stress-reduction techniques ii. programs can be tailored to person's specific problems D. Massage, meditation, and hypnosis 1. Three additional techniques related to relaxation 2. Massage a. variety of massage techniques use various degrees of pressure applied to muscles/joints i. preferred pressure varies with age of person. b. Deep tissue massage is effective in i. reducing anxiety and depression ii. reducing hypertension, pain, or asthma symptoms iii. bolstering immune function 3. Meditation a. transcendental meditation i. a form of yoga in which a relaxed person closes their eyes and repeats a mantra ii. purpose of meditation is to increase ability to create relaxation response when confronted with stressor iii. broader purpose may be “mindful awareness” 1) developing insight regarding essence of experiences, unencumbered by cognitive or emotional distortions 2) learn to detach from cognitive and emotional distortions about pain b. research support for effectiveness i. quasi-experimental designs find lower anxiety and blood pressure in meditators v. non-meditators ii. monks who meditate can lower body metabolism and brain electrical activity iii. meditators show decrease in blood pressure iv. those who practice meditation regularly show reduction in blood pressure and enhanced immune function 4. Hypnosis a. an altered state of consciousness induced by suggestion leading to responsiveness to directions for changes in perception, memory, and behavior b. suggestibility is greatest in children and then declines to a stable level in adulthood c. suggestible people can learn to induce hypnotic state in themselves through self-hypnosis 157

d. research findings of effectiveness i. may be helpful in stress management programs but not more effective than other relaxation techniques ii. people who use either hypnosis or relaxation regularly show improved immune function IV. Using Stress Management to Reduce Coronary Risk A. Section Introduction 1. Many risk factors for CHD have been identified, including age, family history, and people’s experiences and behaviors a. experiences and behaviors should be modifiable B. Modifying Type A Behavior 1. When Type A was identified as a risk factor, efforts began to discover ways to modify it 2. Empirical efforts to reduce Type A a. multidimensional approaches i. Type A men randomly assigned to multidimensional intervention group or exercise groups 1) hostility component was reduced more in multidimensional group b. stress inoculation/relaxation study i. method involved learning about role of arousal and cognitive processes in development of anger as well as relaxation techniques and using soothing comments 1) program was effective in reducing anger 3. Evidence of decreasing Type A resulting in decreased incidence of CHD a. 3 group study including traditional treatment, cardiac counseling group and Type A/cardiac counseling group i. Type A/cardiac counseling group showed biggest decrease in Type A behavior 4. Pharmacological approaches in modification of Type A behavior a. Findings indicated that use of beta-blockers related to less Type A behavior i. suggests that beta-blockers may be good alternative treatment for those at coronary risk who have not responded well to behavioral or cognitive interventions C. Treating Hypertension 1. Typical treatment regimen for hypertension involves medication, weight control, exercise, and reducing intake of cholesterol, sodium, caffeine and alcohol 2. Use of stress management techniques in treating hypertension

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a. findings i. use of single techniques produce limited results ii. multidimensional programs are highly effective in reducing blood pressure 3. Occupational use of stress management programs a. most studies find improvements in psychological and physiological stress b. programs still not widely applied i. evidence of effectiveness is new ii. interventions are costly iii. people who really need to be in these programs may not join, may drop out even if do join, or not adhere to program recommendations

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DISCUSSION TOPICS 1. The Stress-reducing Power of Laughter: Bond reviews the impact of laughter on endorphin release and immune functioning. He also notes that children spend far more time laughing than do adults.

He highlights the professional career of Loretta LaRoche, therapist, adjunct faculty member of The Behavioral Institute of Medicine (an affiliate of Harvard Medical School), and standup comic as she travels around the US delivering humorous tips on how to reduce the stress in our lives. Common themes in her presentation include the contests of whining in which we engage with one another, our "wait" to finally be happy (but in the mean time we must suffer), forgetting to be grateful for what we have, and not letting ourselves "tah dah!" as we did as children. This ideas in this very brief article can be combined with the videotape made by Ms. LaRoche, Humor Your Stress. (1996, WGBH/Humor Potential, 60 min). Every time I've shown it in class, people are wiping tears of laughter off their faces at the end. A very upbeat topic for discussion of stress management.

Source: Bond, J.F. (1999). Take Two Guffaws and Call Me in the Morning! In D. Corbin (Ed.), Perspectives: Stress management. (pp. 127-128). St. Paul, MN: Coursewise Publishing.

2. Living Simply: The article by Scott Sanders, entitled Simplicity, begins with his story of a camping trip with his son and their trip back to "civilization." He observes that "coming home, I can see there are too many appliances in my cupboards, too many clothes in my closet, too many files in my drawers, too many strings of duty jerking me in too many directions. The opposite of simplicity, as I understand it, is not complexity but clutter." (pg. 146). He goes on to state "The simplicity I seek is not the enforced austerity of the poor. I seek instead the richness of a gathered and deliberate life, the richness that comes from letting one's belongings and commitments be few in number and high in quality." (pg. 146). He suggests that, in the history of human evolution, we have come to equate well-being with increase, we feel satisfied when we have more of everything.

A thought-provoking article, this may serve as a discussion point with students on the impact of the demands of modern life as they contribute to stress. Discussion might focus on Sander's 12 ways to simplify life and save the world (see pg. 148).

Source: Sanders, S.R. (1999). Simplicity. In D. Corbin (Ed.), Perspectives: Stress management. (pp. 145-150). St. Paul, MN: Coursewise Publishing.

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3. Music and Stress: Kathleen Ganster reviews the use of music in therapeutic applications. As an intervention, music therapy was first used following World War II by University of Kansas professors E. Thayer Gaston and William Sears. Although initially rejected by hospitals and the medical community, music therapy programs such as the ones located at Duquesne University and Slippery Rock University have maintained a steady number of graduating music therapists since the mid-1970s who work at major hospitals and cancer centers. The forms of music and techniques used by music therapists tend to vary depending on patient and diagnosis. Common areas of application include stress management, relaxation during pain management, as a coping adjunct during chemotherapy, as part of guided imagery therapy with oncology patients, and as stimuli in drawing out the memories of patients with Alzheimer's. It has also been used in programs with autistic and emotional disturbed children. Students in class might be able to identify with the power of music to arouse and calm, and to evoke positive and negative emotional states.

Source: Ganster, K. (1999). The sound of healing. In D. Corbin (Ed.), Perspectives: Stress management. (pp. 129-130). St. Paul, MN: Coursewise Publishing.

4. Ancient Approaches to Stress Management: Very similar to Cannon's and Selye's theories of health and disease are the theories from ancient and widely different cultures. Have the students read the review article by Walton & Pugh (1995), or present the details in a lecture. This paper reviews the fundamental elements of these theories and the current research supporting their validity. Particular attention is given to Ayurvedic methods to control stress and improve health.

Source: Walton, K. G., & Pugh, N. D. (1995). Stress, steroids, and "ojas": neuroendocrine mechanisms and current promise of ancient approaches to disease prevention. Indian Journal of Physiology and Pharmacology, 39, 3-36.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Your Focuses in Coping. The Assess Yourself activity for this chapter has been reproduced in Handout #1. This exercise helps students assess their use of emotion-focused and problem-focused coping strategies. You might have them fill out the assessment on two different types of stressors (one controllable, the other out of their control) to demonstrate the use of different types of coping strategies.

2. Stress Management Exercises: As a companion for this portion of the class, you may wish to have students purchase a copy of Jerrold Greenberg's, Your Personal Stress Profile and Activity Workbook, published by McGraw Hill (ISBN #0-697-22304-3).

The workbook contains a wide variety of 38 different scales and activities relating to stress and stress management that are pertinent to this chapter.

3. Creating a Personal Stress Management Plan: After completing the stress profiles in the above workbook, an additional activity might be to have students identify sources of stress in their lives; categorize the effects of those stressors on their biological, psychological (emotional & cognitive), and social experiences; and then develop a plan for addressing the effects of stress in each of those domains.

4. In-class relaxation exercises. Students have a better feel for relaxation techniques if given the chance to experience it themselves. Obtain a copy of the Letting Go of Stress audiotape from your McGraw-Hill representative. This tape contains several types of relaxation exercises with good examples of progressive muscle relaxation, autogenic relaxation, and imagery.

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Handout #1

Assess Yourself: Your Focuses in Coping.

Instructions: Think about a very stressful personal crisis or life event you experienced in the last year - the more recent and stressful the event, the better for this exercise. How did you handle this situation and your stress? Some of the ways people handle stressful experiences are listed below. Mark an "X" in the space preceding each one you used.

_____ Tried to see a positive side to it. _____ Tried to step back from the situation and be more objective. _____ Prayed for guidance or strength. _____ Sometimes took it out on other people when I felt angry or depressed. _____ Got busy with other things to keep my mind off the problem. _____ Decided not to worry about it because I figured everything would work out fine. _____ Took things one step at a time. _____ Read relevant material for solutions and considered several alternatives. _____ Drew on my knowledge because I had a similar experience before. _____ Talked to a friend or relative to get advice on handling the problem. _____ Talked with a professional person (e.g., doctor, clergy, lawyer, teacher, counselor) about ways to improve the situation. _____ Took some action to improve the situation.

_____ Total of Xs in first six coping strategies. _____ Total of Xs in second six coping strategies.

Which type of strategies did you use the most?

Why?

What functions did your strategies serve?

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RESOURCES Suggested Readings: Coping with Stress Blonna, R. (2007). Coping with stress in a changing world. New York: McGraw-Hill.

Humphrey, J.H. (1992). Stress among older adults: Understanding and coping.

Springfield, IL: C.C. Thomas.

Kendall-Tackett, K.A. (2001). The hidden feelings of motherhood: Coping with stress, depression, and burnout. Oakland: New Harbinger Publications.

Sadeh, A., Keinan, G. & Daon, K. (2004) Effects of stress on sleep: The moderating role of coping style. Health Psychology, 23(5) 542-545.

Reducing the Potential for Stress Catherall, D.R. (2005). Family stressors: interventions for stress and trauma. New York: Brunner-Routledge.

Clark, S. & Cooper, C.L. (2004). Managing the risk of workplace stress: health and safety hazards. New York: Routledge.

Collins, C.F. (2003). Sources of stress and relief for African American women.

Westport, CT: Praeger Publishers/ Greenwood Publishing Group.

Maslach, C. (1997). The truth about burnout: How organizations cause personal stress and what to do about it. San Francisco: Jossey-Bass.

McEwen, B.S. (2004). The end of stress as we know it. New York: Dana Press.

Paton, D. et al (2004). Managing traumatic stress risk: a proactive approach.

Springfield, IL: Charles C. Thomas.

Quick, J.C. (Ed.) (1997). Preventive stress management in organizations.

Washington, DC: American Psychological Association.

Smith, H.W. (1994). The 10 natural laws of successful time and life management: Proven strategies for increased productivity and inner peace. New York: Warner Books.

Stress Management Ellis, A. (1998). Stress counseling: A rational emotive behavior approach. New York: Springer.

Epstein, R. (2000). The big book of stress-relief games: quick, fun activities for feeling better at work. New York: McGraw-Hill.

Everly, G.S. & Lating, J.M. (2002). A clinical guide to the treatment of human stress response. New York: Kluwer Academic/Plenum.

Girdano, D.A., Everly, G.S., & Dusek, D.E. (1990). Controlling stress and tension: A holistic approach. Englewood Cliffs, NJ: Prentice Hall.

Goliszek, A. (2004). 60 second stress management. Far Hills, NJ: New Horizon Press.

Greenberg, J.S. (1993). Comprehensive stress management. Madison: Brown & Benchmark.

Griffin, V., Neblett, E., & Kissinger, E. (2002). Simple solutions: diet & stress – is what you’re eating, eating you? [S.1.]: Lifestyle Matters.

Hilton, J. (2006). Stress relief: simple routines for home, work & travel. London: Gaia.

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Lehrer, P.M., & Woolfolk, R.L., & Sime, W.E (2007). Principles and practice of stress management. New York: Guilford Press.

Linden, W. (2005). Stress management: from basic science to better practice.

Thousand Oaks, CA: SAGE Publications.

Livingstone, B. (2007). The body mind soul solution: healing emotional pain through exercise. New York: Pegasus Books.

Luskin, F. & Pelletier, K.R. (2005). Stress free for good: 10 scientifically proven life skills for health and happiness. San Francisco: HarperSanFrancisco.

Miller, F.L. (2003). How to calm down: three deep breaths to peace of mind. New York: Warner Books.

O’Connell, B. (2001). Solution-focused stress counseling. New York: Continuum.

Posen, D. (2004). The little book of stress relief. Buffalo, NY: Firefly Books.

Romas, J.A. & Sharma, M. (2007). Practical stress management: a comprehensive workbook for managing change and promoting health. San Francisco: Pearson/Benjamin Cummings.

Seaward, B.L. (2006). Essentials of managing stress. Sudbury, MA: Jones and Bartlett.

Sulsky, L. & Smith, C. (2005). Work stress. Belmont, CA: Thomson/Wadsworth.

Thornton, M. (2004). Meditation in a New York minute: super calm for the super busy.

Boulder, CO: Sounds True, Inc. Turkington, C. (1998). Stress management for busy people. New York: McGraw-Hill.

Anger Management Gentry, W.D. (2007). Anger management for dummies. Hoboken, NJ: John Wiley.

Greene, I. (2003). Anger management skills for children. San Diego, CA: P.S.I. Publishers.

Suggested Films and Videos: Coping with Stress 1. Breathing Away Stress. (Films for the Humanities and Sciences, 30 min). Eli Bay leads a class in deep-breathing exercises.

2. Coping with stress. (2003, Allyn & Bacon, 30 min). Looks at role of stress in daily life including information on how to improve personal communication.

3. Reducing Stress. (1992, Films for the Humanities & Sciences, 20 min). Part of The Doctor is in series, this video examines physical problems caused by stress and ways to alleviate it.

4. Stress: Lives in Balance. (2000, Edudex, 30 min). Explores a variety of approaches designed to help people cope with stress.

5. From suffering to freedom. (2005, Behavioral Tech, 50 min). Linehan explains 4 possible responses to devastating pain and 3 skills to cope with extraordinary problems.

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Reducing the Potential for Stress 6. Focusing the Mind. (Films for the Humanities and Sciences, 30 min). Eli Bay leads a class through exercises to clear and focus the mind.

7. Humor Your Stress. (1996, WGBH/Humor Potential, 60 min). Loretta LaRoche demonstrates the use of humor to handle stress by reinterpreting stressful events through a comic perspective.

8. Maximizing Performance. (Films for the Humanities and Sciences, 30 min).

Affirmations, visualizations, and biofeedback are highlighted.

9. Working with Stress/ a presentation of the Center for Disease Control and Prevention. (2002, National Institute for Occupational Safety and Health, 17 min).

Provides information on ways to manage and overcome stressful work environments.

10. Stress inoculation. (1996, New Harbinger Publications, 50 min). Demonstrates Meichenbaum’s stress inoculation procedure.

11. Arrest that stress: how to depressurize your work life. (2003, Briefings Pub Group, 21 min). Presents techniques for cut stress and easing strain on the job.

Stress Management 12. Preventing and Managing Stress. (2001, Stanford Video Media Group, 22 min).

Techniques for recognizing and managing stress.

13. Relaxing Muscle Tension. (Films for the Humanities and Sciences, 30 min).

Exercises for recognizing and relaxing muscle tension are demonstrated; Shiatsu is also examined.

14. The Relaxation Response. (Films for the Humanities and Sciences, 30 min).

Triggering the relaxation response is demonstrated.

15. Stress management. (2002, Human Kinetics, 25 min). Students are given guidelines for maintaining health and promoting wellness.

Internet sites of interest: 1. http://www.stressfree.com - Stress Free net 2. http://www.mindtools.com/smpage.html - Coping skills such as time management and problem solving are highlighted.

3. http://www.star-society.org - Stress and Anxiety Research Society homepage 4. http://www.holisticmed.com/stressfree.html - Stress relief strategies and resources

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TEST QUESTIONS True or False F

1.

According to Richard Lazarus, emotion-focused coping is aimed at controlling stress by either reducing demands of the situation or expanding resources to deal with it.

2.

Marla has just been told she has a serious disease, but tells her best friend that the doctor must be mistaken. She is using the defense strategy known as intellectualization.

(119)

F (120)

T 3.

To date, efforts to develop a reliable and valid research instrument to measure coping (121) have not been very successful.

T

4.

Mr. Goode is a well-known accountant in town who makes a large salary and is president of the Chamber of Commerce. We might expect his social network to contain many non-kin members.

5.

The Amish provide bereaved community members with intense social support for one month only and then have firm expectations that the person is to handle this stressor on his or her own.

6.

Time management techniques are rarely part of a stress management program.

7.

Research has indicated that progressive muscle relaxation is effective with children or adolescents.

8.

Biofeedback has been demonstrated to be more cost-effective and useful than relaxation training alone.

9.

Cognitive therapy might be best characterized as a type of modeling or observational learning technique.

10.

Children between the ages of 7 to 14 are more suggestible to hypnosis than adults.

(124)

F (126)

F (126)

T (129)

F (131)

F (133)

T (136)

Problem-focused coping is used to try to cope when the problem is seen as unchangeable and the stressors cannot be reduced.

A. True B. False

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Matching Match the methods of coping listed with their description in numbers one to five. a. progressive relaxation b. denial c. cognitive restructuring d. time management e. informational control c

I. “This situation is unpleasant, but maybe some good will come of it.”

(133)

d

2. Includes setting goals and making lists in order to control stress.

(126)

a

3. Involves tensing specific muscle groups.

(129)

(128)

4. “The doctor told me that I’ll feel some unusual pressure in my back during this procedure. I’ve got to remember that.”

b

5. “I can’t possibly have cancer!! Your test must be inaccurate!”

e

(120)

Match the following techniques with their descriptions in six through ten. a. systematic desensitization b. biofeedback c. modeling d. cognitive therapy e. stress-inoculation training b (131)

e

6. Questioned due to the cost and complications of the equipment necessary as compared to benefits received.

(135)

7. Designed by Meichenbaum, this program involves steps of conceptualization, skills acquisition and application.

a

8. Involves the use of progressive muscle relaxation paired with a fear hierarchy.

(130)

c (133)

d (134)

9. Little Ashley was afraid of clowns until she saw her older brother Joshua shake one's hand.

10. Based on the belief that our incorrect or maladaptive attitudes need to be disputed.

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Multiple Choice d (118)

b (118)

b (118)

d (118)

d (119)

b (119)

1. Which of the following persons is likely to experience stress? a. 5 year-old Amy b. 15 year-old Jason c. 40 year-old Leslie d. all of the above people 2. A perceived discrepancy between the demands of a situation and the resources of a person is involved in a. disease. b. stress. c. happiness. d. none of the above 3. Which of the following is true about the relationship between perceived discrepancy and the experience of stress? a. Although it was believed for some time that a positive relationship existed between the two, new research indicates that no relationship exists. b. Efforts at coping are done to reduce perceived discrepancies. c. When we are stressed, our ability to perceive discrepancies between demands and resources declines severely. d. Only actual discrepancies, not perceived discrepancies, are related to the experience of stress.

4. Which of the following is NOT true about the coping process? a. It may include avoiding a potentially stressful situation. b. It involves ongoing transactions with the environment. c. It is not a single event. d. It does not include avoidance behavior.

5. According to Lazarus, coping serves to a. alter the problem. b. regulate our emotional response to the problem. c. prevent stress completely. d. both a and b 6. Which of the following is NOT an example of behavioral coping? a. using alcohol b. denying unpleasant facts c. watching TV to distract attention from a problem d. seeking support from friends

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b (119)

d (119)

b (119)

d (120)

d (120)

b (121)

7. Greg has immersed himself completely in his job since the death of his wife. He is likely to be engaging in a. problem-focused coping. b. emotion-focused coping. c. drug abuse. d. denial of her death.

8. Which of the following is NOT an emotion-focused coping approach? a. trying to see the positive side of a stressful situation b. taking one's anger out on another person c. getting busy with other things to keep one's mind off a problem d. trying to find out more about the stressful situation 9. Which of the following persons is engaging in cognitive redefinition? a. Ted lectures himself about not getting medical treatment sooner. b. Maggie tells herself that she is much better off than Alice because her own condition is not as serious. c. Carlos gets opinions from several specialists before deciding on a treatment. d. Daphne goes out with friends every night so she doesn't have to think about her upcoming surgery.

10. Which of the following statements is true about avoidance approaches? a. They are rarely used as coping strategies. b. They are beneficial at all stages in the coping process. c. In general, they are more effective than attention-promoting strategies. d. They are most beneficial during the first few weeks of a prolonged stress experience.

11. Problem-focused coping is LEAST likely to be used under which of the following situations? a. job loss b. final exams c. interpersonal conflicts d. death in the family 12. Can both problem-focused and emotion-focused coping be used together? a. Yes, they can but it’s generally unwise to do so. b. Yes, they can and this is frequently done. c. No. Problem-focused coping is always best to use. d. No. Emotion-focused coping is always best to use.

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13. Which of the following are problems with instruments thus far developed to measure overall coping? a. They expect coping to correlate well with mental or physical health. b. They are generally retrospective measures. c. They aren’t accurate measures of coping. d. all of the above 14. Positive emotions affect coping by a. helping us sustain our coping efforts. b. distracting us from our stress. c. reducing the effectiveness of our coping efforts. d. helping us find meaning to our suffering.

15. When a person copes with stress by actively processing and expressing their feelings, they are engaging in a. denial. b. emotional approach. c. problem-focused coping. d. stress inoculation.

d

16. Which of the following statements regarding the use of coping strategies is (122-123) true? a. People tend to use the same coping strategy regardless of the type of stressor they confront. b. There is no relationship between coping strategies and genetic influence. c. People never use the same strategy twice, even for the same stressor. d. No one coping method is used or is effective in all stressful situations. c (123)

b (123)

17. Compared to middle-aged adults, older adults tend to see stressors as a. easy to change. b. nothing to worry about. c. difficult to change. d. easily addressed by problem-focused coping strategies.

18. According to research men and women differ in their use of problemfocused v. emotion-focused coping EXCEPT when a. no young children live in the household. b. they are similar in occupation and education level. c. they are similar in age. d. they are similar in marital status.

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19. According to the text, disadvantaged persons are more likely to experience a. the belief that they have little control over events in their lives. b. more stressful events. c. less effective coping. d. all of the above 20. Which of the following statements about social networks is true? a. Women use their social support networks more effectively. b. The elderly are likely to have extensive social support networks. c. The nature of social support networks is not related to social prestige, income or education level. d. The use of social and helping organizations as support networks is no greater now than it was decades ago.

21. What do we know from research on self-help groups about their effectiveness? a. Groups that have been around the longest, like Alcohols Anonymous are the most effective. b. Only women benefit from being in such groups. c. Being in a self-help group only helps early in a stress crisis. d. Researchers really don’t have good data on which support groups work best.

22. According to the text, what role does a community have in enhancing social support? a. It can actively increase opportunities for social support by creating programs and making facilities available for group gatherings. b. Communities can do the most by leaving social support up to private and social service agencies. c. Most people seeking social support find community efforts to be ineffective. d. Most people seeking social support find community efforts to be intrusive.

23. Debbie has developed a "what's the use" attitude toward her efforts to stop smoking and has stopped participating in her treatment program. Which type of psychological support does she need most? a. relaxation exercises b. biofeedback training c. self-efficacy enhancement d. all of the above

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24. Allowing workers to have some control over their work hours, which tasks to work on, and the order in which they do them are examples of a. avoidance. b. intellectualization. c. stress-driven coping. d. enhancing personal control.

25. Which of the following is not a part of effective time management? a. Goal-setting. b. Delaying urgent new tasks until the next day. c. Establishing a schedule. d. Prioritizing the day's activities.

26. Which of the following is an accurate assessment of the research findings on the relationship between anxiety and exercise? a. There is no effect of exercise on anxiety. b. Exercise and decreased anxiety are correlated, but the cause of this relationship is not clear. c. Exercise seems to increase anxiety in some cases. d. Exercise has positive effects only in the young.

27. Which of the following is an accurate conclusion based on the research findings regarding the relationship between exercise and physiological measures? a. Regular exercise lowers heart rate and blood pressure. b. Exercise lowers heart rates but not blood pressure. c. Stress has the same health impact on people regardless of fitness level. d. Sports exercise promotes the greatest reduction in heart rate.

28. Irving Janis suggested that preoperative fear is related to postoperative recovery and adjustment. What was the nature of the relationship he suggested? a. Low levels of preoperative fear are related to worsened recovery and adjustment. b. High levels of preoperative fear are related to worsened recovery and adjustment. c. Preoperative fear is related to poor recovery but only in children or the elderly. d. Preoperative fear affects postoperative adjustment but has little impact on recovery.

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29. The most clearly effective methods in preparing people for the stress of surgery a. involve hypnosis. b. are psychotherapies. c. involve drug treatment. d. enhance feelings of control.

30. Using a deep breathing technique to control pain during an invasive procedure is an example of a. hypnosis. b. biofeedback. c. behavioral control. d. cognitive control.

31. Teresa, who has breast cancer, has read several books on treatment for breast cancer and has watched a video on mastectomy surgery. She is exercising a. hopelessness. b. behavioral control. c. cognitive control. d. informational control.

32. Which statement regarding informational control of anxiety is NOT true? a. More information always reduces anxiety. b. You can "know too much,'' and actually increase anxiety. c. Informational control has limits when the patient is a child. d. both b & c

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33. When it comes to providing young children with information prior to a medical (128) procedure, what strategy seems to be most effective? a. Providing the information only to their parents. b. Letting them handle all the surgical tools before the surgery. c. Providing them with information about the sensations they will experience. d. Telling them that crying will ease their fear.

a (129)

34. Benzodiazepines and beta-blockers are a. pharmacological methods of stress management. b. highly recommended for long term use. c. informational-control methods. d. forms of psychosocial stress interventions.

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35. Benzodiazepines are to ____ nervous system as beta-blockers are to _____ nervous system. a. sympathetic; parasympathetic b. central; peripheral c. peripheral; central d. parasympathetic; sympathetic 36. Which of the following are true regarding beta-blockers? They a. cause extreme drowsiness and thus are rarely used. b. are used less frequently than benzodiazepines. c. block the actions of epinephrine and norepinephrine. d. block the activation of the parasympathetic nervous system.

37. The technique of progressive muscle relaxation involves a. progressively increasing the use of muscle relaxants such as betablockers. b. alternately tightening and relaxing specific muscle groups. c. alternating between relaxation exercises and the use of beta-blockers. d. the use of hypnosis.

38. Conclusions regarding the use of progressive muscle relaxation in stress reduction interventions suggest that a. a quick version may be used once the regular procedure has been mastered. b. these techniques work only on adults. c. these techniques work only on children. d. it has been found to be only modestly effective in reducing stress.

39. Which of the following is NOT true of systematic desensitization? a. It is based on classical conditioning. b. It incorporates the use of muscle relaxation. c. It uses psychoanalytic theories. d. It can be used with both adults and children.

40. Rodney is extremely afraid of snakes. To deal with this problem, he is first shown a picture of snakes and told to relax while looking at it. He is likely receiving the treatment known as a. systematic desensitization. b. psychoanalysis. c. biofeedback. d. cognitive restructuring.

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41. Systematic desensitization is based upon the view that fears are learned through the process known as a. operant conditioning. b. modeling. c. behavioral control. d. classical conditioning.

42. A graded sequence of approximations to a feared stimulus is called a. a classical situation. b. systematic desensitization. c. a stimulus hierarchy. d. imagery.

43. In systematic desensitization, the next higher step in a stimulus hierarchy is presented when the a. person's fear is greatest. b. person is calm during the previous step. c. person has gone to sleep. d. fee for the previous step is paid.

44. In the process of counterconditioning, feelings of calm are considered to be a. both the UR and the CR. b. both the US and the CS. c. both the US and the UR. d. the CR only.

45. Biofeedback uses the principles of ___________ to treat fears a. psychoanalysis. b. informational control. c. classical conditioning. d. operant conditioning.

46. Studies on the effectiveness of biofeedback indicate that a. biofeedback is an ineffective intervention. b. muscle relaxation is far superior to biofeedback. c. children are unable to benefit from biofeedback. d. children are better biofeedback subjects than adults.

47. Findings regarding children and biofeedback include the observations that a. their shorter attention span may create a problem in sessions. b. a small percentage of young children are frightened of the equipment. c. children are more likely than adults to practice their training at home. d. all of the above 176

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48. Dr. Murphy believes that his patient, Samuel, has learned his fear of snakes from watching his mother's negative reactions to snakes. Dr. Murphy believes in a _____ explanation of stress-related behavior. a. behavioral control b. biofeedback c. observational learning d. classical conditioning 49. Melamed used modeling procedures to reduce stress in young people anticipating surgery. She found that young children with previous experience with surgery a. showed increased anxiety if they were under the age of 8. b. did not understand the procedures. c. had the greater anxiety reduction than the older participants. d. were more responsive to in vivo experiences than symbolic representations.

50. The process of replacing stress-provoking thoughts with thoughts that are more constructive is called a. systematic desensitization. b. intellectualization c. cognitive restructuring d. rationalization 51. The concepts of "musterbating" and "can't-stand-itis" are forms of _____ ways of thinking according to Albert Ellis. a. illogical b. stressed c. irrational d. restructured 52. In Beck's cognitive therapy approach the focus is on a. changing maladaptive thought patterns. b. helping clients see that they are not responsible for all the problems they encounter. c. treating erroneous beliefs as though they are hypotheses to be tested. d. all of the above 53. Allen’s doctor is teaching him a cognitive technique to reduce his stress in which he is learning to identify stressful life situations, generate lists of possible solutions to the situations and decide on best courses of action to resolve them.

Allen is learning a. biofeedback. b. problem-solving training. c. stress inoculation. d. cognitive restructuring.

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54. Meichenbaum's stress inoculation training includes which of the following processes? a. hypothesis testing and relaxation b. conceptualization, skills acquisition & rehearsal, skills application. c. modeling and biofeedback. d. symbolic modeling and cognitive restructuring.

55. Dr. Smith believes that the most effective way to treat stress is to use many different techniques since stress and coping are complex experiences. She believes in the use of _____ approaches. a. multidimensional therapy b. rational-emotive therapy c. systematic desensitization d. stress inoculation 56. Which of the following statements is true regarding the use of massage as a stress reduction technique? a. It has not been found to be effective in reducing stress but does seem to improve immune function. b. Light massage works better than deep tissue massage. c. Deep tissue massage has been linked to stress reduction and improved immune function. d. There is no research evidence to support the use of massage as a stress reduction technique.

57. Research comparing meditating and nonmeditating participants found a. Meditating participants had greater decreases in blood pressure and lower levels of anxiety. b. Nonmeditating participants had greater decreases in blood pressure, heart rate, and respiration rate. c. There were no differences in blood pressure, heart rate, or respiration rate between the two groups. d. Meditation only works to reduce blood pressure while the person is meditating.

58. Research on the use of hypnosis in stress reduction has found that a. it works better than many other methods in reducing stress. b. treatment depends on how suggestible participants are to hypnosis. c. hypnosis is not necessarily more effective than other relaxation techniques. d. both b and c.

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59. In their Type A behavior reduction program, Ethel Roskies and her colleagues used which of the following approaches? a. hypnotism b. psychotherapy c. relaxation d. multidimensional 60. Which statement regarding psychological approaches in the treatment of hypertension is NOT true? a. Psychological approaches can be used without drugs to treat hypertension. b. Untrained people can easily lower their own blood pressures by trying to relax. c. Relaxation by itself is not always helpful in lowering blood pressure. d. Progressive muscle relaxation, biofeedback, and meditation have all been demonstrated to reduce blood pressure.

Mary is diagnosed with a chronic illness. She attempts to cope with her diagnosis by regulating the feelings that she is experiencing. Mary is using this type of coping: a. Rumination c. Problem-focused coping d. Emotion-focused coping e. Avoidance coping

Short Answer Questions 1. Compare and contrast emotion-focused and problem-focused coping.

2. Compare and contrast systematic desensitization with biofeedback.

3. Compare and contrast problem-solving training with stress inoculation training.

Essay Questions 1. You require surgery sometime in the near future. Using what you've learned in this chapter, how will you prepare for this stressful event?

2. Discuss the effectiveness of the 3 methods of stress management reviewed in the chapter.

3. Consider the idea that the various methods of coping discussed in the chapter represent a multidimensional approach to coping. Defend or refute this notion.

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CHAPTER 6 HEALTH-RELATED BEHAVIOR AND HEALTH PROMOTION CHAPTER OUTLINE I. Health and Behavior A. Section Introduction 1. Greater attention is being given to people’s health behavior since health habits are related to developing fatal and chronic diseases a. illness and early death could be greatly reduced if people changed their lifestyles i. average life expectancy could increase to 85 years B. Lifestyles, Risk Factors, and Health 1. Section introduction a. the lifestyle of even typical people includes risk factors for illness and injury 2. Health behavior a. health behaviors = any activity people perform to maintain or improve their health regardless of perceived health status or whether the behavior achieves goal b. well behavior = any activity undertaken to maintain or improve current good health and avoid illness i. when well, people may not have motivation to put forward effort or make sacrifices for healthful behavior ii. engaging in healthful behavior depends heavily on 1) perception of threat of disease 2) value in behavior reducing threat 3) attractiveness of unhealthful behavior c. symptom-based behavior = when ill, any activity undertaken to determine the problem and find a remedy i. large variability in expression of symptom-based behavior 1) some people are fearful or stoic whereas others are very likely to complain and/or seek help d. sick-role behavior = any activity people undertake to get well after determining they are ill i. sick-role expectations 1) exemption from typical obligations and life tasks 2) an obligation to try to get well (although many don't adhere to recommendations) ii. sick-role behaviors may be influenced by learning and cultural expectations

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3. Practicing health behavior a. health behavior practices i. although shortcomings are noted in level of health behavior performance, percentages still represent an improvement over the past decade b. gender, sociocultural, and age differences are observed in health behaviors i. example: women perform more health behaviors than men ii. explanation: people perform behaviors that are salient to them c. consistency in health behaviors i. conclusions regarding health behaviors 1) although health habits are fairly stable, they do change over time 2) particular health behaviors are not strongly tied to each other 3) health behaviors are not governed by a single set of attitudes or response tendencies ii. reasons for lack of consistency 1) at any given time in life, various factors may differentially affect different behaviors 2) people change with experience 3) life circumstances change C. Interdisciplinary Perspectives on Preventing Illness 1. Health advances occur through efforts to prevent disease and improvements in diagnosis and treatment a. 3 approaches to illness prevention i. behavioral influence - encouraging/demonstrating health behaviors ii. environmental measures - changing the environment such as adding flouride to water supply iii. preventive medical efforts - examples include dental checkups b. there are 3 levels of prevention (primary, secondary, tertiary) related to different levels of health status and with different effects on health behaviors, social network, and health professionals 2. Primary prevention a. involves specific actions taken to avoid disease or injury i. examples: using seat belts, genetic counseling, immunizations b. approaches health professionals may use for primary prevention i. giving medical advice ii. using a system of reminders iii. constructing medical websites 181

3. Secondary prevention a. involves actions taken to identify and treat an illness early in effort to stop or reverse health problem b. includes patient's symptom-based behavior (help seeking), a physician prescribing medications or dietary changes, the patient adhering to medical advice (sick role behavior) c. examples i. annual physical examinations ii. cyclic scheduled laboratory tests to detect disease earlier 4. Tertiary prevention a. involves actions to retard lasting damage, prevent disability, and rehabilitate b. examples i. physical therapy ii. taking medications to control pain or inflammation c. in case of incurable diseases, goals may also be to keep patient comfortable and the disease in remission for as long as possible D. Problems in Promoting Wellness 1. Process of preventing illness and injury operates within a system of interrelated factors a. interrelated factors/problems can impair effectiveness of each component in system b. each component affects each other component 2. Factors within the individual (intrapersonal) a. many healthy behaviors are less pleasurable than the unhealthy alternatives i. some people deal with this by setting limits on the amount of unhealthy behaviors they do b. often have little immediate incentive for changing health behaviors c. prevention requires a change in long-standing behaviors that have become habitual, may involve addictions d. people need to have cognitive resources, self-efficacy, and motivation to engage in health behaviors e. being sick or taking certain medications may affect mood and energy levels therefore also affecting cognitive resources and motivation 3. Interpersonal factors a. social network consists of people with different individual motivations i. having friends or family who model healthful behavior and who give social support/encouragement for behavioral change increases likelihood of making changes ii. interpersonal conflict may emerge due to different motivations and have negative effect on health behaviors 182

4. Community factors a. people are more likely to adopt health behaviors encouraged by government and health care agencies b. issues affecting advice given by health professionals i. have inaccurate information about what patients’ healthrelated behaviors ii. traditionally have focused on treatment rather than prevention although interest in prevention has increased c. issues affecting large-scale community efforts i. public health projects influenced by lack of funds ii. need to consider programs for people of different ages and sociocultural backgrounds iii. health insurance may not cover prevention efforts iv. need to balance public health with economic priorities II. What Determines People's Health-Related Behavior?

A. General Factors in Health-Related Behavior 1. Although people can describe healthy behavior, heredity or genetics appears to influence some health behaviors such as alcoholism 2. Learning a. operant conditioning = acquiring behaviors through learning consequences to a behavior i. types of consequences 1) reinforcement = increases the likelihood a behavior will occur again in the future a) positive reinforcement = a pleasant consequence follows the behavior b) negative reinforcement = behavior removes or ends an unpleasant consequence 2) extinction a) occurs when the consequences maintaining a behavior are eliminated 3) punishment a) occurs when behavior is suppressed by an aversive consequence or something pleasant is removed b. modeling = learning through observing the consequences a model receives 1) affect the observer especially if the model is similar and high status c. role of habit i. occurs when behavior is performed automatically and without awareness ii. habits are less dependent on consequences and more dependent on antecedent cues 183

iii. since habitual behaviors are so difficult to change, “well” behaviors need to be established early in life and unhealthy behaviors eliminated as soon as they appear 3. Social, personality, and emotional factors a. social factors i. ways in which friends/family influence health behaviors 1) encouraging/discouraging health behaviors 2) providing consequences 3) modeling health behaviors 4) communicating values about health ii. gender differences in health-related behaviors may be influenced by parental perceptions of male v. female children b. personality i. personality trait of conscientiousness is associated with practicing health-protective behavior c. role of emotions i. distress over potential illness may interfere with getting preventive screening ii. high levels of stress are associated with unhealthy behaviors such as poor diet, low exercise, smoking, and drinking 4. Perception and cognition a. perceived symptoms influence health-related behaviors i. symptom severity influences help seeking 1) severe symptoms prompt most people to seek medical care 2) moderate symptoms tend to lead people to change health habits to meet needs of health problem b. role of cognitive factors in health behaviors i. people must have correct knowledge and ability to solve problems to engage in healthful behaviors ii. people make judgments that have impact on health 1) assess the condition of their health.

2) make decisions regarding needed changes in health behavior iii. misconceptions on health status can lead to harmful health behaviors 1) example: hypertensives altering medication-taking behavior when lack of symptoms present c. impact of unrealistic optimism i. concept involves peoples’ belief that they are less likely than other people their age or sex to experience negative health situations

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1) belief is based on illogical ideas such as the health problem rarely occurring or not having occurred to them yet ii. when a person is sick or when a threat of illness is clear, people are affected by unrealistic pessimism regarding health iii. importance of findings about unrealistic optimism and unrealistic pessimism 1) revealed that feelings of invulnerability is not unique to adolescents 2) people who engage in health practices tend to feel they would be at risk for problems if they did not do so 3) health professionals can implement intervention designed to help people see risks more realistically B. The Role of Beliefs and Intentions 1. How people think may influence how they behave a. example: people who believe in alternative health models (e.g., reflexology) are apt to behave in ways that support those beliefs 2. The Health Belief Model a. theory based on the assumption that likelihood of taking preventive action is dependent on analysis of threat the person feels regarding a health problem and the pros/cons of taking the action b. perceived threat depends upon i. perceived seriousness - severity of effects if problem is left untreated 1) higher perception of seriousness linked to higher perception of threat and taking preventive action ii. perceived susceptibility - vulnerability to contracting the problem 1) perception of higher risk linked to higher perception of threat and taking preventive action iii. cues to action - being reminded or alerted to the problem 1) being aware of cue increases sense of threat and need for action c. perceived benefits must exceed the perceived barriers or costs for preventive behavior to occur d. likelihood of preventive action is based on the combination of perceived threat and the sum of the cost-benefit ratio e. demographic, psychosocial, and structural variables influence perceptions of benefits, barriers, and risks i. includes age, sex, racial/ethnic background, social class, personality traits, knowledge, or prior experience with health problem 185

f. research supports much of the model i. hundreds of studies have been performed testing different elements of the model ii. findings suggest perceived barriers and perceived susceptibility are strong predictors of health behavior 1) some research also supports cues to action g. theory shortcomings i. does not account for habitual behaviors ii. no standard way of measuring its components 3. The Theory of Planned Behavior a. theory, actually an extension of theory of reasoned action, is based on assumption that people decide on intentions prior to action and intentions are best predictors of behavior b. judgments that determine intention i. attitude regarding the behavior - judgment of whether behavior is a good thing to do based on likely outcome of behavior and whether outcome is rewarding ii. subjective norm - social pressure or appropriateness of behavior based on others' opinions and motivation to comply with that opinion iii. perceived behavioral control - expectation of behavioral success (similar to idea of self-efficacy) c. how intentions are developed i. judgments combine to produce intention that leads to performance of the behavior ii. self-efficacy is important component in development of intention 1) self-efficacy based on analysis of following a) complexity of task b) effort required c) availability of helping resources d. research on theory i. support found for theory assumptions in tests on various health-related behaviors such as donating blood, exercising, using condoms ii. meta-analysis suggests that interventions can change the factors and increase intentions d. theory shortcomings i. intentions and behavior are only moderately related 1) gap can be reduced by intervention that includes careful, specific planning ii. theory does not include prior experience

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e. shortcomings in common with Health Belief model i. both assume people think about health-related behavior in a detailed way ii. people know what illnesses are associated with particular behaviors iii. people know how to accurately estimate risks of illness 4. The Stages of Change model a. model emphasizes readiness to change i. people in one stage show different psychosocial characteristics from people in other stages ii. efforts to change behavior not likely until person has made it to more advanced stages iii. people may regress in stages iv. it is possible to help people move across stages 1) have person describe in detail how they will change 2) develop intervention so that match strategies to person’s needs b. stages of the model (see Figure 6.3) i. precontemplation - person hasn't thought about change or may have been decided against it ii. contemplation - person is aware problem exists and is seriously considering change iii. preparation - person is ready to try to change and plans to pursue a behavioral goal iv. action - person engages in active change efforts v. maintenance - person works to maintain successful behavioral changes c. research support i. findings indicate that people at higher stages of model are more likely to succeed ii. studies have also found processes that lead to regression and value of matching interventions to stages in increasing likelihood of success d. model shortcomings i. as with previously discussed cognitive theories, doesn't account for irrational decisions, which appear to be result of motivational or emotional processes not addressed in model C. The Role of Less Rational Processes 1. Motivational factors in beliefs a. motivated reasoning i. a process by which people's desires and preferences influence the judgments they make about the validity and utility of new information

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ii. when people prefer to reach a particular conclusion, they may use biased processes, such as accepting only information that supports their conclusion, even if their logic is clearly faulty iii. studies demonstrating nonrational thought in healthrelated decisions 1) people with chronic illness who use illogical thought patterns tend to not follow medical advice 2) people who are at high risk for HIV infection and use defense mechanisms deny their risk for AIDS perhaps due to high feelings of threat 3) people use irrelevant information to judge risks in having sex 4) smokers give lower risk ratings than nonsmokers 2. False hope and willingness a. 2 features of health-related behaviors not accounted for well by previous theories i. people who fail to change a negative health behavior often try to do so again in the future ii. many risk behaviors occur spontaneously b. false hopes serve as basis for try change again i. false hopes = believing, without rational basis for belief, that one will succeed in subsequent change efforts ii. stem from observation that, for a while, they were successful in previous attempt(s) and that is reinforcing iii. misinterpret cause of previous failure as lack of effort 1) failure often due to expecting too large change of behavior, too great an effect would occur, and change would occur quickly and easily c. risky behaviors often occur without thought i. people find themselves in tempting situations they didn’t expect ii. issue isn’t that they didn’t intend to do a harmful behavior but that they were willing to do it 1) factors influencing willingness a) positive subjective norms b) positive attitudes toward behavior c) having engaged in behavior before d) having a favorable social image of type of person who does the behavior 3. Emotional factors in beliefs a. stress has negative effects on cognitive processing i. under high stress, people pay less attention to and remember less information from health promotion literature

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b. Conflict Theory model i. model that accounts for both rational and irrational decision making ii. describes the cognitive sequence people use in decision making 1) stages in model a) appraising the challenge as threat or opportunity b) surveying alternatives to the challenge iii. model proposes people experience stress in all major decisions due to importance of decision and conflicts about what to do behaviorally iv. coping with decisional conflict depends on presence or absence of risks, hope, and adequate time 1) different combinations of above produce different coping patterns a) hypervigilance - person sees serious risks and believe that they may have alternatives, but believe they are running out of time so become frantic and make a hasty decision b) vigilance - see serious risks and believe that they have alternatives and time therefore experience less stress and make more rational choices 2) vigilance is most adaptive coping pattern v. theory has not been tested enough to know its strengths or weaknesses III. Development, Gender, and Sociocultural Factors A. Development and Health 1. As people age, the biopsychosocial factors affecting health change a. preventive needs and goals change as a result b. see Table 6.4 for excellent breakdown 2. During gestation and infancy a. birth defects due to genetic abnormalities or harmful factors in the fetal environment affect about 3 out of every 100 births in US b. nourishment as well as hazardous microorganisms and chemicals are passed to fetus from mother c. three prenatal hazards affecting fetus i. maternal malnourishment may lead to low birth weight, poorly developed immune and central nervous systems, and greater infant mortality ii. infections may be passed

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iii. presence of addictive or harmful substances (cocaine, cigarette smoke, alcohol) is related to low birth weight, impaired cognitive functioning, higher infant mortality d. health education is advisable for pregnant women e. breast feeding and childhood immunizations improves immune functioning in infants and children 3. Childhood and adolescence a. increased motor development places children at risk for injuries due to accidents i. ways to reduce likelihood of accidents 1) teaching children safety behaviors 2) providing appropriate supervision 3) decreasing access to dangerous situations ii. cognitive processes in young children are immature b. during adolescence, teenagers have cognitive abilities to make logical decisions but peer pressure may exert a negative, immediate influence i. engaging in multiple interrelated risky behaviors occurs ii. also learning to drive during this time period which contributes to likelihood of accidents 4. Adulthood and aging a. adults are less likely to adopt new behavioral risks to health i. older and younger adults may have similar beliefs about effectiveness of behaviors in preventing illness 1) older adults engage in more healthy behaviors 2) older adults may perceive themselves to be more at risk for disease than younger adults and therefore be more likely to engage in preventive behavior as a result b. living in an industrialized country is associated with living longer and being in better physical and financial condition c. engaging in regular substantial exercise tends to decline with age i. exaggerate dangers of exertion on health ii. underestimating physical capabilities iii. embarrassment regarding performance of physical activities B. Gender and Health 1. Life span expectancy is longer for women depending on the country and age group studied a. factors influencing short life span for males i. males have greater physiological reactivity when under stress contributes to greater likelihood of developing CHD ii. estrogen levels in women delay heart disease by reducing blood cholesterol levels and platelet clotting iii. men smoke and drink more increasing risk for cardiovascular and respiratory disease, cancer, cirrhosis 190

iv. men have higher levels of drug use, unhealthy diets, risky driving and sexual activity v. males less likely to seek medical care vi. work environments of men are more hazardous b. men engage in more strenuous exercise - a behavioral advantage 2. Trends in health problems a. women have higher rates of acute illnesses and nonfatal chronic disease b. women use more medical drugs and services even when pregnancy and reproductive conditions are controlled for C. Sociocultural Factors and Health 1. Section introduction a. study of health in Americans v. British demonstrates 2 trends i. health differs between different countries ii. health differs across different populations of people within a country 2. Social class and minority group background a. health correlates with social class i. people in lower social class are more likely to be born with low birth weight, die in infancy, die before 65, have poorer overall health and longstanding illness in adulthood, or experience more days of restricted activity due to illness b. lower class members have poorer health habits, behaviors and knowledge c. infant mortality and development of chronic illness is much higher among African-Americans d. African-Americans, American Indians, and Hispanics have the highest health problems and risks i. live in environments that don’t encourage practicing positive health behaviors ii. increased vulnerability for 3 health problems 1) substance abuse 2) exposure to HIV 3) higher likelihood of injury or death from violence 3. Promoting health with diverse populations a. solutions to health problems in diverse populations i. reducing poverty ii. creating effective approaches to present health information at low literacy levels b. professionals who are trying to prevent and treat illnesses need to consider: i. biological factors - differing physiological processes ii. cognitive and linguistic factors - differing ideas about illness, body sensation, and symptom interpretation; language differences between professional and patient 191

iii. social and emotional factors - differing levels and coping reactions to stress; differing types and use of social support c. grassroots, culturally relevant health-promotion programs have been developed in some areas i. example: Por La Vita involves increased breast and cervical cancer testing in Hispanic women IV. Programs for Health Promotion A. Methods for promoting health 1. Motivating people to change is an important step in interventions a. people need to want to change and that requires modifying health beliefs and attitudes 2. Providing information a. people need to know what to do, when, where, and how to do it b. sources of information to promote health i. mass media – television, radio, newspapers, magazines 1) simply supplying information on the negative consequences of an activity has had limited success a) people don't want to change the behavior ii. the Internet - databases and detailed information on specific illness or support groups are increasingly located here iii. medical settings - information provided at the doctor's office 1) advantages: most people visit the doctor annually and respect their doctor 2) disadvantages: offices are busy; personnel may not feel they have expertise to help or feel they are intruding in personal lives of patients 3) office system should be structured in such a way to promote giving information a) 5- to 10-minute counseling sessions done in person or over the phone b) developing a system of cues 4) physicians can give personal risk estimates on disease and opportunities to undergo tests a) even when opportunity is available, patients are hesitant to have tests due to anxiety or conflict with other family members who don’t wish to know the risk

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3. Features of information to enhance motivation a. using tailored content i. give information delivered in person, in print, or over the telephone should be specific to the listener and based on characteristics of that person b. message framing i. information emphasizes benefits or costs of behavior or decision 1) gain-framed message - focus on attaining desirable consequences or avoiding negative consequences a) best for motivating behaviors that serve to prevent or recover from illness or injury 2) loss-framed message - focus on getting undesirable consequence and avoiding positive consequences a) best for behaviors that serve to detect a health problem early ii. effectiveness of frame depends on type of health behavior iii. fear appeals are a special type of loss-frame message 1) linked to health belief model concept that people who believe they are more susceptible to risk (threat) when they do not engage in preventive behavior are motivated by fear to engage in the behavior 2) effects of fear appeals are transient 3) ways to make fear appeals more effective a) emphasize organic and social consequences of developing health problem b) provide specific instructions/training for performing behavior c) help bolster self-confidence or self-efficacy for behavior 4. Motivational interviewing a. motivational interviewing is a counseling style designed to help individuals explore and resolve ambivalence to changing behavior i. “client-centered” approach where client has control over conversation and counselor uses reflective listening and directive questioning to determine person’s internal motivation for behavior change is used ii. decisional balance = client lists reasons for and against changing behavior so these can be discussed and weighed iii. interview may involve single or multiple sessions iv. session(s) lead patient to identify benefits and problems and then work through identified problems 193

v. research has found this is a promising method vi. decisional balance is identified has critical component of process 5. Behavioral methods a. techniques that focus on enhancing performance of the preventive act itself by altering antecedents and consequences b. altering antecedents i. providing specific instructions or training ii. creating calendars to indicate when to perform behavior iii. developing reminders of appointments c. altering consequences i. providing rewards when behavior occurs 1) effectiveness depends on type of reward, age of person, person’s interest in performing behavior d. for programs to be effective, they need to consider the viewpoint of the person regarding preventive action and consequences of behavior 6. Maintaining healthy behaviors a. after new behaviors have been developed some lapse or relapse may occur i. lapse - a momentary backsliding ii. relapse - returning to original behavior pattern 1) more common when person tries to change longstanding behavior b. abstinence-violation effect i. when experiencing a lapse destroys confidence in remaining abstinent and precipitates a full relapse 1) can be reduced by training to cope with lapses, maintaining self-efficacy about behavior, and providing “booster” sessions or contacts a) need to provide counseling about dealing with difficult situations that could lead to relapse B. Promoting Health in the Schools and Religious Organizations 1. School-based and religious organization health education may teach children to avoid harmful practices and acquire beneficial behavior 2. Effectiveness of school and religious organization programs a. have demonstrated improvement in blood pressure and cholesterol levels b. have shown improvements in health behavior and physical condition c. characteristics of effective school and religious organization programs i. comprehensive programming ii. program involves children’s parents and community over a long period 194

C. Worksite Wellness Programs 1. Wellness programs are increasing rapidly in workplaces in industrialized countries a. national survey results i. 90% of responding employers had some kind of health promotion activity ii. 1/3 of small worksites and 1/2 of large worksites had comprehensive programs b. impact of employee health on workplace i. poor employee health costs employers in terms of health benefits and absenteeism ii. costs of running wellness programs is offset by savings in health benefits and less cost due to absenteeism 2. Aims of programs a. reducing risk factors such as hypertension, cigarette smoking, diet & weight, physical fitness, alcohol abuse, and stress 3. Advantages of worksite programs a. convenient to attend b. inexpensive for employees c. provides employees with reinforcement d. can structure environment to encourage healthful behavior 4. Johnson & Johnson's "Live for Life" program a. one of the most effective worksite programs developed b. components of the program i. a health screening ii. lifestyle seminar iii. action groups focus on specific problems iv. follow-up contacts v. work environment changes c. evaluation results found improvements in health indicators, absenteeism, and health care costs in program participants D. Community-Wide Wellness Programs 1. Programs designed to reach large numbers of people with intention of improving knowledge and performance on preventive behaviors a. programs often use media to provide information and advice on risk factors b. incentives may also be provided 2. The Three Community Study a. purpose was to change behavior and reduce risk for cardiovascular disease b. three California communities selected for the study i. two communities were given media information on smoking, diet and exercise whereas the third was treated as the control c. results indicate overall cardiac risk increased in the control community and decreased in experimental communities 195

i. best results in older populations and worst results in younger populations, participants with less education, and participants with lower socioeconomic status 3. Other similar programs have demonstrated similar success a. overall impact of programs tend to be modest but significant when population impact is considered E. Electronic Interventions for Health Promotion 1. Internet-based programs 2. Computer-based programs F. Prevention With Specific Targets: Focusing on AIDS 1. HIV infection a. magnitude of AIDS threat i. tens of millions have died around the world ii. over 33 million currently infected iii. millions newly infected each year b. demographics of infection i. largest concentration of infection in sub-Saharan Africa ii. growing incidence in Asia and Eastern Europe iii. declines seen in industrialized countries 1) development of new medical treatments has affected infection process in developed countries c. modes of HIV transmission i. contact between body fluids of infected and uninfected persons through sexual activity or use of shared needles ii. transmission of virus from mother to baby during gestation, delivery or breast-feeding d. risk factors for HIV infection i. in US, male-to-male anal intercourse still major risk factor ii. in US, risk of exposure is growing in low-income and minority groups iii. in other parts of world, major modes of infection include sharing needles and unprotected heterosexual vaginal intercourse iv. females are becoming increasingly at risk v. uncircumsized males are at greater risk vi. unsafe sexual behavior remains major risk 1) prevention efforts have focused on fear messages and providing information to promote safer-sex practices e. factors influencing unsafe sexual behaviors i. ignorance ii. lack of availability of protection iii. promiscuity iv. having sex under influence of alcohol or drugs 1) related to increased negative attitudes and decreased self-efficacy about condom use 196

2) increases willingness to have unsafe sex v. beliefs about the closeness or seriousness of the relationship related to reduced condom use vi. using denial or wishful thinking during decision making in sexual situations vii. beliefs of low self-efficacy about using condoms and decrease in sexual pleasure if one is used viii. embarrassment over buying condoms and errors in using them ix. medical treatments that lower viral load and their link to over-optimistic beliefs f. maladaptive beliefs are demonstrated when behavior contradicts expert information and qualifiers are added to statements 2. Basic messages to prevent HIV infection a. information on basic behaviors, much of which has been designed to arouse fear i. avoid or reduce sex outside of long-term monogamous relationship ii. people who have HIV may not know it and some who do know do not report it to sexual partners iii. drug users shouldn’t share needles unless sterilized iv. women should be tested for HIV before becoming pregnant and, if positive, avoid becoming pregnant b. impact of information on HIV-related knowledge and behavior i. information has been directed toward adolescents and young people, intravenous drug users and their sexual partners, and gays and bisexuals ii. although information increases knowledge, sexually experienced persons don’t follow recommendations for behavior change iii. virginity pledges are commonly broken within a year 1) promoting condom use is more effective in sexually active youth iv. information has reduced risk behaviors in drug users but only so far as it relates to drug behaviors 1) sexual behaviors are not affected c. best organized efforts have been present in gay communities who were already organized through social, political, and religious groups prior to HIV pandemic i. groups became mobilized to address HIV public health campaigns ii. results of efforts in gay community reflect most profound behavioral changes in health-related behaviors ever recorded 3. Focusing on sociocultural groups and women a. intervention efforts must be increased with heterosexual women 197

and disadvantaged sociocultural groups i. some minority groups may be at risk due to less knowledge or distrust of medical system ii. factors placing women at risk for HIV 1) male partner who resists using condoms 2) being socially/economically dependent on male partner 3) having less power in their relationship 4) violence within the relationship 5) partner who interprets request to use condom as sign she doesn’t care for him or suspects him of infidelity iii. interventions with Hispanic and African American women 1) sessions were designed to increase motivation and interpersonal skills for adopting safer sex practices 2) results: more likely to report using safer sex practices & obtaining condoms; less likely to develop STDs 4. Making HIV prevention more effective a. individual counseling (motivational interviewing) has had best success with those already infected b. uninfected people often do not reduce risky behaviors c. well-designed programs should include: i. tailoring the program to sociocultural group needs ii. training in actual skills iii. using methods to reduce behaviors that increase risk of unsafe sex iv. bolstering self-efficacy and advancing people through stages of change v. using respected or popular individuals to lead program vi. encouraging infected person to disclose HIV status vii. reducing nonrational influences on sexual decisions

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DISCUSSION TOPICS 1. The Precaution Adoption Process: The precaution adoption process is a model of preventive behavior not discussed in this chapter but clearly applicable. This model proposes that preventive behaviors occur in stages ranging essentially from uninformed bliss to actively taking precautions against a health hazard. Particularly interesting is Weinstein’s suggestion that people at different stages will think and behave in qualitatively different ways and that intervention strategists need to consider that different kinds of interventions and information will be needed to move people through these stages.

Source: Weinstein, N.D. (1988). The precaution adoption process. Health Psychology, 7(4), 355-386.

2. Private Passions and Public Health: This is an interesting article you may wish to have students read regarding HIV/AIDS. In reviewing the lives of people, it addresses tough personal and interpersonal needs and motivations that underlie what on the surface may appear to be illogical behavior with respect to HIV-testing and risk exposure. For example, the author describes cases of HIV-positive patients who actively try to infect their partners in an attempt to make that person stay with them. Another perspective involves AIDS infection as one of many problems in the lives of some people. A rich article for discussion.

Source: Krajick, K. (1988). Private passions and public health. Psychology Today, 22, 50-58.

3. The Effect of the Environment on Women's Health: Sarafino notes that men’s occupational and recreational experiences have historically put them at risk for illness and injury. VanDusen’s chapter explores a rich set of issues to be considered when evaluating the environmental risks to which women have historically been exposed. She explores environmental agents and situations within the home, neighborhood, and work settings that put women at risk. For example, over a million women working in the clothing and textile industry may be exposed to formaldehyde, flame-retardants, solvents, benzidine-type dyes, noise, vibration, and cotton dust. Nearly half a million hairdressers and cosmetologists are exposed to bleaches, nail varnishes, and hair dye. Household workers are at risk for exposure to chemicals such as solvents, pesticides, and disinfectants and injury due to falls. This author discusses the impact of these environmental hazards on the lives of women and the effects on children during gestation.

Source: VanDusen, K. (1982). The effect of the environment on women's health. In Hongladarom, G.C., McCorkle, R., & Woods, N.F. (Eds.), The complete book of women's health. (pp.163-178).

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4. A Worksite Health Promotion Model for Public Schools: This chapter addresses health promotion/prevention programs in both worksite and school settings. As such, this article may be of interest since it merges principles across both settings. The authors provide a very helpful table comparing general program characteristics for school health education, school health promotion programs, and worksite health promotion. In particular, they suggest that rather than having improved knowledge, attitudes, and behaviors as the outcome goals for health education classes, the goals might be more similar to those of worksite settings: improving student morale, increasing productivity (i.e., grades), and reducing student absenteeism.

Source: Eddy, J.M., Fitzhugh,E., Gold, R.S., & Wojtowicz, G.G. (1996). A worksite health promotion model for public schools. Journal of Health Education, January/February, 4850.

5. Workplace Wellness Program.

According to Cohen (1985), the advantages of a health promotion program at the workplace are: a. most employees go to the workplace on a regular schedule, facilitating regular participation in programs; b. contact with co-workers can provide reinforcing social support, which is believed by many to be a primary force in sustaining a life-style change; c. workplaces offer many opportunities for environmental supports, such as healthy food in cafeterias and office policies regarding smoking; d. opportunities abound for positive reinforcement for program participants; e. programs in the workplace are generally less expensive for the employee than comparable programs in the community; and f. programs in the workplace are convenient.

What are factors that encourage employers to institute such programs? What factors discourage them? Are there workplace factors that serve to increase health risks?

6. Cross-cultural Differences in Reporting Symptoms.

Richard Brislin, in his book on cultural influences on behavior, notes that research instruments (i.e., questionnaires) are frequently difficult to use since the connotative meaning of terminology can vary across cultures. As an example, health or good health can mean different things depending on cultural understandings of the nature of the body and disease etiology. His basic suggestion is that people involved in health care delivery need to be sensitive to cross-cultural variation in symptom reporting, as people tend to report symptoms in culturally-acceptable ways. For example, somatization may be more likely to occur in cultures where signs of weakness, anxiety, or worry are less tolerated. Complaints of gastrointestinal problems, nausea, or tightness in the head/chest may be indicative of homesickness or other stressing life situations. Brislin contends that practitioner knowledge of the bases for somatization within various cultural groups can provide an important context for understanding 200

symptom reporting, can contribute to patients' feeling of acceptance within the medical setting, and ultimately influence positive outcomes in health services delivery.

Source: Brislin, R. (1993). Understanding culture's influence on behavior. (pp. 329 - 334).

Fort Worth, TX: Harcourt Brace Jovanovich.

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ACTIVITIES 1. Assess Yourself: Your Knowledge about AIDS. Students' knowledge regarding AIDS is measured in this self-assessment, reproduced in handout #1.

2. Health Promotion. Have each student choose a problem addressed by public health departments such as cancer, heart disease, drinking, smoking, drugs, or AIDS. Monitor magazines, newspapers, television and radio programs as well as billboards and promotional activities for prevention efforts. Classify the efforts so identified as primary, secondary or tertiary in nature. Are the efforts fear-arousing, information-providing, or skill-building?

3. Health Risk Appraisal. A generous number of health risk appraisals (HRAs) can now be completed on-line. HRAs can be easily found by entering the key phrase "Health Risk Appraisal" on most major search engines. An example site is http://www.nmfn.com/tn/learnctr--lifeevents--longevity .If you did not do this exercise in connection to chapter 1, you may wish to include it here since this chapter speaks directly to using health risk appraisals. As noted before, you may wish to extend this exercise by having students select 1-2 identified risk areas and develop a plan to address these areas.

4. Health Quest activities. A CD-ROM entitled HealthQuest: An interactive exploration of your health and well-being by Gold, R.S., Atkinson, N., Mullen Conley, K., and McDermott, R.J. is available through McGraw-Hill. Three modules include activities and information regarding tobacco, alcohol, and other drugs. Wellness exercises are also integrated into the activities provided.

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Handout #1

Assess Yourself: Your Knowledge about AIDS. Instructions: Answer the following true-false items by circling the T or F. T

F

1.

All people who develop AIDS die from its complications.

T

F

2.

Blood tests can usually tell within a week after infection whether someone has the AIDS virus.

T

F

3.

People do not get AIDS from using swimming pools or restrooms also used by someone with AIDS.

T

F

4.

Some people have contracted AIDS from insects, such as mosquitoes, that have previously bitten someone with AIDS.

T

F

5.

AIDS can now be prevented with a vaccine and cured if treated early.

T

F

6.

People who have the AIDS virus can look and feel well.

T

F

7.

Gay women (lesbians) contract AIDS much more often than heterosexual women but not as often as gay men.

T

F

8.

Health workers have a high risk of getting AIDS from or spreading the virus to their patients.

T

F

9.

Kissing or touching someone who has AIDS can give you the disease.

T

F

10.

AIDS is less contagious than measles.

203

RESOURCES Suggested Readings: Health and Behavior Ajzen, I., Albarraci, D., & Hornik, R. (2007). Prediction and change of health behavior: Applying the reasoned action approach. Mahwah, NJ: Erlbaum Associates.

Brown, J.D., Steele, J.R., Walsh-Childers, K. (2002). Sexual teens, sexual media: Investigating media’s influence on adolescent sexuality. Mahwah, NJ: US Lawrence Erlbaum Associates.

Skelton, J.A., & Croyle, R.T. (1991). Mental representations in health and illness.

New York: Spring-Verlag.

Woolf, S.H., Jonas, S., & Lawrence, R.S. (1996). Health promotion and disease.

Prevention in clinical practice. Baltimore, MD: Williams & Wilkins.

What Determines Health Behavior?

Glanz, K., Lewis, F., & Rimer, B. (1997). Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass.

Gochman, D. (1997). Handbook of health behavior research. New York: Plenum Press.

James, A & Hockey, J. (2007). Embodying health identities. New York: Palgrave Macmillan.

Miller, D., Green, J. (2002). The psychology of sexual health. Oxford: Blackwell Science Ltd. Orbell, S, Perugini, M, & Rakow, T. (2004) Individual differences in sensitivity to health communications: Consideration of future consequences. Health Psychology, 23(4) 388-396.

Raczynski, J.M., Leviton, L.C. (2004). Handbook of clinical health psychology: Volume 2. Disorders of behavior and health. Washington D.C.: American Psychological Association.

Rifkin, E., & Bouwer, E. (2007). The illusion of certainty: health benefits and risks. New York: Springer.

Development, Gender, and Sociocultural Factors Campbell, C.A. (1999). Women, families, and HIV/AIDS: A sociological perspective on the epidemic in America. Cambridge: Cambridge University Press.

Daniels, N. (2008). Just health: meeting health needs fairly. New York: Cambridge University Press.

Parks, D., Morrell, R., & Shifren, K. (1999). Processing of medical information in aging patients: cognitive and human factors perspectives. Mahwah, NJ: Lawrence Erlbaum.

Pearlberg, G. (1991). Women, AIDS, & communities: A guide for action. New York: Women's Action Alliance.

Soares, R. (2007). On the determinants of mortality reductions in the developing world.

Cambridge, MA: National Bureau of Economic Research.

US Government Accountability Office. (2007). Poverty in America: economic research shows adverse impacts on health status and other social conditions as well as the economic growth rate. Washington, DC: US-GAO. 204

Van Vugt, J.P. (Ed.) (1994). AIDS prevention and services: community based research. Westport, CN: Bergin & Garvey.

Health & Wellness Promotion Brownson, R.C., Baker, E.A., & Novick, L.F. (1999). Community-based prevention: Programs that work. Gaithersburg, MD: Aspen Publ.

Cottrell, R., Girvan, J., & McKenzie, J. (1999). Principles and foundations of health promotion and education. Boston: Allyn and Bacon.

Downie, R., Tannahill, C., & Tannahill, A. (1996). Health promotion: models and values. New York: Oxford University Press.

Evers, A., Farrant, W., & Trojan, A. (Eds.). (1990). Healthy public policy at the local level. Boulder, CO: Westview Press.

Fazio, L. (2008). Developing occupation-centered programs for the community. Upper Saddle River, NJ: Pearson/Prentice Hall.

Grant, C., & Brisbin, R. (1992). Workplace wellness: the key to higher productivity and lower health costs. New York: Van Nostrand Reinhold.

Hoeger, W. & Hoeger, S. (1996). Fitness & wellness. Englewood, CA: Morton.

Howatt, W. (2001). Creating wellness at home and in school. Bloomington, ID: Phi Delta Kappa Educational Foundation.

Kerber, B. (1999). Wellness program management yearbook. Manasquan, NJ: American Business Publishing.

Miller, D.F. (1995). Dimensions of community health. Madison, WI: Brown & Benchmark.

Raczynski, J., & DiClemente, R. (1999). Handbook of health promotion and disease prevention. New York: Kluwer Academic.

Schust, C.S. (1996). Community health: Education and promotion manual.

Gaithersburg, MD: Aspen Publ.

Wilson, B., & Glaros, T. (1994). Managing health promotion programs. Champaign, IL: Human Kinetics.

Woolf, S., Jonas, S., & Kaplan-Liss, E. (2008). Health promotion and disease prevention in clinical practice. Philadelphia: Wolters Kluwer Health.

HIV/AIDS Global HIV Prevention Working Group. (2003). Access to HIV prevention: closing the gap. United States: Global HIV Prevention Working Group.

Haacker, M. (2004). The macroeconomics of HIV/AIDS. Washington, DC: International Monetary Fund.

Leviton, L., Hegedus, A., & Kubrin, A. (1990). Evaluating AIDS prevention: contributions of multiple disciplines. San Francisco: Jossey-Bass.

National Institutes on Drug Abuse. (2000). The NIDA community-based outreach model: A manual to reduce the risk of HIV and other blood-borne infections in drug users. Bethesda, MD: NIDA. Seckinelgin, H. (2008). International politics of HIV/AIDS: global disease – local pain.

New York: Routledge.

Tillman, P.S. & Pequegnat, W. (1996). Interventions to prevent HIV risk behaviors: January 1991 through November 1996. Bethesda, MD: NIH. 205

Suggested Films and Videos: Health and Behavior 1. AIDS: No nonsense answers. (1994, Films for the Humanities, 10 min).

Demonstrates prevention behaviors and lifestyle modifications to prevent AIDS infection.

2. Cancer prevention. (1994, The Institute, 10 min). Discusses what causes cancer and how to protect oneself from the disease.

3. Health hazards: What you don't know. (2000, Edudex, 30 min). Focuses on health hazards in the environment.

4. HeartSafe: Healthy choices to protect your heart. (1993, Milner-Fenwick, 50 min). A look at prevention and control of heart disease.

5. Living with cancer. (2000, Edudex, 30 min). Video covers advances in cancer treatment and discusses social support as a factor in living with cancer.

What Determines Health Behavior?

6. If AIDS is so bad, how come we don't know anybody who has it? (1990, Metropost, 23 min). Demonstrates faulty beliefs that contribute to the spread of AIDS. 7. In human terms. (2000, Edudex, 30 min) Program analyzes disease throughout the world community.

Development, Gender, and Sociocultural Factors 8. Breast health: Complete series. (1999, Edudex, 24 min). Provides a complete breast health curriculum.

9. Conceiving the future. (1993, PBS Video, 57 min). Discusses how genetics provides powerful ways to predict health and determine the future of an embryo.

10. Fetal alcohol syndrome: A focus on prevention. (1997, Edudex, 20 min). Offers advice on prevention of FAS. 11. Pandemic. (1993, PBS Video, 57 min). Describes how some doctors are leaving the hospital to prevent AIDS at its source.

Programs for Health Promotion 12. Avoiding Infectious and Sexually Transmitted diseases. (1998, Films for the Humanities and sciences, 29 min). Profiles STDs such as HIV, symptoms, and risk factors.

13. B.S.E. for teens: with Jennie Garth. (1999, Edudex, 7 min). Program encourages teens to adopt the use of BSE. 14. Preventing skin cancer. (2001, Edudex, 25 min). Reviews the various kinds of skin cancers and shows how to protect against them.

15. Testicular self-examination. (1995, Edudex, 5 min). Self-examination of the testes is demonstrated.

16. Planning healthy lifestyles. (2002, Human Kinetics, 30 min). Students are given guidelines for maintaining health and promoting wellness.

17. Introduction to wellness. (2002, Human Kinetics, 25 min). Maintaining health and wellness and a healthy lifestyle is discussed.

206

Journals of interest American journal of health behavior – PNG Publications

Internet sites of interest: Workplace Wellness 1. http://www.wellnessjunction.com/ - A commercial website oriented to workplace wellness.

2. http://www.corporatewellness.com/ - Corporate Wellness webpage (worksite wellness programs).

Prevention 3. http://www.welcoa.org/ - Wellness Councils of America webpage 4. http://www.md-phc.com/index.html - Preventive Health Center 5. http://www.tht.org.uk/ - HIV infection information 6. http://www.health.org/ - The National Clearinghouse for Alcohol and Drug Information (links to prevention programs).

7. http://hivinsite.ucsf.edu/ - HIV InSite Gateway to HIV and AIDS knowledge 8. http://www.livingto100.com/ - Living to 100 life expectancy calculator – gives detailed prevention and health behavior change information.

Other Sites of Interest 9. http://www.healthypeople.gov - Healthy People 2010 website 10. http://www.nachc.com/ - National Association of Community Health Centers 11. http://www.cancer.org/ - American Cancer Society homepage 12. http://www.healthyself.org/healthyselfhome.htm - Site for health living resources 13. http://www.americanpregnancy.org - American Pregnancy Association – Site promoting reproductive and pregnancy wellness 14. http://www.healthysex.com - Sexual risk knowledge checklist of facts 15. http://www.who.int/topics/health_promotion/en/ – World Health Organization health promotion page 16. http://odphp.osophs.dhhs.gov/ - Office of Disease Prevention and Health Promotion

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TEST QUESTIONS True or False F

1.

Changing health habits is likely to reduce mortality rates only partially.

2.

Sick role behavior as defined in the text would describe an individual who seeks out treatment for the purpose of getting well.

3.

People’s health habits are extremely stable and do not change over time.

4.

Dan is caught smoking by his parents, who are psychologists. His parents decide to make Dan stay in his room so that the behavior will stop. This is an example of negative reinforcement.

5.

The Health Belief Model proposes that people will take some health-related action if a threat is perceived and if the perceived benefits of acting outweigh the perceived costs.

6.

John has just begun thinking about quitting smoking cigarettes. Although he is thinking about changing, according to the stages of change model, if he were to actually attempt a quit effort at this point his chances of success are slim.

7.

Across their life span, people’s preventive needs and goals tend to remain fairly constant.

8.

Biological factors and poverty have only a small impact on health promotion programs with diverse populations.

9.

Fear-arousing warnings, such as those found on packs of cigarettes, are a special case of loss-framed messages.

10.

Worksite wellness programs such as the Live for Life program have been shown to reduce health risk behaviors, job stress, absenteeism, and medical claims.

(142)

T (143)

F (144)

F (149)

T (151)

T (154)

F (157)

F (161)

T (164)

T (167)

The Health Belief Model and Planned Behavior model are considered stage based models while the Transtheoretical model is a continuum model. a. True b. False

208

Matching Match one of the following with the examples in numbers 1-5. a. positive reinforcement b. negative reinforcement c. extinction d. punishment e. modeling b 1. When Bob is under stress he experiences heartburn, which he relieves through the (148) use of antacids. a (148)

e (149)

d (149)

c (148)

2. Dr. Peterson gives his patients a new toothbrush and tasty mouthwash for attending regular dental checkups.

3. Frank took up golf because his fellow executives all played, and his wife Cheryl started taking walks because her friends in the neighborhood go on walks.

4. Sharon got sick the first time she tried a cigarette and never smoked again.

5. Sylvia was placed on medication to control her high blood pressure. After several weeks, she could feel no difference so she stopped taking her pills.

Match the following with a characteristic found in 6-10. a. theory of planned behavior b. conflict theory c. health belief model d. stages of change model e. motivated reasoning d

6. Involves spiraling toward successful change.

(154)

e

7. When desires and preferences influence judgments about new information.

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8. As applied to health behaviors, interested in studying intentions that are determined by attitudes regarding the behavior, the influence of beliefs of others, and ability to control a behavior.

9. Health behaviors are determined by the perceived seriousness of the threat and perceived cost of the behavior.

10. The view that health challenges may be perceived as either a threat or opportunity.

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1. The current trend of raising health consciousness is a. unprecedented in history. b. unlikely to affect mortality rates. c. similar to another such movement in the mid-1800s. d. no different than the way people have always behaved.

2. If people adopted lifestyles that promoted wellness, how would the rate of illness and early death be affected? a. Neither would not be affected in any way. b. Rates of illness would be affected but not rates of early death. c. Rates of early death would be affected but not rates of illness. d. Both would be reduced.

3. Even if people adopted all recommended health behaviors and cures were found for major diseases, the upper limit of the average life expectancy of people in technologically advanced countries is likely not to exceed: a. 75 years. b. 85 years. c. 90 years. d. 95 years.

4. How have the ten leading causes of death changed from the late 1960's to today? a. Deaths from diseases of early infancy are no longer in the top ten. b. Deaths from cancer and lung disease have decreased. c. Deaths from heart disease and stroke have increased. d. AIDS has become one of the top ten leading causes of death today.

d

5. Ted complains to his friends about recurring pain in his shoulder and has been looking up information on the Internet about possible causes for his pain. Ted's behavior is an example of _____ behavior. a. well b. sick-role c. irrational d. symptom-based (143)

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6. You call your boss to let her know you won't be in today because you have the flu. You stay home where you take the appropriate medicines, rest, and drink plenty of fluids. Your behaviors are examples of _____ behaviors. a. rational b. sick-role c. symptom-based d. cognitive 7. According to the research on cultural differences in response to symptoms and health behaviors, which of the following persons is most likely to be affected by their family’s culture of origin? a. James, a recent immigrant. b. Frank, a fifth generation immigrant whose ancestors came from China. c. Both are affected equally. d. Neither are affected.

8. The greatest percentage of adults engage in which of the following healthrelated behaviors? a. Rarely snack. b. Eat breakfast almost every day. c. Exercise regularly. d. Average two or more drinks per day.

9. Which of the following statements about health habits/behaviors is supported by research? a. Health habits tend not to be linked to one another. b. Health habits always remain stable over time. c. One single set of attitudes tends to govern our health behaviors. d. Very few people practice health habits on a regular basis.

10. Which of the following statements about testicular cancer is not accurate? a. It affects mostly younger men. b. It has a high cure rate if treated early. c. It can be detected early by monthly testicular self-examinations. d. It is more prevalent than breast cancer.

11. Which of the following statements about breast self-examination (BSE) is not accurate? a. Most American women know about BSE but don't practice it on a monthly basis. b. The low practice of BSE may be due to low confidence, fear, embarrassment, and lack of knowledge about its importance. c. Simple reminders could increase the frequency of BSE practice. d. BSE results in only a modest level of breast cancer detection.

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12. Which is an example of an environmental preventive approach to tooth decay? a. repairing cavities b. demonstrating good brushing technique c. reinforcing children for brushing their teeth d. fluoridation of local water supplies 13. Showing your children how to drive a car safely is an example of a(n) _____ approach to prevention. a. environmental measure b. tertiary c. behavioral influence d. precontemplation 14. A local physician encourages his patients to eat an appropriate diet, exercise, not smoke, use seat belts, and get plenty of sleep. This doctor is encouraging a. primary prevention. b. secondary prevention. c. tertiary prevention. d. behavior modification.

15. Which of the following is NOT an example of primary prevention? a. using a condom b. engaging in regular exercise c. pre-conception genetic counseling d. taking a prescribed blood pressure medicine 16. After finding a lump during her monthly BSE, Maggie is on her way to receive a mammogram. Maggie's trip to the lab is an example of a. primary prevention. b. secondary prevention. c. tertiary prevention. d. behavior modification.

17. Which of the following is NOT an example of secondary prevention? a. following a prescribed diet to control blood pressure b. school hearing or vision tests c. an annual physical examination d. physical therapy following a stroke

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18. Actions taken to reduce the damage of a disease or rehabilitate a patient are generally referred to as a. primary prevention. b. secondary prevention. c. tertiary prevention. d. cognitive restructuring.

19. Which is an example of tertiary prevention? a. a cardiac rehabilitation program for people who have recently had a heart attack b. regular dental checkups for children with healthy teeth c. going to the doctor when you have a sore throat d. being in a monogamous sexual relationship 20. Which of the following people is engaging in tertiary prevention? a. David, who schedules and attends annual physical checkups with his physician b. Linda, a healthy woman who works out at the gym 4-5 times per week c. Frank, who has just tested negative for HIV d. Amy, who receives chemotherapy for breast cancer 21. Which is an important factor in determining whether a person will adopt a wellness lifestyle? a. encountering few barriers to changing behaviors b. motivation to engage in the new behaviors c. knowledge and skills to change an existing behavior d. all of the above 22. Woo is attempting to lose weight. Which of the following interpersonal factors will support his effort? a. His girlfriend doesn’t agree with the diet he has chosen. b. He has a close friend who supports his new diet and weight loss goals. c. His coworkers don’t understand why he’s so concerned about his weight. d. His lack of a strong social network 23. When a community attempts to reduce illness and injury, it may need to address which of the following problems? a. diversity of age and sociocultural background of its citizens b. funding for public health programs c. creating a balance between the health and economic needs of the community d. all of the above

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24. Which of the following statements is true regarding the relationship between heredity and health behaviors? a. Heredity may influence some health-related behaviors. b. Heredity has little to no influence on health-related behaviors. c. Heredity is the best predictor of health-related behaviors. d. Little to no research exists on this relationship.

25. Wendy says she smokes because it makes her less nervous. Her smoking behavior is being maintained through a. positive reinforcement. b. negative reinforcement. c. punishment. d. extinction.

26. Sam's parents punish him when he doesn't wear his bike helmet while riding his bike. What best predicts if this punishment will affect Sam's future helmet-wearing behavior? a. The type of punishment he receives. b. The severity of the punishment. c. Sam's expectation that the punishment will be repeated if he doesn't wear the helmet. d. The quality of accompanying explanations made by Sam's parents.

27. Observing a model is most likely to affect our behavior when the model is a. an older person. b. a high status person. c. a person similar to us. d. b & c 28. Anna, a habitual smoker, lights up a cigarette after eating dinner. When the phone rings in the other room, she answers it and lights up another cigarette from the pack by the phone. She is surprised later that she didn't realize she had two cigarettes going at once. It appears her smoking behaviors are governed by the _____ of her behavior. a. consequences b. social approval c. antecedents d. genetic influence 29. You want your children to grow into healthy adults. Which of the following practices will facilitate that? a. changing bad health habits in your children as early as possible b. engaging in healthy practices yourself c. telling your children that having good health is important to you d. all of the above 214

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30. Results from a study of hypertensive patients' perceptions of symptoms found that these patients a. make accurate estimates of their blood pressure levels. b. are poor estimators of their own blood pressure. c. estimate their blood pressure well, but not as well as normotensives. d. rarely change their medication-taking behaviors in light of the symptoms they experience.

31. Weinstein's research on beliefs about individuals' future health found that people tend to a. be overly optimistic about future health. b. be overly pessimistic about future health. c. exaggerate the severity of health risks. d. seldom think about their future health.

32. Manuel has just experienced a severe health scare regarding his heart.

According to Weinstein, Manuel is likely to a. display unrealistic optimism about his future health. b. show unrealistic pessimism about his future health. c. show no change in attitudes. d. become very realistic about his health.

33. Which of the following is NOT a factor in people's perceived threat of illness or injury? a. perceived seriousness of the health problem b. perceived susceptibility of the health problem c. reminders or alerts regarding a health problem d. unrealistic optimism 34. Applying the health belief model, women who do regular breast self-examinations (BSEs) a. believe they are susceptible to breast cancer. b. believe developing breast cancer would have serious effects. c. believe the benefits of BSE's outweigh the costs. d. all of the above 35. Which of the following statements regarding research on the health belief model is true? a. Research supports the major theoretical components of the model. b. The model has received support for a very limited scope of health behaviors. c. The “cues to action” component has received no support. d. Very little research has been done on the model.

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36. One of the shortcomings with the health belief model is a. the lack of research designed to test the model. b. that it only accounts for habitual behaviors. c. that there is no standard way of measuring its components. d. that more recent models suggest it is simply wrong.

37. The theory of planned behavior is based on the fundamental notion that a. people develop behavioral intentions before engaging in voluntary behavior. b. behavioral intentions are the best predictors of actual behavior. c. expectations of success influence behavior. d. all of the above.

38. Annie’s parents strongly disapprove of her smoking habit. Which component of the theory of planned behavior is reflected in this variable? a. Annie's personal attitude b. subjective norms c. perceived personal control d. perceived severity 39. Jason says he would like to exercise more but simply doesn't have the money to pay for a gym membership. His behavioral intention is being most affected by a. personal attitude. b. attitudes of important others. c. low personal control. d. low motivation to comply with the wishes of others.

40. According to the stages of change model, people go through five stages of intentional behavior change in the following order: a. precontemplation, contemplation, preparation, action, maintenance b. preparation, precontemplation, contemplation, action, maintenance c. preparation, action, precontemplation, contemplation, maintenance d. precontemplation, contemplation, preparation, maintenance, action e. maintenance, precontemplation, contemplation, preparation, action 41. Which of the following represents an effort to move a person from one stage of change to another? a. describing in general terms how they will change their behavior b. having them stay in the precontemplation stage c. matching the change strategy to the stage they are in d. if they are in the precontemplation stage, having them talk with someone who has successfully changed their own behavior

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42. JillAnn believes it unlikely that she could contract a sexually transmitted disease from her new boyfriend because he’s so nice to her. JillAnn's reliance on irrelevant information in making sexual health decisions is a form of a. precontemplation. b. reasoned action. c. rational thinking. d. motivated reasoning.

43. Willy has been drinking and finds himself in a situation where he can have sex with someone he just met at a bar. Which of the following predicts if he will engage in sexual actions with this virtual stranger? a. If he has friends who have had sex under similar circumstances. b. If he thinks having sex will reflect positively on how sexually attractive he is to others. c. If he done this before. d. all of the above 44. Conflict theory emphasizes the impact of ___________ on all major decisions. a. stress b. irrational thinking c. emotional stability d. complete information 45. According to conflict theory, the only consistently adaptive decision-making pattern in the face of health risks is a. hypervigilance. b. vigilant coping. c. unconflicted change. d. defensive avoidance.

46. Health goals during gestation and infancy tend to include which of the following? a. helping the parents to achieve the knowledge and capacity for the physical, emotional, and social needs of the baby b. establishing healthy behavioral patterns for nutrition, exercise, recreation, and family life c. anticipating and guarding against the onset of chronic disease d. prolonging the period of effective activity and ability to live independently

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47. Which of the following has been referred to as "nature's vaccine"? a. penicillin b. exercise c. a good heredity d. breast milk 48. The leading cause of death during childhood and adolescence is a. accidents. b. impaired immune functioning. c. childhood diseases. d. birth defects.

50. Which of the following health-related cognitions or behaviors is less likely in older adults than in younger adults? a. starting new health risk activities since they don’t have long to live and want to enjoy themselves b. practicing fewer health behaviors c. getting regular medical checkups d. getting regular exercise 51. Research on gender and health has shown that women a. tend to live longer than men. b. have fewer health problems than men. c. tend to get more exercise than men. d. (excluding pregnancies) use medical services less than men.

53. Research on social class, ethnicity, and health shows a. social class is not related to health status. b. higher disease incidence in African-Americans, American Indians, and Hispanics as compared to European Americans. c. equal knowledge of risk factors for disease regardless of social class. d. all of the above 54. According to the text, which of the following would significantly increase health in diverse populations? a. reducing poverty b. creating information approaches to reach populations with low literacy rates c. making health-promotion services culturally sensitive d. all of the above 55. A common approach in mass-media health promotion campaigns includes a. information about using the Internet. b. communication of negative consequences of unhealthy behaviors. c. self-help clinics. d. both b and c 218

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55. Using fear-arousing messages can be most effective under which of the following conditions? a. when the seriousness of the health problem is emphasized b. when combined with messages that indicate people can perform healthful behaviors c. when used in combination with gain-framed messages d. both a and b 56. Which of the following factors influence the effectiveness of reinforcers for increasing health behaviors? a. type of reward b. income level of the person c. sociocultural background of the recipient d. the person’s gender 57. Thelma is upset with herself because she’s just eaten a piece of chocolate cake and thinks she’s completely “blown” her diet plan. She decides that she just isn’t cut out for diets and eats the rest of the cake. This is an example of _____ (if Thelma believed she shouldn’t eat any cake at all while on her diet). a. lapse b. relapse c. abstinence-violation effect d. motivated reasoning 58. Which of the following represents a benefit of school health programs? a. They can be used in place of physical education programs that are more costly. b. They can easily be taught by even beginning school teachers. c. They help children establish healthy behaviors early. d. They are more effective in developing countries than in industrialized countries.

58. According to the textbook, worksite health programs a. take advantage of peer and employer support for motivational purposes. b. are cost effective for businesses and employees. c. can create environmental support to foster behavior change. d. all of the above

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60. Overall, evidence on the effectiveness of community-based wellness programs suggests that: a. such programs tend to produce modest changes. b. any program that produces modest change in the health behavior of a population is likely to have a large impact on disease. c. such programs work best in older populations. d. all of the above

1. Which of the following is one of the important elements in determining preventive health behaviors, according to the Health Belief Model?

A. perceived threat B. subjective norms C. perceived efficiency D. behavioral intention E. stage of readiness

2. The primary outcome variable being explained/predicted in the Health Belief Model is …

A. outcome-efficacy B. self-efficacy C. perceived disability D. likelihood of getting sick E. none of these

3. According to the Transtheoretical Model of change, when a person is almost ready to instigate change, and spends time thinking about how to implement a new behavior, s/he is in the ____________ stage.

A. maintenance B. precontemplation C. action D. contemplation E. preparation

Short Answer Questions 1. Compare and contrast primary, secondary, and teritary prevention. Given an example of each approach to prevention.

2. Discuss the similarities and differences between the Health Belief model and the Theory of Planned Behavior.

3. Briefly describe conflict theory and discuss how it incorporates stress into its model.

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Essay Questions 1. Jeff has just had a heart attack. Using one of the cognitive theories of change, describe how cognition will affect Jeff’s efforts to make lifestyle changes.

2. Suppose you want to develop a health promotion program at your school to reduce alcohol consumption. Using information from this chapter, what factors would you attempt to incorporate into your promotion program?

3. Review and discuss the prevention programs developed to provide effective intervention regarding HIV exposure.

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CHAPTER 7 REDUCING SUBSTANCE USE AND ABUSE CHAPTER OUTLINE I. Substance Abuse A. Section Introduction 1. Term “addicted” used to refer to excessive use of alcohol and drugs a. then - common knowledge that these substances had psychoactive effects on mood, cognition or behavior b. now – recognize that other substances also have psychoactive qualities and other behaviors are referred to as “addictive” B. Addiction and Dependence 1. Definition of addiction a. condition produced by repeated consumption of a natural or synthetic substance in which the person has become physically and psychologically dependent on the substance 2. Physical dependence a. the body has adjusted to the substance and requires it for normal functioning i. tolerance – process through which body increasingly adapts to substance and larger doses of the substance required to produce the same effect ii. withdrawal – unpleasant physical and psychological symptoms experienced when a substance is discontinued or markedly reduced once person has become dependent b. substances differ in the extent to which they produce dependence 3. Psychological dependence a. definition = compulsion to use a substance for its pleasant effect without necessarily being physically dependent on it b. despite knowing that substance impairs psychological and physical health, people may come to rely heavily on it and spend good deal of time obtaining and using it c. dependence develops through repeated use d. persons not dependent on substance experience less tolerance and withdrawal e. absence of substance may result in craving – motivational state involving strong desire to use substance f. addicted persons tend to become psychologically dependent before they become physically dependent. g. substances differ in the extent to which they produce psychological dependence

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4. diagnosing substance dependence and abuse a. depends on extent and impact of clear and ongoing use b. abuse = when dependence has produced at least one of the following problems: i. failure to fulfill important obligations ii. putting self or others at risk for injury iii. having substance-related legal difficulties c. classification of psychiatric disorders now includes pathological use of tobacco, alcohol, and drug C. Processes Leading to Dependence 1. Section introduction a. section covers factors associated with substance use and abuse i. apply to all addictive substances ii. are described in main theories of substance dependence iii. have been shown to have role in developing and maintaining dependence 2. Reinforcement a. definition = process through which consequence strengthens behavior upon which it is contingent b. types of reinforcement i. positive reinforcement 1) event or item person finds to be pleasant or wants added after behavior has occurred a) example: “buzz”/elation after smoking ii. negative reinforcement 2) reducing or removing aversive circumstance after behavior has occurred a) example: reduction of stress after smoking c. other information on relationship of reinforcement to substance use/abuse i. both positive and negative reinforcement occur very soon after use of substance ii. dependence and abuse occur partly because users rely on substance to regulate cognitive and emotional states 3. Avoiding withdrawal a. because withdrawal is unpleasant, people want to avoid it i. if person has experienced withdrawal, continue using substance because they want to avoid it ii. example: delirium tremens b. each substance has its own set of withdrawal symptoms 4. Substance-related cues a. people associate substance use with internal/environmental stimuli that are regularly present during its use b. association occurs through classical conditioning i. several responses may be present, but critical one is craving 222

c. evidence for role of cues to substance dependence i. learning cues enables body to anticipate and compensate for substance’s effect ii. incentive-sensitization theory proposes that dopamine enhances salience of stimuli associated with substance use so they become powerful in directing behavior iii. impact of cues 1) grab substance user’s attention 2) arouse anticipation of reward gained from substance 3) compel person to get more substance and use it 5. Expectancies a. definition = ideas about the outcomes of behavior developed either through own experience or from watching experiences of others b. example related to alcohol use i. drinking alcohol often incorporated in “fun” activities ii. children observe adults drinking and having “fun” iii. before ever having a drink for themselves, children have associated drinking with a positive outcome iv. teens see drinking as “sociable” and “grown up” – 2 things they want to be c. outcomes and expectancies can be either positive or negative 6. Genetics a. evidence of genetic influence on smoking i. twin studies find odds of cigarette smoking and dependence on tobacco more similar for identical twins ii. genetic markers have been identified for smoking b. evidence of genetic influence on drinking i. twin, adoption and animal studies have found genetic influence for developing alcohol problems ii. genetic marker has been found for this too c. genetic markers for smoking and alcohol use are different II. Smoking Tobacco A. Section Introduction 1. History a. early explorers found native populations using tobacco and took it to Europe in the 1500's for use in medicinal purposes b. mass-production began in early 1900's and popularity grew rapidly 2. Smoking trends a. today, 1.3 billion smokers worldwide b. in US, peak of popularity was in the 1960's with 53% males and 34% females smoking i. impact of Surgeon General's report in 1964 on dangers of smoking 1) prior to report most people didn’t know about dangers 223

2) since report, numbers of smokers have declined to current rates of 23% males and 18% females as smokers.

3) number of teen smokers has dropped to 14% 3. Cigarette manufacturers still profit from increased price of cigarettes and international sales a. although smoking has declined in industrialized countries, it has increased in developing countries B. Who Smokes and How Much?

1. Section introduction a. there are 5 times more nonsmokers than smokers 2. Age and gender differences in smoking a. few Americans begin smoking regularly before age 12 b. majority of smokers begin before age 20 i. becoming a habitual smoker develops gradually taking several years to reach consumption levels consistent with adult level c. patterns in development of smoker i. many people start out as infrequent smoker, trying out the habit on a less-than-daily pattern; some will progress to a daily pattern up to half-pack a day ii. pattern starts in eighth grade involving more teens in later grades iii. teens who don’t plan on completing college are at higher risk of progressing to heavy smoking iv. percentages of smokers level off in adulthood and declines after 40 years of age v. many adults are former smokers b. gender differences in smoking i. more men than women smoke worldwide and in US gender gap is decreasing ii. cigarette advertising targeting one gender or the other has contributed to gender shifts in smoking rates c. important observation - smoking prevalence can be altered 3. Sociocultural differences in smoking a. 80% of world's smokers live in developing countries b. in the US, smoking prevalence differs across age and ethnic groups i. high school seniors: majority are White ii. early adults: for men and women, majority are White iii. after 45 years: for men, majority are African American but for women, percentages are roughly equal c. patterns across social classes i. percentage of smokers declines with increase in education, income, and job prestige d. declines in overall percentage of smokers have been offset by number of heavy smokers 224

C. Why People Smoke 1. Section introduction a. initial experience of smoking is usually unpleasant b. many teens know that smoking is unhealthy but try it again anyway 2. Starting to smoke a. modeling and peer pressure influence smoking in teenage years i. modeling from parents and friends 1) teens usually smoke first cigarette in company of and receive encouragement from peers ii. media models such a having a favorite movie star who smokes also influences teens b. personal characteristics related to smoking i. being rebellious or a risk-taker ii. not living up to expectations of parents or authority figures iii. believing that smoking defines them as tough, cool, independent iv. believing that smoking enhances image by looking mature, glamorous, exciting c. girls and Whites are more influenced by smoking by peers or parents 3. Becoming a regular smoker a. individuals who have their fourth cigarette are likely to become regular smokers b. psychosocial factors that influence starting also influence continuing to smoke c. factors related to continuing to smoke include i. at least 1 parent who smokes ii. perception that parents are unconcerned or encourage smoking iii. having siblings/friends who smoke iv. receptiveness to tobacco advertisements v. peer pressure to smoke vi. positive attitudes about smoking vii. low harm assessment for smoking viii. believing they could quit smoking if they wanted to d. other related findings i. having family or friends who smoke reduces beliefs that smoking is harmful ii. teens usually smoke and smoke more in the company of others who smoke iii. teens who smoke receive more offers for cigarettes from friends e. impact of reinforcement on smoking i. taste of cigarette reported as positive reinforcement 1) research shows that changing taste of cigarette to make it less pleasant reduces smoking in some smokers ii. some smokers report smoking cigarettes reduces stress 225

1) smokers with greater stress smoke more 2) smokers report less anxiety and more ability to express opinions during stressful situations when allowed to smoke a) however, findings suggest they don’t actually perform better or feel more relaxed than nonsmokers 3) smoking may reduce stress temporarily but increase it in the long run f. biological factors sustain smoking i. nicotine passes from smoking mother to baby during pregnancy and making child more susceptible to addictive effects of nicotine ii. genetics have been linked to likelihood of becoming a smoker, how easily/strongly become physically dependent on tobacco and how easy/difficult it is to quit smoking iii. insula, an area of the brain, controls desire to smoke 1) when damaged, people lose desire to smoke 4. The role of nicotine a. physical dependency is due to substances in cigarette smoke i. carbon monoxide - reduces oxygen-carrying capacity of blood ii. tars - don't affect desire to smoke iii. nicotine - arouses the body and is the addictive chemical in cigarette smoke 1) effects of nicotine include release of chemicals in central and sympathetic nervous systems that result in arousal, increased alertness, heart rate and blood pressure a) contributes to the positive and negative reinforcement of smoking b. nicotine regulation model i. smokers smoke to regulate the amount of nicotine in the body and avoid withdrawal symptoms.

1) evidence: ultralow tar cigarette smokers smoke more cigarettes ii. model doesn't explain why ex-smokers still crave cigarettes or people who smoke but don't get addicted c. a complete explanation of the development and maintenance of smoking probably involves biological, psychological, and social factors

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D. Smoking and Health 1. Section introduction a. annual deaths related to smoking i. in 2010, 6 million deaths worldwide were related to smoking ii. by 2030, it’s projected that 8 million deaths a year will be related to smoking b. health impact of smoking i. smoking reduces life expectancy ii. smoking increases risk of illness 1) more smoked, greater the odds of developing lung cancer 2) if quit smoking, odds will reduce to that of nonsmoker within 15 years iii. smoking and nicotine impair immune function 2. Cancer a. studies linking smoking with cancer i. statistics showed nonsmokers live longer than smokers ii. laboratory studies using animals exposed to cigarette tar linked tobacco tars and other byproducts of tobacco smoke to cancer b. prospective studies link smoking to cancers of the lung, mouth, pharynx, esophagus, bladder, pancreas and kidney c. lung cancer prevalence rates paralleled smoking prevalence i. additional support from this type of research comes from increase of lung cancer in women as their smoking rates increased and decrease in prevalence in men as their smoking has decreased d. effect of smoking on lungs i. smoke causes irritation in cells below surface of the lung and destroys the protective cilia ii. lung cancer originates in bronchial tubes due to continual contact of carcinogens with bronchial lining 3. Cardiovascular Disease a. prevalence of CHD i. leading cause of death worldwide ii. in US, 34% of deaths and claims more lives than cancer, accidents and several other causes combined iii. 1 in 7 of persons who die from CHD are under 65 year old b. smoking and risks for CHD i. smokers are 2-4 times more likely to develop CHD ii. more a person smokes, greater the likelihood iii. having greater stress plus smoking aggravates risk for CHD iv. smokers tend to lifestyles that include other risk factors for CHD (such as physical inactivity)

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c. how nicotine and carbon monoxide contribute to cardiovascular functioning i. nicotine - constricts blood vessels, increases heart rate, cardiac output, and blood pressure ii. carbon monoxide - reduction of oxygen to the heart may cause damage and lead to atherosclerosis d. smoking is linked to greater levels of serum cholesterol and size of plaques on artery walls e. quitting smoking reduces cholesterol levels within 2 months and risk of heart attack or stroke within a few years 4. Other illnesses a. smoking is linked to development of chronic obstructive pulmonary disease i. includes emphysema and chronic bronchitis with permanently decreased airflow on exhalation ii. 80% of COPD cases are related to smoking iii. COPD incapacitates its victims by reducing their mobility and life functioning; also causes over 2.7 million deaths each year b. smoking is also linked to acute respiratory infections i. children of smokers more likely to develop pneumonia ii. smokers more likely to develop common cold due to immune system impairment III. Alcohol Use and Abuse A. Section Introduction 1. Alcoholic beverages were commonly consumed in ancient cultures 2. Puritans in colonial America enforced laws against drunkenness 3. Temperance movement led to Prohibition 4. Repeal of Prohibition was followed by increased use of alcohol and softening attitudes about alcohol B. Who Drinks, and How Much?

1. Age, gender, and alcohol use a. drinking is influenced by age and gender i. females experience more intoxication than males do from same amount of alcohol 1) less blood volume 2) metabolize alcohol less quickly b. drinking often begins in adolescence i. 72% of high school seniors have tried alcohol by the end of high school ii. males report more drinking than do females and this difference continues into adult life iii. 60% of young and middle-aged adults drink but prevalence declines in older adults 228

2. Sociocultural differences in using alcohol a. alcohol use varies widely across cultures i. in US, per capita consumption is 2.3 gallons of ethanol 1) alcohol use across countries is differentiated into those countries that integrate alcohol use into daily life v. those countries that restrict its use a) daily drinking occurs more in “integrating” countries whereas intoxication occurs more in “restricting” countries ii. in US ,more white Americans drink than other race/ethnic groups iii. drinking on a daily basis is higher for White Americans, Native and Hispanic Americans than for Black and Asian Americans 1) drinking rates in Native Americans are moderating 3. Problem drinking a. in US, 64% of adults drink at least occasionally i. most are light-to-moderate drinkers ii. many drink heavily but don’t necessarily meet definition of substance abuse b. patterns of drinking i. binge drinking = drinking 5 or more drinks on single occasion at once during 30-day period 1) 10% of adolescents, 42% of 18- to 25-year olds, 22% of those over 25 drink at least occasionally 2) binge drinking is a problem on college campuses 3) most who develop problems with drinking do so within 5 years of starting to drink ii. heavy use drinking = binge drinking 5 or more times in a month 1) next step toward alcohol abuse a) 17% of adults in US become alcohol abusers b) rates of alcohol abuse among women nearing those among men iii. problem drinkers = drinking heavily on a regular basis and who suffer social and occupational impairments from it 1) characteristics include getting drunk frequently, drinking alone or during the day, driving while drunk 2) alcohol abuse more common among men 3) abuse likely to develop between ages of 18 to 29 in both sexes iv. alcoholics = people who abuse alcohol, are physically dependent on it, have a high tolerance for it, have blackout periods or substantial memory loss and experience delirium tremens when they stop drinking

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c. images of alcoholic v. real "typical" alcoholic or problem drinker i. stereotypic image: scruffy looking, unemployed male derelict with no family or friends ii. demographics of actual alcoholics: married, living with family, employed, increasingly women 1) although those in lower social classes are at greater risk for abusing, more problem drinkers are in higher classes and hold high-status jobs 2) problem drinking increases in adolescence, increases sharply in early adulthood, and declines in ages thereafter iii. alcohol abuse is major social problem that affects large numbers of people from all segments of societies around the world C. Why People Use and Abuse Alcohol 1. Chief reasons for starting are social and cultural factors a. children and adolescents acquire expectancies about the positive effects of alcohol from watching others enjoy themselves while drinking i. the more TV ads for alcohol seen by teens, the more likely they are to drink in the future 2. Developmental aspects a. same factors that initiated drinking intensify to maintain it b. for adolescents and young adults i. role of peers increases 1) for teens, drinking occurs with peers at parties or in car a) teens who don’t plan to complete college drink more b) persons who start drinking in early adolescences more likely to become problem drinkers in adult life 2) for late adolescents and early adults, drinking occurs almost always with friends or at bars ii. why social aspects of drinking is important 1) modeling has an influence on drinking rates 2) social atmosphere creates a subjective norm that drinking is appropriate and desirable 3. Role of reinforcement and substance-related cues a. positive reinforcement occurs when person likes the taste or feeling they get or perceives it facilitates business or social functioning i. increases expectancy of desirable consequences when considering drinking in the future b. negative reinforcement occurs when alcohol is used to reduce stress or negative feelings i. although tension is reduced initially, as more alcohol is consumed, anxiety or depression actually worsens 230

4. Other psychosocial factors that differentiate problem drinkers from those who do not abuse alcohol a. perceive fewer negative consequences for drinking b. experience higher levels of stress c. live in an environment that encourages drinking d. have experienced major trauma e. having family members who drink heavily f. strong reaction to substance-related cues 5. Developmental and biological factors related to problem drinking a. heredity plays stronger role when abuse begins before age 25 b. family history of alcoholism is related to more tolerance to alcohol c. having a specific gene pattern is linked experiencing stronger cravings for alcohol after a drink d. those with high genetic risk for dependence find alcohol more rewarding each time they drink 6. Genetics combine with psychosocial processes in the development of problem drinking D. Drinking and Health 1. Health hazards associated with drinking a. how drinking could hurt others i. drinking during pregnancy could result in fetal alcohol syndrome or impaired learning ability even at lower alcohol consumption 1) best advice is to not drink at all during pregnancy ii. increased risk of accidents 1) drunk driving is associated with 39% of traffic deaths each year b. judging degree of impairment from drinking i. drinking impairs cognitive, perceptual, and motor performance for several hours after consumption ii. problems with assessing levels of impairment 1) misconceptions about the effects of alcohol a) thinking the effects of alcohol will disappear once one starts a task that requires attention b) underestimating the impact of later drinks in a series c) believing that beer and wine have different effect than hard liquor 2) “super-sizing” drinks but still counting it as 1 drink c. how drinking could hurt the drinker i. development of diseases such as cirrhosis of the liver, some forms of cancer, high blood pressure, and heart and brain damage as a result of long term drinking

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2. Potential benefits of drinking in moderation a. lower morbidity and mortality rates have been associated with light or moderate drinking, esp. for wine i. improves blood cholesterol levels ii. reduces cardiovascular and endocrine reactions IV. Drug Use and Abuse A. Section Introduction 1. Definition a. drug = psychoactive substances other than nicotine and alcohol that can cause physical or psychological dependence 2. Brief history a. use of drugs have long history i. use of marijuana in China in 27 centuries B.C. ii. in US, addiction to narcotics in patent medicines in 19th century 1) laws against use of narcotics began in early 1900s 3. See “highlight” box regarding types and effects of drugs a. stimulants = chemicals that produce physiological and psychological arousal b. depressants = chemicals that decrease arousal and increase relaxation c. hallucinogens = chemicals that produce perceptual distortions d. narcotics = sedatives that relieve pain B. Who Uses Drugs and Why? 1. Age, gender, and sociocultural differences in drug use a. developmental trends in drug use i. use tends to begin in adolescence, except for tranquilizers, barbiturates, and painkillers which tends to occur in adulthood through prescriptions ii. high use drug in adolescence is marijuana with 43% of teens using before graduating from high school 1) use is 3 times higher than any other drug 2) teen use of other drugs occurs later and at lower prevalence a) use of cocaine in teens is at 7% iii. use of drugs fluctuates over time and has been decreasing 1) use influenced by teens’ beliefs in harmfulness of drugs, not drug availability b. gender patterns in drug use i. males use drugs more than females 1) use pattern increases from ages 12 to 25 years old and then declines c. patterns based on year in school and race/ethnicity i. use increases with grade in school ii. use is lower in seniors who plan to attend college 232

iii. use is higher in White students followed by Hispanic and then Black students d. polysubstance abuse is likely in some users i. likelihood of moving from less serious drugs to more serious drugs depends on how heavily earlier drug was used ii. smoking cigarettes and using alcohol linked to using other drugs later 2. Why adolescents use drugs a. factors determining initial and early stages of use i. availability of drug and social learning 1) seeing peers/important adults model use and attitudes about drugs influences use 2) use of marijuana is more influenced by peers who are likely to introduce teen to drug b. after starting, continued use is influenced by whether person liked the experience. i. reinforcing effect of anxiety/tension reduction is noted ii. drug-related cues associated with drug elicit effect of drug and compel further use iii. social pressure and encouragement also maintain and increase drug use c. factors linked to progression to drug abuse i. personality traits linked to drug abuse include rebelliousness, impulsivity, sensation seeking, low social conformity, low commitment to religious beliefs, and acceptance of illegal behavior C. Drug Use and Health 1. Health effects of drug use not as well documented as those of drinking or cigarette smoking a. drug use still less prevalent than drinking and smoking b. users often unwilling to reveal their drug use to researchers due to illegal nature of behavior 2. Known health effects a. babies born to addicted mothers may also be addicted b. millions of teens/young adults drive under the influence of drugs – increased risk of accidents c. use of marijuana linked to lung damage similar to that of smoking cigarettes d. use of (crack) cocaine is linked to cardiovascular and neurological problems as well as poor general health

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V. Reducing Substance Use and Abuse A. Preventing Substance Use 1. Section introduction a. focus of prevention programs is helping people avoid beginning to use specific substances to begin with b. factors that need to be considered i. when do people tend to start 1) use often begins in junior high school and increases sharply in high school a) prevention programs need to be focused during those times ii. why do people start 1) need to focus on psychosocial factors that encourage use c. addressing substance use in college i. prevalence of substance use is higher among high school students to later join fraternities and sororities in college ii. frequency of binge drinking is higher in Greek system than elsewhere on campus iii. prevention programs need to be directed toward all students but esp. toward those in Greek system d. substance focus of programs i. historically prevention programs have focused on use of a particular substance only ii. now programs focus on use of all three substances 1) areas of focus include public policy & legal issues, health promotion & education, and family involvement 2. Public policy and legal approaches a. governments attempt to reduce per-capita consumption of substances by creating barriers to buying and using them i. strategies for reducing use of tobacco 1) increasing price through taxation 2) restricting advertisement and purchase of cigarettes ii. strategies for reducing use of alcohol 1) increasing price through taxation 2) prohibiting underage purchase or consumption 3) limiting number of purchase outlets has not been effective iii. strategies for reducing use of drugs 1) making possession, sale, and consumption illegal

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3. Health promotion and education a. historically fear-arousing warnings have been used i. approach doesn’t consider prior social experiences and current psychosocial forces that influence use ii. knowing that a substance is harmful isn’t sufficient to prevent use iii. problems with approach points out need to know why teen use the substance b. psychosocial influences i. research has identified that social influences and associated social skills, rather than knowledge of long-range health consequences, affect teen substance use 1) these factors have been incorporated into schoolbased programs c. examples of smoking prevention efforts i. social influence approaches 1) teach skills for resisting social pressures to smoke 2) techniques included a) discussion/films on how others influence smoking b) modeling/role-playing refusal skills c) requiring public disclosure of intention to smoke ii. life skills training approaches 1) address general social, cognitive, and coping skills 2) focus on increasing a) personal skills including critical thinking and coping b) general social skills such as assertiveness and conversation making iii. programs also involve follow-up assessments of self-report and biochemical analyses d. success of approaches i. evidence suggests that children who have gone through these programs are less likely to begin smoking and fewer are likely to start smoking over the next 15 years e. ways to improve future programs i. programs should be long enough to have an impact, be administered correctly/fully, and have “booster” sessions ii. programs need to start before 5th grade and focus on attitudes about smokers iii. need to get parents involved and, if they smoke, influence them to quit while child is young

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f. extension of smoking prevention efforts to other substances i. results indicate that similar programs are effective in preventing/reducing drinking and marijuana use 4. Family involvement approaches a. programs focus on getting parents more actively involved in supervision of their children b. research evidence as to why this focus is important i. children without supervision are 4 times more likely to use ii. children less likely to use if know their parents would disapprove and/or punish them for doing so iii. parents of teens who use often don’t know about it c. programs include weekly session designed to teach parenting skills to help children delay or reduce using i. skills include 1) how to monitor behavior and use appropriate discipline 2) teach ways to resist peer pressure 3) how to reduce family conflict B. Quitting a Substance without Therapy 1. Section introduction a. in most societies, substance use has been viewed as deviant behavior i. nonusers resent substance use ii. users feel guilty about offending others and recognize that use is unhealthy/irrational b. at same time, users often think they are as healthy as nonusers and aren’t concerned about potential health problems i. few users (29%) seek therapy to quit 2. Stopping smoking on one’s own a. motivation to quit i. primary motivation for quitting is concern for health ii. small percentage of people who start smoking have actually quit within 20 years from starting b. effectiveness of attempts to quit on own i. over 60% who attempt to quit eventually succeed and remain abstinent over 7 years ii. heavy smokers have much more difficulty quitting and report more difficulty with withdrawal symptoms iii. results suggest that most people can quit smoking on their own c. factors that influence success in quit effort i. have made the decision they are ready to quit ii. feel confident they can succeed iii. smoke less than pack a day iv. experience less stress v. have less nicotine dependence and less craving and withdrawal symptoms vi. highly motivated 236

vii. willing to try again even if fail in current attempt d. methods used in community-wide stop-smoking contest i. majority try quitting cold turkey ii. use oral substitutes iii. most “go it alone” although some use support buddy iv. most used cognitive strategies v. some used reward or punishment strategies e. invalid beliefs often prevent success in quitting i. switching to “light” cigarettes under belief they reduce health risks ii. pointing that some smokers they know lived to old age 3. Stopping alcohol and drug use on one’s own a. little is known on quitting alcohol and drug use on own b. estimates that approximately 20% of drinkers quit on own based on changes observed in research control groups c. factors that influence successful quitting these substances on own i. higher self-esteem ii. few past experiences with intoxication iii. social networks with members who drink less iv. social support from spouse v. changed pros/cons of drinking 4. Early intervention a. early intervention efforts try to identify people at risk for substance abuse and then provide them with information to reduce risk b. efforts are successful for light drinkers but not heavy drinkers i. also providing information for persons at risk for problem drinking is effective in reducing risk c. successful programs have occurred with high-risk drinkers in college, medical, and worksite settings i. employee assistance programs are helpful but employees with addictions don’t tend to seek help 1) EAPs don’t identify problem until it is usually severe 2) workers are concerned about employer finding out about problem 3) program may help to reduce workplace stress that influences substance use C. Treatment Methods to Stop Substance Use and Abuse 1. Section introduction a. users who seek treatment are typically psychologically and physically dependent on substance, which reduces chances of success

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2. Psychosocial methods for stopping substance abuse a. use stages of change model to address desire and readiness for change i. although most who seek treatment want to change, others have been coerced to enter treatment by family, employer or law ii. critical transition period for change involves move from contemplation to preparation/action stages of model 1) ways to encourage transition a) giving clear advice on why and how to change b) removing barriers to change c) introducing external consequences d) offering helping and showing helping attitude b. implement methods based on motivational interviewing to bolster person’s self-efficacy c. provide positive reinforcement for stopping or reducing use i. programs that incorporate have been shown to be more effective in reducing use or supporting abstinence than those that don’t d. might use aversion strategies i. examples 1) satiation = doubling/tripling smoking rates 2) use of emetics = medications that produce nausea when targeted substance is used ii. use of these methods have been linked to greater abstinence at followup e. address substance-related cues i. to extinguish impact of cues, therapists have repeatedly exposed person to cues without allowing them to use substance f. reduce negative reinforcement i. teach stress management to reduce negative reinforcement of substance use 1) progressive muscle relaxation 2) meditation 3) cognitive restructuring g. incorporate cognitive-behavioral methods 3. Highlight box (pg. 201) a. box reviews process of detoxification b. should treatment be residential or out-patient? c. should goal of treatment be abstinence or controlled substance use?

4. Clinical methods and issues box (pg. 203) a. box covers behavioral methods to control environmental conditions sustaining undesirable behaviors i. self-monitoring = recording information about problem behavior ii. stimulus control = eliminating substances/cues for substance or behavior in environment 238

iii. response substitution = replacing problem behavior with different behavior iv. behavioral contracting = spelling out conditions and consequences regarding problem behavior in writing 5. Self-help groups a. use of Alcoholics Anonymous for problem drinking i. thousands of chapters around the world for alcoholics and their families b. AA philosophy i. once an alcoholic, remain an alcoholic throughout life ii. taking even one drink can precipitate a drinking binge – abstinence is the program goal iii. Twelve Steps are based on spiritual awakening, public confession, and contrition iv. need to attend meetings on regular basis 1) promotes franks discussions 2) develop friendships with ex-drinkers 3) receive encouragement and knowledge from others who have quit c. effectiveness of AA i. originally no good evidence of treatment effectiveness due to anonymity and lack of systematic information keeping ii. recent evidence of effectiveness 1) interventions conducted by professional therapists finds AA as effective as other methods 2) longer and more frequently person uses AA, less binge drinking and better social functioning iii. AA probably not effective for people who don’t believe in God b. discusses principal of self-management 6. Chemical methods for treating substance abuse a. chemical treatments used in smoking interventions i. nicotine replacement therapy = reduces cravings and withdrawal symptoms ii. bupropion hydrochloride and varenicline = antidepressant medication b. chemical treatments used in alcohol abuse treatment i. disulfiram (Antabuse) = emetic used to produce nausea if person drinks ii. naltrexone = blocks “high” feeling c. chemical treatments used in narcotic addiction treatment i. methadone = has physiological effects similar to opiates but doesn’t produce euphoria and prevents euphoria if person does use opiates; used in methadone maintenance program ii. buprenophine = also blocks euphoria effect of opiates 239

7. Multidimensional programs a. use of psychosocial or chemical methods by themselves are not as effective as combining methods into multidimensional approach i. combined effectiveness has been demonstrated for each substance group b. other features to consider in designing multidimensional programs i. use biochemical analyses to verify self-report at beginning of program ii. brief daily phone calls improves client performance on certain aspects of interventions (such as recording progress) iii. involving family/significant others improves outcome iv. having physician actively involved in program improves success D. Dealing With the Relapse Problem 1. Section introduction a. preventing backsliding or relapse is a major problem in treatment programs 2. The relapse problem a. likelihood of relapse is highest in first few weeks/months of program b. rates of relapse range from 50% to 80% c. relapse is a problem in treatment for all 3 substance groups 3. Why people relapse a. withdrawal symptoms contribute strongly to relapse i. users need to know that cravings and symptoms will diminish within a short period of time b. satisfaction with results of having quit also contribute to likelihood of relapse c. other factors contributing to relapse (see Table 7.4, pg 205) i. low self-efficacy ii. negative emotions such as anxiety or frustration iii. high craving iv. expectation that using substance again will be reinforcing v. low motivation vi. lack of constructive social support d. relapse factors related to smoking i. reduced perception of health risks for smoking following a relapse 1) means person has moved to lower stage of change and will need support to move back to action stage ii. weight gain during quit attempt 1) ex-smoker has increased caloric intake 2) metabolism has declined 3) person will need to control diet, exercise more, or use nicotine patch to control metabolism 240

4. Can relapses be prevented? a. 3 approaches to reducing occurrence of relapse i. relapse prevention method 1) method based on view that relapse occurs through cognitive events of abstinence violation effect 2) therapist-supervised self-management program involving a) identification of high-risk situation b) development of specific behaviors and thought patterns to help in high-risk situations c) practicing effective coping skills in high-risk situations ii. incorporation of booster sessions iii. continuing to use chemical methods after formal treatment ends

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DISCUSSION TOPICS 1. Culturally Sensitive Treatment Approaches: Two discussions are of interest here. First, Moncher and colleagues were interested in attempting to identify Native American youth at risk for substance abuse. They found significant risk factors for substance abuse included the presence of family and peer models of smoking and drinking, level of school adjustment, rebellious behavior, religiosity, and cultural identification. All but the latter factor is identified in Sarafino’s discussion in the textbook. Moncher and colleagues suggest that skills for functioning in the dominant culture or being bicultural are important predictors of resisting substance use. The authors suggest that many intervention programs should incorporate discussion and teaching of bicultural skills as a way of reducing frustration due to not being able to maneuver effectively within these different cultural environments.

In David Matsumoto’s writings on culturally sensitive treatment approaches, he contends that health professionals and medical communities have a tendency to treat diseases based on the assumption that all people are the same. He suggests that it is important to keep in mind that cultures differ in their causal explanations and treatment approaches. With regards to substance abuse, Matsumoto points to research indicating that alcohol abuse, in some cultures, is viewed as a lack of spirituality. To admit addiction would be a source of embarrassment and shame, and the frank admission of alcohol abuse encouraged in Western treatment serves as a barrier to treatment. Additionally, given the differing emphasis on social relations across cultures, he argues that including family members in intervention programs would be essential for intervention with some cultural groups.

Sources:

Moncher, M., Holden, G. & Trimble, J. (1990). Substance abuse among NativeAmerican youth. Journal of Consulting and Clinical Psychology, 58, 408-415.

Matsumoto, D. (2000). Culture and psychology: People around the world, (pp. 247249). Belmont, CA: Wadsworth.

2. Research on chemical dependency in women: In this chapter, Sharon Hall discusses a number of issues related to women’s experiences with chemical dependency. After a basic review of the gender trends in substance use, she notes that etiological factors contributing to substance use may vary to some extent between women and men. For example, she cites literature suggesting alcoholism in women may be influenced by dependency needs, power needs, sex role conflicts, low self-esteem, and having a history of sexual abuse. Excessive alcohol use has been linked to gynecological and obstetric dysfunctions and a greater risk for liver disease.

Disease progression also tends to be gender linked. Concerns regarding fetal alcohol syndrome are also unique to women. Treatment issues particular to women are also reviewed including the need for intervention sensitivity towards familial responsibilities, child care, and family opposition to treatment. For women smokers, unique risk factor concerns include the relationship between oral contraceptive use and risk for cardiovascular disease, as well as the effects of smoke on the fetus. Nicotine is metabolized more slowly from the 242

bodies of women. In treatment, weight gain is likely to be addressed as a concern by women more so than for men. A section of the chapter addresses the particular problems of prescription drug misuse in older women.

Source:

Hall, S. M. (1994). Women and drugs. In Adesso, V.J., Reddy, D.M., & Fleming, R. (Eds.), Psychological perspectives on women’s health, (pp. 101-126). Washington: Taylor & Francis.

3. Perceptions of smoking in a Hispanic population: The authors begin their chapter by pointing out that successful behavioral intervention rests on understanding the attitudes and expectancies of populations of interest. They hypothesized that there were significant differences in attitudes and expectancies related to cigarette smoking in their Hispanic and non-Hispanic White participants. Participants were asked about their smoking patterns, generalized attitudes about smoking (e.g., how pleasurable it is), perceived situational antecedents of smoking, and perceived consequences of smoking and of quitting. Their results indicated that Hispanics smoke less, were less likely to ascribe habit or relaxation as antecedents to smoking, more concerned about harming the health of their children, and saw quitting as setting a good example for their children. They suggest that smoking cessation programs for Hispanic participants may need to give special consideration to these aspects in an intervention program.

Source:

Marin, G., VanOss Marin, B., Perez-Stable, F.J., Sabogal, F., & Otero-Sabogal, R. (1995). Cultural differences in attitudes and expectancies between Hispanic and nonHispanic White smokers. In A.M. Padilla (Ed.), Hispanic Psychology: Critical issues in theory and research. Thousand Oaks: Sage.

4. Dissonance and alcohol use: Claude Steele and colleagues have conducted several studies investigating alcohol use using principles of cognitive dissonance theory. This article is a good example of a theorybased, experimental approach to the study of alcohol use. Based on the assumption that cognitive dissonance is experienced as a negative emotional state, the authors explored the relationship between the amount of alcohol consumed by moderate and heavy drinkers and dissonance-reducing effects of alcohol. When heavy drinkers were placed in a classic dissonance-arousing situation (a counter-attitudinal paradigm), their later drinking increased if they were not given an opportunity to change an earlier attitude. General conclusions drawn from this research suggest self-regulated drinking affects levels of cognitive dissonance and, importantly, “normal social-psychological processes may play a role in the etiology of alcohol abuse.”

Source:

Steele, C.M., Southwick, L.L., & Critchlow, B. (1981). Dissonance and alcohol: Drinking your troubles away. Journal of Personality and Social Psychology, 41(5).

5. How we get addicted: This article seeks to educate readers about the links between neurochemistry and addiction. Particular discussion is given to the role of dopamine in addictions. The results of 243

animal studies and PET scans of known addicts are reviewed in great detail. This article could be the basis for some class discussion on biological factors that influence reactions to chemical substances. While the textbook addresses the role of genetics and heredity, this article focuses almost exclusively on the neurochemical effects of substance use.

Source:

Nash, J. M. (May 5, 1997). How we get addicted...and how we might get cured. Time Magazine, pg. 69-76.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: What's True About Drinking? In handout #1, this self-assessment on misconceptions about drinking is reproduced. After students complete the handout they might also be asked to add any additional myths not included in the handout.

2. Assess Yourself: Do You Abuse Alcohol? This second self-assessment is reproduced in handout #2. You might compare questions on the handout to the DSM-IV diagnostic criteria for alcohol abuse and discuss any differences in these definitions.

3. Public Policy and Substance Abuse. Public policy differs with regard to the abuse of different substances as reflected in current laws and regulation. Ask the students to identify the many different regulations affecting the availability and use of various substances.

Another idea might be to have an officer from the local law enforcement agency office specializing in drug enforcement come to the class to review the local, state, and national drug laws. Compare the different legal treatment of cigarettes, alcohol, marijuana, morphine and heroin. Address any local "hot" drugs that are of current law enforcement concerns.

Under what circumstances may each be used and by whom?

4. Behavior Therapy versus Nicotine Patch. If this is an upper level class, it is important to have students read primary sources in journals. Assign the paper by Cinciripini et al.

(1996), which reports the results of a smoking cessation program. In Cincipirini et al.'s study, smoking behavior, distress, tension, fatigue, withdrawal, and coping were compared in two groups of subjects: one group that received cognitive-behavioral therapy (CBT) only and another that received CBT plus the nicotine patch. What components of CBT were used in this study? Which group did better over time and why?

SOURCE: Cinciripini, P.M., Cinciripini, L.G., Wallfisch, A., Haque, W., Van Vunakis, H. (1996).

Behavior therapy and the transdermal patch: Effects on cessation outcome, affect, and coping. Journal of Consulting and Clinical Psychology, 64, 314-23.

5. Stimulus Control and Response Substitution. Smoking serves as an excellent example of a behavior frequently under stimulus control and amenable to intervention through response substitutions. Have the students find a peer or family member who smokes and evaluate the situations under which they smoke. The stimuli should include times of the day, locations (e.g., desk, car), social situations, emotional state, and activity.

Also, have students identify the specific components of the smoking act. For example, what brand of cigarettes are smoked? With what are they lit? Where are they kept? The goal of this behavior analysis is to suggest what aspects of the stimulus and response could be changed to reduce smoking.

6. Treatment Options. Local agencies are often eager to come to classes to discuss their community prevention efforts or intervention programs, and students are often interested in 245

learning about these efforts. In particular, ask such speakers to describe in some detail their prevention or intervention approaches. As students observe the presentation, ask them to keep notes on intervention strategies that they identify from the textbook.

7. Hidden Messages in Alcohol and Cigarette Ads. Ask students to bring in cigarette and alcohol advertisements. Discuss the messages of the ad. What is being sold? What is being promised? Who is the intended audience? Are particular social influence tactics being used?

8. Online Intervention Programs. A number of online or web-based intervention programs are currently available. Have students locate one and then analyze it for treatment components. Take particular note of any outcome data the site might have available.

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Handout #1

Assess Yourself: What's True About Drinking?

Instructions: Place a check mark for each of the following statements that are accurate.

_____ Alcohol is a stimulant that energizes the body. _____ Having a few drinks enhances performance during sex. _____ After drinking heavily, people usually sober up when they need to, such as to drive home. _____ Most people drive better after having a few beers to relax them. _____ Drinking coffee, taking a cold shower, and getting fresh air help someone who is drunk to sober up. _____ People are more likely to get drunk if they switch drinks, such as from wine to beer, during an evening rather than sticking with the same kind of drink. _____ Five 12-ounce glasses of beer won't make someone as inebriated as four mixed drinks, such as highballs. _____ People seldom get drunk if they have a full meal before drinking heavily. _____Hangovers can be cured by several methods. _____ Most people with drinking problems are either criminals or over 50 years of age.

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Handout #2

Assess Yourself: Do You Abuse Alcohol?

Instructions: Ask yourself the following questions about your drinking.

1. Do you usually have more than 14 drinks a week (assume a drink is one mixed drink with 1 ¼ ounces of alcohol, 12 ounces of beer, or the equivalent)?

2. Do you often think about how or when you are going to drink again?

3. Is your job or academic performance suffering because of your drinking?

4. Has your health declined since you started drinking?

5. Do family or friends mention concerns about your drinking to you?

6. Do you sometimes stop and start drinking to "test" yourself?

7. Have you engaged in drunk driving during the past year?

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RESOURCES Suggested Readings: Substance Abuse Bachman, J.G., O’Malley, P.M., Shuldenberg, J.E., et al. (2002). The decline of substance use in young adulthood: Changes in social activities, roles, and beliefs. Mahwah, NJ: Lawrence Erlbaum Associates.

Boren, J., Onken, L., & Carroll, K. (2000). Approaches to drug abuse counseling. NIH Publication.

Lingemann, H. & Carter-Sobell, L. (2007). Promoting self-change from additive behaviors: practical implications for policy, prevention, and treatment. New York: Springer.

McCrady, B.S., & Epstein. E.E. (1999). Addictions: A comprehensive guidebook. New York: Oxford Press.

McDowell, D.M., & Spitz, H.I. (1999). Substance abuse: From principles to practice.

Philadelphia: Brunner/Mazel.

Packer, A. (2006). Wise highs: how to thrill, chill & get away from it all without alcohol or other drugs. Minneapolis, MN: Free Spirit Pub. Ruiz, P., Strain, E., & Langrod, J. (2007). The substance abuse handbook. Philadelphia: Wolters Kluwer Health.

Stimmel, B. (2002). Alcoholism, drug addiction, and the road to recovery: Life on the edge.

New York: Haworth Press.

Tims, F., Leukefeld, C., & Platt, J. (2001). Relapse and recovery in addictions. New Haven, CT: Yale University Press.

Tracy, S., & Acker, J. (2004). Altering American consciousness: the history of alcohol and drug use in the United States, 1800-2000. Amherst, MA: University of Massachusetts Press.

Witkiewitz, K., Marlatt, G.A. (2007). Therapist’s guide to evidence-based relapse prevention.

Boston: Elsevier Academic Press.

Smoking Tobacco Burns, E. (2007). The smoke of the gods: a social history of tobacco. Philadelphia: Temple University Press.

Center fpr Substance Abuse Prevention. (1994). Tips for teens about smoking. Rockville, MD: author.

Cinciripini, P.M., Cinciripini, L.G., Wallfisch, A., Haque, W., Van Vunakis, H. (1996). Behavior therapy and the transdermal patch: Effects on cessation outcome, affect, and coping. Journal of Consulting and Clinical Psychology, 64, 314-23.

Haslam, C, & Lawrence, W. (2004). Health-related behavior and beliefs of pregnant smokers. Health Psychology, 23(5) 486-491.

Rabin, R., & Sugarman, S. (2001). Regulating tobacco. New York: Oxford University Press.

Stern, L. (1999). The smoking book. Chicago: UChicago Press.

Stewart, G. (2003). Smoking. San Diego, CA: Kidhaven Press.

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Alcohol Use and Abuse Beechem, M. (2002). Elderly alcoholism: Intervention strategies. Springfield, IL: Charles C. Thomas.

Bufe, C. (1991). Alcoholics Anonymous: Cult or cure? San Francisco: See Sharp Press.

Burns, E. (2004). The spirits of America: a social history of alcohol. Philadelphia: Temple University Press.

Cook, P. (2007). Paying the tab: the economics of alcohol policy. Princeton: Princeton University Press.

Cuadrado, M., Lieberman, L. (2002). Traditional family values and substance abuse: The Hispanic contribution to an alternative prevention and treatment approach. New York: Kluwer Academic/ Plenum Publishers.

Hartigan, F. (2000). Bill W.: A biography of Alcoholics Anonymous cofounder Bill Wilson.

New York: St. Martin's Press.

Lankford, R. (2007). Alcohol abuse. Detroit: Greenhaven Press.

Nakaya, A. (2008). Alcohol. Farmington Hills, MI: Greenhaven Press.

Peterson, J.V., Nisenholz, B., Robinson, G. (2003). A nation under the influence: America’s addiction to alcohol. Needham Heights, MA: Allyn and Bacon.

Raphael, M.J. (2000). Bill W. and Mr. Wilson: The legend and life of AA's cofounder.

Amherst: UMass Press.

Wilcox, D.M. (1998). Alcoholic thinking: Language, culture, and belief in Alcoholics Anonymous. Westport, CT: Praeger.

Drug Use and Abuse Aue, P. (2006). Teen drug abuse. Detroit: Thomson/Gale.

Kaufman, E. (1991). Help at last: A complete guide to coping with chemically dependent men. New York: Gardner Press.

Landry, M.J. (1994). Understanding drugs of abuse: The processes of addiction, treatment, and recovery. Washington: American Psychiatric Press.

National Institute on Drug Abuse. (2000). Anabolic steriod abuse. Rockville: author.

Stares, P.B. (1996). Global habit: The drug problem in a borderless world. Washington: Brookings Institute.

Suggested Films and Videos: Substance Abuse 1. Changing Lives. (2003, Films for the Humanities and Sciences, 81 min). Follows a group of recovering addicts through a group therapy session at a rehabilitation institute, and describes Project SAFE, a treatment program for disadvantaged mothers.

2. Chemical dependency: Childhood environment. (1990, Insight Media, 15 min). Highlights the effects of family chemical dependency on children.

3. Psychology of addiction. (2000, Insight Media, 34 min). Illustrates the psychological distortions accompanying addiction.

4. Relapse prevention. (1992, Insight Media, 55 min). Focus is on ways to develop cognitive skills to prevent relapse.

5. Stages of change for addictions. (2001, Insight Media, 80 min). Identifies the stages of dealing with addiction.

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6. Substance abuse and the elderly. (1996, Insight Media, 27 min). Discusses substance abuse in the elderly and treatment/intervention issues.

7. The disease of addiction. (1999, Insight Media, 30 min). Reviews the addiction as disease perspective.

8. Altered States: a history of drug use in America. (2004, Films for the Humanities & Sciences, 57 min). Documentary on drug use and abuse in America.

9. Cognitive-behavioral relapse prevention for addictions. (1996, American Psychological Association, 57 min). Marlatt presents methods for preventing relapse.

Smoking Tobacco 10. Butt out. (1992, Xenejenex Productions, 35 min). Describes a quit smoking plan including getting ready to quit, coping with triggers, treatment options, and overcoming setbacks.

11. Smoking: The most preventable cancer. (2000, Edudex, 14 min). A review of smokingrelated diseases.

12. The truth about tobacco. (2002, Films for the Humanities, 29 min). Contrasts interviews with people suffering from illnesses related to smoking, to interviews of teenage smokers.

Alcohol Use and Abuse 13. Making of a hangover. (2002, Films for the Humanities and Sciences, 51 min). Tracks physiological and psychological changes in seven individuals as they drink with their friends at a bar.

14. Substance abuse disorders. (1992, Annenberg/CPB, 60 min). Explores addiction to alcohol and other drugs.

15. The truth about alcohol. (2002, Films for the Humanities, 31 min). Examines the consequences of using and abusing alcohol.

16. The red road to sobriety. (2005, Kifaru Productions, 90 min). Places the alcohol problems of Native Americans within the context of historical destruction of indigenous peoples and culture and the stereotype of the drunken Indian.

17. Women and alcohol. (2006, ABC News Productions, 16 min). Segment of the TV program “20/20” shows growing trend of binge drinking in young women.

18. Fetal alcohol exposure: changing the future. (2006, Films for the Humanities & Sciences, 31 min). Addresses questions of diagnosis and disabilities associated with FASD. 19. Women and alcoholism. (2004, Films for the Humanities & Sciences, 28 min). Details the special risks alcohol creates for women, what help is needed and where to go when it is.

Drug Use and Abuse 20. Animated Neuroscience and the Action of Nicotine, Cocaine, and Marijuana in the Brain.

(2001, Films for the Humanities and Sciences, 25 min). Describes the neurochemical functioning of the brain, and how substances interact with this process to produce their effects.

21. Cocaine: Treatment and recovery. (1990, Cinemed, 60 min). A series of three 60 minute videos regarding withdrawal and treatment, the use of crack from an African-American perspective, and relapse prevention.

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22. Crack USA: County under siege. (1990, Ambrose Video, 42 min). Set in Palm Beach County, FL, video shows community experience with crack.

23. Enemy within: Drugs in the workplace. (1990, MTI Films, 27 min). Presents the problem of drugs in the workplace for employers, employee assistance programs, and drug testing.

24. Methamphetamines. (1990, Cinemed, 60 min). A series of three 60 minute videos available regarding the pharmacology, treatment and recovery for methamphetamine users.

Internet sites of interest: Smoking 1. http://www.lungusa.org/index/html - American Lung Association (page on tobacco control and quitting smoking).

2. http://www.tobaccofree.org/ - Tobacco Free, master list of anti-tobacco links 3. http://www.na.org/ - Narcotics Anonymous World Services – resources 4. http://www.quitnet.com - Quitnet site for quitting smoking 5. http://www.quitsmoking.com/kopykit/reports/smokeout.htm - information on the Great American Smokeout and quit smoking information Alcohol and Drug Use 6. http://www.aa-intergroup.org/ - Online Intergroup of Alcoholics Anonymous 7. http://www.alcoholics-anonymous.org/ - Alcoholics Anonymous 8. http://www.nida.nih.gov/ - National Institute on Drug Abuse from the National Institutes of Health 9. http://www.sos4parents.com/ - SOS 4 Parents – Help for worried parents of difficult teenagers 10. http://www.egetgoing.com/ - eGetgoing Online Recovery web page – Drug and Alcohol treatment and chemical dependency rehabilitation program 11. http://www.health.org/ - U.S. Department of Health and Human Services and SAMHSA’s National Clearinghouse for Alcohol and Drug Information 12. http://www.niaaa.nih.gov - National Institute on Alcohol Abuse and Alcoholism

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TEST QUESTIONS True or False T

1.

Users who go on to become addicted to a substance usually become psychologically dependent on it first.

2.

Since the Surgeon General's report on the dangers of smoking in the 1960's, cigarette manufacturers have suffered major declines in sales.

3.

Nicotine is the active ingredient in tobacco smoke that has been linked to cancer.

4.

The nicotine regulation model falls short of explaining why people still crave cigarettes months and even years after they quit smoking.

5.

Lifetime prevalence rates indicate that approximately 13% of all drinkers abuse alcohol.

6.

Cocaine may have harmful effects on the cardiovascular system.

7.

Stanley Schachter (1982) interviewed ex-smokers and found that over 60% who tried to quit were unsuccessful.

8.

Long-term alcoholics and problem drinkers who drink at lighter levels can both successfully use controlled drinking strategies.

9.

The treatment strategies in Alcoholics Anonymous have been found to be more effective than other treatment interventions delivered by professional

(175)

F (177)

F (182)

T (182)

T (188)

T (195)

F (198)

F (201)

F (203)

therapists.

F (205)

10.

Incorporating a person’s physician into their intervention program for reducing substance abuse is likely to prevent the person from wanting to participate and reduce the effectiveness of the program.

253

Matching Match the techniques with their descriptions in 1-5: a. aversion strategies b. self-monitoring c. stimulus control d. response substitution e. behavioral contracting d (203)

1. Involves replacing a problem behavior with a behavior incompatible with the problem.

a

2. May involve satiation or imagined negative scenes.

(201)

e

3. Specifies what rewards and punishers are applied in controlling a behavior.

(203)

b (203)

4. Records are kept on the problem behavior such as the times, places, and circumstances of each occurrence.

c

5. May involve removing ashtrays or matches from the home of a smoker.

(203)

Match the following agents with their descriptions in 6-10: a. emetine b. morphine c. barbiturate d. marijuana e. methadone d

6. A hallucinogen which causes perceptual distortions.

(193)

b

7. A narcotic or pain reducing substance.

(193)

a

8. Like Antabuse, may be used in the treatment of alcohol abuse.

(202)

c

9. Depressant which decreases arousal and increase relaxation.

(193)

e

10. A chemical which blocks the effects of heroin.

(204)

254

Multiple Choice d (175)

a (175)

a (175)

a (175)

b (175)

d (175)

1. The definition of addiction has come to include a. physical dependence. b. psychological dependence. c. repeated consumption of a substance. d. all of the above 2. Howard has developed a physical dependence on nicotine, which means a. his body requires it for "normal" functioning and he'll most likely experience withdrawal symptoms if he tries to quit smoking. b. he is probably experiencing serious interpersonal problems because of this substance. c. he very likely is failing to fulfill important obligations to others. d. he probably feels compelled to smoke cigarettes.

3. The process in which the body requires increasingly large doses of a drug to achieve the same effect is best described as a. tolerance. b. withdrawal. c. dependence. d. addiction.

4. In the past Randi had only to drink two beers before she felt a "buzz." Now she must drink five or more beers to get that "buzz." Randi is exhibiting a. tolerance. b. withdrawal. c. psychological dependence. d. addiction.

5. Nora has been feeling irritable since she quit smoking last week. She is experiencing symptoms of _____. a. tolerance. b. withdrawal. c. dependence. d. abuse.

6. According to the text, the potential for psychological dependence is lowest for a. marijuana. b. heroin. c. cocaine. d. LSD.

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b (175)

c (176)

c (176)

d (177)

a (177)

c (177)

7. Steve shows a persistent pattern of drinking too much and often drives drunk.

He meets the criteria for the diagnosis of a. physical dependence. b. substance abuse. c. withdrawal. d. tolerance.

8. Mary drinks to reduce the stress she feels at the end of a long day whereas John drinks simply because he "likes the taste of a good beer." Mary's drinking is maintained by _____ reinforcement whereas John's is maintained by _____ reinforcement. a. positive; positive b. positive; negative c. negative; positive d. negative; negative 9. Samuel has intense cravings for a cigarette when he sees his friend, George.

According to the text, the sight of George serves as a __________. a. positive reinforcement b. negative reinforcement c. substance-related cue d. tolerance cue 10. Steve grew up seeing his parents and their friends having fun at annual Super Bowl parties at which large amounts of alcohol were consumed. According to expectancy theory, Steve is likely to develop ____ attitudes toward alcohol via ____. a. negative; social learning b. positive; classical conditioning c. negative; classical conditioning d. positive; social learning 11. Which of the following statements about the influences of heredity on addiction is not true? a. Smoking and alcoholism share the same genetic markers. b. The specific genes responsible for smoking have been identified. c. The specific genes responsible for alcoholism have been identified. d. If one identical twin smokes, the co-twin is also likely to smoke.

12. Which of the following statement regarding cigarette smoking is true? a. It is at an all-time high in the USA. b. It has declined to the point that many tobacco companies now face bankruptcy. c. It reached its greatest popularity in the U.S. in the mid-60's. d. It was introduced to America by Columbus.

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b (178)

a (179)

c (179)

c (181)

d (181)

c (182)

13. Which of the following smokers is in the age level with the highest percentage of smokers in the USA? a. Daniel, age 45 b. Greg, age 25 c. Samantha, age 12 d. Caroline, age 60 14. Which of the following statements about smoking prevalence is true? a. Black men over the age of 45 are more likely to smoke than White men of the same age. b. Hispanics are more likely to smoke than persons from any other race/ethnicity group. c. Smoking rates increase with education. d. Smoking rates are highest in high income individuals because they can afford to buy cigarettes.

15. Which of the following persons is most likely to continue smoking beyond a few cigarettes? a. Joseph, whose parents don't smoke b. Lynn, whose friends all think smoking is "uncool" c. Conrad, a rebellious, risk-taking adolescent d. none of the above 16. Research on stress and smoking has led to each of the following conclusions except a. smoking is commonly identified as a way to reduce stress. b. adult smoking increases with stress. c. smoking is a good long-term tension reducer. d. smokers report less anxiety if allowed to smoke.

17. Which of the following statements reflects the biological influences on smoking? a. No relationship between heredity and smoking has been discovered. b. Heredity influences the ease with which a person becomes dependent on tobacco. c. Heredity may influence the strength of physical dependence on tobacco. d. both b and c.

18. Which substance in inhaled cigarette smoke is readily absorbed into the bloodstream and reduces the ability of the blood to carry oxygen? a. tar b. nicotine c. carbon monoxide d. carbon dioxide 257

d (182)

a (182)

a (182)

b (184)

d (185)

19. Nicotine, the addictive substance in cigarettes: a. triggers catecholamine release. b. acts as a stimulant. c. is found naturally only in tobacco. d. all of the above 20. The idea that smokers pace their smoking to maintain the levels of nicotine in their blood is most consistent with which of the following theories? a. nicotine regulation b. psychosocial c. psychological dependence d. biobehavioral 21. Researchers have found that when habitual smokers are provided with low-nicotine cigarettes they: a. smoke more to maintain their nicotine intake b. smoke about the same number of cigarettes. c. smoke less because of low-tar cigarettes taste awful. d. are very likely to stop smoking after a short period of time.

22. Which of the following is true regarding the relationship between prevalence of lung cancer and smoking? a. Lung cancer has decreased in prevalence and thus its relationship with smoking is unclear. b. Rates of lung cancer mortality started to rise about 20 years after the increase in smoking. c. The gap between women and men who smoke in mortality due to lung cancer remains the same as it was 40 years ago. d. Mortality rates due to lung cancer are the same as in the days of Christopher Columbus.

23. Which is not true about passive smoking? a. It can cause cancer in healthy nonsmokers. b. Children of smokers have more respiratory infections than children of nonsmokers. c. The smoke that comes from the end of a burning cigarette contains high concentrations of carcinogens. d. Designating some tables in the corner of a restaurant as smoking tables and the rest as nonsmoking eliminates the exposure of nonsmokers to the harmful effects of smoke.

258

a (185)

c (185)

a (187)

c (187)

d (188)

b (188)

24. Risk factors that link smoking to cardiovascular heart disease (CHD) include a. having a lifestyle that includes other risk factors. b. low blood pressure which causes the nicotine to be metabolized more slowly. c. being a female. d. having relatively low stress levels in one's life.

25. The substances in cigarettes which contribute to cardiovascular disease are a. tar and carbon. b. winston and salem. c. carbon monoxide and nicotine. d. filters and menthol.

26. The movement in America which advocated total abstinence from alcohol was called a. temperance. b. behavior modification. c. behaviorism. d. the Roaring 20's.

27. Which of the following statements is true regarding gender differences in alcohol consumption? a. Men drink more than women only in adolescence. b. Men drink more than women during adolescence but women drink more during adult life. c. Men drink more than women throughout the lifespan. d. Women drink more than men only in adolescence.

28. Historically, _____ occurs more in countries that incorporate drinking into daily life, whereas _____ occurs more in countries that restrict alcohol use. a. alcoholism; problem drinking b. problem drinking; alcoholism c. intoxication; daily drinking d. daily drinking; intoxication 29. The phrase "lifetime prevalence rate" refers to a. number of new cases in a year. b. proportion of individuals who have experienced the problem at any point in their lifetime. c. another term for mortality rate. d. another term for morbidity rate.

259

c (189)

d (190)

a (191)

b (192)

a (192)

d (194)

30. Most problem drinkers are a. college students. b. unemployed. c. married. d. separated from their families.

31. Which of the following concepts accounts for the fact that Hank tries to keep pace with his friends in terms of number of drinks consumed when they are out together at a bar? a. abstinence violation effect b. substance-related cues c. negative reinforcement d. modeling 32. James has a history of alcoholism in his family. Which of the following might happen to James that would be less likely to happen to his friends without a similar family history? a. stronger cravings for alcohol after his first drink b. stronger dislike for the taste of alcohol c. lower tolerance for the effects of alcohol d. his family history will not have any impact on his drinking 33. Jose has had 5 glasses of beer and decides he needs to drive to the grocery store. He says to his roommate “I always sober up as soon as I get behind the wheel.” He is _____ the effects of alcohol on his ability to drive. a. over-estimating b. under-estimating c. accurately estimating d. cognitively restructuring 34. Heavy drinking has been linked to all of the following health problems except a. asthma. b. cirrhosis. c. brain damage. d. high blood pressure.

35. Which of the following drugs is the most commonly used drug in the US? a. cocaine b. barbiturates c. heroin d. marijuana

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d (194)

a (195)

b (195)

c (195)

d (195)

a (196)

36. The strongest factor in determining teenagers’ decreasing use of drugs is a. stress b. genetics c. drug availability d. beliefs about the harmfulness of drugs.

37. Factors that predict the movement from drug use to drug abuse include a. rebelliousness and sensation seeking. b. rebelliousness and genetics. c. high levels of social conformity and social learning. d. impulsivity and stress.

38. In comparison to the research on the effects of smoking and drinking on health, the research on effects of drug use on health is a. well documented. b. not well documented. c. rapidly catching up. d. hampered by negative public opinions.

39. Which statement is accurate regarding long-term effects of marijuana and and tobacco use? a. They both are linked to CHD. b. They both are linked to the development of cancer. c. They both are linked to lung damage. d. Marijuana use has no long term effects on health.

40. Which of the following effects of using crack cocaine are linked to increased risk for stroke and heart attack? a. blood vessel constriction b. increase in heart rate c. cardiac arrhythmia d. all of the above 41. Prevention programs are currently being designed to deal with the use of multiple substances. What are the primary reasons for doing so? a. initial use of all three substances occurs in adolescence and for similar reasons b. cost and convenience c. for convenience reasons only d. this is how prevention programs have always been delivered

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a (196)

c (197)

b (197)

c (198)

c (199)

d (199)

42. Setting legal drinking ages and restricting sales of alcohol to certain times of are examples of a(n) _____ approach to prevention. a. public policy or legal b. behavior modification c. health promotion and education d. early intervention 43. Successful programs designed to prevent teenage drug abuse have incorporated which of the following components? a. A mass media campaign that emphasizes the negative consequences of drug use. b. Project DARE. c. Social influence and life skills training. d. Stress reduction.

44. According to the text, which of the following is the primary focus in “family involvement” approaches? a. getting parents to stop smoking b. getting parents more actively involved in supervision of their children c. getting parents to use more harsh punishment d. increasing parental understanding of modern youth 45. Attempting to quit smoking on one's own is a. rarely successful. b. equal in success rate compared with a structured program. c. one of the most common ways to quit smoking. d. effective only if the person uses satiation too.

46. Which of the methods below was not used by the majority of people trying to quit smoking in a stop-smoking contest? a. Quitting ''cold turkey''. b. Going it alone. c. Providing material rewards for success. d. Using oral substitutes.

47. Which of the following is a problem with employee assistance programs? a. They identify substance abuse problems only after they become severe. b. Most employees with substance abuse problems don’t use them. c. Employees with substance abuse are often concerned their employer will find out and thus don’t use the program. d. all of the above

262

c (200)

a (200)

d (201)

a (202)

c (203)

c (203)

48. According to the stages of change model, what is the critical transition point for readiness to attempt stopping the use of a substance? a. the shift from precontemplation to contemplation b. the shift from preparation to action c. the shift from contemplation to preparation/action d. none of the above 49. Melinda is entering a stop-smoking program that uses reinforcement as part of the program. Her friend, Jan, is entering a program that does not use reinforcement. Which person is more likely to be successful? a. Melinda b. Jan c. both will be successful d. neither will be successful 50. Present research indicates that alcoholics who can drink in moderation and in a controlled fashion are a. relatively common. b. generally rare. c. only found among long-term alcoholics who have increased their tolerance for the drug. d. usually young, with a short-term drinking problem.

51. Kyle is taking the drug known as emetine. He can expect which of the following effects from the drug? a. Nausea if he drinks alcohol while he's taking it. b. Perceptual distortions since it is a hallucinogen. c. Decreased arousal and increased relaxation. d. Pain relief.

52. According to recent research, how effective is Alcoholic Anonymous in reducing alcohol use? a. AA’s effectiveness is still unknown at present. b. AA is as effective as other current methods. c. AA is less effective than other methods. d. AA is more effective than other methods.

53. Todd removes all ashtrays from his car and home to help him to stop smoking. He is using a strategy called: a. behavioral contracting. b. response substitution. c. stimulus control. d. self-deception.

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b (203)

c (204)

d (204)

c (205)

b (205)

c (206)

54. Frank's favorite cigarettes of the day and the hardest to give up are those he has right after dinner. Frank decides to begin taking a walk after dinner instead of smoking. This is an example a. behavioral contracting. b. response substitution. c. stimulus control. d. self-deception.

55. What is one of the major problems with using Antabuse as part of a treatment program to get people to stop drinking? a. It doesn’t work on most people. b. It’s cruel to make people nauseous. c. It’s difficult to get people to take it consistently. d. It substitutes one addiction for another.

56. You are a smoker who has decided to quit. Which of the following programs would likely be most effective for you? a. quitting ''cold turkey'' b. using a nicotine patch c. providing material rewards for success d. a multidimensional program 57. Maria has just finished formal treatment for her addiction to cocaine. If she experiences a relapse, when is the most likely time that will happen? a. within the next few weeks b. at the one year point following treatment c. at the seven year point following treatment d. relapse is highly unlikely 58. Of the following people, who is most likely to relapse following their stop-smoking program? a. Mark, a light smoker b. Gina, a heavy smoker c. Bill, whose wife is very supportive of his quit attempt d. Jill, who is very sure she will be effective in her quit attempt 59. According to research, when smokers relapse what phenomenon is observed? a. They are able to immediately attempt another quit effort and be successful. b. They usually give up trying to quit entirely. c. They decrease their perceptions of the health risks of smoking. d. They switch to a low tar cigarette.

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d (206)

60. Marlatt’s relapse prevention method involves which of the following? a. involvement of a therapist b. practicing coping skills in actual high-risk situations c. identification of high-risk situations d. all of the above

Alcoholics Anonymous takes the position that drinking in moderation: a. is to be encouraged only for long-term alcoholics who might not stop any other way. b. should be encouraged only for short-term alcoholics. c. is in opposition to their goal of total abstinence. d. should be encouraged for everyone since it reduces stress.

Which of the below choices is NOT one of the developmental or biological factors associated with why people use and abuse alcohol? a. heredity b. family history of alcoholism c. specific gene patterns related to craving d. social media messages

In terms of processes leading to dependence, which of the below does NOT represent one of the 5 processes? a. b. c. d. e.

Avoiding withdrawal Reinforcement Peer pressure Expectancies Substance-related cues

Short Answer Questions 1. Discuss the relationships between the terms addiction, physical dependence, tolerance, withdrawal, psychological dependence and substance abuse.

2. Sometimes people label others as an "alcoholic" erroneously. Based on the definition from the text, what criteria would need to be met for this term to be accurate? How is it differentiated from problem drinking?

3. Distinguish between the various types and effects of the different categories of drugs.

Essay Questions 1. Your aunt is concerned that her adolescent daughter might begin smoking. Based on the information you've gained from this chapter, what suggestions might you give her regarding prevention?

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2. Your neighbor, a 35 year-old 2-3 pack-a-day smoker for the past 15 years, has finally decided he wants to quit smoking and has asked for your advice on how to go about doing so. What information could you give him regarding smoking cessation techniques and their likelihood for success?

3. You may have noticed the similarity in treatment approaches for attempting to prevent and/or get people to quit using tobacco, alcohol, and chemical substances described in this chapter. Give an overview of the major approaches used in prevention or treatment.

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CHAPTER 8 IMPROVING NUTRITION, WEIGHT CONTROL AND DIET, EXERCISE, AND SAFETY CHAPTER OUTLINE I. Nutrition A. Components of Food 1. Chemical components of food a. carbohydrates - sources of energy. i. simple sugars - glucose and fructose ii. complex sugars -sucrose, lactose, and starch b. lipids - provide energy i. includes saturated and unsaturated fats and cholesterol ii. diet should contain 10% - 30% fat. c. proteins - involved in cell synthesis i. comprised of approx. 20 amino acids - half are essential for body functioning and found only in the diet d. vitamins - organic chemicals that regulate metabolism and body functions i. fat-soluble vitamins (A, D, E, and K) - dissolve in fats and stored in body's fatty tissue. ii. water-soluble vitamins (B and C) - are not stored in the body but are excreted in urine. e. minerals - inorganic substances important in body development and functioning. i. examples: calcium, phosphorus, potassium, sodium, iron, iodine, and zinc.

2. Fiber a. a non-nutrient component of food not used in metabolism but needed for digestion.

3. Six basic food groups a. consists of grains, fruits, vegetables, milk products, meat and fish and Oils and Sweets. (Figure 8-1, page 211). b. contain all necessary nutrients and fiber for most people. i. taking too much of some nutrients may result in a form of poisoning. ii. pregnant women may need to adjust diets and take supplements such as iron and vitamin B

230

iii. antioxidants such as vitamins A, C, and E reduce cell damage from oxidation 4. Unprocessed foods are generally healthier than processed foods.

5. Food additives may cause allergic reactions in some or may be carcinogenic.

B. What People Eat 1. Diets vary by gender and across cultural groups. a. study of 23 countries revealed that women generally eat healthier diets than men, but there were marked national differences 2. American diets have increased in consumption of sugar and animal fats and proteins but decreased in fiber.

3. The way food is prepared has changed. a. increase in fried or deep fried foods. b. increase in processed, fast foods.

4. Pattern of American food consumption has become healthier in some ways. a. reduced consumption of red meats. b. increased consumption of fish/poultry, cereal/grains, and fruits/vegetables. c. however, many people consume too few nutrients and need supplements.

5. Less healthy in other ways a. increased intake of sugars, soft drinks, fats, and oils b. decreased consumption of essential nutrients.

(Table 8.2 compares the diets available for consumption in different countries) 6. Diets are determined by biopsychosocial factors. a. biological influences i. preference for sweet and avoidance of bitter foods appears to be inborn. ii. fatty foods activate pleasure centers in the brain. b. food availability and exposure to certain foods via television increases liking in children. c. portion sizes, freedom to choose food, and availability of foods are also important factors 7. Nutritional differences are reflected in the height of children around the world.

C. Nutrition and Health 1. Section introduction a. public response to mass media campaigns to eat healthier i. some products from health food stores are beneficial, others have dubious worth. ii. becoming a vegetarian can range from avoiding red meats to consuming no animal products.

- essential to maintain balance of protein and other 231

essential nutrients.

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2. Diet and atherosclerosis a. cholesterol is the dietary culprit in atherosclerosis. i. produced by our bodies with remaining coming from diet. ii. may form plaques in blood vessels depending on presence of lipoproteins. b. types of lipoproteins i. low-density lipoprotein (LDL) - a "bad" cholesterol associated with increased plague deposits. ii. high-density lipoprotein (HDL) - a "good" cholesterol that carries away LDL to be processed or removed by liver. iii. triglycerides are in most fats consumed and increase risk of heart disease iv. omega-3 fatty acids occur at high levels in fish, reduce triglycerides, and raise HDL v. trans-fatty acids are in processed oils such as margarine and increase LDL c. normal levels of cholesterol i. “bad” cholesterol is most important and depends on 5 risk factors - age (over 45 for men, 55 for women) - cigarette smoking - high blood pressure - HDL cholesterol below 40 - family history of early cardiovascular disease ii. scores are total number of risk factors indicated - scores of 0-1 indicates low risk - higher scores should keep LDL level below 70 d. cholesterol levels are determined partly by heredity and lifestyle. i. smoking raises LDL, lowers HDL. ii. diets high in animal products contain high concentrations of cholesterol. e. controlling cholesterol i. cholesterol intake shouldn't exceed 300 mg. daily. ii those at higher risk should have levels assessed iii. start good eating habits in childhood. iv. use of medications such as statin drugs can reduce LDL while not affecting HDL. v. reducing cholesterol is linked to retarding/reversing development of atherosclerosis and risk for heart disease - substituting low cholesterol foods - switching to fish or poultry in place of red meats - using low cholesterol vegetable fats for cooking vi. marked reductions are associated non-illness death

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3. Diet and hypertension a. hypertension is classified as blood pressure exceeding 140/90. i. 700 million people worldwide, and 25% American adults ii. doctor recommended lifestyle change are first methods to reduce hypertension. b. sodium intake i. body needs 500 mg. of sodium a day; recommended amounts of less than 2300 mg. daily. ii. most Americans consume average of 3,270 mg. daily iii. reducing sodium intake reduces blood pressure in hypertensives c. caffeine intake i. increases reactivity to stress and increases blood pressure temporarily. ii. studies indicate a positive correlation of intake to heart disease 4. Diet and cancer a. studies relating certain types of cancer to low fiber and high saturated fat diets are inconsistent i. it is advisable to eat little fatty meats and more fruits, vegetables, and breads and cereals b. studies on the role of vitamins A, C, and E are not definitive. i. nutritionists recommend against taking high doses.

5. Interventions to Improve Dietary Components a. can focus on a single dietary component or an overall diet b. most effective approaches incorporate theories of health related behavior. c. interventions can include i. behavioral and educational methods ii. training and cooperation by members of the household iii. support groups iv. long-term follow-up program v. addressing the person’s food preferences

II. Weight Control and Diet A. Desirable and Undesirable Weights 1. Section introduction a. criteria for judging desirability of weight i. attractiveness - being the "wrong" weight affects self-esteem, especially in girls.

- greater percentage of girls than boys were dieting, reflecting gender differences in concerns with weight. ii. healthfulness - studies of mortality and morbidity rates of men and 234

women show that those in certain weight/height ratios have far lower rates of chronic disease and longer life spans 2. Overweight and obesity a. until 1990s, overweight was evaluated by degree of departure from desirable weight charts. b. current methods include the use of the body mass index (BMI) i. overweight - BMI exceeds 25 ii. obese - BMI exceeds 30 3. Sociocultural, gender, and age differences in weight control a. prevalence of overly fat people differs by nationality, sociocultural factors, gender, and age. i. U.S. has more overweight/obese persons than other countries.

- more than 2/3 of Americans are overweight, 1/2 of those are obese.

- 1/6 children and adolescents is overweight or obese - men are more likely to be overweight but more women are obese.

- African American and Hispanic women are more likely to be obese than are European American women.

- higher percentage of overweight Hispanic men than African American or White - percentage of overweight people peaks at 50-75 years of age. b. percentage of overweight individuals has increased substantially in the last few decades B. Becoming Overly Fat 1. Section introduction a. fat is added by consuming more calories than used by metabolism. i. stored as adipose tissue b. reasons for weight gain as we age i. accumulation of periodic weight gains ii. less physical activity and declines in metabolism 2. Biological factors in weight control a. fat tissue is less metabolically active. i. contributes to lower metabolic rate. ii. once overweight, may not still be overeating. b. malfunctioning endocrine glands explain only small percentage of obese persons. c. heredity plays a role. i. evidence from animal studies has identified defective genes that disrupt balance of energy intake and metabolism ii. twin adoption studies have consistently found genetic link 235

iii. relationship of fatness in parents to that of children d. heredity and Set Point Theory i. Set Point Theory proposes that each person has a certain weight the body strives to maintain through hypothalamic functions. ii. hypothalamus may affect weight by - affecting amounts of enzymes that contribute to functioning of fat cells.

- regulating levels of insulin; hyperinsulinemia is a condition of having high serum levels of insulin. iii. set point activity also affected by number of fat cells that develop.

- as children gain weight, they do so by adding fat cells - the number of fat cells can increase, but not decrease - when persons who have fat-cell hyperplasia attempt to diet, body reacts as if going through food deprivation and energy stores of fat are maintained more efficiently.

- important reason why diet and exercise in children is critical.

3. Psychosocial factors in weight control a. psychosocial factors involved in weight control include emotions, stress, and lifestyles. b. restrained eaters are prone to overeating when experiencing certain emotions c. depression puts an individual at risk for binge eating i. binge eating occurs when a person eats a large amount within a short period of time ii. frequent binge eating is a common feature of obesity d. lifestyle patterns such as alcohol use and watching television can contribute to weight gain e. obese individuals are more sensitive to external food-related cues f. obese and restrained eaters are less sensitive than unrestrained eaters to the amount of fat in the food they consume i. unrestrained eaters adjust their intake of the food to compensate

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4. Overweight and health a. normal and overweight people tend to rate their health the same. b. factors to consider in measuring health of normal v. overweight people. i. degree of overweight - greater the severity of obesity, greater the risk of developing and dying from hypertension, CHD, diabetes, stroke, and cancer.

- the BMI of an overweight person is related to decreasing lifespan, and increased medical costs ii. level of fitness - people who are heavy but physically active and fit have lower mortality for CHD and diabetes. ii. distribution of weight - ratio of waist to hip girth is associated with hypertension, diabetes, CHD, and mortality.

5. Preventing overweight a. preventing obesity needs to start in childhood i. childhood obesity continues into adulthood. ii. developing excess fat cells as a child makes weight problems likely. iii. 1/3 of mothers of overweight children claim their child is at the right weight b. special attention to improving diets and physical activity in children can be done in schools. i. especially important for children who are already overweight or have family history of obesity. c. ways for parents to help their children i. encouraging exercise and restricting TV watching ii. not using unhealthful food rewards iii. not buying high-cholesterol or sugary foods iv. using healthful foods as desserts v. having children eat healthful breakfast and no snacks at night vi. monitoring child's BMI C. Dieting and Treatments to Lose Weight 1. Section introduction a. millions of people are dieting due to concerns for health, unattractiveness, and stigma. i. in the U.S. fatness is concerned unattractive, especially in females ii. many blame heavy individuals for their condition

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b. best approach to weight loss i. only one-third follow appropriate guidelines for losing weight. ii. losing weight gradually and making permanent lifestyle changes. iii. individuals are most likely to succeed at dieting if they have a high degree of self-efficacy and constructive social support iv. most people can lose weight on their own but others need help from weight loss programs.

2. Commercial and ''fad diet'' plans a. "miracle diets" generally require some unique dietary regimen. i. may be nutritionally unsound or produce unpleasant/unhealthy side effects. ii. examples: Scarsdale diet, Beverly Hills diet, Atkins diet, low-calorie liquids. iii. little empirical evidence for success claims. b. fad diets aren't good substitute for exercise and moderate, balanced meals.

3. Exercise a. benefits of exercise i. increases metabolism ii. focuses on reduction of body fat iii. exercise plus dieting leads to greater weight loss than dieting alone. iv. aids in maintaining weight loss 4. Behavioral and cognitive methods a. conclusions regarding usefulness of behavioral methods in weight control i. behavioral techniques are helpful, but not for all patients. ii. behavioral programs have low drop-out rates. iii. about 10% of original weight is lost in the first 4 months. iv. more effective than other approaches with exception of medical treatments. v. on average individuals who complete a program gain much of it back in the first year, but many maintain loss b. common behavioral techniques used in weight loss programs i. nutrition and exercise counseling ii. self monitoring iii. stimulus control iv. altering the act of eating v. behavioral contracting c. using rewards for not engaging in sedentary activities d. family-based behavioral programs help obese children and their parents lose weight together.

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e. cognitive methods include: i. motivational interviewing increases personal commitment and self-efficacy ii. problem-solving training - learning strategies for dealing with every day difficulties encountered when trying to stick to a diet.

5. Self-help groups and worksite weight-loss programs a. self-help groups i. example - Weight Watchers, a self-help group that incorporates behavioral techniques such as self-monitoring along with nutritional information and group meetings into program ii. little research has been done on success of programs - one study found moderate weight loss for those who complete a program.

- attrition rates assessed at 50% within first six weeks. b. worksite-weight-loss programs i. generally use behavioral techniques but not particularly successful - high dropout rates and little weight loss most likely due to low motivation. ii. increasing motivation may occur by - gearing program to stage of readiness - providing incentives - e.g., weight loss competitions 6. Medically supervised approaches a. medications i. sibutramine – suppresses appetite ii. orlistat reduces conversion of calories to fat but produces only small weight loss. iii. combining medication and behavioral treatments is better than either alone iv. because of side effects, drugs recommended usually only for obese persons. b. very low calorie diets i. diets with fewer than 800 calories per day, usually for the very obese ii. not recommended for patients with heart disease. c. bariatric surgery involves changing the structure of the stomach reduce appetite and consumption d. liposuction removes adipose tissue from the body; this is considered cosmetic as apposed to a weight reducing method d. choosing appropriate methods requires matching methods to person's weight problems and characteristics.

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7. Relapse after weight loss a. reasons for relapse often involve food cues, negative emotions, and boredom b. relapse can be limited by follow-up treatment programs including frequent therapist contact and social support. c. methods for effective weight loss i. use behavioral techniques. ii. reduce calorie and fat content of diet. iii. continue to exercise after weight has been lost. iv. avoid situations that prompt relapse. v. invoke social support from family and friends.

D. Anorexia and Bulimia 1. Section introduction a. anorexia nervosa i. maintain weight 15% below normal weight, fear weight gain, distorted body image, and absence of menstruation. ii. death can occur due to low blood pressure, heart damage, or cardiac arrhythmias. iii. more common in dancers, models, and athletes. b. bulimia nervosa i. recurrent binge eating followed by purging via vomiting or laxative use. ii. medical problems include inflammation of digestive tract and cardiac problems. iii. individuals are aware that their eating pattern is abnormal, fearful of losing control of eating, and are selfcritical following an episode. c. current prevalence data is likely to be an underestimate i. population prevalence approx. 0.5-1.0% for anorexia and 1-2% for bulimia. ii. 90% of those diagnosed are female 2. Why people become anorexics and bulimics a. genetic and physiological factors i. twin studies find anorexia and bulimia are more likely to appear in both twins. ii. functioning of neuroendocrine and neurotransmitter processes may be abnormal. b. cultural factors i. changes in the "ideal figure" and increased pressure to be slim. ii. individuals with anorexia and bulimia often start dieting normally as teens and then adopt extreme practices. c. cognitive factors i. individuals with anorexia and bulimia overestimate or distort body size.

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3. Treatments for anorexia and bulimia a. first priority in treatment is restoring normal weight. b. relapse rates for anorexics tend to be fairly high. c. treatment includes cognitive methods to address irrational thinking. d. most successful treatments for bulimia include cognitive and behavioral methods plus antidepressant drugs III. Exercise A. The Health Effects of Exercise 1. Types and amounts of healthful exercise a. isotonic exercise--builds strength and endurance, exert muscle force in one direction moving a heavy object b. isometric exercise--builds strength, rather than endurance, exert force against an immovable object c. isokinetic exercise--builds strength and endurance by exerting muscle force in more than one direction d. aerobic exercise--physical exercise that requires high levels of oxygen over an extended period of minutes 2. Psychosocial benefits of exercise a. reduces stress and anxiety. b. work performance and attitude improve. c. enhances self-concept.

3. Physiological effects of exercise a. increased production of endorphins. b. slows the decline in fitness with age. c. increases longevity. c. decreases risk of coronary heart disease, lowers blood pressure, and reduces the risk of some forms of cancer d. risks include accidents, injuries, heat exhaustion, or cardiac arrest, and potential use of anabolic steroids.

4. Liabilities to exercise a. Injuries, accidents. b. Sudden cardiac death. c. Use of anabolic steroids.

B. Who Gets Enough Exercise, Who Does Not, And Why? 1. Section introduction a. around the world most people have lifestyles that promote regular, vigorous, sustained activity naturally. b. peoples in industrialized countries tend to have more sedentary lifestyles. i. adults in these cultures choose not to exercise.

2. Gender, age, and sociocultural differences in exercise a. those who exercise tend to be the young, upper SES, educated, with a history of exercise.

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b. are more likely to be male and white c. the elderly seem to be limited more by misconceptions about appropriate activity than physiological limitations

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3. Reasons for not exercising a. common reasons given for not exercising i. lack of time ii. no convenient place iii. too much stress in their lives iv. social influences and beliefs b. positive influences on exercising i. high self-efficacy regarding ability to exercise. ii. higher perception of vulnerability to illness. iii. enjoyment of the exercise C. Promoting Exercise Behavior 1. Strategies to promote exercise a. pre-assessment i. examining purposes for exercising and assessing health status. b. exercise selection i. tailoring exercises to meet health needs of person and interests. c. exercise conditions i. determining when and where the person will exercise ii. obtaining necessary equipment. iii. setting a fixed or flexible schedule. d. goals i. determining specific sequence of outcomes in a behavioral contract. e. consequences i. determining appropriate rewards for exercise. f. social influence i. exercising with partners ii. enlisting support and encouragement from family and friends. g. record keeping i. charting progress on weight goals and exercise performance.

2. Other factors in promoting exercise behavior a. rewards needed for increasing exercise and decreasing sedentary behaviors. b. physicians can increase activity by giving verbal and written advice on specific exercise goals and behaviors. c. sedentary people are more likely to stick with a program of high frequency exercise rather than high intensity c. telephone contacts to assess progress and provide advice are successful. d. need to assess readiness to start and stick to an exercise program.

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IV. Safety A. Accidents 1. Number of intentional and unintentional injuries is equal to the effects of heart disease, cancer, and stroke combined a. More than 121,000 individuals in the U.S. die each year from unintentional injuries and accidents.

2. Traffic accidents account for half of all accidental deaths a. driver training classes do little to reduce accidents. b. automobile and highway design and legal restrictions can decrease accidents. i. examples: extra brake light, laws against drivers using cell phones, raising legal driving age. c. use of protective equipment such as helmets, seat belts, and protective car seats for children has risen sharply. i. laws requiring use are probably helpful but not sufficient.

B. Environmental Hazards 1. Exposure to ultraviolet rays may lead to skin cancer which can be prevented with sun screen. a. tanned appearance interpreted as "healthy" and "fashionable". b. interventions using gain-framed messages produce more sunscreen use than do those with loss-frame messages.

2. Potential household and workplace hazards a. lead poisoning b. radon c. asbestos d. radiation 3. "Right to Know" laws a. some states require employers to inform and train employees on use of hazardous materials. b. community agencies may be required to provide information and supportive measures to community members in presence of an environmental hazard.

4. Considerations regarding chemicals/gasses in the environment a. not all chemicals or gasses are harmful. b. exposure to toxic or carcinogenic substances poses little risk when exposure is infrequent or dosage small. c. some harmful substances have benefits that outweigh their dangers.

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DISCUSSION TOPICS 1. Vegetarian Diets.

As Sarafino points out, individuals who avoid some or all animal products can obtain necessary amino acids by carefully planning their diets. This is especially true for ova-vegetarian and vegan diets, which exclude milk products and all animal products, respectively. Certain foods lack essential amino acids (i.e., amino acids people must eat in order to manufacture protein). Particularly when complete sources of protein such as meat, eggs or milk are not eaten, eating certain dietary recommendations must be followed. An excellent description of vegetarian diets is found in Lappe (1982). For example, legumes are deficient in methionine, cystine, and tryptophan, but if combined with grain (which lack in lysine and isoleucine) a complete set of amino acids is present. Such is the case with a diet of rice and beans. If one combines a grain (lacking lysine and isoleucine) with milk which is high in lysine and isoleucine, again a complete set of amino acids is consumed. A good example is macaroni and cheese. Another complementing set of foods is seeds and legumes.

Source: Lappe, F.M. (1982). Diet for a Small Planet. New York: Ballantine Books.

2. Men and muscles.

One of the significant themes in this chapter is the impact of cultural beauty ideals on women. The experiences of those with anorexia and bulimia and the high prevalence of dieting speak to the influence of cultural pressures to be thin. Barry Glassner, in his chapter "Men and Muscles", reviews cultural pressures on men to be muscular. Boyhood desires to be remembered as "athletic stars" are transformed in muscular college men who report being happier with themselves. Having muscular upper bodies correlated with higher self-esteem in a large study of Psychology Today readers. Additionally, high school athletes are more likely to hold higher-status, better-paying jobs in adulthood. When addressing why men "work out", Glassner distinguishes between the obsessive, sporadic binge exerciser and the moderate exerciser who has made exercise an integrated part of life. Some men, he contends, exercise intensely as a way to bring discipline and order into their otherwise stressful or chaotic lives. For them, exercise or body building acts as a form of "therapeutic narcissism." For others, exercise is not a highly charged activity but rather a part of life that occupies a significant portion of one’s free time but is set aside for other priorities. Likely active in sports and other physical activities since childhood, this type of exerciser does not exercise to displace frustration. Instead, in keeping with continuity theory, this second type of exerciser is merely extending his earlier behavioral practices into adulthood. As a result, Glassner maintains that his exercise patterns are likely to be maintained.

Source: Glassner, B. (1992). Men and muscles. In Kimmel, M.S., & Messner, M.A. (Eds.), Men's lives. (pp 287-298). New York: MacMillan.

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3. Eating disorders and ethnicity.

Factors that may be related to the etiology of eating disorders include cultural norms, expectations, and definitions of beauty. Many studies note that dissatisfaction with body shape and size is particularly pervasive among adolescent European American females. The prevalence of eating disorders among this group of women is relatively high when compared to African American adolescent females. It may be that the image of beauty for white females is more rigid than that of African American females, who tend to place more emphasis on a wider variety of characteristics such as personality, positive attitude, and sense of self in their perception of beauty (Parker, Nichter, Nichter, Vuckovic, Sims, & Ritenbaugh, 1995). However, Parker et. al. (1995) notes that that there has been mounting concern in recent years that the incidence of eating disorders may rise among African Americans as they become increasingly acculturated to European American culture and adopt rigid ideals of achievement and thinness. Students may find the following articles interesting in examining the belief that weight is a reflection of some aspect of character.

Sources: Hsu, L.K. (1987). Are the eating disorders becoming more common in Blacks.

International Journal of Eating Disorders, 6(1), 113-123.

Parker, S., Nichter, M., Nichter, M., Vuckovic, C. S., & Ritenbaugh, C. (1995). Body image and weight concerns among African American and White adolescent females: Differences that make a difference. Human Organization, 54(2), 53-114.

Rucker, C.E., & Cash, T.F. (1992). Body images, body-size perceptions, and eating behaviors among African-American and White college women. International Journal of Eating Disorders, 12(3), 291-299.

4. Schematic processes in eating disorders.

Vitousek & Hollon (1990) apply cognitive theory to the explanation of eating disorders. Specifically, they argue that "eating disordered individuals develop organized cognitive structures (schemata) around the issues of weight and its implications for self that influence their perceptions, thoughts, affect, and behavior" (pg. 192). Moreover, they suggest that persistence of eating disorder behaviors represents the automatic processing nature of schematic processing. Their article is a rich example of how schema (cognitive) theory may contribute to our understanding of the etiology and maintenance of eating disorders.

Source: Vitousek, K.B., & Hollon, S.D. (1990). The investigation of schematic content and processing in eating disorders. Cognitive therapy and research, 14(2), 191-214.

5. Factors influencing safety equipment.

Manufacturers design warning labels to alert consumers to the hazards present in their products. However, research on warning labels has found that they have relatively little influence on safety behaviors. Compliance to warnings has been demonstrated to increase when the cost of compliance was reduced (i.e., following the warning did not require significant effort), when others modeled the safety behavior, 246

when the warning is made explicit, when people feel threatened by potentially serious injury, when people have had prior experience with injury due to the hazard, and when warnings are consistent with people's beliefs. Features of warning designs studied in research include the readability of warnings, letter size, font type, location, color, format, word message content, and symbols (pictographs). Four design elements appear to be crucial: (1) identification of the hazard, (2) the level of the hazard, (3) consequences of not avoiding the hazard, and (4) how to avoid the hazard. In some studies, providing warnings at the beginning of safety instructions was effective in increasing compliance, as was increasing the salience and size of the sign, adding color, and providing a pictograph. The Hathaway & Dingus article listed below examines the effects of compliance costs and explicit consequences information on the use of safety equipment.

Sources: Hathaway, J.A., & Dingus, T.A. (1992). The effects of compliance cost and specific consequence information on the use of safety equipment. Accident Analysis & Prevention, 24, 1-7.

McCarthy, R.L., Finnegan, J.P., Krumm-Scott, S., & McCarthy, G.E. (1984). Product information presentation, user behavior, and safety. Proceedings of the Human Factors Society 28th Annual meeting. Santa Monica, CA.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Your Weight Control Patterns. Have students review Handout #1: Your Weight Control Patterns. Since some students may feel uncomfortable responding to these questions, classroom discussion might focus on whether such direct questions would be likely to produce genuine responses. In particular, do some students find the classification ratings alarming?

2. Exercise energy expenditure. On handout # 2 is a list of average energy expenditure in various activities in kcal/min. Have the students calculate how much energy they use in their weekly exercise. What variables account for differences in the amount of energy used?

3. Kilocalorie activity. Handout # 3 contains an exercise for calculating average kilocalories expended during a day's activities. After students have completed the handout, have them compare their energy expenditure to the following averages for individuals of different ages. Have students consider different ways they could adjust their kilocalorie expenditure.

Age (in years) Gender Male Female

17-19 44 35

20-29 40 35

30-39 38 3331

40-49 37 30

50-59 36 29

60-69 34

4. Food Diary. Have the students keep a record of everything they eat in a day. Using a book of calorie values (e.g., Nutritive Value of Foods, Home and Garden Bulletin no. 72, published by the Department of Agriculture, online at: www.nal.usda.gov/fnic/foodcomp/Data/HG72/hg72_2002.pdf) or an online calorie counter, have students calculate the number of calories they consume each day. Instruct students to calculate the milligrams of cholesterol and sodium consumed. How does their consumption compare to the average American diet of 450 mg. of cholesterol per day? How does their daily intake of sodium compare with the "safe and adequate" range of 1,100 to 3,300? What percentage of their diets is composed of fats? What is the recommended percentage? This exercise is useful in illustrating possible problem areas in students' diets. It is also useful in illustrating the difficulty in accurately recording and estimating caloric intake. Information about food diaries and a sample diary can be found at: http://familydoctor.org/299.xml There are also numerous online food diaries such as: http://www.nutrawatch.com/

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5. Food Standards. The order of ingredients listed on a food label may indicate dramatic differences in the proportions of the ingredients. Download a copy of the United States Department of Agriculture's Standards and Labeling Policy Book from: http://www.fsis.usda.gov/OPPDE/larc/Policies/PolicyBook.pdf 6. Body Mass Index. Have students calculate their BMI using the formula given on page 211 of the textbook. Pass out copies of the Metropolitan Life Insurance height and weight charts. The updated 1983 charts can be found at: http://www.halls.md/idealweight/met.htm , or on page 211 of the Sarafino textbook.

7. Eating Disorders. There are usually a number of professionals in the local community (or a nearby community) who specialize in the treatment of eating disorders.

Ask one of these clinicians to come to class to talk about his or her clinical practice and experiences.

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Handout #1

Assess Yourself: Your Weight Control Patterns For each of the following questions, place a check mark if your answer is yes. ___

1. Do you watch your calorie intake more carefully than anyone else you know?

___

2. Do you weigh less than the "desirable weight” range for your height and frame given in Table 8.3 on page 217?

___

3. Do you think gaining a few pounds during a holiday season would be a terrible thing?

___

4. Have you ever eaten so much so quickly that you felt like you lost control of your eating?

___

5. If yes, has this happened more than about 10 times in the past year?

___

6. Have you ever eaten a lot and then tried to "purge" the food by using laxatives, diuretics, or self-induced vomiting?

___

7. If yes, has this happened more than about 10 times in the past year?

___

8. Have you felt a lot of emotional distress in recent months?

___

9. Do you often eat fewer than two meals a day?

___

10. Do you regularly exercise more than 10 hours a week to lose weight?

___

Total "yes" responses.

A high number suggests that you may be at risk for an eating disorder. If your total “yes” responses are between 3 - 5, you may want to consider getting professional help, especially if your situation seems to be getting worse. If your total “yes” responses are 6 or more, you should seek help right away. You can find help through your college's counseling office or by contacting The National Eating Disorders Association, American Psychological Association, or the American Psychiatric Association.

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Handout #2

Exercise energy expenditure (kcal/min) Weight (lbs) Activity Basketball Circuit training Climbing hills With no load With 22 lb. pack Cycling Leisure Racing Dancing Ballroom Choreographed Football Golf Running 9 min/mile 8 min/mile 7 min/mile 6 min/mile Swimming Crawl, fast Crawl, slow Tennis Walking

110

150

190

6.9 9.3

9.4 12.6

11.9 15.9

6.1 7.0

8.2 9.5

10.4 12.0

5.9 8.5

8.0 11.5

10.1 14.5

2.6 8.4 6.6 4.3

3.5 11.4 9.0 5.8

4.4 14.4 11.4 7.3

9.7 10.8 12.2 13.9

13.1 14.2 15.6 17.3

16.6 17.7 19.1 20.8

7.8 6.4 5.5 4.0

11.0 10.6 7.4 5.4

13.9 13.4 9.4 6.9

Weekly energy expenditure: ________

Source: Matarazzo, J.D., Weiss, S.M., Hord, J.A., Miller, N.E., & Weiss, S.M. (1984). Behavioral Health . New York: J. Wiley & Sons. Reprinted by permission of J. Wiley & Sons, Inc.

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Handout #3

Energy Expenditure 1. Add up all the hours of sleep and naps you had yesterday.

2. Multiply the total number hours of sleep and naps (line 1) by 1.

_____ (x1)

3. Add up the total number of hours spent in moderate activity.

4. Multiply the hours spent in moderate activity (line 3) by 4.

_____ _____

(x4)

5. Add up the total number of hours spent in hard activity.

_____ _____

6. Multiply the hours spent in hard activity (line 5) by 6.

(x6)

_____

7. Add up the total number of hours spent in very hard activity.

_____

8. Multiply the hours spent in very hard activity (line 7) by 10.

(x10) _____

9. Add up the figures in lines 1, 3, 5, and 7.

10. Hours spent in light activity is equal to 24 hours minus the hours in lines 1,3,5,& 7.

11. Multiply the figure in line 10 by 1.5.

(1 + 3 + 5 +7) =

_____

24 - (1 + 3 + 5 + 7) =

_____

(x15) _____

12. Add up the figures in lines 2, 4, 6, 8 & 11.

(2 + 4 + 6 + 8 + 11) = _____ This figure is the total kilocalories per kilogram of body weight expended per day.

13. To calculate the total number of calories you expended in one day, multiply your total body weight in kilograms (weight in pounds divided by 2.2046 = weight in kilograms) by the figure in line 12. __________ x __________ = __________________ Body wt. (kg) line 12 total calories expended

Source: Matarazzo, J.D., Weiss, S.M., Hord, J.A., Miller, N.E., & Weiss, S.M. (1984). Behavioral Health. New York: J. Wiley & Sons. Reprinted by permission of J. Wiley & Sons, Inc.

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RESOURCES Suggested Readings: Nutrition Anderson, E.S., Winett, R.A., & Wojcik, J.R. (2000). Social-cognitive determinants of nutrition behavior among supermarket food shoppers: A structural equation analysis. Health Psychology, 19(5), 479-486.

Bryant, C.A. (1985). The cultural feast: An introduction to food and society. St.Paul: West.

Kumanyika, S.K., VanHorn, L., Bowen, D., Perri, M.G., Rolls, B.J., Czajkowski, S.M., & Schron, E. (2000). Maintenance of dietary behavior change. Health Psychology, 19(1), 42-56.

Logue, A.W. (1991). The Psychology of Eating and Drinking. New York: W.H. Freeman.

Lowe, M.R. (1993). The effects of dieting on eating behavior: A three-factor model.

Psychological Bulletin, 114, 100-121.

McIntosh, E.N. (1999). American food habits in historical perspective. New York: Praeger.

Messina, M., & Messina, V. (1996). The dietitian's guide to vegetarian diets: Issues and applications. Gaithersburg, MD: Aspen.

Mintz, S. W. (1996). Tasting food, tasting freedom: Excursions into eating, culture, Steptoe, A., Perkins-Porras, l., Rink, E., Hilton, S., & Cappuccio, F.P. (2004).

Psychological and Social Predictors of Changes in Fruit and Vegetable Consumption Over 12 Months Following Behavioral and Nutrition Education Counseling. Health Psychology, 23(6) 574-581.

United States Department of Agriculture. (1996). The food guide pyramid.

Washington, DC: author.and the past. Boston: Beacon Press.

Weight Control and Diet Alexander-Mott, L., & Lumsden, D.B. (1994). Understanding eating disorders: Anorexia nervosa, bulimia nervosa, and obesity. Washington, DC: Taylor & Francis.

Andersen, A.E. (Ed.) (1990). Males with eating disorders. New York: Brunner/Mazel.

Claude-Pierre, P. (1997). The secret language of eating disorders: The revoluntionary new approach to understanding and curing anorexia and bulimia. New York: Times Books.

Greeno, C.G., & Wing, R.P. (1994). Stress-induced eating. Psychological Bulletin, 115, 444-464.

Immel, M.H. (Ed.) (1999). Eating disorders. San Diego: Greenhaven Press.

Jeffery, R.W., Drewnowski, A., Epstein, L.H., Stunkard, A.J., Wilson, G.T., Wing, R.R., & Hill, D.R. (2000). Long-term maintanence of weight loss: Current status.

Health Psychology, 19(1),5-16.

Manton, C. (1999). Fed up: Women and food in America. Westport,CT: Bergin & Garvey.

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Robert-McComb, J.J. (2001). Eating disorders in women and children: Prevention, stress management, and treatment. Boca Raton, FL: CRC Press.

Shah, M., & Jeffery, R.W. (1991). Is obesity due to overeating and inactivity, or to a defective metabolic rate? A review. Annals of Behavioral Medicine, 13, 73-81.

Exercise Allen, M., & Moss, J. (2000). Workouts for working people: How you can get in great shape while staying employed. New York: Villard.

Biddle, S.J.H., & Mutrie, N. (2001). Psychology of physical activity: Determinants, well-being, and interventions. London: Routledge.

Dishman, R.K. (1994). Advances in exercise adherence. Champaign, IL: Human Kinetics.

Griffin, J.C. (1998). Client-centered exercise prescription. Champaign, IL: Human Kinetics.

Hayes, K. (2002). Tone your body tone your mood: The workout therapy workbook.

Oakland, CA: New Harbinger Publications.

Hoeger, W.W.K., & Hoeger, S.A. (1996). Fitness & wellness. Englewood, CO: Morton.

McAuley, E., Talbot, H., & Martinez, S. (1999). Manipulating self-efficacy in the exercise environment in women: Influences on affective responses. Health Psychology, 18(3), 288-294.

Powers, S.K., & Dodd, S.L. (1999). Total fitness: Exercise, nutrition, and wellness.

Boston: Allyn and Bacon.

Prentice, W.E. (1996). Get fit stay fit. St. Louis: Mosby.

Sallis, J.F., Prochaska, J.J., Taylor, W.C., Hill, J.O., & Geraci, J.C. (1999). Correlates of physical activity in a national sample of girls and boys in grades 4 through 12.

Health Psychology, 18(4), 410-415.

Seraganian, P. (1993). Exercise psychology: The influence of physical exercise on psychological processes. New York: Wiley.

Safety Barling, J., Frone, M.R. (2004). The psychology of workplace safety. Washington, D.C.: American Psychological Association.

Christoffel, T., & Gallaher, S.S. (1999). Injury prevention and public health: Practical knowledge, skills, and strategies. Gaithersburg, MD: Aspen.

Education Development Center. (1991). Preventing injuries. Newton, MA: author.

Quick, J.C., Tetrick, L.E. (2003). Handbook of occupational health psychology.

Washington, D.C.: American Psychological Association.

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Suggested Films and Videos: Nutrition 1. Applied nutrition. (Edudex, 30 min). Experts discuss and analyze the nutrition and lifestyle changes for three people.

2. Beyond nutrition: Eating for health. (1999, Edudex, 22 min). Explores the positive effects of good eating habits.

3. Cholesterol watch. (1993, Great Performance, Inc., 71 min). Provides information about how to avoid high cholesterol diets when shopping, planning menus, and dining out.

4. Diet and health: Cardiovascular disease. (Edudex, 30 min). The role of nutrition, lifestyle, and heredity in CHD are covered.

5. How to read the food label. (2000, Edudex, 15 min). Explains nutritional information found on food packaging.

Weight Control and Diet 6. Dying to be thin. (1995, Films for the Humanities & Sciences, 28 min). Follows a young woman through hospitalizations and outpatient therapy as she lives with anorexia.

7. Fat chance in a thin world. (1995, Ambrose Video Publishing, 57 min). A good film that reviews the biological, psychological, and social aspects of weight.

8. Frontline: Diet Wars. (2004, PBS Video, 60 min). Compares the latest dieting trends and the marketing behind them.

9. Eating disorders. (2000, Edudex, 28 min). Profiles four people who have had eating disorders.

10. Eating for life. (2000, Edudex, 24 min). Program includes common sense diet guidelines.

11. Killing us softly 3: Advertising's image of women. (Media Education Foundation, 34 minutes). Jean Kilbourne discusses the beauty ideal for women as portrayed in the media.

12. Recovering bodies: Overcoming eating disorders. (Media Education Foundation, 34 min). Useful information about recovery and healing strategies for eating disorders.

Follows the lives of seven college women.

13. Scientific American Frontiers: Losing It. (2004, PBS Video, 60 min). A look at the problems encountered by individuals trying to lose weight and keep it off.

14. Slim hopes: Advertising and the obsession with thinness. (1995, Media Education Foundation, 30 min). Explores manner in which women are portrayed by the media and the impact this has on girls and women offering a new way to think about anorexia and bulimia.

15. The discovery of Dawn. (1996, NEWIST, 30 min). Documents causes, symptoms, and effects of eating disorders.

16. Weight Watchers: before and after. (2001, New Video, 50 min) Biography of the success of Jean Nidetch in losing weight and starting a successful weight-loss program.

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Exercise 17. Physical fitness: Working it out. (2000, Edudex, 30 min). The health benefits of regular exercise are documented.

18. Physical fitness & wellness. (1995, CNN, 73 min). Covers many aspects of health and physical fitness including developing a lifetime fitness program.

19. Ten reasons to get fit and stay fit. (2001, Edudex, 25 min). A visit to a kinesiology lab and tips for sticking to fitness programs.

20. The new you: Exercise. (2000, Edudex, 15 min). A noted nutritionist describes the benefits of exercise. A teacher's guide is available.

Safety 21. Consumer concerns and food safety. (Edudex, 30 min). Looks at use of pesticides and alternative growing methods.

22. Health hazards: What you don't know. (2000, Edudex, 30 min). Looks at environmental hazards in home, workplace, and community.

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Internet sites of interest: Diet and Weight loss 1. http://www.jennycraig.com/ - Jenny Craig weight loss programs 2. http://www.nutrisystem.com/ - Nutrisystem's online weight loss program 3. http://www.thin4lifeusa.com/ - Herbalife website 4. http://www.eatright.org/Public/ - American Dietetic Association 5. http://www.dietition.com - ask the dietitian website 6. http://www.cnn.com/HEALTH/ - CNN food & health news.

7. http://www.vrg.org/ - The Vegetarian Resource Group website 8. http://www.myfit.ca - fitness, nutrition, and exercise website.

9. http://www.something-fishy.com/ - eating disorders website.

Exercise and Fitness 10. http://www.health.com/health - Health Magazine online 11. http://www.acefitness.org/ - American Council on Exercise website 12. http://spot.colorado.edu/~collinsj/ - website with many links regarding sport and exercise psychology 13. http://www.psyc.unt.edu/apadiv47/ - APA Division 47 - Exercise and Sport Psychology website 14. http://www.usda.gov/ - United States Department of Agriculture 15. http://www.health-fitness-tips.com/ - website for health and fitness.

16. http://www.physsportsmed.com - Physician and Sports medicine website.

Safety 17. http://www.syndistar.com/browse/safety - Syndistar's health & safety website 18. http://www.nsc.org/ - National Safety Council 19. http://www.nhtsa.dot.gov/ - National Highway Traffic Safety Administration

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TEST QUESTIONS True or False F

1.

Fiber is a nutrient used in metabolism.

2.

High density lipoproteins (HDL) are associated with a decreased likelihood

(211)

T of

the build-up of fatty plaque in blood vessels.

(213)

T

3.

Doug eats animal meats at every meal, whereas Susan eats a diet rich in fruits, fiber and vegetables. Considering their eating patterns, it is likely that Susan is at a lower risk for cancer than is Doug.

4.

Karl who was overweight as a child and adolescent is equally likely to be an obese adult as his wife Nancy, who was trim in her youth but gained weight during pregnancy.

5.

Individuals who lose weight and regain it will find it easier to subsequently lose weight again.

6.

Anorexia nervosa is characterized by binge eating followed by purging.

7.

Continuous exercise requiring high levels of oxygen is called aerobic exercise.

8.

The most common reason people give for not exercising is that they simply don't have the time.

9.

The total number of years lost from unintentional and intentional injuries combined is the same as the total number of years lost

(215)

F (220)

F (224)

F (229)

T (232)

T (235)

T (238)

from heart disease, cancer and stroke combined.

F (239)

10.

Driver education courses are the single most important factor in reducing traffic accidents.

258

Matching Match the following classification of food components (a-e) with an example or description listed in items 1-5: a. carbohydrates b. lipids c. proteins d. vitamins e. minerals e

1. Calcium and potassium

(211)

d (211)

2. Fruits and vegetables such as spinach, broccoli, cantaloupe or apricots contain beta-carotene which the body converts to one of these

b

3. Cholesterol

(210)

a

4. Glucose and lactose

(210)

c

5. Composed of amino acids

(210)

Match the following weight loss techniques (a-e) with their descriptions in items 6-10: a. Weight Watchers b. Scarsdale diet c. Behavioral techniques d. Bariatric surgery e. Worksite weight-loss programs e (225)

c

6. Plagued by high drop-out rates and producing small weight loss unless combined with competitions.

(225)

7. With the exception of medical treatments, some of the most effective methods for losing weight.

b

8. A fad diet

(225)

d

9. The most drastic medical treatment for obesity.

(227)

a (226)

10. A self-help approach that uses behavioral techniques, nutritional information, and group meetings.

259

Multiple Choice a (210)

c (210)

b (210)

d (211)

c (211)

b (211)

b (211)

1. Simple sugars are to _____ as amino acids are to _____: a. carbohydrates; proteins b. fats; vitamins c. proteins; fiber d. vitamins; minerals 2. Cholesterol and saturated and unsaturated fats are classified as a. carbohydrates. b. a special class of proteins. c. lipids d. fat-soluble vitamins 3. Amino acids are components of ____ that are responsible for _____. a. minerals; nerve transmission b. proteins; synthesis of new cell material c. lipids; providing energy d. vitamins; converting nutrients into energy 4. Calcium and iron are classified as a. inorganic proteins. b. amino acids. c. lipids. d. minerals.

5. Which of the following is not considered a nutrient? a. fats b. proteins c. fiber d. minerals 6. Amanda has just found out she is pregnant. She should do which of the following: a. Nothing. Her typical diet should be just fine. b. Take recommended supplements due to her greater need for all nutrients. c. Take more iron, but no other additional nutrients. d. Take more vitamins but less iron.

7. People can get all the nutrients and fiber they need a. only by taking vitamin supplements. b. by eating healthy diets. c. by eating only a vegetarian diet. d. by eating high protein diets.

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b (211)

d (211)

c (212)

d (212)

a (212)

c (213)

c (213)

8. Larry has decided to protect his health by taking large doses of vitamins A & D. This is a ___ idea since large amounts of these vitamins _____. a. good; have proven to be cures for some cancers b. bad; may harm the liver and kidneys c. good; are aphrodisiacs d. bad; are only excreted as waste 9. Who is most likely to be affected by food additives? a. People who are allergic to them. b. Everyone, since additives tend to be harmful to our health. c. Children. d. Both a and c.

10. Which cultural group avoids eating dietary fat the most? a. Americans b. Israelis c. Columbians d. Japanese 11. Which is NOT true of changes in the American diet since 1980? a. Consumption of red meat has decreased. b. Consumption of fish has increased. c. Consumption of fruits and vegetables has increased. d. Consumption of sugars has decreased.

12. Evidence indicates that a preference for sweet tastes is a. biological. b. learned. c. not present in most babies. d. present only in America children.

13. The main dietary contributor to atherosclerosis is a. salt. b. caffeine. c. cholesterol. d. fiber.

14. The type of lipoprotein associated with decreased cholesterol deposits in blood vessels is a. low-density (LDL) b. very low density (VLDL) c. high-density (HDL) d. very-high-density (VHDL)

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d (214)

b (215)

c (215)

c (215)

b (215)

d (214)

d (216)

15. Cholesterol level in the blood is influenced by a. diet. b. heredity. c. smoking. d. all of the above.

16. The dietary substance most strongly associated with hypertension is a. cholesterol. b. sodium. c. caffeine. d. fiber.

17. Which one of the following people is most likely to experience hypertension and coronary heart disease? a. Joseph, who drinks no coffee. b. Frederick, who drinks only decaffeinated coffee. c. Michael, who drinks 3 cups of coffee each morning. d. None of the above.

18. High fat and low fiber diets are particularly associated with cancer of the a. liver b. colon c. throat d. stomach 19. Early studies found that diets rich in _____ are associated with lower cancer risk. This finding is not _____. a. fat; supported b. beta-carotene; definitive c. lipids; supported d. sodium; definitive 20. How might an individual reduce his/her serum LDL levels? a. Use vegetable oils containing coconut or palm oil. b. Avoid polyunsaturated oils and consume only saturated fats. c. Eat more eggs at breakfast. d. Substitute monounsaturated fats for other fats in the diet.

21. Recent research with animals has shown that reducing caloric intake by 30% a. decreases metabolism. b. slows the aging process. c. increases longevity. d. all of the above.

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c (217)

c (217)

b (217)

d (217)

b (219)

c (219)

a (219)

22. In a study of overweight girls and boys, self-esteem levels a. were not affected by weight levels. b. went down for boys but not for girls over time. c. went down for both boys and girls but raised as boys got older. d. went down for girls but not for boys over time.

23. We tend to judge the desirability of our weight based on the criteria of: a. attractiveness and BMI. b. actual weight and BMI. c. attractiveness and healthfulness. d. stamina and body shape.

24. The body mass index (BMI) is used to a. measure an individual’s bulk or stockiness. b. determine whether a person is overly fat. c. determine an individual’s cholesterol levels. d. all of the above 25. People are classified as obese when their BMI exceeds _____. a. 10 b. 20 c. 25 d. 30 26. The common belief that "glandular problems" lead to obesity is true a. in most cases. b. in only a small percentage of people. c. only for males. d. only for females.

27. Which of the following statements regarding self-reported eating is not true? a. Underreporting is very common. b. Women are more inaccurate than men. c. Obese people report eating more than normal-weight people. d. Heavy and normal weight people may differ in the accuracy of their reports.

28. The theory that the body has a certain weight that it strives to maintain is called: a. set-point theory. b. restraint theory. c. equilibrium theory. d. maintenance theory.

263

d (220)

d (220)

d (220)

a (221)

a (220)

b (221)

29. The mechanism in the brain thought to control body weight is a. the medulla. b. the endocrine gland. c. the frontal lobe. d. none of the above.

30. High serum levels of insulin influence which of the following? a. Sensations of hunger. b. Pleasantness of sweet tastes. c. How much we eat. d. all of the above 31. Which of the following facts about fat cells are true? a. Their number increases mainly in childhood and adolescence. b. Their number can increase but not decrease. c. They are related to the body's set point. d. all of the above 32. Two people, one obese and the other normal weight, are at a dinner party where some very bad-tasting food has just been served. Who is likely to eat the most? a. The normal-weight person. b. The obese person. c. They will eat the same amounts of food. d. Neither is likely to eat anything.

33. Nan, a restrained eater, is upset that she didn't follow her diet today by having a sugary snack. Which of the following is she most likely to do according to the restraint theory? a. Overindulge since she's already "blown it". b. Stop eating once she realizes she violated her diet. c. Go for a jog to take her mind off her diet. d. Resolve to try harder in the future on her diet plan.

34. Which of the following statements about the relationship between weight and health is NOT true? a. Obesity is positively correlated with increasing risk for disease. b. A small ratio of waist to hip girth is associated with higher rates of disease. c. Compared to those who are sedentary, heavy people who are fit have lower risk for death and illness. d. Overweight and normal weight people rate their health the same.

264

d (222)

d (223)

c (225)

b (226)

c (226)

d (226)

35. Prevention programs for overweight should begin in childhood because: a. this is the best time to prevent the development of excess fat cells. b. children and adolescents who are obese are more likely to be obese as adults. c. children have an easier time exercising. d. both a and b.

36. Parents may help their children maintain a healthy weight by; a. encouraging regular exercise and discouraging TV viewing. b. monitoring their children’s BMI. c. controlling the types of food that are present in the home. d. all of the above.

37. Besides medical treatment, the most effective method(s) for losing weight is/are a. dieting. b. exercise. c. behavioral methods. d. yo-yo or crash diets.

38. Which of the following is NOT used in behavioral weight loss programs? a. Nutrition and exercise counseling. b. Liposuction. c. Stimulus control training. d. Altering the act of eating.

39. Bob has tried diet programs in the past but has had trouble maintaining his diet plan when he goes away on business trips and has to eat at restaurants. Which of the following is an example of how he could deal with this problem using problem-solving training? a. Not worrying about it. A few days off his diet is no big deal. b. Decide to fast during business trips. c. Asking the wait staff at the restaurant how foods are prepared and selecting low-calorie ingredients and preparation methods. d. Exercise more immediately prior to and following business trips.

40. Research on work-site weight-loss programs indicates that the most needed factor to ensure their success is a. proper nutrition information b. a strong aversive component c. use of self-monitoring d. motivational techniques such as weight-loss competitions

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d (227)

d (228)

d (229)

b (229)

c (231)

a (232)

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d

41. Very-low-calorie diets (VLCD's): a. are used mainly for those who are obese b. can have serious side effects, such as cardiac problems c. are used only when other approaches have failed d. all of the above 42. Uri has successfully completed a weight-loss program and now wants to make sure he is able to maintain his weight loss. Which of the following will aid him in his maintenance efforts? a. Continue his exercise regimen. b. Permanently eat a lower-calorie and fat diet. c. Use behavioral methods to avoid relapse situations. d. all of the above 43. Which of the following statements regarding anorexia nervosa is true? a. It is most common in females. b. It is marked by intense fears of becoming fat. c. It is characterized by a weight loss of at least 25%. d. all of the above 44. Which of the following statements regarding bulimia nervosa is NOT true? a. It is more prevalent than anorexia nervosa. b. Bulimics rarely think this eating pattern is abnormal. c. A person may exhibit some bulimic behaviors without being diagnosed as a bulimic. e. It has been recognized as a clinical syndrome since the 1970s.

45. Which of the following treatments for bulimia nervosa is most effective? a. Antidepressants b. Aversive techniques c. Cognitive/behavioral plus antidepressants d. Aversive plus behavioral contracting 46. Weight-lifting and push-ups are forms of _____ exercise. a. isotonic b. isometric c. isokinetic d. aerobic 47. Dancing can be a great form of ______ exercise. a. isotonic b. isometric c. aerobic d. isobaric 48. Which of the following is not a demonstrated effect of exercise?

266

(233)

d (235)

a. Weight loss. b. Enhanced self-esteem. c. Stress reduction. d. All of these are effects of exercise.

49. Which group does not tend to exercise frequently? a. People who believe they are susceptible to illness. b. Young adults. c. Members of the upper SES. d. Older people.

a 50. Which of the following factors is least likely to influence older adults' participation (235) in exercise? a. Their physical functioning. b. Exaggerated notions of risk of exercise. c. Limited previous involvement in exercise. d. Sedentary social role models. b (238)

b (238)

c (238)

51. An important factor in getting a person to start and stay with an exercise program is a. the convenience of the program. b. their readiness to begin a program. c. their physical ability. d. their knowledge about exercises and health.

52. The most frequent accidental fatalities involve a. domestic accidents. b. traffic accidents. c. air travel. d. fires.

53. When comparing the years lost due to unintentional and intentional injuries to years lost due to heart disease, cancer, and stroke, research finds: a. more years are lost due to disease than to injury. b. more years are lost due to injury than to disease. c. the years lost are similar. d. neither result in significant years lost.

a 54. Of the following, which strategy has been least effective in reducing traffic accidents?

(239) a. Driver training courses. b. Auto design changes. c. Highway marking changes. d. Raising the driving age.

267

c (238)

d (239)

d (240)

b (240)

a (240)

b (241)

55. Which of the following statements regarding the use of seat belts is true? a. Seat belt use is unrelated to traffic fatalities. b. Seat belt use has been unaffected by the passage of laws requiring them. c. After the passage of laws requiring them, seat belt use increased significantly. d. Only about 15% of drivers use their seat belts.

56. Before going on an afternoon hiking trip, fair-skinned Joel uses plenty of sunscreen on exposed areas of his body. The use of sunscreens a. may prevent premature aging of the skin and skin cancers. b. is recommended for exposure of over an hour. c. is recommended by dermatologists. d. all of the above 57. The odorless radioactive gas radon: a. may be reduced by properly ventilating basements b. enters the house from the ground c. may cause lung cancer d. all of the above 58. Exposure to asbestos is strongly connected to a. hypertension b. lung cancer c. heart disease d. brain damage 59. "Right to Know" laws require that a. Employers notify and train employees on the use of hazardous materials. b. Employees have the right to refuse handling hazardous materials. c. Communities have the right to inform only those who really need to know about the presence of dangerous hazards. d. Communities are freed from the requirement of informing inhabitants of the presence of dangerous hazards.

60. Exposure to carcinogenic substances a. invariably leads to cancer. b. is not usually dangerous in small or infrequent doses. c. no longer occurs in today’s environment. d. might be outweighed in risk by benefits.

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Short Answer Questions 1. Briefly describe the five components of food and explain their role in metabolism.

2. Your couch potato friend tells you that exercise is grossly overrated. Refute his armchair logic.

3. Explain the significance of "Right to Know" laws.

Essay Questions 1. Develop and elaborate an argument that supports the statement that weight is a biopsychosocial phenomenon.

2. You have just been hired to develop a successful weight reduction and exercise program for your company. Outline the basics of your plan.

3. Discuss the general trends in effective safety intervention programs.

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CHAPTER 9 USING HEALTH SERVICES CHAPTER OUTLINE I. Types of Health Services A. Specialized Functions of Practitioners 1. Nature of specialization a. medical care system consists of large numbers of physicians of various medical specialties i. as knowledge and skills grow and change, individual physicians can’t perform service of several specialties simultaneously with high degree of skill ii. as a result, patients are likely to receive care from multiple professionals 2. Advantage of a system organized by specialty a. allows patient to receive greatest level of expertise available for each aspect of treatment 3. Drawbacks a. lack of communication between specialists resulting in primary physician not having complete picture of case needs b. brief, impersonal contact with patient B. Office-Based and Inpatient Treatment 1. First contact with medical professional a. usually first meet with physician who may treat illness, refer to a specialist, or recommend hospitalization.

2. Hospital care a. most complex facilities in health care. i. generally used by patients with serious illness who require attention on continuous basis or require complex equipment or procedures ii. use array of sophisticated equipment and practitioners from many specialties. iii. provide care ranging from emergency care to prevention services. iv. may offer health promotion facilities v. may have specialized missions (e.g., caring for children or treating certain diseases such as cancer) 3. Nursing homes a. provide long-term and personal care. i. care given mostly to handicapped or frail elderly. ii. average size of facility is 100 bed home. iii. quality of care has been raised as a concern.

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4. Outpatient or home health care a. recent trend due to health care costs and technological advances. i. technology examples: pacemakers or insulin pumps ii. patients tend to begin care on inpatient basis, then are discharged for home care b. advantages i. less expensive ii. patient can be at home and potentially return to work/school c. disadvantages i. lack of caregivers in the home setting ii. lack of transportation to clinic C. The American Health Care System 1. Paying for medical care a. insurance plans through employers b. Medicare/Medicaid for the elderly and low-income c. Over 15% of Americans not insured i. people of color are more likely to be uninsured 2. Fee-for-service programs a. patients choose own physicians who must accept insurance plan payment amount b. insurance pays certain percentage of fees 3. Managed-care programs a. members' choice of physicians and services restricted although 70% of employed Americans opt for managed-care b. physicians given financial incentives for cost-saving behaviors i. may foster suboptimal care c. health-maintenance organization (HMO) is one type of managedcare plan i. member can receive services from any affiliated physician at little to no additional fee but have annual fee ii. physicians paid salary or by number of patients seen/services conducted d. preferred provider organizations (PPOs) negotiate discounted fees with specific physicians.

4. Comparison of quality of care from HMO, PPO and fee-for-service a. problems with assessing quality i. plans vary in policies and structures ii. research on PPO and fee-for-service has been quasiexperimental and on large, well-established HMOs (not newly developed programs) b. experiences of HMO patients i. more trouble getting in to see doctor when ill ii. less likely to be admitted to hospital and leave earlier iii. more preventive exams/procedures iv. face obstacles in treatment but care is comparable v. less satisfaction with care but more satisfaction with cost 269

5. Criticisms/concerns about HMOs a. consumer groups find substantial variation across plans and urge potential members to choose from plans carefully b. although consumer ratings are available, there is reason to question their value 6. General evaluation of American health care a. care is among finest in world b. system has flaws i. skyrocketing costs ii. not accessible to people without insurance iii. so complex and has so many managed care options, decisions can be intimidating D. Health Care Systems in Other Countries 1. National health insurance programs exist in Canada and most of European Union a. system less complicated than in the U.S. but still has excellent care 2. Systems vary in structure and financing a. insurance may be provided by government or employers b. physicians may be employed by government or are in private practice c. Canadian system as an example i. provides coverage for everyone, financed by payroll taxes ii. provinces pay citizens medical bills, determine own policies, and negotiate with medical association on fees that will be charged iii. physicians are employed privately iv. aside from usual medical care, system also covers prescription drugs, long-term care and mental health services 3. Compared to U.S., other systems far less expensive in terms of costs per citizen and percentage of gross domestic product spent on health care. a. problems i. funding shortages contribute to long waits and inability to get needed treatment II. Perceiving and Interpreting Symptoms A. Section Introduction 1. Information learned from experiences with illness a. symptoms accompany illness b. certain symptoms reliably signal certain illnesses c. some symptoms more serious than others d. when symptoms go away, you’re well

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B. Perceiving Symptoms 1. Perceiving symptoms is more complicated than simply perceiving internal sensations. a. people are not accurate in assessments of internal states and external symptoms b. perceiving symptoms vary across people and differ within the same person across time 2. Individual differences a. differences across people may be due to: i. simply having more symptoms ii. differing in experience of same symptom - evidence: pain research has found that almost all people have a uniform threshold for pain but differ in their tolerance of that pain iii. some people may notice the changes more quickly but may not be more accurate (i.e., overestimate the change) - internally focused people who seek treatment tend to have less severe illness and perceive recovery as slower 3. Competing environmental stimuli a. environments that contain a lot of sensory information or which are exciting are negatively related to symptom reporting.

4. Psychosocial influences a. role of cognitive factors demonstrated by impact of receiving placebo b. expectations influence symptom perception. i. example: misleading information regarding point in menstrual cycle affects symptoms reported c. Interaction of cognitive, social, and emotional factors is seen in medical student's disease and mass psychogenic illness. i. factors that contribute to these phenomena 1. vague, subjective nature of common physical symptoms 2. exaggeration of symptoms and their importance 3. modeling of reactions 4. feeling negative emotions such as stress 5. Gender and sociocultural differences a. women report discomfort at lower stimulus intensities and request termination of painful stimuli sooner than men i. explanation: sex hormones and sex-role beliefs b. people from different cultures differ in their reactions to and perceptions of illness symptoms. i. different cultural norms reinforce symptom experiences and symptom-reporting behavior.

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ii. examples: - Asian cultures report more physical symptoms with psychological bases - American pain patients report more impairment - African American heart attack patients’ symptoms less typical and delay getting treatment longer B. Interpreting and Responding to Symptoms 1. Prior experience with an illness may increase or decrease accuracy of interpretation of symptoms. a. symptoms may be interpreted as signs of stress 2. Commonsense models of illness are cognitive representations of illness developed through direct experience or from available information about illness a. models affect health behavior i. incorrect information may contribute to not adopting preventive behavior, seeking treatment, following medical advice, or adapting well psychologically b. components of models i. illness identity – name and symptoms of disease ii. causes and underlying pathology – how one gets the disease and physiological events that occur with it iii. time line – prognosis including how long it takes symptoms to occur and last iv. consequence – seriousness, effects, outcome of illness c. many types of information used in constructing model i. example: prevalence information – rare diseases seen as more serious 3. Conflict theory: fear/stress may interfere with rational decision making.

4. Lay referral systems may provide advice and interpretation of symptoms. a. Information given i. help in interpreting symptom ii. advice about seeking medical attention iii. recommended remedies iv. advice on consulting another in lay referral network who has experience with the symptom III. Using and Misusing Health Services A. Section Introduction 1. Pharmacists are frequently the first "medical" contact for many people a. may recommend over-the-counter medications or seeing a physician if condition doesn’t improve 2. Although people generally try to avoid having to see physician, physician contact averages six per year per person

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3. Reasons for contact with a physician a. acute conditions i. examples: flu, common cold, fractures or dislocations, sprains or strains, wounds, and ear infections b. chronic conditions i. examples: hypertension, orthopedic problems, arthritis, diabetes, asthma and heart disease B. Who Uses Health Services?

1. Age and gender a. age i. young children and elderly use services more frequently b. gender i. more women than men see physician. ii. possible explanations 1. higher actual frequency of symptoms.

2. less hesitancy to admit symptoms.

3. socialization of gender roles.

2. Sociocultural factors in using health services a. surveys on usage rates conclude that: i. usage increases with income ii. low income persons more likely to use outpatient clinics and emergency rooms for care, probably because they’re less likely to have regular physician iii. although SES gap in usage still exists, this has declined since Medicare/Medicaid were introduced b. because patients must cover costs not covered by insurance or may not have insurance at all, low income influences using health services i. low income related to: - greater frequency of illness and longer hospital stays - less knowledge about and seeking prevention care - poor access to health counseling services - lower beliefs in susceptible to illness - feeling less welcomed by health care professionals - experiencing language barriers c. distinguishing users from nonusers. i. users - children, women, elderly from upper SES. ii. nonusers - lower SES, minority, males in adolescence and early adulthood.

C. Why People Use, Don't Use, and Delay Using Health Services 1. Ideas, beliefs, and using health services a. concerns about iatrogenic conditions, health problems that result from treatment errors or side effects, deter some from seeking treatment.

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b. patients may not trust practitioners, worry about confidentiality, or fear discrimination.

2. The health belief model and seeking medical care a. symptoms initiate decision-making about seeking care. i. threat perception of the symptom is a function of: - cues to action – symptoms, advice, information from media - perceived susceptibility – likelihood of contracting illness - perceived seriousness – physical and social consequences of illness ii. sum of perceived benefits and perceived barriers combine to determine likelihood of seeking care. b. support for model suggests a weak relationship; therefore, other factors are probably important determinants in seeking health care.

3. Social and emotional factors and seeking medical care a. emotional states such as anxiety , fear and expectation of pain and/or embarrassment may lead to avoidance of medical or dental care b. social factors i. seeing seeking help as a sign of weakness or a violation of social role contributes to delay ii. lay referral factors may contribute to help seeking - encouraging another to seek treatment may be a “social trigger” - example: sanctioning – asking/insisting that person have symptoms treated 4. Stages in delaying medical care a. treatment delay - time between noticing a symptom and seeking medical care. i. stages of treatment delay - appraisal delay - time to interpret symptom; affected most by sensory experience of symptom.

- illness delay - time between recognizing one's ill and deciding to seek care; affected by thoughts about symptom.

- utilization delay - time between deciding and actually seeking care; affected by perceptions of benefits/barriers. b. not having pain is a major factor in treatment delay, which is problematic since pain is not a symptom in many serious diseases c. advice: knowing symptoms of serious illness and realizing that some illnesses don’t have signs we often rely on is critical D. Using complementary and alternative medicine (CAM) 1. definitions: a. complementary: treatments used along with conventional medicine b. alternative: treatments used instead of conventional medicine 274

c. five types of CAM i. manipulative and body-based methods – maneuver or move parts of body (e.g., chiropractic and massage procedures) ii. biologically based methods – materials found in nature (e.g., herbal products and dietary supplements) iii. mind-body interventions – enhancing body’s ability to manage body function and symptoms (e.g., progressive muscle relaxation and meditation) iv. energy therapies – hypothesized or known physical energy fields believed to exist and surround body v. alternative medicine systems – medical system that differ from and often precede traditional Western medicine; tend to use preceding methods (e.g., Chinese medicine and homeopathy) d. characteristics of people who use alternative medicine methods i. most influenced by religious or cultural backgrounds that endorse these methods ii. in US, characteristics include - being well-educated - having beliefs consistent with method - having symptoms that haven't improved with use of conventional medicine. e. research on CAM i. surveys indicate most respondents satisfied with medical treatment and, if had used CAM, had gotten better results from medical treatments (improvements in only 10%-30% of cases, similar to placebo) - best CAM results were for chiropractic and deeptissue massage for back pain ii. problem with CAM methods is little to no scientific evidence of safety or effectiveness - if sufficient evidence has been found, they get incorporated into traditional treatment (e.g., dietary supplements, biofeedback, deep tissue massage, relaxation) E. Problematic Health Service Usage 1. What constitutes misuse

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a. overuse – often thought to be due to hypochondriasis i. hypochondriasis - excessive worry about health, monitoring body sensations and believing one is ill despite evidence or reassurances to the contrary. ii. evidence that somatic complaints increases with neuroticism. iii. Increased physical complaints in the elderly are generally connected to real problems, not hypochondriasis 2. Some medical complaints, that may look like misuse of services, simply may not be currently confirmed by medical community a. example: chronic fatigue syndrome i. once thought to be a form of mononucleosis, then inconsistent support for it being linked to psychiatric disorder.

IV. The Patient/Practitioner Relationship A. Patient Preferences for Participation in Medical Care 1. Patient/practitioner relationship depends on what patient wants and what practitioner provides 2. Patients differ in the degree they wish to participate in their medical care. a. most want to know about illness and how to treat it but some want more information 3. Factors associated with information/involvement needs a. gender – women want more information b. age - elderly less likely to seek information and more likely to prefer physicians to make health-related decisions made for them c. receiving desired amount and type of participation enhances adjustment and satisfaction d. level of active/inactive involvement predicts adjustment during and speed of recovery 4. Practitioner inclination toward patient participation a. may be less inclined to share authority and decision making b. may have incorrect belief that clients unable to understand medical information and make good decisions 5. Outcomes of mismatches in patient/physician beliefs about desire for participation a. may cause patients to: i. experience more stress ii. not follow doctor’s directions iii. switch doctors 6. Conclusion: physicians need to assess and consider what patient wants B. The Practitioner's Behavior and Style 1. Byrne and Long’s analyses of practitioners’ style of interaction a. general finding: physicians’ interaction style tend to remain consistent across all clients treated

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b. types of interaction i. doctor-centered interaction style - questions requiring brief answers - focus on initial problem while ignoring other issues - focused on the link between problem and organic cause ii. patient-centered interaction style i. open-ended questions ii. opportunities for client to introduce new facts iii. avoids medical jargon iv. allows patients to participate in decision-making 2. Use of medical jargon may create confusion, incorrect ideas, and dissatisfaction a. McKinlay’s research on patient understanding of terms a. results indicated that only 39% understood all 13 words in study i. notably, physicians expected even less comprehension than that b. reasons for use of jargon i. habit ii. belief that patient doesn't need to know iii. belief about what benefits patient/medical staff - reduces stress in patient - keeps interaction short iv. elevates status of physician 3. Preferred characteristics in physicians include competence, sensitivity, warmth, and concern a. characteristics are assessed by conversation and body language b. greater satisfaction ratings are given for physicians who give patients a chance to talk, take time to listen, give clear explanations, and project feeling of concern 4. Consequences of patient-centered behavioral style a. higher patient satisfaction ratings b. fewer appointment cancellations b. more significant diagnostic facts gained from their patients C. The Patient's Behavior and Style 1. Troublesome patient behavior a. Survey results from physicians indicate following patient behaviors are problematic i. expressing criticism of or anger toward physician ii. ignoring or not listening to advice iii. insisting on unnecessary tests, medications, or procedures iv. demanding inappropriate endorsement of disability claims v. sexual remarks or behaviors 2. Potential of malpractice makes physicians wary of patients and creates less job satisfaction 3. Other patient factors that interfere with patient-practitioner communications 277

a. high level of or lack of realistic communication regarding distress about health (e.g., neuroticism or not talking about worries at all) b. vague, misleading, or unclear description of symptoms, affected by patient’s i. degree of attention to internal symptoms ii. commonsense models of illness, which may lead to reporting only what they believe is important iii. emphasizing or downplaying symptoms believed to signs of serious illness iv. limited grammar (if young) or different primary language from physician 4. Ways to improve communication a. interview training programs for physicians b. symptom checklists/questionnaires before doctor visits 5. Low follow-up feedback to physician can lead to assumptions that diagnosis was correct, treatment effective, and regimen completed as designed V. Compliance: Adhering to Medical Advice A. Section Introduction 1. Adherence and compliance a. definition: degree to which patients carry out prescribed treatments and behaviors. b. “adherence” is considered more satisfactory term since ‘compliance” suggests a reluctant response to an authoritarian command B. Extent of the Nonadherence Problem 1. Difficulty with assessing rates of nonadherence a. failures to adhere occur for different types of medical advice b. advice may be violated in many different ways c. problems with how to assess nonadherence 2. Methods of assessing adherence a. physician estimates of adherence i. problem - practitioners don’t really know if patient is adhering; tend to overestimate compliance. b. patient self-report i. problem - patients tend overreport adherence due to lying or wishful thinking. ii. could be supplemented with verifying reports from family or objective methods.

- pill or quantity accounting.

- medication-recording dispensers.

- biochemical tests.

3. Adherence rate to medical advice is roughly 40% and 60% overall a. varies with type of medical advice, duration of regimen, and purpose of treatment.

278

b. adherence rates may overestimate due to motivation of people who agree to participate in studies and measurement insensitivity to forms of nonadherence.

C. Why Patients Do and Do Not Adhere to Medical Advice 1. Section Introduction a. degree of adherence affected by: i. characteristics of the illness or regimen ii. characteristics of the person iii. characteristics of the patient/physician interaction 2. Medical regimens and illness characteristics a. Factors that contribute to lower adherence rates i. attempts to change long-standing personal habits ii. complex regimen with complicated tasks iii. long-term regimen iv. unaffordable or too expensive costs v. noticeable or worrisome side effects of treatment vi. low perception of the seriousness of illness by the patient 3. Age, gender, and sociocultural factors a. combination (i.e., interaction) of personal and demographic characteristics are associated with adherence b. patient age affects adherence, depending on type of illness c. adolescents less likely than others to comply with long-term treatments that single them out d. vision, hearing, and cognitive impairments in elderly may contribute to noncompliance. d. gender-influenced appearance concerns and cultural beliefs regarding "cure" may lead to nonadherence 4. Psychosocial aspects of the patient a. personal beliefs outlined in health belief model i. threatened person who believes benefits of regimen outweighs costs is more likely to be adherent b. rational nonadherence i. noncompliance that is deliberate and based on valid reasons - believing the medication isn't working - finding side effects to be troublesome - confusion about regimen - lack of money to engage in regimen - testing for recurring presence of illness

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c. cognitive and emotional factors i. information contained in Table 9.2 - patients forget most of what doctor tells them, but instructions/advice are forgotten more than other information - more information patient is told, more patient forgets - patients remember: what told first; what they consider important - intelligence and age of patient doesn’t influence how much they remember - moderate anxiety is related to best recall - more medical knowledge related to better recall d. self-efficacy beliefs and social support (either family, friends, or selfhelp) influences adherence D. Patient/Practitioner Interactions 1. Svarstad's findings regarding adherence to treatment regimen a. patients' knowledge about their treatment is often incomplete b. physicians often do not provide detailed information c. patients ask few questions d. more explicit directions resulted in higher compliance 2. Adherence and the patient/practitioner relationship a. patients of patient-centered physicians are more likely to adhere to advice. i. patients' satisfaction with physician behavioral style is related to higher compliance.

E. Increasing Patient Adherence 1. Noncompliance and health outcomes a. hospital admissions higher for people who don’t follow regimen i. examples: higher mortality rates due to arrhythmia and kidney disease and HIV rebound. b. noncompliance is not always detrimental i. impact of noncompliance is greater for serious illness than less serious conditions ii. some treatments may result in iatrogenic conditions ii. some doctors may prescribe unnecessary medications c. compliance cut-off point for illnesses need to be established as perfect adherence may not be necessary 2. Improving physicians' communication skills a. first step to correcting nonadherence may be to thoroughly explain and repeat instructions regarding regimen b. teaching physicians about the problems associated with adhering a regimen may result in more time spent on giving information to patients

280

3. Methods for presenting medical information a. simplifying verbal instructions by using clear language b. using specific and concrete statements c. breaking down complicated or long-term regimen into smaller segments d. emphasizing key information e. using simple, written instructions f. having patients repeat instructions 4. Improving psychosocial factors in patients a. one effective approach may be to have patient state explicitly that he or she will comply to regimen. b. for long-term or lifestyle change regimen, recruiting family or group support systems can provide instrumental and emotional support. c. behavioral methods used to promote adherence i. tailoring the regimen to be compatible to patient's habits and rituals ii. providing prompts and reminders iii. self-monitoring iv. behavioral contracting d. Advantages of behavioral methods i. active involvement of patient in design and execution of regimen ii. regimen carried be self-administered VI. Focusing on Prevention A. Section Introduction 1. Chronic care model a. current approach used in health care systems that focus on secondary and tertiary prevention b. application of chronic care model may be possible for primary prevention programs i. six features of chronic care model that need to be incorporated: - organization of care: explicit, obvious priority given to primary prevention - clinical information systems: data regarding need for preventive services in files - delivery-system design: prevention interventions designed by physicians and carried out by nonphysicians - decision support: guidelines, training, reminders to staff to identify patients who need prevention interventions - self-management support: information and referrals to clients and families - community resources: extend prevention to community self-help programs 281

DISCUSSION TOPICS 1. Physician stereotypes about female health and illness.

Researchers analyzed 336 tape-recorded interviews between male doctors and their male or female patients. Both types of patients received a similar number of spontaneous explanations from the physician. The women asked more questions and in turn received more explanations than did men but not more time per explanation (i.e., the explanations were perfunctory). The doctors in the study reported that women's symptoms were more likely to be psychological in nature and they were more pessimistic about recovery. These authors suggest that physician stereotypes regarding women and women's health may interfere with patient-physician communication.

Source: Wallen, J., Waitzkin, H., & Stoeckle, J.D. (1979). Physician stereotypes about female health and illness: A study of patient's sex and the informative process during medical interviews. Women & Health, 4(2), 135-146.

2. Explaining illness.

Bryan Whaley’s edited volume is wholly concerned with how people understand the nature of illness. Much of his book covers understandings and communications of illness across different age groups and cultures. Chapters review the processes involved in explaining illness to patients with limited literacy, to older adults, and to children. A multicultural perspective is taken in chapters that focus on Native Americans, Latinos, Asian and Pacific Islanders, and African Americans. One interesting chapter addresses the pharmacists’ role in explaining illness and medicine to patients. This is a noteworthy discussion given Sarafino’s statement that many patients interact with health care professionals first at the pharmacy. Schommer notes the transition from the pharmacist as a dispenser of medicine to dispenser of information has been a slow movement. He discusses studies that reveal that the prevalence of pharmacist-patient communication is low; between 30-87% of patients received no verbal consultation in a 1992 study. This finding was in stark contrast to a 1989 study in which pharmacists ranked “counseling patients” as the most important pharmacy practice activity. Pharmacist’s attitude toward counseling patients influenced the likelihood of spending time in this professional activity.

Patients rated professional services given by a pharmacist as of less importance that those of the physician.

Source: Whaley, B.B. (2000). Explaining illness: Research, theory, and strategies. Mahwah, NJ: Lawrence Erlbaum.

3. Illness prototypes.

Bishop & Converse (1986) conducted two studies to investigate the extent to which people organize and recall information about physical symptoms using prototypical conceptions of disease. They base their research on the theoretical concepts of schema and prototypes. Specifically, they believed that symptoms were cognitively linked to 282

disease states and this linkage would affect whether the symptom indicates a particular disease. For example having teary eyes and nasal discharge would indicate the presence of hay fever, while chest pain may represent an impending heart attack. In their research, these authors manipulated a list of symptoms in terms of degree of prototypicality to various diseases and found that high prototype symptoms were significantly more likely to be labeled as indications of disease and recalled later. This research might be used as a starting point for a discussion on the role of symptoms in determining whether one is ill.

This discussion could be enriched by considering that some symptoms occur within the context of several diseases.

Source: Bishop, G.D., & Converse, S.A. (1986). Illness representations: A prototype approach.

Health Psychology, 5(2), 95-114.

4. Primary care for lesbian patients.

This article summarizes common concerns for lesbian patients and speaks to the importance of establishing a supportive, nonjudgmental doctor-patient relationship. In particular, the authors caution that clinical questions and clinic forms should be worded in such a way as to not build barriers to information gathering. For example, questions that assume intimate partnership or marital relationship with a male and the use of contraception should give way to new questions that inquire into the type of relationship an individual has and whether contraception is desired. Appropriate information brochures on STDs and HIV should be sensitive to lesbian sexual practices. The physician should be adequately knowledgeable and prepared to make referrals to local gay/lesbian support groups. Lastly, the issue of confidentiality regarding sexual orientation in medical charts needs to be addressed in a sensitive manner. Students may be aware of changes made in the information gathering sheets at their own physician's office or clinic and could discuss the necessity of this information in the medical setting.

Source: White, J., & Levinson, W. (2000). Primary care of lesbian patients. In Sample, C.J. (Ed.), Perspectives: Women's health. (pp.21-29). St.Paul: Coursewise Publishing.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Do you know medical terms' meanings? Have students complete Handout #1: Do you know the meanings of medical terms? This handout can be supplemented with your own list of medical terms that members of the class have encountered and found ambiguous or confusing. Were the terms used to communicate or obfuscate? If the latter, what were the circumstances of the exchange?

2. Medical Style. Have students complete Handout #2 and then discuss the "bedside manner" or style of their physicians. Classify them as either doctor-centered or patient-centered.

3. Health Care Protection. Have students consider their health care alternatives. For those who are employed, compare the options for health care available. Compare the relative benefits available, as well as the relative costs. Consider which of the available programs would be preferable under the following conditions. a. You are a single individual in good health. b. You have your own physician who you would like to use. c. You have a large family. d. You anticipate a major illness or hospitalization over the next year. e. You have a medical condition which requires frequent medical visits.

4. Alternative Treatment. Invite one or several practitioners of alternative medical treatment to class (e.g., massage therapist, Reiki healer, homeopathic healer, acupuncturist, herbalist, hypnotist). Ask them to describe the treatment they use, the philosophy behind the treatment, and the types of illnesses they treat. You might also ask them to speculate why people choose their treatment.

5. Failures of Today's Health Care System. Ask students to bring in articles, clipped from newspapers or magazines, on health care costs or failures of the health care system. Have volunteers present their articles, or have students make a bulletin board.

6. Communication with Health Care Professionals. Have students role play a situation in which a physician gives detailed instructions to a patient. (To make things easier for the "physician," have typed instructions available for various treatments.) Then, to demonstrate information transmittal and retention, have each member of the class jot down the instructions as they remember them after the role play is completed.

7. Adherence to Medical Procedures. Have students give personal examples with noncompliance with a prescribed medical regimen. Why did they not comply? Ask them to discuss what might improve their compliance to the regimen the next time.

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Handout #1

Assess Yourself: Do You Know the Meanings of Medical Terms?

Instructions: Match the terms with the definition given below. _____ antibiotic _____ breech _____ enamel _____ glucose _____ membrane _____ mucus _____ protein _____ purgative _____ suture _____ umbilicus

1. The rump or back part.

2. A small scare on the abdomen; the navel.

3. A substance that make up plant and animal tissue.

4. A simple sugar that the body manufactures from ingested food.

5. A joining together of separated tissue or bone, or a device to achieve this joining.

6. A sheet of tissue that covers or lines a body organ.

7. An agent that works against bacterial infections.

8. A hard, glossy coating or surface.

9. A substance or procedure that causes a cleansing of a body organ, as occurs in a bowel movement.

10. A secretion of body tissues.

Would you have known the definition if they hadn't been given to you? Would your friends – especially one who have not gone to college – know the terms?

285

Handout #2

Your doctor's medical style Consider for a moment your last visit with your physician. Of the techniques Sarafino describes, which of the following did the physician use?

_____ Used clear, straightforward language. _____ Used concrete statements. _____ Broke a complicated regimen into smaller segments. _____ Emphasized key information. _____ Used written instructions. _____ Had you repeat the instructions.

Use the following scale to rate your satisfaction with your last doctor's visit.

1 very satisfied

2

3

4

5

6

286

7 very dissatisfied

RESOURCES Suggested Readings: Types of Health Services Feldman, S. (2003). Managed behavioral health services: Perspectives and practice.

Springfield, IL: Charles C. Thomas.

Goldsmith, S.B. (1990). Choosing a nursing home. New York: Prentice Hall.

Konner, M. (1993). Medicine at the crossroads: The crisis in health care. New York: Panetheon Books.

Sahler, O.J., Carr, J.E. (2003). The behavioral sciences and healthcare. Ashland, OR: Hogrefe & Huber Publishers.

Salamon, M.J., Rosenthal, G. (1990). Home or nursing home: Making the right choices. New York: Springer Pub. Snook, I.D. (1992). Hospitals: What they are and how they work. Gaithersburg, MD: Aspen.

Stamm, B.H. (2003). Rural behavioral health care: An interdisciplinary guide. Washington, DC: American Psychological Association.

Perceiving and Interpreting Symptoms Ellington, L., & Wiebe, D.J. (1999). Neuroticism, symptom presentation, and medical decision making. Health Psychology, 18(6), 634-643.

Halpern-Felsher, B.L., Millstein, S.G., Ellen, J.M., Adler, N.E., Tschann, J.M., & Biehl, M. (2001). The role of behavioral experience in judging risk. Health Psychology, 20(2), 120-126.

Hanner, L. (1991). When you're sick and don't know why: Coping with your undiagnosed illness. Minnetonka, MN: DCI Pub. Reese, S.L., & Johnson, K. (1999). Staying strong: Reclaiming the wisdom of AfricanAmerican healing. New York: Whole Care.

Skelton, J.A., & Croyle, R.T. (Eds.) (1991). Mental representation in health and illness.

New York: Springer-Verlag.

Using and Misusing Health Services Gochman, D.S. (1990). Health Behavior. New York: Plenum Press.

Hummert, M.L., Nussbaum, J.F. (2001). Aging, communication, and health: Linking research and practice for successful aging. Mahwah, NJ: Lawrence Erlbaum Associates.

Weinstein, N.D. (2000). Perceived probability, perceived severity, and health-protective behavior. Health Psychology, 19(1), 65-74.

Wilcox, S., & Stefanick, M.L. (1999). Knowledge and perceived risk of major diseases in middle-aged and older women. Health Psychology, 18(4), 346-353.

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The Patient/Practitioner Relationship DiMatteo, M.R., Sherbourne, C.D., Hays, R.D., Ordway, L., Kravitz, R.L., McGlynn, E.A., Kaplan, S., & Rogers, W.H. (1993). Physicians' characteristics influence patients' adherence to medical treatments: Results from the medical outcomes study. Health Psychology, 12, 93-102.

Frank, R.G., McDaniel, S.H., Bray, J.H., et al. (2004). Primary care psychology.

Washington, DC: American Psychological Association.

Leigh, H., & Reiser, M.F. (1992). The patient: Biological, psychological, and social dimensions of medical practice. New York: Plenum.

Compliance: Adhering to Medical Advice Christensen, A.J., Moran, P.J., & Wiebe, J.S. (1999). Assessment of irrational health beliefs: Relation to health practices and medical regimen adherence. Health Psychology, 18(2), 169-176.

DiMatteo, M.R. (2004). Social support and patient adherence to medical treatment: A meta-analysis. Health Psychology, 23(2) 207-218.

Schwarzer, R., & Renner, B. (2000). Social-cognitive determinants of health behavior: Action self-efficacy and coping self-efficacy. Health Psychology, 19(5), 487-495.

Suggested Films and Videos: Types of Health Services 1. Alternative medicine. (1997, Edudex, 29 min). Explores the incorporation of alternative approaches into American society.

2. Alternative medicine: Expanding your horizons in healthcare choices. (1995, Aquarius Productions, 29 min). Reviews alternative or complementary health systems, such as naturopathy, homeopathy, Chinese & Indian medicine, and others.

3. America’s Struggling Healthcare System. (2003, Films for the Humanities and Sciences, 4 part series, 23 min each). The current state of healthcare in the U.S. and possibilities for a better solution.

4. Complementary medicine. (2000, Edudex, 25 min). Takes a look at a unique hospital program that incorporates complementary medicine.

5. Healthcare crisis: Who's at risk? (2000, Edudex, 56 min). Explores the human side of the health care crisis in America.

The Patient/Practitioner Relationship 6. Doctors using high technology. (1999, Edudex, 30 min). Covers recent advances in medicine.

7. Frontline: Dangerous Prescription. (2003, PBS Video, 60 min). A look at the FDA and individuals’ ability to understand the safety and risks of their prescriptions.

8. Medicine at the crossroads: Code of silence. (1993, WNET/BBC-TV, 57 min). Takes the viewer into the world of medical training, cross-cultural experiences with disease, and the patient interface with medical systems.

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9. Medicine at the crossroads: Temple of science. (1993, WNET/BBC-TV, 57 min). The world of the teaching hospital is highlighted using Johns Hopkins as an example.

Sophisticated technological successes and production of leading doctors/scientists are placed in contrast with primary care provision.

Internet sites of interest: 1. http://www.ivillagehealth.com/- resources for women’s health issues 2. http://www.pitt.edu/~ejb4/min/ - The Minority Health Network 3. http://www.amfoundation.org/ - website for the Alternative Medicine Foundation 4. http://www.ama-assn.org/ - American Medical Association website 5. http://www.usnews.com/usnews/health/hosptl/tophosp.htm - Best Hospitals ratings as of 2004 6. http://my.webmd.com - Web MD health site with medical information and tips on health and wellness 7. http://www.med.usf.edu/~kmbrown/Health_Belief_Model_Overview.htm - a website that reviews the Health Belief Model.

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TEST QUESTIONS True or False F

1.

In the United States, home health care has become popular only because of the cost of health procedures.

2.

Bert had some symptoms about which he was concerned. He asked his wife and co-workers about them and was urged to contact a doctor.

These people constituted a lay referral system.

3.

Although women contact their physicians more frequently (on average) than do men, this is due to the increased visits necessitated by pregnancy and childbirth. Taking pregnancy into account, the utilization rates of medical services are the same for the sexes.

4.

Lack of knowledge regarding prevention and personal beliefs about low susceptibility to illness have been shown to affect the use of health services in low-income people.

5.

Your friend, Tim, has to undergo painful back surgery. The Health Belief Model would predict that he will be reluctant about the surgery unless some definite improvement in his back pain was possible.

6.

Wayne has a rash on his leg and is trying to decide if he should get some over-the-counter ointment at the pharmacy or go to a dermatologist.

Wayne is experiencing illness delay.

7.

Patients rate physician characteristics such as sensitivity and warmth as more critical than physician competency levels.

8.

Practitioners tend to overestimate the degree to which patients comply with medical treatments.

(245)

T (251)

F (252)

T (253)

T (254)

T (255)

F (261)

T (264)

F 9.

In terms of the sheer amount of information physicians should give to patients, more (265) is generally better.

290

Matching Match the institution listed below with the descriptions in items 1-5. a. hospitals b. nursing homes c. home health care d. preferred provider organizations e. health maintenance organization b

1. provide care for individuals needing long-term medical and personal care

(245)

a

2. The most complex facilities in the health care system

(244)

d

3. A group insurance plan with negotiated fees for services

(246)

e

4. Involves prepaid medical services with a salaried physician

(246)

c (245)

5. A less expensive option than inpatient care for individuals with chronic illnesses

Match the following concepts with their descriptions in items 6-10: a. lay referral system b. health belief model c. commonsense model of illness d. treatment delay e. mass psychogenic illness b (254)

a

6. Perceived threat depends on perceived susceptibility and perceived seriousness

(251)

7. Help interpret a symptom, give advice about seeking medical attentions and recommend a remedy

d

8. Major factor is not having pain

(255)

e (249)

9. Widespread symptom perception among a large group of individuals with no confirmed medical basis for the symptom.

c

10. Ideas and expectations about illnesses developed through experience.

(251)

291

MULTIPLE CHOICE b (244)

a (244)

1. The chief advantage of a health care system organized into specialties is a. good patient-doctor communication b. patients receive the best expertise for each aspect of each problem c. lower expense d. faster delivery of services 2. The most complex facilities in the health-care system are a. hospitals b. nursing homes c. doctors' offices d. emergency clinics

a

3. Hospitals are to _____ as nursing homes are to _____.

(244-45) a. emergency care; long term care b. long term care; emergency care c. inpatient services; home health care services d. outpatient services; inpatient services d (245)

d (245)

c (246)

4. The shift from outpatient services occurred for which of the following reasons? a. Declining number of hospitals. b. Lack of quality health care in this country. c. An increasing number of healthy people. d. Rising costs of hospital and nursing home services.

5. Which of the following statements about outpatient services is true? a. Their use has been declining in recent years. b. Outpatient services are much more expensive than inpatient services due to their technology-intensive services. c. Outpatient services has had no effect on nursing home admissions. d. Technological advances have made outpatient services a possibility for more patients.

6. Research on health maintenance organizations (HMOs) and conventional private-practice health care has shown a. private practice care to be superior. b. HMOs provide superior care. c. patients using HMOs face major obstacles getting the treatment they need d. private-practice patients have more illnesses.

292

c (246)

d (246)

d (246)

d (246)

d (247)

c (248)

7. Which of the following statements is a finding of research on HMOs and private-practice care? a. Private-practice patients are more likely to visit their physician. b. HMO patients express more satisfaction with their physicians. c. Hospital admission rates are lower for HMO patients. d. HMOs provide a better quality of service than private-practice clinicians.

8. Marie's place of employment is enrolled in a managed-care plan in which she is encouraged to choose health care providers from a list of affiliated physicians and hospitals who offer their services at a discount to employees.

Marie's company is enrolled in a. a Medicaid program. b. a Medicare program. c. a home health care program d. a preferred provider organization 9. Compared to fee-for-service patients, HMO patients are more likely to a. be satisfied with the care they receive. b. be admitted to the hospital. c. face few obstacles to treatment. d. receive preventive examinations.

10. Which is a limitation of the American health care system? a. It is not accessible to all Americans. b. It offers too many managed-care alternatives, which confuses consumers. c. Health care is distributed unequally, even among those who are insured. d. All of the above are true.

11. Studies of the correlation between self-estimates and physiological measures of heart rate and nasal congestion show that a. people consistently detect only large changes in both. b. people accurately estimate heart rate but not nasal congestion. c. people accurately estimate nasal congestion but not heart rate. d. none of the above 12. Studies of heat and pain thresholds have shown that a. people feel pain at widely varying temperatures. b. heat does not cause pain. c. almost all individuals report pain at rather uniform temperatures. d. all individuals report pain at 30 C.

293

c (248)

c (248)

d (248)

d

13. Linda could be described as an internally-focused individual. Which of the following behavioral patterns would she be most likely to demonstrate? a. Reporting less pain than do other people. b. Being more accurate in her perception of internal body changes. c. Overestimating changes in her bodily functions. d. Reporting faster recovery from illness than do other people.

14. Which individual below is most likely to notice internal sensations such as pain? a. An Olympic athlete sprinting for the finish. b. A police officer in pursuit of a felon. c. A single person at home reading a boring textbook. d. All will notice internal sensations equally.

15. As part of a study on joint pain, Bill has received an inert substance to control his pain. Bill has received a _____ and his pain is likely to _____. a. analgesic; go down b. mild tranquilizer; go up c. mild tranquilizer; be unaffected d. placebo; go down 16. Which of the following demonstrates the effect of cognitive factors on symptom

(249) perception?

a. Research on premenstrual symptoms. b. Psychogenic illness. c. Medical student's disease. d. All of the above. c (249)

d (249)

17. A high school student fainted after eating the "mystery meat special" in the cafeteria. Upon witnessing this, thirty other students who had eaten the same thing subsequently fainted. Tests showed no harmful substances in the air or in the "mystery meat." These students were likely suffering from a. food poisoning. b. the placebo effect. c. psychogenic illness. d. conversion hysteria.

18. Which of the following is a contributor to psychogenic illness? a. Modeling. b. Stress. c. Emotional factors. d. All of the above.

294

b (249)

a (248)

a (251)

b (251)

a (251)

d (251)

19. When comparing disability from chronic low back pain in six different countries, in which country was the greatest impairment reported? a. Japan. b. United States of America. c. Italy. d. Mexico.

20. Janet's family has a history of breast cancer. When she notices a small lump in her breast, she attributes it to premenstrual symptoms. According to conflict theory, Janet may be engaging in a. hypervigilant coping. b. medical student's syndrome. c. psychogenic illness. d. Zola's denial.

21. Commonsense models involve all of the following components except: a. adherence b. illness identity c. causes and underlying pathology d. time line 22. Dwayne believes that he can tell by the feeling in his head when his blood pressure is high. He says the feeling goes away quickly if he takes his medicine but can last all night when he doesn't take his medicine. Dwayne is using a a. health regimen. b. commonsense model. c. medical technique. d. natural barometer.

23. Rare diseases are perceived as _______ than common ones. a. more serious b. less serious c. more likely to be genetically linked d. more prevalent 24. People with faulty commonsense models of illness are affected in which of the following ways? a. They may not seek appropriate treatment. b. They may not adjust well psychologically to an illness they develop. c. They may be less likely to follow doctor's advice. d. All of the above.

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25. Which of the following is NOT a function of a lay referral system? a. Help interpret symptoms. b. Perform minor medical procedures. c. Recommend remedies. d. Recommend consulting another lay referral person.

26. Before many people seek medical attention they seek advice from friends, relatives or coworkers. These individuals constitute a. an extended family. b. a lay referral system. c. a PPO d. an HMO. 27. Which of the following is NOT true regarding lay referral networks? a. The actions they recommend tend to be more accurate than physicians. b. Their recommendations are likely to make conditions worse. c. Their recommendations can lead to delay behaviors. d. Most people in the United States never rely on lay referral networks.

28. The first health professional with whom many people consult is a. a dentist. b. a chiropractor. c. a pharmacist. d. a member of their lay referral network.

29. Which of the following is NOT usually classified as an acute condition? a. Flu. b. Fractures. c. Arthritis. d. Sprains.

30. Which of the following is NOT usually classified as a chronic condition? a. Arthritis. b. Flu. c. Asthma. d. Diabetes.

31. Which age group is most likely to visit a physician for chronic disease treatment? a. the elderly b. adults of all ages c. children d. infants

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32. Which of the factors below is not correlated with the frequency of usage of health care services? a. Gender. b. Socioeconomic status. c. Income. d. All of these are correlates with health care usage 33. The difference in health care system usage between males and females a. may exist because of the hesitance of men to admit having symptoms. b. disappears if visits for pregnancy are controlled for. c. illustrates the poor health of females in general. d. demonstrates that males are healthier than females.

34. Social programs like Medicare and Medicaid a. help account for the increase in physician visits in the late 60's. b. were introduced in the mid-50's. c. are impediments to health care utilization. d. all of the above 35. The lower frequency of health care usage by the lower classes is accounted for partially by a. a lower incidence of disease. b. mistrust of the health care system. c. availability of a regular health care source. d. the high quality of physicians attracted to low-income regions.

36. Iatrogenic conditions are a. health problems as a result of medical treatment. b. present only if practitioners make mistakes. c. congenital heart defects. d. likely to affect the heart.

37. According to the health belief model, which of the following initiates a decision making process to seeking medical care? a. Perceiving benefits to be greater than costs. b. Perceiving costs and seriousness of disease to be significant. c. The presence of threatening symptoms. d. The availability of accessible health care.

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38. According to research, what is the role of emotions in seeking health care? a. They always increase the likelihood that a person seeks health care. b. individuals perceive diseases, such as cancer, to be so serious that they avoid seeking medical examinations out of extreme fear and anxiety c. Emotions tend not to impede seeking medical care. d. Fear is the single more important variable that prevents people from seeking medical care.

39. Expectations of pain a. keep 5% of Americans from visiting the dentist. b. often relate to reluctance to seek cancer care. c. are perceived as part of cancer. d. all of the above 40. Larry finally decides to go to the doctor about his persistent cough after about 2 weeks of steady prodding and encouragement by his wife and daughter.

His treatment has likely been triggered by a. sanctioning. b. interpersonal crisis. c. perceived interference. d. final incentives 41. The time a person takes to interpret a symptom as a sign of illness is called a. treatment delay. b. appraisal delay. c. illness delay. d. utilization delay.

42. The time taken after recognizing a sign of illness until deciding to seek medical attention is called a. treatment delay. b. appraisal delay. c. illness delay. d. utilization delay.

43. Researchers have found that a major non-illness life problem or event will tend to a. decrease total treatment delay of an illness. b. increase total treatment delay of an illness. c. decrease the likelihood of illness. d. increase impulse delay.

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44. The absence of pain is a major factor in treatment delay. A serious problem associated with this fact is a. it increases the ultimate cost of health care. b. pain is a major symptom of all diseases. c. pain is not a major symptom of many serious diseases. d. disease and pain are unrelated.

45. An accurate conclusion regarding the effectiveness of alternative medicines is that a. most physicians use them as frequently as they do prescription medications. b. some methods appear to have medical value. c. they have absolutely no value and shouldn't be used. d. there is an abundance of scientific evidence for their effectiveness.

46. Those exhibiting hypochondriasis tend to a. recognize real symptoms of illness. b. associate real but benign bodily sensations with illness. c. make up or imagine bodily sensations. d. neglect to use the health care system.

47. The condition known as chronic fatigue syndrome is a good example that a. if a medical test can't measure symptoms, the patient is probably hypochondriacal. b. some illnesses are purely psychosomatic. c. some medical problems simply can't be confirmed yet by medical tests. d. chronic fatigue syndrome is not a medically confirmed condition 48. Which patient will most likely adjust to their recovery better and recover faster? a. Luisa, whose doctor insists that she follow the prescribed regimen. b. Melba, who takes an active role in deciding about treatment. c. Alma, who prefers to let her physician make all the decisions. d. All will recover equally well and at the same rate.

49. Which of the behaviors is NOT associated with a "doctor-centered'' style of relating? a. Use of medical jargon. b. Focus on the first problem mentioned by the patient. c. Asking questions that require only brief answers. d. Open-ended questions.

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50. Perhaps the most important medical benefit of a more patient-centered approach is a. greater patient understanding. b. increased likelihood of healing. c. greater amounts of diagnostic information. d. decreased appointment cancellations.

51. Patients describe symptoms for the same health problem differently because a. they differ in the attention they pay to internal states. b. they may emphasize a symptom they believe reflects serious illness. c. they may downplay a symptom they believe reflects serious illness. d. all of the above 52. The dissatisfaction with the term "compliance" is a. that patients rarely follow recommendations anyway. b. its suggestion that patients reluctantly submit to physicians' authoritarian demands. c. not a common position in health psychology. d. only discussed in psychology and not in medicine.

53. Findings on medical adherence indicate that a. doctors overestimate adherence b. patients honestly report their adherence. c. overall adherence rate is 90%. d. adherence is very easy to measure.

54. Which of the following has research shown to play the smallest role in medical regimen noncompliance? a. Patient personality traits. b. Complexity of regimen. c. Duration of regimen. d. Illness severity as judged by patients.

55. Which group is most likely to take their medicine as prescribed? a. Adolescent diabetics. b. Female diabetics who are concerned with controlling their weight. c. Arthritic patients over age 55. d. Adolescents taking antibiotics.

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56. Which of the following is an example of rational nonadherence? a. Lindy, who stops her diet because she isn't losing weight. b. Vanessa, who stops buying her medicine because she doesn't have the money. c. Mike, who skips chemotherapy because it makes him so sick he doesn't feel he can spend quality days with his children. d. all of the above 57. Research on patient memory as related to their interactions with practitioners shows a. intelligent patients remember more than less intelligent ones. b. older patients remember less than younger ones. c. patients remember what they're told first. d. patients remember most of what their doctors say.

58. Research on medical consultations shows that about _______ of the time is spent giving information to the patient. a. 10% b. 25% c. 50% d. 65% 59. Which of the following statements best represents conclusions regarding the impact of nonadherence on health outcomes? a. Nonadherence has little to no impact on health outcomes. b. Nonadherence tends to make most medicine-taking schedules completely useless. c. The impact of nonadherence depends on the particular health problem and treatment prescribed. d. Studies of nonadherence have been inconclusive.

60. Which of the following is NOT a feature of a chronic care model? a. How care is organized. b. Having guidelines and training for identifying and carrying out treatment. c. Providing self-management support. d. Incorporating a lay referral network.

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Short Answer Questions 1. Compare and contrast inpatient treatment modalities.

2. Compare and contrast the US versus Canadian health care systems.

3. What factors in the practitioner-patient interaction relate to patient adherence to the practitioner’s advice?

Essay Questions 1. Imagine for a moment that your eye has been watering for the past 2 hours. What factors will determine if you go to the doctor?

2. Discuss how a person’s ideas about illness influence seeking medical care.

3. Newly hired by a health care clinic, what advice do you have for your boss regarding ways to increase adherence among the clinic’s patients?

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CHAPTER 10 IN THE HOSPITAL: THE SETTING, PROCEDURES AND EFFECTS ON PATIENTS CHAPTER OUTLINE I. The Hospital -- Its History, Setting and Procedures A. Section Introduction 1. Hospitals in industrialized countries are typically large institutions with separate wards/building for different kinds of health problems and treatment procedures.

2. Over history, hospitals have become a place to get well – not just place to die. b. How the Hospital Evolved 1. Special places to care for sick haven’t always existed. a. ancient Greeks had temples where sick could pray and receive advice. b. first special facilities for care attributed to Roman military who established separate barracks for ill and disabled soldiers 2. Institutions for care of sick from 18th through 20th century a. early Christian monasteries had a charitable function that cared for the sick, orphans, poor, and travelers in need b. during 18th and 19th centuries, hospitals became more specialized but with important changes: i. only cared for the "worthy" poor who, with care, could become contributing citizens ii. wards became established for different disease c. hospitals in the American colonies similar to those in Europe i. example: Pennsylvania Hospital was the first, opened in 1751 as a result of efforts by Benjamin Franklin d. early hospitals had bad reputation for poor care i. upper and middle classes were generally treated at home e. growth in number of hospitals in US went from 178 in 1873 to 4,3000 in 1909 i. growth due to advances in knowledge and technology ii. a more positive reputation resulted and patients from all social classes uses their care 3. Today's hospitals provide a wide variety of services including tests, rehabilitation, research, and teaching.

B. The Organization and Functioning of Hospitals 1. Hierarchical structure of organization a. board of trustees – top level of hierarchy consisting of business and professional people from the community whose function in long-range planning and fund-raising 303

b. hospital administrators – part of second tier of hierarchy whose function is controlling the day-to-day business functions of the hospital c. medical staff – charged with providing medical care to patients i. physicians - positions include medical director (Chief of Staff), attending (staff) physicians, residents (in teaching hospitals) - generally engaged in private practice that draws patients to the hospital where doctor has received admission privileges ii. nurses i. hospital employees who care for patients and manage the ward ii. frequently spend a great amount of time with the patients compared to physicians iii. allied health workers i. occupations include physical therapists, respiratory therapists, laboratory technicians, pharmacists, assistants, and dieticians ii. given less authority than nurses iv. lowest tier of hierarchy i. orderlies and maintenance workers C. Roles, Goals, and Communication 1. Section introduction a. actions and roles of members of medical staff are generally dictated by presenting health problems of patient i. in emergencies, quick assessment needed - usual procedures are known and roles performed without instruction.

- physician is in charge.

2. Coordinating patient care a. assessment and treatment require array of personnel with different specialties i. care may seem fragmented or uncoordinated. ii. may assign coordination to a particular staff position but direct communication is best.

3. Health hazards in hospitals a. exposure to chemicals or disease-causing microorganisms poses a risk for hospital personnel as well as patient.

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i. example: nosocomial infections, infections patient contracts while in hospital, are responsible for thousands of deaths annually b. regulations for hospital infection control have been established i. hospitals must have an Infection Control Committee led by epidemiologist ii. medical staff must include Infection Control Nurse (ICN) c. compliance with infection control procedures i. physicians were least likely to comply ii. ICNs more likely to correct personnel of equal or lower status iii. behavioral interventions to increase use of infection control procedures are effective but fade over time iv. ways to enable feedback and get staff from all levels of hierarchy to adhere are needed D. The Impact of the ''Bottom Line'' 1. Efforts to regulate medical costs a. introduction of Medicare i. initially made situation worse because it encouraged overcharging, longer hospital stay, and more tests. ii. now helps contain costs through its prospective-payment system - payment for treatment is predetermined by the "diagnosis-related groups" - if treatment cost exceeds DRG level, hospitals assume cost.

- if treatment cost is under DRG level, hospitals keep excess payment.

2. Changes in hospital procedures a. admission rates and length of stay have decreased i. more procedures done on outpatient basis ii. medical procedures are more efficient iii. patients are being discharged earlier b. changes have been made to create “home-like” atmosphere in hospitals II. Being Hospitalized A. Relations with the Hospital Staff 1. Social role of patient entering hospital a. dependent on the medical staff for their lives b. unfamiliar with hospital structure, procedures, and terminology

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2. Anxiety is most common and pervasive emotional state of hospitalized patient. a. basis of anxiety varies with stage of diagnosis i. diagnosis unknown: what is the illness, what outcomes will occur, will illness affect life ii. diagnosis known: what will treatment be like, will treatment be successful b. lack of information contributes to anxiety i. may be due to lack of time, deliberately withholding information, disguising information through jargon on part of medical staff ii. when information isn't given, patients may seek it from indirect sources which may lead to incorrect or misleading information.

- inaccurate beliefs contributes to nonadherence or emotional suffering.

3. Depersonalization or “nonperson” treatment a. treating the patient as if wasn't there or not a person. b. reasons for engaging in depersonalization i. practitioners want to distance themselves. ii. stress of the job requires physician protect self emotionally - hectic nature of job - heavy responsibilities 4. Psychosocial components of burnout among health care professionals: a. definition: psychosocial and physical exhaustion that results from chronic exposure to high levels of stress with little personal control b. psychosocial components of burnout i. emotional exhaustion - feeling of being drained ii. depersonalization - lack of personal regard for others and developing callous attitudes toward them iii. perceived inadequacy of professional accomplishment feeling of falling short of personal expectation for work performance c. research findings i. high levels of emotional exhaustion commonly reported ii. occupational differences reported on depersonalization and sense of accomplishment - nurses low on depersonalization and doctors low on lack of sense of accomplishment - differences due to sex differences in empathy, pay & status iii. more time spent in direct care of patients, greater the risk of emotional exhaustion

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d. what can be done to reduce burnout? i. provide opportunities to mix direct care with other types of tasks ii. establish support groups iii. provide training in stress management and coping methods B. Sick-role Behavior in the Hospital 1. For most people, entering the hospital presents an unfamiliar and strange environment that requires psychological and social adjustment. a. lack of privacy b. strict rules and time schedules c. having activities restricted d. having little control over events e. being dependent on others 2. People had prior ideas of how they should behave in the hospital. a. research finds that having active/passive sick-role beliefs predicts hospital behavior i. same research indicates medical staff have ideas regarding “good”, “average”, and “problem” patients - a “good” patient is cooperative, uncomplaining and stoical - a “problem” patient is uncooperative, complaining, overemotional and dependent. b. types of problem patients i. seriously ill patients with severe complications or poor prognosis who require a lot of attention.

- staff tends to forgive their behavior. ii. not seriously ill but take more time than is warranted by their illness.

- patient behavior may be due to reactance, a reaction to loss of freedoms and control - negative reactions from staff to this kind of “problem” patient include administering sedatives or arranging early discharge 3. Most patients try to be considerate to staff since they have difficult job. a. also try to be "good" patient so as not receive negative treatment as problem from medical staff.

III. Emotional Adjustment in the Hospital A. Section Introduction 1. Emotional reactions to hospitalization a. anxiety levels typically are high at admission and prior to operation but decline during next few weeks b. in some cases, anxiety may actually increase over time 2. Adjustment is a function of age, gender, and characteristics of illness a. young adults have more difficulty coping with serious illness 307

than older adults b. men more distressed by illness that interferes with physical abilities whereas women more distressed by disfigurement B. Coping processes in hospital patients 1. Section introduction a. goals of coping include altering the problem or regulating the emotional response b. problem-focused coping i. actions that reduce demand of stressor or expand resources for dealing with it c. emotion-focused coping i. more common when stressful conditions are believed uncontrollable and may include denial, distraction, seeking social support 2. Cognitive processes in coping a. attributions of blame i. blaming self or others is linked to poor adjustment ii. some studies find blame of others most strongly related to poor adjustment.

- sense of injustice may underlie blame. iii. additional aspects of research on blame - thinking patterns may be highly convoluted - research has been correlational b. beliefs of personal control i. patients expect some loss of personal control in hospital but hospital environment actually encourages beliefs that personal involvement is irrelevant - encourages "good" patient behavior which leads to state of helplessness and then depression.

3. Helping patients cope a. experiment on comments during full anesthesia i. positive comments by medical staff are linked to quicker recovery ii. importance of finding - negative comments are often made during surgery - it is possible to help patients with constructive statements during surgery b. providing psychological counseling i. study found brief counseling improved recovery and decreased depression & anxiety c. having a roommate i. rooming with a recovering similar roommate linked to less anxiety - assume that discussions/talking was associated with the lower anxiety - discussion with preoperative roommate may lead to 308

emotional contagion that exacerbates anxiety B. Preparing patients for stressful medical procedures 1. Why prepare for surgery? a. high preoperative anxiety and fear is linked to poor adjustment and recovery 2. Psychological preparation for surgery a. effective methods enhance sense of control b. types of control addressed in approaches i. behavioral control - performing actions such as special breathing techniques ii. cognitive control - focusing on benefits of medical procedures iii. informational control - gaining knowledge about events or sensations c. findings on effectiveness of control techniques i. preoperative psychological control techniques reduce anxiety and hypertension ii. information provided must be clear and straightforward and patients may need to discuss it with medical/psychological staff 3. Psychological preparation for nonsurgical procedures a. Some nonsurgical procedures are not painful but produce strange, frightening sensations b. Interventions to reduce anxiety i. cognitive and informational control reduces anxiety during cardiac catheterization ii. informational and behavioral control aided endoscopy patients - reduces emotional reaction and gagging 4. Coping styles and psychological preparation a. People differ in use of avoidance v. attention (vigilant) strategies b. Content and repetition of preparation needs to match coping strategies of patient. i. little information is related to greater stress in “monitors” whereas more information negatively affects “blunters” ii. viewing information more than once may be important for those who use avoidance

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C. When the Hospitalized Patient is a Child 1. Section introduction a. child’s level of psychosocial development make hospital experience difficult i. less able to influence or understand what is happening to them ii. at young ages, may feel abandoned or unloved iii. may believe they were put in hospital as punishment for misbehavior 2. Hospitalization in the early years of childhood a. sources of stress for young children i. immobilization or reduction in activity ii. separation distress - universally affects children most around 15 months old but tends to decline with age - involves stages of intense crying, calling and searching for parents followed by despair behaviors and anxious behaviors once back home iii. misconceptions about cause of illness and need for treatment in young children - hospitalization seen as a punishment for breaking rules; reinforced when parents make statements that link illness with breaking rules or threaten trip to doctor due to disobedience iv. seeing other patients with disfigurement 3. Hospitalized school-age children a. unlike younger children, children in this age group are better able to adjust to separation but still may have some misconceptions about illness b. difficult aspects in hospitalization at this age i. distressed by limited independence and influence in hospital ii. growing cognitive abilities allow them to think about and worry about outcomes of illness iii. separation from friends can lead to loneliness iv. may be embarrassed by exposing their bodies or needing assistance with “private” activities c. historically, children have been poorly prepared by parents for hospitalization but this is improving 4. Helping children cope with being hospitalized a. at admission i. better if parents are present - most hospitals now allow ''rooming-in'' by parent

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b. common preparation techniques i. involve leaflets, home discussions, puppets, training in coping skills and relaxation, video presentations of experiences and successful coping ii. research on effectiveness of video presentation found less anxiety before and after surgery and faster recovery; thus practice is cost-effective measure - some children become more anxious by preparation c. effects of presentation depend on child's age, coping style, and previous medical experience. i. age: young children need preparation right before procedure whereas older children can receive a few days before ii. prior experience: if prior experience was negative, preparation could increase anxiety iii. coping styles: children who use avoidance strategies may not benefit from preparation as much d. what hospitals are also doing to prepare children i. staff trained in working with children ii. having parent present for procedures iii. using distraction during procedures iv. arranging for play and entertainment IV. How Health Psychologists Assist Hospitalized Patients A. Section introduction 1. Health psychologists work with psychosocial problems that lead to and/or result from illness. a. take action to correct factors that produced the disease b. help clients and families cope with illness c. provide psychological counseling to reduce depression and pessimism 2. Expanded activities of health psychologists a. consulting with patient's specialists b. assessing client's needs for and providing preparation to cope c. help with adherence d. developing behavioral programs e. assist with rehabilitation processes B. Initial steps in helping 1. Most referrals for psychological services come from other medical professionals a. problematic since these professionals aren't trained to assess psychological needs of clients 2. Consultation involves interviewing referring medical staff, patient & family, chart review, and psychological testing

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C. Tests for psychological assessment of medical patients 1. Minnesota Multiphasic Personality Inventory a. psychological test developed to assess personalities that underlie psychiatric disorders b. scales relevant to health i. hypochondriasis - preoccupation with health ii. depression - feelings of unhappiness iii. hysteria - tendency to use avoidance strategies c. trends i. high scores on scales are linked to development of psychophysiological disorders ii. depression scores are linked to compliance d. drawbacks i. takes 1 1/2 hrs. to complete ii. measures other traits not relevant to treatment for medical issues 2. Specialized tests for medical patients a. The Millon Behavioral Health Inventory- assesses specific psychosocial factors and decision-making issues relevant for medical patients. i. information provided includes client’s coping style, negative health habits, stress moderators, reaction to illness, and prediction of problems with treatment regimen b. The Psychosocial Adjustment to Illness Scale - assesses seven psychosocial characteristics of life associated with adjustment to medical illness. i. characteristics measured: 1. health care orientation 2. vocational environment 3. domestic environment 4. sexual relationships 5. extended family relationships 6. social environment ii. studies have found that scale measures adjustment problems with serious illnesses accurately D. Promoting patient's health and adjustment 1. Following assessment, application of appropriate therapeutic techniques is necessary a. cognitive and behavioral methods are successful b. group discussion and cognitive behavioral methods may be helpful with psychosocial problems 2. Limitations include decline program effectiveness and relapse prevention over long periods of time 3. Health psychologists can enhance effectiveness by improving techniques and developing ways to work effectively with other medical professionals 312

V. When the Illness Is Terminal A. The patient’s age 1. Terminally Ill Child a. children under 5 think person will come back b. children 8 and older realize death is final c. terminally ill children should be informed of their illness 2. Terminally Ill Adolescent or Young Adult a. feelings of anger and emotional distress about dying young 3. Terminal illness in Middle-Aged and Older Adults a. elderly cope better with death than younger individuals B. Psychosocial adjustments to terminal illness 1. How people cope with terminal illness a. denial is principal mechanism used during terminal illness b. John Hinton and 3 stages of stress 2. Does adapting to dying happen in stages? a. Kubler-Ross and five stages C. Medical and psychological care of dying patients 1. The terminal phase of care begins when medical judgment indicates that the patient’s condition is worsening and no treatment is available a. palliative care focuses on reducing pain and discomfort 2. Medical staff and coping a. Individuals that work with terminally ill individuals may have trouble coping D. A place to die –Hospital, Home or Hospice?

1. Home care for the dying patient a. terminally ill people can receive very good care at home b. home care can be physically and emotionally exhausting for caregivers 2. Hospice care for the dying patient a. involves a medical and social support system b. can be delivered at home or inpatient facilities

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DISCUSSION TOPICS 1. Do clients get what they want?

Margaret Nelson conducted a study exploring clients’ choices during childbirth experiences. Birthing choices by expectant mothers are informed by hospital sponsored classes, personal reading, discussions with friends/family, personal prior experiences, and the ongoing socialization by medical personnel during prenatal visits.

Other factors, such as hospital standard operating procedures, medical emergencies, staff shortages, or a rapid labor may influence the eventual procedures that the patient receives. As a result, a discrepancy may emerge between what the patient wants and what occurs. Nelson notes that when a discrepancy occurs three outcomes are possible: (1) the client may back away from her original choice but maintain the belief in the right to choose, (2) the client may reconsider the right to make choices in the future or (3) the client may maintain the commitment to the early choice and right to make choices. Using a sample of 322 pregnant women, Nelson measured their choices regarding 7 procedures surrounding hospital childbirth (e.g., episiotomy, medication during labor, etc.), outcomes during the birthing experience as they pertain to these procedures, and intent regarding these procedures in future pregnancies. Findings indicate that not all patients made their own birthing choice; in other words, some allowed medical personnel to decide what needed to be done. Regardless of choice, there were few differences between those who choose a procedure and those who didn’t in whether the procedure was actually done. In fact, anywhere from 17% to 82% of women did not get what they wanted, depending on procedure. Nelson concluded that the assumption that patients are given more authority and choice may not be supported.

Source: Nelson, M.K. (1981). Client responses to a discrepancy between the care they want and the care they receive. Women & Health, 6(3/4), 135-152.

2. Humor in the hospital: Humor, described as an indirect mode of communication, finds its way into the health care setting. Although there are only a small number of studies addressing the use of humor in the hospital, Robinson contends that humor serves three valuable functions within the world of health and illness: a communication function, social function, and psychological function. Humor allows for the communication of difficult feelings surrounding health situations and serves as a vehicle for broaching difficult topics. Socially, humor provides an avenue for coping with the disrupted roles of daily life that occur when a person is ill. Robinson also describes humor as an equalizing force that decreases status and role distance between patient and physician. It aides in soothing social conflict (i.e., violations of social norms about the privacy of our bodies), promotes group solidarity by bringing people closer together, and restores a sense of social control to the patient. Psychological functions include anxiety/tension relief, an outlet for anger or hostility, denial, and coping with tragedy. This book provides a framework for understanding the research on humor and offers ways to cultivate the use of humor.

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Source: Robinson, V.M. (1991). Humor and the health professions: The therapeutic use of humor in health care. Thorofare, NJ: Slack Inc. 3. When the doctor becomes the patient.

Within a week of graduating from Harvard Medical School, Jody Heymann was in the hospital, not as an eager young resident but as a patient. While on a visit to friends, her husband awoke in the middle of the night to her tonic clonic seizure. Although both physicians, the first thing her husband had to do at the emergency room was complete insurance information and wait away from her. Dr. Heymann was diagnosed with a "space-occupying lesion" in the brain which eventually had to be surgically removed.

Her brief article provides an illuminating snapshot on the world of a seriously ill patient who received little response to questions, insensitive care while in the hospital, and little follow-up care. What she learned about recovery came from friends who had been previously ill.

Source: Heymann, J. (May, 1995). From doctor to patient. (pp. 216-217 and 274-276) Glamour Magazine.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Who's who in physician care. Have students complete Handout #1 reproduced from pg. 277 in the text. Discuss the impact of mysterious specialty titles and multiple specialties in health care settings on patients' experience with the health care system.

2. Sounds of the hospital. Films for the Humanities & Sciences carry an audiotape of hospital sounds. Play several for students and ask if they can guess what the sound is.

Discuss might focus on the "alien" sound of this environment, esp. for children.

3. Hospital services. As the competition for business becomes more intense, and as hospitals expand their view of health care, a wider range of services are being advertised to the public by many hospitals. Ask the students to collect advertisements of local hospitals for their programs. Classify the offerings as being for primary, secondary, or tertiary prevention.

4. Health care professionals. Invite the university health center physician and/or nurse to come to class to talk about the role of the health care professional. Encourage students to ask questions about making diagnoses, communicating with patients, helping patients to cope, health care provider stress, and patient compliance. Ask them to define a "good" patient and a "problem" patient.

5. Hospital behaviors. Discuss the different expectations students have about being hospitalized. How often would they expect to see their physician? Nurse? How long would they expect it would take for a nurse to answer a request for assistance? Do they feel it better to keep quiet about treatment they consider inadequate, or should they complain? To whom would they complain? What result might they expect?

6. Hospital preparation. Discuss which preparations would be useful for a hospital stay. If staying in a hospital, what was or would be unfamiliar? What are students' expectations regarding dress, meals, pain, procedures, consent, visits, and so on? For those who have been in a hospital, what advice can they give to others? What preparations would they recommend?

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Handout #1

Assess Yourself: Who's Who in Physician Care Hospitals contain many specialized personnel. If you were hospitalized, chances are that you would receive care from at least two of the ten types of medical specialists listed below. Do you know what their specialty areas of illness or treatment are? ______

Anesthesiologist

______

Cardiologist

______

Neurologist

______

Orthopedist

______

Oncologist

______

Gastroenterologist

______

Hematologist

______

Otolaryngologist

______

Proctologist

______

Radiologist

Specialty areas: 1. Cancer 2. Blood 3. Nervous system 4. Colon and rectum 5. Painkilling drugs 6. Ear, nose, and throat 7. Bones & joints 8. X-rays 9. Heart 10. Digestive system

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RESOURCES Suggested Readings: The Hospital – History, Setting, and Procedures Carpenter, D. (2001). Our overburdened ERs. Hospitals & health networks, 75(3), 44-47.

McCabe, J.B. (2001). Emergency department overcrowding: A national crisis.

Academic Medicine,76(7), 672-674.

Mishra, S.K. (2001). Hospital overcrowding. The Western Journal of Medicine, 174(3), 170.

Snook, I.D. (1992). Hospitals: What they are and how they work. Gaithersburg, MD: Aspen.

Emotional Adjustment in the Hospital Clark, E.J., Fritz, J.M., & Rieker, P.P. (1990). Clinical sociological perspectives on illness and loss: The linkage of theory and practice. Philadelphia: Charles Press.

Frank, A.W. (1991). At the will of the body: Reflections on illness. Boston: Houghton Mifflin.

Frank, A.W. (1995). The wounded storyteller: Body, illness, and ethics. Chicago: University of Chicago Press.

Krohne, H.W.& Slangen, K.E. (2005). Influence of Social Support on Adaptation to Surgery. Health Psychology, 24(1), 101-105.

Young-Mason, J. (1997). The patient's voice: Experiences of illness. Philadelphia: Davis.

How Health Psychologists Assist Hospital Patients Costa, P.T., & VandenBos, G.R. (1990). Psychological aspects of serious illness: chronic conditions, fatal diseases, and clinical care. Washington, DC: American Psychological Association.

Cummings, N.A., O’Donohue, W., Hayes, S.C., et al. (2001). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. San Diego, CA: Academic Press.

Fredericks, L.E. (2001). The use of hypnosis in surgery and anesthesiology: Psychological preparation of the surgical patient. Springfield, IL: Charles C. Thomas.

House, A., Mayou, R., & Mallinson, C. (1995). Psychiatric aspects of physical disease.

London: Royal College of Physicians.

Leigh, H., & Reiser, M.F. (1992). The patient: Biological, psychological, and social dimensions of medical practice. New York: Plenum Medical Book Co.

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Suggested Films and Videos: 1. Doctors using high technology. (1999, Edudex, 30 min). Explores recent advances in high technology.

2. Health care: What price? (Edudex, 30 min). Program looks at inequalities in health care and ethical considerations in allocating limited health care resources.

3. Healthcare crisis: Who's at risk? (2000, Edudex, 56 min). Looks at uninsured in the health care system.

4. Medicine at the crossroads: The magic bullet. (1993, WNET/BBC-TV, 57 min).

Looks at the expectation that medicine can provide "a pill" to solve all health problems.

5. The medical marketplace. (Edudex, 30 min). Compares ways medical care is delivered. Managed care is contrasted to traditional methods.

6. Ready or not: An introduction to end of life care. (2001, Aquarius Healthcare Videos, 35 min). Designed for health care professionals to aid in understanding dying patients.

7. So you want to be a doctor. (1992, Films for the Humanities and Sciences, 60 min). Follows medical students through training.

8. When Doctors Get Cancer. (1995, PBS Video, 57 min). Presents four physicians who have cancer or their children have died of cancer, discusses patient care and treatment.

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Internet sites of interest: Foundations and Organizations 1. http://medicalreporter.health.org/tmr0497/PAC.htm - Patient Advocacy Coalition 2. http://www.patient-education.com/ - The Patient Education Institute 3. http://www.mdchoice.com - MDchoice website 4. http://www.medhelp.org - Med Help International 5. http://www.npsf.org - National Patient Safety Foundation 6. http://www.law.wisc.edu/patientadvocacy/ - The Center for Patient Partnerships 7. http://www.nln.org - The National League of Nursing 8. http://www.ama-assn.org/ -American Medical Association 9. http://www.patientadvocate.org - Patient Advocate Foundation 10. http://www.ptct.com - Patient Care Technologies organization 11. http://www.nhpco.org - The National Hospice and Palliative Care Organization Healthcare Information 12. http://www.allsands.com/Health/Advice/patientsbillof_vpt_gn.htm - The patient's bill of rights created by the American Hospital Association 13. http://www.quackwatch.com/02ConsumerProtection/commtips.html - website on doctorpatient communication tips 14. http://www.nlm.nih.gov - US National Library of Medicine 15. http://www.fda.gov - an FDA consumer website 16. http://familydoctor.org - Patient information through the American Academy of Family Physicians.

17. http://www.unt.edu/bmed/links.html - Behavioral Medicine links

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TEST QUESTIONS True or False F

1.

By the end of the nineteenth century, hospitals had evolved to the point that only the wealthy could afford to use them.

2.

Despite modern techniques, it is estimated that roughly 5-10% of patients contract an infection while hospitalized.

3.

The use of depersonalization by medical staff may be a method of self-protection from the stress of caring for another human with serious health problems.

4.

Maslach and Jackson (1982) in a study of burnout discovered that nurses showed the greatest degree of depersonalization and physicians reported the greatest dissatisfaction with their sense of accomplishment.

5.

Becoming overly-compliant and exacting in following medical orders in the hospital are symptoms of reactance.

6.

Problem-focused coping is used to try to cope when the problem is seen as unchangeable and the stressors cannot be reduced.

7.

In Taylor's (1979) view, good patients are often just in a state of helplessness.

8.

The breathing techniques taught as part of the Lamaze preparation for childbirth is an example ofbehavioral control.

9.

When "monitors" are given little information about upcoming medical procedures, their anxiety tends to increase.

10.

The Minnesota Multiphasic Personality Inventory is useful in medical settings because of its specific orientation to health values and behaviors.

(275)

T (278)

T (281)

F (281)

F (282)

F (284)

T (284)

T (288)

T (289)

F (295)

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Matching Match the following terms with their description in items 1-5: a. hospital administrators b. medical director c. staff or attending physicians d. residents e. nurses c

1. Have been granted "admission privileges" by a committee of physicians.

(276)

e

2. Non-physician employees of the hospital with patient care responsibilities.

(277)

a

3. Non-medical employees of the hospital without patient care responsibilities.

(276)

b

4. The Chief of Staff.

(276)

d

5. Medical school graduates employed in teaching hospitals.

(277)

Match the following instruments or preparation strategies with their description in items 6-10: a. Lamaze b. Minnesota Multiphasic Personality Inventory c. Millon Behavioral Health Inventory d. The Psychosocial Adjustment to Illness Scale e. video preparation c (295)

a

6. Gives information regarding a patient's basic coping style and psychogenic attitude.

(288)

7. Teaches natural childbirth techniques that promote informational, behavioral. and cognitive control.

b

8. Contains scales which measure hypochondriasis, depression and hysteria.

(295)

d (295)

9. Assesses patient's health care orientation, vocational environment and domestic environment.

e

10. “Ethan has an operation”

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Multiple Choice b (275)

b (275)

d (275)

c (275)

a (275)

c (275)

a (276)

1. When most Americans die, they are a. at home. b. in hospitals. c. in accidents. d. diagnosed with an infectious disease.

2. The idea of having special facilities to house and treat the sick probably began with the a. Greeks. b. Romans. c. French. d. American colonies.

3. Which of the following is true regarding the earliest hospitals? a. They also housed the poor and other dependents. b. They were associated with monasteries. c. They served a charitable function. d. all of the above 4. Which change(s) took place in hospitals in the 18th and 19th centuries? a. A deepened association with monasteries. b. Use of X-rays for diagnosis. c. Establishment of wards for different illness categories. d. all of the above 5. The campaign to build the first hospital in the American colonies was led by a. Benjamin Franklin. b. Thomas Jefferson. c. King George III. d. George Washington.

6. Until the 20th century, hospital inhabitants were mostly a. the rich. b. the middle class. c. the poor. d. orphans.

7. The highest authorities in U.S. hospitals are typically a. business and professional people b. nurses c. doctors d. medical researchers

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8. In order to practice medicine in a hospital setting, physicians must have admission privileges granted to them by _____. a. their patients. b. the Medical Director. c. the Board of Directors. d. a committee of physicians.

9. Miguel is a nurse at a nearby hospital. His typical job functions include: a. patient care. b. managing hospital wards. c. receiving directives from physicians. d. all of the above 10. A hospital administrator has ordered a cutback on extra tests but Dr. Smith has just ordered a panel of additional tests for one of his patients. Who is most likely to get caught in between this conflict? a. The Chief of Staff. b. A nurse. c. An orderly. d. Dr. Smith.

11. Which is not an example of an allied health worker in a hospital setting? a. Physical therapist. b. Orderly. c. Lab technician. d. Dietitian.

12. What is the best way a hospital can avoid fragmented patient care? a. Put the medical director in charge. b. Put the chief hospital administrator in charge. c. Put a head nurse in charge. d. Require direct communication between physicians and other allied health workers.

13. The spread of nosocomial infections in hospitals a. has been eliminated due to sterilization techniques. b. has been increased in the last 100 years. c. affect as many as 5-10% of all patients. d. is not a problem mainly due to antibiotics.

14. Guidelines designed to reduce nosocomial infections require a. an Infection Control Committee. b. an epidemiologist. c. an Infection Control Nurse as part of the medical staff. d. all of the above 324

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15. Research indicates that the hospital personnel least likely to comply with infection control regulations are a. nurses. b. physicians. c. orderlies. d. lab technicians.

16. Hospital personnel feel least comfortable giving corrective feedback to a. patients b. those of lower status. c. those of equal status. d. those of higher status.

17. The system of fee payment adopted by Medicare which calculates the fee based on the average cost of treating patients with the same diagnosis is called a. the prospective payment system. b. income-averaging. c. revenue-sharing. d. none of the above 18. How is a "diagnostic-related group" calculated? a. It is a negotiated fee between hospitals and doctors. b. The American Medical Association calculates it based on epidemiological data. c. It is based on past recovery rates of similar cases. d. It is simply the lowest cost for treating a disease.

19. The primary goal of most hospitals is a. providing long-term care. b. providing rehabilitation. c. treating people quickly and discharging them in good health. d. discharging people as quickly as possible regardless of health status.

20. The average length of hospital stay has been a. increasing for all patients. b. decreasing for all patients. c. decreasing for all but surgical patients. d. increasing for all but surgical patients.

21. Which of the following have contributed to the decline in admissions and lengths of hospital stay? a. Fewer procedures being done on an outpatient basis. b. The increasingly complicated nature of medical procedures. c. Patients being released at earlier stages of recovery. d. The general increase in healthy behaviors in the population.

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22. Evidence generally suggests that decreasing length in hospital stays a. has not been harmful to patients. b. has been harmful to patients. c. has not occurred. d. actually increases expenses.

23. What is the reason patients sometimes fail to get the information that they need in the hospital? a. Test results may not be finished. b. Information is disguised by jargon. c. Doctors are too busy and don't have enough time to provide information. d. all of the above 24. Which of the following statements regarding anxiety is true? a. It ranks second behind depression as the most common emotion felt by hospitalized patients. b. Once patients are admitted to the hospital and "settle in", they seldom experience anxiety. c. The source of anxiety varies in people who have received a diagnosis compared to those who haven't. d. Anxiety is the by-product of anger at one's physician.

25. Irving's doctor ceased to speak to him at all while he was treating him for a skin laceration, instead directing all questions to Irving's wife. Irving was the victim of a. his physician's feelings of perceived inadequacy of professional accomplishment. b. malpractice. c. personalization. d. depersonalization.

26. Medical practitioners may engage in depersonalization a. because of stress. b. because of their hectic schedules. c. to help them deal with their own emotions. d. all of the above

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27. Which of the following is not characteristic of ''burnout?" a. Drug and alcohol abuse. b. High job satisfaction. c. High absenteeism. d. Chronic exposure to high stress.

28. Which statement is least likely to be made by a sufferer of "burnout?" a. "Working with people all day is a strain." b. "I am positively influencing other lives by my work." c. "I worry that this job is hardening me emotionally. " d. "I feel highly stressed."

29. When Hank is in the hospital he expects that he should be pampered and taken care of by the nurses. Hank could be classified as a _____ patient. a. problem b. active c. passive d. good 30. Maslach and Jackson suggested that the low degree of patient depersonalization found in nurses may reflect a. a sex difference in empathy. b. their sensitive training. c. their greater level of patient contact. d. their high pay and status in the medical hierarchy.

31. After his prostate operation, Luis began to complain about everything: his treatment by nurses, the quality of the hospital food, the competence of his Doctor. The medical staff would describe Luis as a _____ patient. a. good c. problem d. senile e. passive 32. Marvella doesn't complain about the constant pain in her abdomen following her surgery but chooses instead to "tough it out." Which is probably NOT true? a. She is a passive patient. b. She will take an active role in her recovery. c. The nursing staff will label her as a "good" patient. d. She will be cooperative and calm with the staff.

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33. Mark is angry about the visiting rules at his hospital because it limits the number of people who can visit him at one time. Mark's reaction is a form of a. passivity. b. reactance. c. anxiety. d. emotional exhaustion.

34. How might the medical staff respond to "problem patients"? a. Provide them with reassurance and explanations. b. Ignore their problem behavior. c. Arrange for an early discharge. d. all of the above 35. The anxiety level of most surgical patients: a. remains stable throughout the hospital stay. b. declines immediately prior to surgery. c. increases after surgery. d. none of the above 36. Nancy is distressed by her recent diagnosis with breast cancer. According to research, her distress is (at least in part) very likely due to a. concerns with loss of vigor and physical ability. b. "good" patient behavior. c. concerns with disfigurement. d. reactance.

37. Research on blame attribution and health problems has shown that a. blaming others leads to better adjustment. b. blaming others leads to poorer adjustment. c. blame attribution has little effect on adjustment. d. blaming family members leads to better adjustment than self-blame.

38. Research indicates that feelings of helplessness and depression a. decrease with increased time in the hospital b. are directly related to health c. increase with hospital time, even if health improves d. are not affected by time in the hospital 39. Research on anesthetized patients found that a. they can remember exactly what is said to them. b. they recovered more quickly than patients who hadn't had positive suggestions. c. negative comments are never made during surgery. d. constructive statements heard under anesthesia have no impact on recovery.

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40. Having a hospital roommate reduces anxiety under which of the following conditions? a. Only if both roommates are awaiting impending surgery. b. Only if roommates are not having similar surgery. c. Only if one of the roommates has already had successful surgery. d. Only if both roommates are pre-surgical and can share their anxiety with each other through discussion.

41. Which of the following is not true of patients with high preoperative anxiety? a. They report more pain than those with low anxiety. b. They report more depression during recovery. c. They report less anxiety during recovery. d. They stay in the hospital longer.

42. Generally speaking, the most useful approach to helping patients cope with impending surgery is to a. assure them of the safety of the procedure. b. assure them of the doctor's competence. c. depersonalize them. d. enhance their sense of control.

43. A nurse told Maria that one way she could speed her post-surgical recovery was to cough periodically to minimize congestion. The nurse was encouraging her to engage in a. behavioral control. b. cognitive control. c. informational control. d. remote control.

44. Andrew was counseled to think about the positive aspects of his impending surgery in order to reduce his stress. He was being encouraged to use a. behavioral control. b. cognitive control. c. informational control. d. emotional control.

45. One medical procedure in which a patient has little or no behavioral control is a. endoscopy. b. childbirth. c. post-surgical recovery. d. cardiac catheterization.

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46. In preparation for her valve-replacement surgery in her heart, Sherry was shown a video on the surgical procedure and postsurgical recovery. In addition, in private sessions with the clinical health psychologist, she learned to recognize signs of her own anxiety and how to control these. Sherry received training in a. behavioral control b. cognitive control c. informational control d. b and c 47. Research indicates that pain and complication during childbirth a. is less likely in cultures that view it as an easy and open process. b. is less likely in cultures where childbirth is viewed as private. c. is not affected by cultural viewpoints. d. is universally high across all cultures.

48. Lamaze training emphasizes a. social support in the form of a birthing coach. b. control enhancement. c. minimal use of medication. d. all of the above 49. Research on natural childbirth supports which of the following statements? a. Most obstetricians do not think it should be used. b. The control techniques actually increase birth anxiety. c. Research is inconclusive because women who select natural childbirth may be different from those who don't. d. Even with Lamaze training, women are likely to use just as much painkilling medication as those who don't use Lamaze.

50. "Monitors" reported the greatest amount of distress under which of the following information conditions? a. High information. b. Low information. c. Written information. d. Verbal information.

51. The most serious source of distress from hospital stays in young children appears to be a. separation from parents. b. fear of the unknown. c. allergic reactions. d. restraint of activity.

330

c

52. Cross-cultural studies on separation distress in children have found that

(290)

a. this phenomenon does not occur in medical settings. b. children in many cultures demonstrate separation distress. c. children only show separate distress in long-tern separations. d. separate distress lasts for years in most children. a (290)

d (291)

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53. When a parent says "If you drink too much soda, you'll stunt your growth" they are linking _____ with getting sick. a. disobedience b. compliance c. having fun d. anxiety 54. Which aspect of hospitalization is likely to be least distressing to an 11 year old? a. worry about the outcome of their illness b. loneliness and boredom c. embarrassment at bodily exposure d. separation anxiety 55. Information given to children about impending medical procedures a. produces benefits for all children. b. should never include puppets. c. may increase anxiety in some children d. tends to be fairly cost prohibitive.

56. The role of the health psychologist: a. often involves correcting psychological factors which lead to disease. b. has expanded greatly since the 1970s. c. may involve minor surgical procedures. d. involves little contact with other professionals.

57. The MMPI scale that evaluates an individual's tendency to cope with problems by avoidance and developing physical symptoms is a. hysteria b. depression c. hypochondriasis d. schizophrenia

331

b (295)

b (295)

a (295)

58. Which of the following statements about the Minnesota Multiphasic Personality Inventory (MMPI) is not true? a. It is the most widely used personality test. b. It was developed specifically for use in medical settings. c. It is usually completed in about 1-1/2 hours. d. All of the above are true.

59. Which test assesses a patient's basic coping style and psychogenic attitude? a. Minnesota Multiphasic Personality Inventory b. Millon Behavioral Health Inventory c. Psychosocial Adjustment to Illness Scale d. Medical Compliance Incomplete Stories Test 60. Which is not a characteristic assessed by the Psychosocial Adjustment to Illness Scale? a. Hypochondriasis. b. Psychological distress. c. Health care orientation. d. Domestic environment.

Short Answer Questions 1. Describe the roles and responsibilities of three occupational jobs in the hierarchy of an American hospital system.

2. Trace the changes that have occurred in hospitals since their early development.

3. Compare and contrast the "good" patient and "problem" patient roles.

Essay Questions 1. Discuss the process of depersonalization and explain how it is related to professional burnout. What are the consequences of depersonalization?

2. Distinguish between the psychological experiences and preparation techniques for surgical versus nonsurgical procedures.

3. Your 8-year-old nephew will be going to the hospital to have his tonsils removed.

Help him through the experience by developing a plan based on information from this chapter.

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CHAPTER 11 THE NATURE AND SYMPTOMS OF PAIN CHAPTER OUTLINE I. What is Pain?

A. Section introduction 1. Definition: pain is the sensory and emotional experience of discomfort usually associated with actual or threatened tissue damage 2. The importance of pain a. virtually all people experience pain and it’s the most frequent medical complaint b. severe, prolonged pain may dominate the lives of its victims c. pain has economic and social consequences B. The qualities and dimensions of pain 1. Section introduction a. sensations of pain vary and have different qualities i. example - pain has been described as burning, throbbing, sharp, dull, itching b. pain also differs in origin and duration 2. Organic versus psychogenic pain a. organic pain results from tissue damage b. psychogenic pain occurs in the absence of organic damage c. researchers used to consider these separate entities but now concede that, simply because there are differences in presence of tissue damage, the psychological experience of pain is similar i. all pain involves interplay of physiological and psychological factors ii. organic and psychogenic pain now conceptualized as a continuum rather than dichotomy - different pain experiences involve a mixture of organic and psychogenic factors - example: pain disorder, a somatoform disorder, involves chronic pain with no detectable physical basis. iii. caution - not finding a demonstrated physical basis for pain doesn't mean there is none 3. Acute versus chronic pain a. length of pain experience is important descriptive dimension. i. most painful conditions are temporary and can be alleviated with medications or other treatments - generally similar painful conditions that occur in the future aren’t directly connected with an earlier pain experience ii. acute pain is temporary, usually less than six months 332

- high anxiety while pain exists but subsides as pain decreases ii. chronic pain lasts more than a few months - high levels of anxiety that develops into feelings of hopelessness and helplessness - pain interferes with activities, goals, sleep, loss of jobs with resulting low income b. factors used in description of chronic pain i. effects of chronic pain depend on whether underlying condition is: - benign or malignant - continuous or episodic c. types of chronic pain i. chronic/recurrent pain - benign causes characterized by repeated and intense episodes of pain - examples - migraine headaches, tension-type headaches, and myofascial pain ii. chronic/intractable/benign pain - discomfort present all the time with varying levels of intensity and not due to malignant condition - example - chronic low back pain iii. chronic/progressive pain - continuous discomfort associated with malignant condition and which becomes increasingly intense - examples - rheumatoid arthritis and cancer C. Perceiving Pain 1. Section introduction a. pain sense properties i. there are no specific receptor cells that transmit only pain signals ii. pain results from many types of noxious stimuli iii. pain includes a strong emotional component 2. The physiology of pain perception a. Noxious stimulation triggers chemical activity at site of injury i. serotonin, histamine, and bradykinin are released which promote immune system activity, cause inflammation, and activate nerve fibers ii. nociceptors - free nerve endings that carry information to spinal cord and brain - A-delta fibers are coated in myelin and are associated with sharp, well-localized, distinct pain - terminate in motor/sensory areas of brain - signal receives immediate attention

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- C fibers are not coated with myelin and are associated burning, aching pain - terminate in the brainstem, forebrain and other diffuse regions of the brain - signal less likely to capture attention but more likely to affect mood, emotional state, motivation b. referred pain - pain originating in internal organs is often perceived as coming from other parts of the body i. results from shared spinal cord pathway for organ and skin - people more familiar with sensations from skin; mislabel pain signal as being from skin 3. Pain without detectable body damage a. onset of pain syndromes i. pain often began with tissue damage but persisted long after healing completed ii. pain spread and increased in intensity. iii. pain became stronger than pain from initial damage. b. types of pain syndromes i. neuralgia.- stabbing pain along the course of a nerve - example: trigeminal neuralgia – spasms of pain in face ii. causalgia - recurrent episodes of severe burning pain iii. phantom limb pain - sensation/pain in an amputated limb or limb with peripheral nerve damage c. suspected causes for pain syndromes i. some form of neural damage is suspect but doesn’t explain why people with obvious neural damage don’t also develop pain syndromes ii. full explanation is puzzle but probably some combination of physiological and psychological factors involved 4. The role of the "meaning" of pain a. masochists, individuals who like pain, attach a different meaning to pain, which is developed via classical conditioning b. Beecher's studies i. 49% injured soldiers during WW II rated pain was moderate or severe and 32% required medication.

- pain signaled the end of their ordeal in battle. ii. 75% of surgical patients rated pain as moderate to severe and 83% requested medication.

- pain signaled the beginning of a personal disaster.

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II. Theories of Pain A. Early theories of pain 1. Specificity theory - proposed that a separate system of receptors, peripheral nerves, pathway to brain, and area in brain for pain perception exists 2. Pattern theory - argued that pain receptors are shared with other senses and that the intense pattern of neural activity is perceived as pain 3. Criticisms of these theories a. pattern theory doesn't explain why innocuous stimuli produce causalgia and neuralgia b. theories don't explain why psychological factors contribute to pain experience i. example: people under hypnosis feel less pain B. The gate-control theory of pain 1. Section introduction a. theory developed by Melzack and Wall that integrates and improves on earlier theories i. suggests a physiological mechanism by which psychological factors affect pain ii. accounts for observations that earlier theories couldn't 2. The gating mechanism a. gating mechanism, which permits or inhibits pain signals, is located in the substantia gelatinosa of the dorsal horns of the spinal cord's gray matter i. A-delta and C fibers pass through the gate and stimulate transmission cells which send the signals to the brain. ii. the opening and closing of the gate is controlled by - the amount of activity in the pain fibers - the amount of activity in other peripheral fibers - messages from the brain iii. when the gate is open, pain is perceived 3. Evidence on the gate-control theory a. Empirical evidence i. supporting evidence - stimulation of the periaqueductal gray region of midbrain may produce analgesia in animals during painful stimulation and surgery - morphine works by activating brainstem to send impulses down spinal cord III. Biopsychosocial Aspects of Pain A. Neurochemical transmission and inhibition of pain 1. Effects of stimulation-produced analgesia (SPA) a. stimulation to the brainstem produces insensitivity to pain

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b. substance P is produced by small-diameter pain fibers and crosses the synapse to the transmission cells, triggering activation of pain signals c. SPA occurs when substance P release is blocked 2. Stimulation of the periaqueductal gray area a. chain of activity i. stimulation to periaqueductual gray travels from brain to spinal cord ii. serotonin activates inhibitory interneurons which release endorphins which inhibit the release of substance P b. endogenous opioids (endorphin and enkephalin) and opiates (morphine and heroin) alleviate pain in same way – by binding to receptors in CNS, thus inhibiting substance P i. evidence: chronic pain patients have diminished levels of endogenous opioids in their blood 3. Mechanism of action for opiates and opioids a. naloxone blocks the action of opiates and opioids and the analgesic effect of electrical stimulation to periaqueductal gray area i. injections of naloxone are related to increased pain experiences b. role of endogenous opioids in pain and analgesia is complicated i. issues - nalaxone doesn’t always block SPA - neurotransmitters may have different effect on momentary vs. long term pain - chronic pain sufferers do not experience tolerance to morphine like is seen when morphine is taken for momentary pain c. having endogenous opioids serves adaptive function i. enables action to be taken to promote survival after serious injury or significant stress (e.g., battlefield stress) B. Personal and social experiences and pain 1. Learning and pain a. pain is learned through the association of pain with antecedent cues and consequences i. examples - distress associated with migraine aura; physiological reactions to words/phrases associated with pain ii. learning influences pain behaviors such as - facial/audible expression of distress - distorted ambulation or posture - negative affect - avoidance of activity

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b. pain behaviors may be maintained by operant conditioning i. secondary gains through attention, being relieved of chores, receiving disability payments 4. Social processes and pain a. families give social reinforcement for pain through attention, (solicitous) care, and affection, which leads to a vicious cycle of even more pain behaviors i. being overly solicitous increases patients' dependency and decrease their self-efficacy and self-esteem 5. Gender, sociocultural factors, and pain a. women and men differ in types of pain and reactions to pain i. women - arthritis, migraine headache, myofacial neuralgia and causalgia; report pain interferes with daily activities ii. men - back pain and cardiac pain b. differences in pain reports among different sociocultural groups both between different racial-ethnic groups in the US and between US and other countries i. other studies have found no difference c. knowing about ethnic/gender differences doesn’t assist in treating an individual C. Emotions, coping processes, and pain 1. Section introduction a. cognitive processes mediate the link between emotion and pain. i. empirical support: study on dental patients found anxiety played role in pain expectations and pain memories 2. Does emotion affect pain? a. anxiety and stress correlate with pain i. empirical evidence of causal link between stress and headache pain - self-report studies find migraine and musclecontraction headaches occur after heightened stress and Type A persons have more frequent chronic headaches - study with stressful task found 1/4 of occasional headache sufferers and 2/3 chronic headache sufferers developed headache during experiment - still questionable whether stress causes pain however b. pain itself is a significant stressor 3. Coping with pain a. chronic pain patients tend to use emotion-focused coping strategies (such as hoping, praying, or distraction) due to common belief of little control over pain i. these approaches not found to be effective b. research using MMPI results to explore effectiveness in dealing with pain 337

i. three conclusions - persons with chronic pain show high scores on hypochondriasis, depression, hysteria (the neurotic triad) yet normal scores on remaining scales - neurotic triad pattern is reflected regardless of whether there is a known organic source for pain - persons with acute pain have scores within normal range on all scales c. does chronic pain cause maladjustment? i. evidence that the answer is “yes” - persons whose pain has ended show reduction in psychological disturbance - depression is common in pain patients - helplessness leads to depression - patients begin to catastrophize d. maladjustment may also lead to pain i. depressed persons more likely to develop chronic pain condition in future e. pain and maladjustment involve interactive processes IV. Assessing People's Pain A. Section introduction 1. A variety of methods have been developed to assess pain in both research and clinical settings a. using multiple methods increases accuracy of assessment B. Self-report methods 1. Interview methods in assessing pain a. interviews are conducted with patient and family or coworkers to provide background information during early stages of treatment b. elements of the interview i. history of the pain ii. patient's emotional adjustment iii. patient's lifestyle before pain iv. impact on patient's lifestyle v. social context of the pain episodes vi. factors which trigger the pain vii. typical efforts to cope 2. Pain rating scales and diaries a. scales involve rating some aspect of pain, often the intensity of the pain b. types of pain rating scales i. visual analog scale - rating pain by placing a mark on a line with labels at the end points ii. box scale - series of numbers inside boxes that represent levels of pain intensity iii. verbal rating scale - describing pain by choosing words or 338

phrases that reflect experience c. advantages to rating scales i. pain can be rated quickly and frequently ii. change in pain can be traced iii. patterns of pain can be reflected iv. aspects of pain from environment can be noted and changed d. clients need to be trained to learn what to say if others see them making notes, reminding themselves to make ratings, and what to do if they forget to do a rating e. pain diaries - detailed record of person's pain experiences 3. Pain questionnaires a. McGill Pain Questionnaire i. involves ratings of words according to 20 affective, sensory, and evaluative dimensions ii. MPQ yields a pain rating index and present pain intensity iii. advantages of MPQ - empirically confirmed that pain is a multidimensional event - produced evidence that people with different pain syndromes report different symptoms iv. disadvantages of MPQ - requires strong English vocabulary - requires fine distinctions between words b. Multidimensional Pain Inventory is another, more recently developed pain assessment B. Behavioral assessment approaches 1. Section introduction a. because people exhibit pain behaviors, should be able to assess pain by observing behavior i. assume that pain behaviors vary depending on types and patterns of pain - example: if pain is intense v. moderate, a headache v. low back pain, recurrent v. intractable 2. Assessing pain behavior in structured clinical sessions a. UAB Pain Behavior Scale - nurses rate patients on ten behaviors b. videotaped performance of standard activities in structured clinical sessions i. patients rated on performance of pain behaviors (e.g., guarded movement, etc.) ii. behavioral assessments correlate with self-ratings of pain 3. Assessing pain behavior in everyday activities a. family members can be trained to observe and rate most common pain behaviors i. observations include frequency and amount of time pain 339

behaviors demonstrated and how others react to the pain behavior b. spouse may complete a pain diary, including date/time/location of episode, behavior observed that suggested pain, assessor’s thoughts/feelings during episode, assessor’s assistance efforts c. procedures provide additional data regarding interpersonal issues that influence pain episodes C. Psychophysiological measures 1. Psychophysiology – study of mental or emotional processes as reflected by changes they produce in physiological activity 2. Types of measures a. electromyograph (EMG) measures degree of muscle tension i. empirical results - studies find differences in EMG activity in pain/no pain patients in affected muscles when patient is physically/psychologically stressed but not during periods of inactivity - EMG findings reflect pain levels when gathered over extended period of time b. autonomic (heart rate & skin conductance) activity i. empirical results - interpreting increases in activity is difficult/not useful because autonomic activity is related more to ratings of pain rather than strength of pain stimulus, are inconsistently associated with chronic pain, and occur in absence of pain but presence of other events (e.g., stress) c. electroencephalograph (EEG) recordings – measure of electrical activity in brain i. empirical results - amplitudes increase with intensity of pain, decrease when analgesia taken, and correlate with self-report of pain d. because psychophysiological measures are affected by other factors, probably best used as supplements to self-report and behavioral assessments

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V. Pain in Children A. Section introduction 1. Children experience same pain conditions as adults. a. may also experience a unique form of pain referred to as "growing pains" 2. Little research was done on children prior to 1980s a. assumed nervous systems were too immature to experience pain B. Pain and children's sensory and cognitive development 1. Newborns experience pain a. evidence i. crying when spanked at birth ii. "pain" facial expressions and crying that varies during noxious medical procedures 2. Expression of pain is affected by limited language development. a. may demonstrate pain through pain behaviors such as crying, rubbing affected area, clenching jaws b. younger children have fewer words to describe pain compared to older children C. Assessing pain in children 1. Self-report provides limited information. a. clinicians rely on interviews, behavioral and physiological assessments i. in children under 5, assessments made via behavioral observations (e.g., vocalizations, facial expressions) ii. with older children, visual analog scales and verbal rating scales can be used with faces depicting varying degrees of distress 2. Pain questionnaires for children a. questionnaires have been developed to assess pain experience and psychosocial effects on child/family i. examples: Pediatric Pain Questionnaire and Children's Comprehensive Pain Questionnaire 3. Other methods of assessment a. behavioral and physiological assessments b. pain diaries kept by child or parents c. structured clinical assessments by health care workers 4. Factors that affect children's pain experiences a. parental models and reinforcement for pain behaviors b. little known about personality and family characteristics that contribute to intensity/frequency of children’s pain experiences

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DISCUSSION TOPICS 1. Women and the experience of pain.

Karel Gijsbers and Catherine Niven have written a thought-provoking chapter on pain experiences in women. They begin by stating one of the most reproducible findings in pain research is the sex difference in pain threshold and tolerance. Women are more sensitive to experimentally produced pain and report pain more than do men in the clinic. Gijsbers and Niven state that, for women, pain is "almost certainly influenced by their reproductive capacities" (pg. 43). Pain may be experienced in menstruation and childbirth. Such experiences are argued to "influence their perception of other pains not specifically related to reproduction" (pg. 43). Additionally, the need to convince others of the existence of their pain may tend to exacerbate the situation. Some discussion is given to the role of hormones in greater pain sensivitiy. With regard to coping strategies, Gijsbers and Niven observe that, since women tend to have lower pain thresholds and less tolerance for what is labeled as painful, they "may also have greater reason and opportunity to acquire a sophisticated repertoire of strategies for dealing with pain." (pg. 55).

Source: Gijsbers, K., & Niven, C.A. (1993). Women and the experience of pain. In Niven, C., & Carroll, D. (Eds.), The health psychology of women, (pp.43-57). Langhorne, PA: Harwood Academic Pub. 2. Myths about chronic pain.

Laura Hitchcock, herself a clinical psychologist and Director of the National Chronic Pain Outreach Association, recounts her experience in training and personal experiences with chronic pain. As an intern, prevalent notions about the characteristics of chronic pain patients were that they use their pain for secondary gain, play "pain" games, are addicted to narcotics or at least prefer mood-altering drugs to reduce pain, are suffering from personality disorders or are hypochondriacs and exaggerators, have unmet dependency needs or are from a dysfunctional family, are doctor shoppers, or are unwilling to learn to live with pain.

Following her own back injury, her viewpoint on chronic pain changed substantially. For one, she came to believe that more professional energy is needed in seeking to reduce the experience of pain rather than the emphasis on reducing the frequency of pain behaviors.

Moreover, she came to appreciate the role that stigmatization and stereotyping plays in the chronic pain experience.

Hitchcock proposes that four common myths/misconceptions form barriers to effective intervention for chronic pain. They include the belief that: (1) chronic pain in the presence of no discernible tissue damage is psychogenic. Hitchcock points two observations: what was viewed as psychogenic 10 years ago has now been found to be organic with improved technology and some cases of psychogenic pain have been wrongly diagnosed.

342

(2) chronic pain is usually an expression of depression. - although appearing less frequently (as Sarafino points out), the relationship between chronic pain and depression appears to suggest more that the former (chronic pain) results in the latter (depression).

Moreover, she contends that the stigmatized treatment of chronic pain patients contributes to their depression.

(3) patients receiving disability exaggerate pain for financial gain. - the loss of income due to chronic pain exceeds the financial gains due disability money. Therefore, the underlying logic falls apart.

(4) narcotic drugs aren't appropriate for treatment of chronic, nonmalignant pain. - also as noted by Sarafino, physician concern about addiction is contradicted by data that shows narcotics taken for pain relief result in little addiction. Hitchcock points to Melzack's animal research that suggests the biological mechanisms of acute pain differ from those of chronic pain and that this difference may lay at the heart of the addiction issue.

Why are these myths prevalent? Hitchcock suggests several processes may be at work here. First, professionals (and others) may be inappropriately applying their own experiences with pain to those of the chronic pain sufferer. Second, when faced with uncertainty, as is the case in understanding the causes of many chronic pain cases, a tendency to "blame the victim" emerges. Third, because professionals tend to work with a unique population of patients, their general view of patients becomes skewed. Fourth, it is difficult for physicians to give "authority" to the patients regarding the understanding of their pain. And finally, the American culture endorses the concept of maintaining a "stiff upper lip" in the face of adversity.

Source: Hitchcock, L.S. (1998). Myths and misconceptions about chronic pain. (pp. 517-523). CRC Press 3. Assessing pain.

Paul Karoly has written a very extensive chapter on the central issues, difficulties, and methodologies for assessing pain. Describing pain from a multidimensional approach, he acknowledges the definitional difficulty in this area of health research and practice (as parallels Sarafino's description of the various types of pain). In his chapter, he provides a comprehensive survey of assessment objectives, including ultimately the self-management of pain adaptation. A good deal of the chapter is spent on an overview of 10 assessment strategies and procedures used in a multifacted treatment approach. One particularly interesting approach involves the use of an "articulated thoughts" paradigm in which pain patients listen to an audiotape of conversations and make comments on how pain influences their social response. In the conclusion of his writing, Karoly notes that the complex approach to assessment of pain reflects the "inherent complexity of the human experience of pain" (pg.510). This chapter provides a comprehensive and in-depth discussion of the issues in pain assessment.

Source: Karoly, P. (1985). The assessment of pain: Concepts and procedures. In Karoly, P. (Ed.), Measurement strategies in health psychology. (pp. 461-516). New York: Wiley.

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ACTIVITY SUGGESTIONS 1. Pain dimensions. Have the students think about a pain they have experienced recently. Write down the words used. Referring to page 312 in the text, identify the words which correspond to the affective, sensory, and evaluative dimensions measured by the McGill Pain Questionnaire (Melzak, 1975).

2. A culture of analgesia. Assign the students to do the following exercise the next time they are in the grocery store. Have them estimate the amount of shelf footage (or number of products) devoted to pain relief. Compare that with a similar estimate of other medications not devoted to pain relief. Discuss what this relationship reflects about our culture (e.g., desire to be independent, mobile).

3. Advertising and pain. Have students keep track of the number of commercials for pain products or obtain popular magazines and count the advertisements devoted to pain relievers. Have them bring these advertisements to class to discuss any culturally-relevant messages they may imply.

4. Placebos. It has been said that one should use new treatments while they are still effective as a comment on the extra-therapeutic effects of most treatments. Discuss the usefulness of placebos as a form of therapy and the ethical implications of their use. Is it ethical to use them if an effective treatment exists? Is it ethical not to consider placebos if an alternative treatment has side-effects? Is the deception involved a compromise of the trust between the physician and patient? Consider the nature of psychological treatments. How do psychological interventions differ from a placebo treatment? What then comprises the effectiveness of psychological treatment?

5. Birth pains. According to Wideman and Singer (1984), different cultures may vary on the expectation they have for the pains involved in childbirth. Even within our own culture, differences exist. Ask students to share what they would expect birth pains to be. Where were these expectations learned?

6. The Gate Control Theory of Pain. To help students conceptualize the Gate Control Theory of Pain, use examples like acupuncture, natural childbirth techniques, narcotics, transcutaneous stimulation, and audio analgesia, to demonstrate the many ways in which the gate to consciousness may be closed.

7. Physical Therapy. Invite a physical therapist to speak to the class regarding physical pain and its relief. The prevention of and treatment of back pain is an extremely useful and popular topic.

8. The nature of pain. Show a provocative video on pain (e.g., Pain and Healing, listed in the “Suggested films/video section” below, which interviews 344

patients with phantom limb pain, another born with no ability to feel pain, patients undergoing hypnosis for pain, live footage of pain experiments, is a good one).

After showing the video, ask the class to talk about pain. Why is it beneficial?

When is it not beneficial? What is real pain?

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RESOURCES Suggested Readings What is Pain?

Edwards, R.R., Doleys, D.M., Fillingim, R.B., & Lowery, D. (2001). Ethnic differences in pain tolerance: Clinical implications in a chronic pain population.

Psychosomatic Medicine, 63(2), 316-323.

Gorman, T.J. (2000). Reconsidering worlds of pain: Life in the working class(es).

Sociological Forum, 15(4), 693-717.

Sandkuehler, J. (2000). Learning and memory in pain pathways. Pain, 88(2), 113118.

Wall, P.D. (2000). Pain: The science of suffering. New York: Columbia University Press.

Wall, P.D., & Jones, M. (1991). Defeating pain: The war against a silent epidemic.

New York: Plenum Press.

Theories of Pain Hardcastle, V.G. (1999). The myth of pain [computer file]. Cambridge, MA: MIT Press.

Horn, S. & Munafo, M. (1997). Pain: Theory, research, and intervention. Buckingham: Open University Press.

Sharp, T.J. (2001). Chronic pain: A reformulation of the cognitive-behavioural model.

Behaviour Research & Therapy, 39(7), 787-800.

Biopsychosocial Aspects of Pain Jensen, M.P., Romano, J.M., Turner, J.A., Good, A.B., & Wald, L.H. (1999). Patient beliefs predict patient functioning: Further support for a cognitive-behavioural model of chronic pain. Pain, 81(1-2), 95-104.

Jones, A. & Zachariae, R. British. (2004). Investigation of the interactive effects of gender and psychological factors on pain response. Journal of Health Psychology, 9(3), 405-418.

Keefe, F.J., Lumley, M., Anderson, T., Lynch, T., & Carson, K.L. (2001). Pain and emotion: New research directions. Journal of Clinical Psychology, 57(4), 587-607.

Ranjan, R. (2001). Social relations and chronic pain. (Dordrecht, Netherlands: Kluwer Academic Publishers.

Assessing People’s Pain Farrar, J.T., Portenoy, R.K., Berlin, J.A., Kinman, J.L., & Strom, B.L. (2000). Defining the clinically important difference in pain outcome measures. Pain, 88(3), 287-294.

Woolf, C.J. (1999). Implications of recent advances in the understanding of pain path physiology for the assessment of pain in patients. Pain, Sup. 6, 141-147.

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Suggested Films and Videos: 1. Pain: The language of the body and mind. (2003, Films for the Humanities & Sciences). A three-tape series that contains reviews of the management of pain, psychology of pain, and physiology of pain.

2. Physician assisted suicide vs. pain management. (1999, EONetwork productions, 31 min). Discussion of physician assisted suicide versus pain management and a patient’s right to die.

3. Reporting symptoms of pain. (2002, Video Press, 20 min). A seminar presented to residents and nursing assistants on how to identify pain in verbal and nonverbal patients.

Internet sites of interest: Foundations and Organizations 1. http://www.theacpa.org/ - American Chronic Pain Association 2. http://www.painfoundation.org/ - The American Pain Foundation 3. http://www.painmed.org/ - The American Academy of Pain Medicine 4. http://www.iasp-pain.org - International Association for the Study of Pain 5. http://www.ampainsoc.org/ - The American Pain Society 6. http://www.headaches.org - National Headache Foundation 7. http://www.amputee-coalition.org - Amputee Coalition of America Pain Information 8. http://www.cpmission.com/index.html - Our Chronic Pain Mission information website 9. http://www.painandhealth.org/pain-links.html - general pain resources 10. http://www.cancer-pain.org/ - site on management of cancer pain 11. http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm - National Institute of Neurological Disorders and Stroke – chronic pain information page.

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TEST QUESTIONS True or False T (306)

1.

Organic pain and psychogenic pain differ only in the degree of tissue damage.

F

2.

Rheumatoid arthritis and cancer cause pain which Turk, Meichenbaum and Genest (1983) might classify as chronic-recurrent.

3.

Sharp, well-localized pain is transmitted along A-delta fibers.

4.

According to gate control theory, the gating mechanism is found in a portion of the thalamus.

5.

You have a really bad sunburn and developed blisters on the worst areas. You have third-degree burns.

6.

Research indicates that placebos have no physiological effect.

7.

Terry suffered from pain following a vasectomy. His wife felt sorry for him and performed many of his chores for him. It is plain that Terry's pain has a secondary gain.

8.

Most research suggests that chronic pain leads to psychological disturbance - not the other way around.

9.

The EMG is useful for assessing the muscle tension frequently associated with pain.

10.

One common way of measuring pain in children under the age of five is to observe the pain behaviors they exhibit

11.

Acute pain patients tend to develop maladaptive coping strategies, such as catastrophizing their illness

(308)

T (310)

F (315)

F (309)

F (319)

T (319)

T (323)

F (329

T (330)

F

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Matching Match the following with the statements in one through five. a. A-delta fibers b. C-fibers c. serotonin, histamine, bradykinin d. nociceptors e. endogenous opioids b

1. Associated with diffuse, dully burning or aching sensations

(310)

d

2. Nerve endings that respond to pain

(310)

e

3. Endorphin and enkephalin

(317)

c

4. Promote immune system activity and cause inflammation at the injury site

(310)

a

5. Associated with sharp, well-localized, distinct pain

(310)

Match the following with the statements in six through ten. a. referred b. phantom limb c. causalgia d. neuralgia e. analgesia d

6. Shooting or stabbing pain along the course of a nerve

(310)

a

7. In a heart attack, the pain may be felt in the shoulders, or arms

(310)

e

8. State of not being able to feel pain

(316)

c

9. A burning pain, usually at the site of an old wound

(311)

b

10. A pain experienced in amputees

(311)

349

Multiple Choice a (305)

d (305)

b (306)

b (306)

c (306)

d (306)

1. Congenital insensitivity to pain a. can indirectly lead to death. b. does not exist. c. has numerous health advantages. d. is relatively common.

2. Which of the following statements about pain is true? a. Some people are insensitive to pain. b. Pain serves a useful purpose. c. Pain is the most common medical complaint. d. All of the above statements are true.

3. The experience of pain a. is an uncommon medical symptom. b. is the most compelling force in seeking medical care. c. actually discourages most sufferers from seeking medical care. d. none of the above 4. Damage deep within the body is most likely to be marked by a. no pain at all. b. dull, aching pain. c. sharp pains. d. burning sensations.

5. Discomfort caused by tissue damage is referred to as a. chronic pain. b. phantom pain. c. organic pain. d. psychogenic pain.

6. Timothy has a stabbing pain in his back but his physician cannot find any injury to his spinal column or surrounding muscles. Timothy's pain is likely to be classified as a. chronic pain. b. phantom pain. c. organic pain. d. psychogenic pain.

350

a (307)

a (307)

b (308)

c (308)

a (308)

d (308)

7. Which of the following statements regarding pain is true? a. Pain is best characterized along a continuum of organic and psychogenic causes. b. Pain always occurs with the presence of tissue damage. c. People with psychogenic pain have different pain experiences than do people with organic pain. d. Pain disorders result from very serious tissue damage.

8. Chronic discomfort that is psychogenic in origin is referred to as a. pain disorder. b. malingering. c. chronic-organic syndrome. d. acute pain.

9. Andrea has been experiencing a pain in her back for over a year. She has stopped engaging in all her favorite sports and social activities as a result.

Andrea would most likely be classified as having _____ pain. a. acute b. chronic c. C-fiber d. psychogenic 10. George cut his hand today and is a great deal of acute pain. What else is George likely to experience? a. Increased sleeping. b. A sense of helplessness and hopelessness. c. Increased anxiety. e. An elevated MMPI score.

11. The high levels of anxiety associated with acute pain a. typically subside as pain decreases. b. appears unrelated to the pain. c. are alleviated with brief medical consultations. d. increases with decreasing pain levels.

12. Chronic pain sufferers tend to a. often leave their jobs. b. feel worn down and exhausted. c. become increasingly irritable with their families. d. all of the above.

351

c (308)

b (308)

a (308)

d (308)

b (309)

a (309)

d (309)

b

13. Molly is experiencing a shooting but dull pain in the muscles of her head, neck, and back. This syndrome is referred to as a. acute pain. b. somatoform disorder. c. myofascial pain. d. progressive-malignant syndrome.

14. Cancer and rheumatoid arthritis are frequently associated with a. chronic-recurrent pain. b. chronic-progressive pain. c. chronic-intractable pain. d. chronic-benign pain.

15. Migraine and muscle tension headaches are most characteristic of which category of chronic pain? a. Recurrent. b. Intractable. c. Benign. d. Progressive.

16. Receptor cells specific only to pain a. are destroyed in 3rd-degree burns. b. are destroyed in 2nd-degree burns. c. are found in the dermis. d. do not exist.

17. During which of the following phases of burn treatment would a patient experience debridement? a. Emergency phase. b. Acute phase. c. Rehabilitation phase. d. Psychological intervention.

18. The primary approach for controlling acute pain due to burn is a. analgesic medication. b. informational control. c. behavioral control. d. cognitive control.

19. Third-degree burns are often marked by a. little initial pain b. nerve ending damage c. destruction of the epidermis and dermis d. all of the above 20. The cutting away of dead tissue in burned areas is called 352

(309)

d (309)

c (310)

d (310)

a (310)

b (310)

a. myofascia. b. debridement. c. the emergency phase. d. the rehabilitation phase.

21. Psychological approaches to pain control in burn patients a. are generally ineffective due to the severity of the pain. b. had the effect of increasing requests for medication. c. avoid discussing tanking and debridement procedures. d. none of the above 22. Afferent nerve endings that respond to pain stimuli and signal injury are called a. algogenic substances. b. substance P. c. nociceptors. d. referred pain fibers.

23. The releasing chemicals that are part of the physiology of pain a. exist naturally in tissue. b. promote immune system activity. c. cause inflammation at the site of an injury. d. all of the above 24. The fatty coating which enables neurons to transmit impulses more quickly is called a. myelin. b. nociceptor. c. algogenic substance. d. A-delta.

25. C fibers are involved in a. acute pain sensations b. dull pain sensations c. sharp, well-localized pain sensations d. an "average" degree of pain

353

a (310)

d (310)

a (310)

b (311)

a (310)

b (311)

26. Pain originating from internal organs but perceived as coming from other parts of the body is called a. referred pain b. benign pain. c. intractable pain d. recurrent pain 27. Which of the following may typically result in referred pain? a. heart attack b. toothache c. inflammation of the diaphragm d. all of the above 28. Which of the following provides an explanation for the phenomenon known as referred pain? a. People are more familiar with sensations from the skin than from internal organs. b. People who experience referred pain suffer from neurological damage. c. Referred pain happens only in those people who have had a limb amputated. d. Referred pain is purely a psychological problem.

29. Which of the following is among the characteristics common to neuralgia, causalgia, and phantom limb pain? a. They always occur in the absence of any tissue damage. b. The pain they produce is present long after tissue damage has healed. c. Pain intensity remains at the same level as was experienced at the time of tissue damage. d. These pain syndromes rarely last more than 6 months.

30. Randi has been diagnosed with a case of neuralgia. She is most likely to experience a. shooting pain. b. burning pain. c. pain in her back. d. pain that is provoked only by an extremely noxious stimulus.

31. Anthony reports intense burning pain at the site where he was stabbed by an attempted robber some time ago. Anthony may be experiencing a. neuralgia. b. causalgia. c. referred pain. d. hysterical pain.

354

d (310)

b (318)

c (312)

c (312)

a (312)

c (312)

32. Which of the following is pain felt when no noxious stimulation is present? a. neuralgia b. causalgia c. phantom limb pain d. all of the above 33. Masochists are believed to learn to enjoy pain through the process of a. operant conditioning. b. classical conditioning. c. brainwashing. d. experimentation.

34. In his classic work on the meaning of pain in soldiers and surgical patients, Beecher found which of the following? a. Soldiers experienced far more pain than surgical patients. b. The soldiers' wounds were probably less extensive than the intensive wounds left by surgery. c. The soldiers were far less likely than surgical patients to request medication. d. The extreme fright experienced by soldiers made their pain worse.

35. According to Beecher, the difference in meaning of pain for soldiers versus surgical patients a. was not related to the amount of pain experienced. b. explained the lower levels of pain reports in soldiers because they were in denial. c. explained the higher levels of pain reports in surgical patients because the surgical event was interpreted as a major life disruption. d. was trivial.

36. Which of the following is true regarding specificity theory? a. It suggested the presence of a pain area in the brain. b. It has been unanimously supported by research. c. It proposed no separate system for perceiving pain. d. It successfully addresses the cause of phantom limb pain.

37. Which of the following is NOT true regarding pattern theory? a. The sensations for pain and touch share common receptors. b. It accurately explained the experiences of neuralgia and causalgia. c. It proposed there is separate system for perceiving pain. d. Intense patterns of neural activity are associated with the experience of pain.

355

a (312)

d (312)

a (313)

d (314)

c (314)

b (314)

a (315)

d

38. Specificity theory is to _____ as pattern theory is to _____. a. separate; shared b. chronic; acute c. acute; chronic d. shared; separate 39. The problems with the acceptance of pattern theory include a. the requirement of intense stimuli to trigger pain. b. the overlooking of psychological factors in pain. c. the pain area of the brain does not exist. d. all of the above 40. While under deep hypnosis, people report a. feeling less pain than when in a waking state. b. feeling more pain than when in a waking state. c. no differences in the experience of pain. d. they are distracted.

41. Ischemia is another name for a. the cold pressor procedure. b. phantom limb pain. c. chronic pain. d. insufficient blood flow.

42. Higher pain thresholds are reported by people exposed with which of the following experimental stimuli? a. A lecture or a funny movie. b. A funny movie or a baseball game. c. A relaxing tape or a funny movie. d. White noise or a lecture on pain.

43. Which of the following procedures can be used to measure pain threshold? a. The cold pressor procedure. b. The muscle-ischemia procedure. c. Debridement. d. Hypnosis.

44. According to gate-control theory, the proposed gating mechanism is located in a. the substantia gelatinosa. b. the periaqueductal gray. c. the gray matter of the brain. d. the thalamus.

45. According to gate-control theory, the gating mechanism receives input 356

(315)

from a. transmission cells, the periaqueductal gray, and the spinal cord b. A-delta fibers, transmission cells, and c-fibers c. large-diameter fibers, small-diameter fibers, and transmission cells d. pain fibers, other peripheral fibers, and descending messages from the brain

c (316)

b (316)

b (316)

a (317)

d (317)

46. Which of the following closes the gating mechanism according to the gate-control pain theory? a. Depression. b. Anxiety. c. Medication. d. Boredom.

47. According to gate-control theory, who is likely to experience the most pain? a. Arnie, who massaged his shin after he hit it on the coffee table. b. Marge, who is bored and depressed. c. John, who is focusing intently on the good book he is reading. d. Fred, who is watching an exciting baseball game.

48. "Squeaky", a laboratory rat, has an electrode implanted in the periaqueductal gray area of his midbrain. When electrical stimulation is turned on, Squeaky is likely to a. feel pain. b. feel analgesia. c. start vocalizations. d. begin pain behaviors.

49. In stimulation-produced analgesia, a. the release of substance P is blocked. b. substance P is released. c. substance P is manufactured. d. the transmission cells are activated.

50. Franklin fractured his foot during the second half of a soccer match but continued to play for the remainder of the game with little discomfort, due to the release of a. substance P. b. algogenic substances. c. gelatinosa. d. endogenous opioids.

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a (317)

c (317)

d (319)

b (321)

c (321)

d (321)

c

51. The substances known as endorphins and enkephalins a. play a partial role in analgesia. b. are the chemical agents found in aspirin. c. play no role in analgesia. d. are opiates.

52. Before his tooth extraction, David received an injection of naloxone. He is likely to experience a. hallucinations since it is an opioid. b. analgesia. c. pain. d. sedation.

53. An inert substance that produces an effect is called a. naloxone. b. an opioid. c. a neurotransmitter. d. a placebo.

54. Which set of patients is most likely to have a physiological reaction to pain-related words? a. Hypnotized persons. b. Those who use emotion-based coping strategies. c. Migraine sufferers. d. Phantom limb pain patients.

56. Patients with low back pain from which country reported more suffering and disability? a. New Zealand. b. Mexico. c. United States. d. Japan.

57. Which of the following best states the relationship between stress and pain? a. Stress and pain are not related. b. Stress may cause pain but not vice-versa. c. Pain may cause stress but not vice-versa. d. Stress may cause pain and pain may cause stress.

58. The majority of evidence regarding chronic pain and neurotic

(322) maladjustment as measured by the MMPI indicates that

d

a. some people have "pain-prone" personalities. b. psychopathy and pain are not related. c. chronic pain often seems to lead to maladjustment. d. hysteria is the best predictor of chronic pain.

59. Which of the following is a self-report method of pain assessment?

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(325)

d (329)

a. An electromyograph. b. electroencephalograph. c. UAB Pain Behavior Scale. d. McGill Pain Questionnaire.

60. Which of the following is considered evidence that children experience pain? a. "Pain" facial expressions. b. Changes in patterns of crying. c. Rubbing hurt parts of the body. d. all of the above

Short Answer Questions 1. Provide support for the idea that organic and psychogenic pain should be considered as a continuum.

2. Compare and contrast early theories of pain with the gate-control theory.

3. Explain the role of endogenous opioids in the pain experience.

Essay Questions 1. Your medical school friend has the unfortunate attitude that "pain is all in your head."

Convince her otherwise.

2. Using the gate-control theory, devise a plan to minimize pain during your next visit to the dentist.

3. The text author suggests "all pain experiences involve an interplay of both physiological and psychological factors." Provide a comprehensive statement that supports this viewpoint.

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CHAPTER 12 MANAGING AND CONTROLLING CLINICAL PAIN CHAPTER OUTLINE I. Clinical Pain A. Section introduction 1. Definition of clinical pain - any pain that requires or receives professional attention 2. Why treat clinical pain a. deserves treatment in and of itself, not just because it may be a symptom of some progressive disease b. humanitarian reasons c. treatment produces medical and psychosocial benefits for patient B. Acute clinical pain 1. Most acute pain has little survival value.

2. Many surgical patients experience higher-than-necessary pain. a. American Pain Society recommends assessing pain intensity and satisfaction with pain relief after surgery - a 1/3 change in pain ratings probably meaningful pain relief for patients b. unnecessary post-surgical pain may lead to adverse physiological changes which can lead to death C. Chronic clinical pain 1. The realization that pain is chronic frequently leads to helplessness. a. neurotic triad dominates personalities and parallels changes in lifestyles, employment status, and family lives b. half of chronic pain patients reportedly consider suicide c. long-term psychosocial problems and impaired interrelationships can emerge 2. Characteristics of chronic pain syndrome a. symptoms i. tissue damage or irritation ii. persistent pain complaints and pain behaviors iii. disrupted daily activity patterns iv. disrupted social, marital, employment, and recreational activities v. excessive use of drugs or repeated surgery vi. disturbed sleep patterns vii. increased anxiety or depression b. usually first two symptoms plus one of remaining symptoms are demonstrated c. more symptoms patient has, greater impact pain has and greater maladjustment it produces 361

3. Accurate distinction between acute and chronic pain needs to be made to insure that appropriate pain relief techniques are used.

II. Medical Treatments for Pain A. Section introduction 1. Early treatments for pain relief included piercings with a “vigorous” twig, alcohol and medicines laced with opium B. Surgical methods for treating pain 1. Surgery represents a radical approach to treating chronic pain. a. early surgical procedures involved removing or disconnecting parts of the peripheral nervous system or spinal cord to prevent pain i. pain relief didn't last ii. this procedure rarely used today due to possibility of paralysis b. current surgical procedures i. types of procedures - synovectomy - removal of inflamed membranes in arthritic joints - spinal fusion - joins two or more vertebrae to treat severe back pain ii. little evidence these procedures are more effective in long term than non-surgical methods iii. such procedures most appropriate when person is severely disabled and nonsurgical treatments have failed C. Chemical methods for treating pain 1. Section introduction 2. Types of pain-relieving chemicals a. peripherally acting analgesics i. act by inhibiting synthesis of neurochemicals that sensitize nociceptors to algogenic substance at site of damage. ii. examples - aspirin, acetaminophen, ibuprofen. b. centrally acting analgesics i. narcotics that bind to opiate receptors in CNS and inhibit nociceptor transmission or alter perception of pain stimuli. ii. examples - morphine, codeine, Percodan, Demerol. iii. medical concerns about tolerance and addiction over long term use. c. local anesthetics i. block nerve cells in region from generating impulses. ii. examples - novocaine, lidocaine, bupivacaine. iii. long term use not recommended due to side effects.

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d. indirectly acting drugs i. drugs that affect nonpain conditions that produce or contribute to pain. ii. examples - sedatives, tranquilizers, antidepressants 3. Using chemicals for acute pain a. factors that influence administration of medications i. intensity, location, and cause of pain ii. physicians administer drugs based on characteristics of drug, patient and sociocultural factors b. half of all patients are undermedicated i. children and minorities frequently undermedicated ii. reasons - physician beliefs about child's pain perception - physician concerns about addiction - patient not asking for meds c. conventional methods for administering pain medications i. pills or injections - administered on a prescribed schedule or as needed (PRN) ii. epidural block - injection near the spinal cord iii. patient-controlled analgesia - although physicians have been concerned about abuse potential, patients actually decrease medication when given control - caution should be used with young, high anxiety, low social support patients 4. Using chemicals for chronic pain a. narcotics are used for severe pain in terminal illness. i. patients still tend to be inadequately medicated ii. patients may fear addiction and want to be "good" patient iii. narcotics in low doses can provide effective pain relief without progressively larger doses b. increasing use of narcotics approached with caution. i. findings on low dose relationship with addiction need to be confirmed with various types of patients and pain conditions ii. some people are still at high risk for addiction iii. studies are needed to see how daily doses of narcotics affects patients' lives iv. research needs to discover why tolerance and addiction are less likely when taken for pain relief c. chemical methods alone are not enough for controlling pain i. three psychosocial findings that suggest need for other approaches

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- chronic headache patients use maladaptive coping strategies to deal with stressors - arthritis patients with feelings of helplessness before drug treatment report poor treatment results - patients who receive placebo drugs report pain relief 5. Collaborating with other professionals a. team approach may involve physicians, psychologists, and other health professionals. i. patient may be reluctant to accept psychologist's role because interpret it as sign of that physician believes pain isn’t real - physician needs to reassure patient regarding roles of other team members b. role of pain groups i. team members also likely to experience similar problems, provide support for talking about them, can say things to patients that others may not be able to, and can confront patient’s “pain games” c. goals of treatment i. goals include: - reducing frequency and intensity of pain - improving patient’s emotional adjustment - increasing social and physical activity - reducing use of analgesic drugs III. Behavioral and Cognitive Methods for Treating Pain A. Section introduction 1. Impact of gate-control theory on concept of pain and treatment a. theory argued biochemical, motivational, and cognitive processes affect the pain experience i. health care workers have begun to change how they conceptualize and treat pain b. psychological techniques help patients to: i. cope more effectively with pain ii. reduce their reliance on drugs B. The operant approach 1. Initial chapter example involved extinction for pain behaviors and reinforcement for appropriate behavior 2. Operant approach can be used with people from all age groups, in a variety of settings, and both before and after pain has produced difficulty for person.

3. Main goals in operant approaches a. reduce need for medication i. medications are put on fixed administration schedule that receiving meds independent of requests for meds b. reduce disability that accompanies pain conditions 364

i. train people in social environment to monitor and record pain behaviors and reward physical activity 4. Effectiveness of operant techniques a. has been shown to increase activity and decrease use of drugs b. limitations i. when rewards are discontinued, patients have a tendency to revert to old pain behaviors ii. not all chronic pain patients benefit from operant techniques iii. effectiveness is low if patient or others in social environment unwilling to cooperate or if receiving disability benefits C. Fear reduction, relaxation, and biofeedback 1. Fear and stress are identified as triggers for pain a. if fear and stress can be controlled, should be able to reduce pain 2. Fear reduction a. fear leads to avoidance of certain activities, resulting in negative reinforcement b. negative reinforcement makes fear persist c. systematic desensitization helps reduce fears 3. Relaxation and biofeedback a. stress has been thought to trigger migraine and tension-type headaches by dilating arteries/contracting muscles - recent research has found that nervous system dysfunction is involved in these types of headache 4. Progressive muscle relaxation involves focusing attention to specific muscle groups while tensing and relaxing muscles.

5. Biofeedback involves EMG feedback of muscle tension or temperature feedback.

6. Both procedures appear effective in relieving pain. a. clarification to this conclusion i. majority of studies have been done on headache pain ii. although both methods about equally effective with headache pain, EMG biofeedback somewhat more effective - great deal of variability in range of improvements (17-94%). iii. other psychological factors play a role in pain reduction - placebo conditions more effective than simply monitoring headache pain - massage therapy over time can reduce pain - explanation: patient’s thoughts, beliefs, and spontaneous cognitive strategies probably contribute to success of relaxation and biofeedback 7. Durability of effects of relaxation and biofeedback techniques for pain a. Blanchard and colleagues found significant reduction in 365

headache pain in a 5 year longitudinal study. i. these methods don’t provide all pain relief most patients need D. Cognitive methods 1. Section introduction a. thoughts during acute pain i. in one study, 80% of subjects focus on negative emotions and pain - focusing on negative aspects of experience is linked to increased pain b. thoughts during chronic pain i. some people use active coping such as ignoring pain or engaging in interesting activity ii. other people use passive coping, which leads to vicious cycle of learned helplessness and more passivity c. family and friends influence and reinforce coping behaviors d. beliefs about pain influence coping behaviors i. active coping occurs more in those who understand the nature of their pain and believe their condition will improve ii. practitioners need to know and address patients' beliefs 2. Distraction involves focusing on non-painful stimuli in the environment to divert attention. a. technique is most effective with mild or moderate pain b. aspects of task that affects its effectiveness i. amount of attention the task requires ii. if the task is interesting or engrossing iii. the task is viewed as a credible activity to relieve pain 3. Nonpain (guided) imagery involves imagining a mental scene unrelated to or incompatible with the pain for as long as possible a. therapist guides patient to include aspects of different senses in image i. most common images are pleasant b. difference between imagery and distraction i. imagery is based on imagination whereas distraction is focus on real objects in environment c. factors that influence effectiveness i. best when it attracts significant attention and is involving ii. most useful for mild to moderate pain iii. some individuals not adept at imaging scenes 4. Redefinition involves substituting constructive or realistic thoughts for those that arouse feelings of threat or harm. b. varieties of redefinition i. coping statements that emphasize ability to tolerate discomfort ii. reinterpretive statements that negate unpleasant aspects of discomfort 366

iii. information about sensations to expect iv. deconstructing illogical beliefs 5. Value of cognitive strategies in controlling pain a. effectiveness with acute pain. i. distraction and imagery are effective with mild/moderate pain ii. redefinition is effective with strong pain b. effectiveness with chronic pain i. effectiveness depends on severity of pain, type of illness, cognitive methods used - redefinition found to be more effective in relieving chronic pain than distraction in studies on arthritis, amputation, and spinal cord injury ii. programs combining behavioral and cognitive methods as effective as chemical methods in reducing pain IV. Hypnosis and Interpersonal Therapy A. Hypnosis as a treatment for pain 1. Section introduction a. section introduction i. in 1800s, dramatic stories about surgery using only hypnosis as analgesia captured attention 2. Can hypnosis eliminate acute pain? a. surgical patients claim not to feel pain under hypnosis i. presence of pain behaviors suggested that pain was being suppressed - intensity of acute pain was probably reduced ii. hypnosis not effective for all people - people vary in susceptibility to being hypnotized 3. Possible mechanisms responsible for pain reduction effect of hypnosis a. physiological changes in brain and spinal cord b. deep relaxation c. cognitive factors that produce increased attention to internal images 4. In laboratory research, Barber (1982) found a. suggestible people receive the greatest pain relief b. regardless of whether hypnotized or not, subjects who were told to try not to feel pain used distraction and redefinition c. pain reduction from hypnosis equal to that obtained with cognitive strategies 5. Can hypnosis relieve chronic pain? a. hypnosis reduces chronic pain i. studies on recurrent headache, low back pain, cancer pain find hypnosis as effective as relaxation ii. pain relief greatest in those people high is suggestibility - what is it about high suggestibility that helps people 367

apply psychological methods to control pain?

B. Interpersonal therapy for pain 1. Description: a therapy approach that uses psychoanalytic and cognitive-behavioral perspectives to help people deal with emotional difficulties by changing the way they interact with and perceive their social environment. a. purpose of insight therapy i. discover underlying motivations for problems - awareness of motivations may lead to controlling behaviors and emotions.

- showing how pain behaviors are part of "pain games" that maintain identity as "suffering person".

2. Patients and families can come to understand problems in the family system. a. areas explored may be changes in roles, communication, sexual relationship b. benefits include new perspective and increased cooperation c. useful in treating depression that is common in pain patients V. Physical and Stimulation Therapies for Pain A. Section introduction 1. Counter-irritation a. involves concept of reducing one pain by creating another b. historical example i. cupping - placing heated glass cup on skin to produce bruise c. practice forms basis for present-day stimulation techniques B. Stimulation therapies 1. Why counter-irritation works a. distraction from stronger pain to milder pain b. gate-control theory suggests mildly irritating stimuli closes pain gate i. led to the development of transcutaneous electrical nerve stimulation (TENS) in which an electrode is placed on the skin near pain area and a mild electrical current is supplied - success of treatment has been largely anecdotal - generally viewed as not effective for acute or chronic pain and, in those cases where it is successful, effects are short-lived 3. Acupuncture – ancient Chinese technique in which needles inserted into special locations and twirled or electrically charged a. effectiveness is limited i. rarely effective for surgical patients in Western cultures ii. produces only mild analgesia in most people iii. degree of analgesia depends not on location of needle but intensity of stimulation 368

iv. patients who can be easily and deeply hypnotized receive most benefit. v. evidence that procedure may be useful for headache or low back pain. c. Why acupuncture works i. since procedure produces analgesia in some animals, must rule out suggestion or distraction as cause ii. plausible explanations include closing of pain gates or release of opioids C. Physical therapy 1. Treatment involves a variety of techniques to enhance muscular strength and tissue flexibility. a. exercise is common feature of program.

2. Programs, tailored to patient’s needs, are planned between physical therapist and patient. a. paced to increase sense of accomplishment without overexertion, reinjury or failure b. widely used for arthritis and low back pain 3. Research findings comparing physical therapy and cognitive behavioral approach i. both approaches result in pain reduction and improvements specific to program used - physical therapy is linked to improved physical functioning and cognitive-behavioral to improved psychosocial functioning. ii. chronic pain patients might benefit from receiving both treatments in combination VI. Pain Clinics A. Section introduction 1. Pain clinics, or pain centers, provide effective pain control treatments. a. program organization and treatment options vary across centers B. Multidisciplinary programs 1. Intervention methods include medical, psychosocial, physical therapy, occupational therapy and vocational elements in both assessment and treatment.

2. Typical program goals a. reducing pain b. improving functioning c. decreasing drug usage d. enhancing social factors e. reducing use of medical services 3. Services are integrated to achieve specific goals.

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C. Evaluating the success of pain clinics 1. Procedures and results of treatment programs at two pain centers. a. common procedures for programs i. program conducted by hospital-affiliated pain clinic ii. treatment provided on inpatient basis for 4 weeks with weekends off iii. group treatment with variety of treatment techniques iv. staff provided medical, psychological, physical, and occupational therapy v. program included medication reduction procedure, physical therapy, relaxation and biofeedback training, cognitive-behavioral group therapy, family involvement and therapy plus other methods b. results from first program i. assessment at beginning and end of program as well as a 6- and 12-month follow-up ii. at end of program, activity levels had increased and pain experiences and behaviors as well as drug use had decreased iii. at follow-up, activity levels remained high, 1/2 were employed, and pain had continued to decrease c. results from second program i. study design included experimental and control groups ii. at follow-up, treatment group reported less pain, depression, and interference of pain in lives; less use of medications; higher rate of employment 2. Meta-analyses of studies on multidisciplinary treatment for chronic pain a. less pain and more likely to have returned to work b. treatment costs only a fraction of medical and disability payments c. reduction in helplessness and catastrophizing during treatment program led to decreases in pain severity and anxiety d. not all patients benefit from this kind of treatment but most do

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DISCUSSION TOPICS 1. The psychologist and multidisciplinary pain management teams.

For students who may be considering a career as a clinical or counseling psychologist specializing in pain treatment, this article provides some much needed professional perspective. It’s relatively brief and you might wish to assign it to students prior to a discussion. Simon and Folen, themselves both specialists in pain treatment, provide an extensive overview of important issues for psychologists as part of a multidisciplinary pain team. For example, among their tips on developing a working relationship with physicians on the team, they suggest modeling the professional demeanor of one’s medical colleagues and immersing oneself in the “culture of the hospital setting.” Rather than a 9-to-5 work orientation, adopt a work schedule that is responsive to urgent care. Wear a white lab coat so as to fit in with one’s medical colleagues. Write reports with little psychological jargon and make them direct and to the point. One’s office should be in the same building as other medical professionals and be decorated in a similar fashion as theirs. Gain appropriate board certification (the norm in the medical community) and hold memberships in respected pain societies.

Publish in pain journals as opposed to psychological journals.

Simon and Folen also note that a good deal of the activity of the psychologist in such a setting is education of other medical professionals regarding issues such as placebos and assessment of comorbid psychological conditions. These authors also suggest that treatment for psychological intervention is critical before pain interventions begin because of the exacerbation of pain symptoms due to depression and anxiety. In many pain clinics, pain treatment teams are led either by an anesthesiologist, a physician, or a psychologist. Thus, the psychologist in this setting has taken on an increasingly important role.

Source: Simon, E.P., & Folen, R.A. (2001). The role of the psychologist on the multidisciplinary pain management team. Professional Psychology: Research & Practice, 32(2), 125-134.

2. Culture and pain.

Matsumoto raises the issue of cultural differences in pain in his book on Crosscultural psychology. As noted in the previous chapter, culture is very likely to have an influence on every aspect of the pain experience. Specifically, it is likely to affect our perception of pain, the expression of pain, and the treatment of pain. Matsumoto suggests that cross-cultural differences in pain experience may be due to how language affects our perception and cognition. In other words, how we categorize and understand a pain experience may be related to the language we use to describe it.

Given that the McGill Pain Questionnaire contains numerous written descriptions of the pain experience, one point of discussion might be whether the English language contributes to our vast description of pain experience.

Matsumoto also raises the issue of cultural influences on pain display. He suggests that people from different cultures “may have different rules governing the 371

expression, perception, and feeling of pain.” (pg. 160). Since assessment and treatment are closely linked to the observation of and reduction of pain behaviors, this might be another interesting point for discussion with students.

Lastly, Matsumoto contends that cultural differences in pain management techniques might affect the ways in which patient and medical professionals interact.

Discussion might center on some of the intervention techniques that might be more widely used in the US in contrast to those in other countries.

Source: Matsumoto, D. (2000). Culture and psychology: People around the world. (pg. 160).

Belmont, CA: Thomson Learning.

3. Behavioral treatment of chronic pain.

This chapter provides an in-depth presentation of a chronic pain treatment approach using a cognitive-behavioral intervention. Major treatment components include behavior modification, physical therapy, marital therapy, and cognitive restructuring and attributional changes. Assessment techniques are reviewed in detail as is the progression of treatment phases. A sample case is reviewed and examples of scoring charts are included. This chapter would be a good example of a multifaceted treatment program for students to review. Perhaps discussion could also include addressing the cultural points raised in Discussion item #2 above as they might affect this type of treatment program.

Source: Follick, M.J., Ahern, D.K., & Aberger, E.W. (1987). Behavioral treatment of chronic pain. (pp 237-270). In Blumenthal, J.A., & McKee, D.C. (Eds.), Applications in behavioral medicine and health psychology: A clinician’s source book. Sarasota, FL: Professional Resource Exchange, Inc. 4. From the perspective of a biofeedback therapist.

Dr. Aleene Friedman is a biofeedback therapist who, in this brief 1 st person article, describes her treatment experiences with Joyce, a persistent headache sufferer.

More specifically, she describes her use of electromyography (EMG) to help Joyce learn the source of her upper body tension that resulted in her frequent headaches.

Temperature training, imagery, and other lifestyle changes were incorporated to promote general relaxation. This is a brief and interesting example of a biofeedback approach that students would find very readable.

Source: Friedman, A. (1997). Treating chronic pain. (pp 272-276). In Sattler, D.N., & Shabatay, V. (Eds.), Psychology in context: Voices and perspectives. Boston: Houghton Mifflin.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Would behavioral or cognitive methods help your pain? Have students complete Handout # 1. Discuss the recommendations given in the box on pg. 348.

2. Observed pain. While pain can be a highly subjective experience, attempts have been made to assess the presence of pain in a more subjective manner.

Ask the students to identify ways they could tell if someone was in pain.

Compare their responses to the audiovisual cues described by Follick, Ahern, and Aberges (1985). For example, alterations of movement, facial expression, statements and sounds emitted should be included.

Source: Follick, M., Ahern, D.K. & Abergesp E.W. (1985). Development of an audiovisual taxonomy of pain behavior. Health Psychology, 4, 555-568.

3. Pain relievers. Have the students survey a drugstore for pain relieving medications. Collect examples of products available, and types of pains treated.

Classify the medications as peripherally acting analgesics, centrally acting analgesics or local anesthetics. Which contain aspirin, acetaminophen or ibuprofen? Illustrate the number of analgesics listed in the Physician's Desk Reference. Share descriptions of the indication, contraindications and side effects of representative medications.

4. Pain control. Contact a local pain control clinic and invite a practitioner to come to class to talk about various methods of pain control, including hypnosis, biofeedback, therapeutic touch, cognitive-behavioral techniques.

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Handout #1

Assess Yourself: Would Behavioral or Cognitive Methods Help Your Pain?

Instructions: For each of the following questions about your recent experiences relating to pain, put a check mark in the preceding space if your answer is "yes".

______

Have you been experiencing strong pain three or more days a week for more than a month?

______

Do you take painkillers four or more days a week?

______

Do you often take painkillers to prevent pain before it begins?

______

Has your pain been getting worse?

______

Have you cancelled or avoided making social plans in the past month because you thought your pain would interfere with them?

______

Do you ever drink alcohol to relieve your pain or the stress it produces?

______

Have you seen more than three physicians about your pain?

______

Are you afraid of performing physical activities, feeling they could elicit or aggravate your pain condition?

______

Has your pain caused you to feel depressed and helpless for more than a couple of weeks or so?

______

Do family or friends either seem annoyed by your pain or often ask how your pain is doing?

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RESOURCES Suggested Readings: Clinical Pain Bates, M.A. (1996). Biocultural dimensions of chronic pain. Albany: SUNY Press.

Caudall, M.A. (2002). Managing pain before it manages you: Revised Edition. New York: Guilford Press.

Gatchel, R.J. (2005). Clinical essentials of pain management. Washington, DC: American Psychological Association.

Hanson, R.W., & Gerber, K.E. (1990). Coping with chronic pain: A guide to patient self-management. New York: Guilford Press.

Johnson, C. & Webster, D. (2002). Recrafting a life: Solutions for chronic pain and illness. New York: Brunner-Routledge.

Keefe, F.J., Crisson, J.E., Urban, B.J., & Williams, D.A. (1990). Analyzing chronic low back pain: The relative contribution of pain coping strategies. Pain, 40, 293-301.

Mercado, A.C., Carroll, L.J., Cassidy, J.D., & Cote, P. (2000). Coping with neck and low back pain in the general population. Health Psychology, 19(4), 333-336.

Salerno, E., & Willens, J.S. (1996). Pain management handbook: An interdisciplinary approach. St.Louis: Mosby.

Sinatra, R.S. (Ed.) (1992). Acute pain: Mechanisms and management. St.Louis: Mosby-Year Book.

Thomas, V.N. (Ed.) (1997). Pain: Its nature and management. London: Balliere Tindall.

United States Department of Health and Human Services. (1991). Working together to relieve your pain. Bethesda, MD: author.

Wall, P.D., & Jones, M. (1991). Defeating pain. New York: Plenum Press.

Medical Treatments for Pain Fishman, S. (2000). The war on pain: How breakthroughs in the new field of pain medicine are turning the tide against suffering. New York: HarperCollins.

Behavioral and Cognitive Methods for Treating Pain Bittman, B. (1995). Reprogramming pain: Transform pain and suffering into health and success. Norwood, NJ: Ablex.

Hatch, J.P., Fisher, J.G., & Rugh, J.D. (1987). Biofeedback: Studies in clinical efficacy.

New York: Plenum Press.

Philips, H.C., & Rachman, S. (2001). The psychological management of chronic pain (2nd ed.). New York: Springer.

Tumlin, T.R. (2001). Treating chronic pain patients in psychotherapy. Journal of Clinical Psychology, 57(11), 1277-88.

Winterwood, C., Beck, A.T., Gruener, D. (2003). Cognitive therapy with chronic pain patients. New York: Springer Publishers.

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Hypnosis and Insight-Oriented Psychotherapy Fredericks, L.E. (2001). The use of hypnosis in surgery and anesthesiology.

Psychological preparation of the surgical patient. Springfield, IL: Charles C. Thomas.

Friedman, A.M. (1992). Treating chronic pain: The healing partnership. New York, NY: Insight Books/Plenum Press.

Hilgard, E.R. & Hilgard, J.R. (1994). Hypnosis in the relief of pain. Philadelphia, PA: Brunner/Mazel.

Pain Clinics Burns, J.W. (2000). Repression predicts outcome following multidisciplinary treatment of chronic pain. Health Psychology, 19(1), 75 -84.

Suggested Films and Videos: 1. Acute pain management. (1993, Medcom/Trainex, 28 min). Presents new pain management guidelines.

2. Anesthesia in a nutshell. (2004, Network for Continuing Medical Education, 60 min).

Discusses the critical role of the anesthesiologist in the management of pain in surgery patients.

3. Pain management. (Films for the Humanities & Sciences, 30 min). Part of the Doctor is in series, this film illustrates approaches to pain control and includes footage with Dr. Ronald Melzack.

4. Pain relief advances. (2000, Edudex, 30 min). New advances in the treatment of pain are reviewed.

5. Pregnancy, labor, and delivery – Pain control during labor and delivery. (2004, Concept Media, 29 min). Explores pharmacological and non-pharmacological methods for managing the pain of labor.

6. The management of pain. (2003, Films for the Humanities and Sciences, 25 min).

Looks at three types of pain medications, their origins and actions, as well as alternative treatments.

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Internet sites of interest: Organizations 1. http://www.paincare.org/ - The National Foundation for the Treatment of Pain 2. http://www.aapainmanage.org/ - the American Academy of Pain Management 3. http://www.asipp.org/ - American Society of Interventional Pain Physicians 4. http://www.sppm.org/ - Society for Pain Practice Management 5. http://www.achenet.org - American Councial of Headache Education 6. http://www.pain.com/ - a website devoted to information on pain and pain management.

Pain Management Information 7. http://www.diamondheadache.com - information on Diamond Headache Clinic 8. http://www.spine-health.com - information on treatment for back pain.

9. http://www.mensanaclinic.com/ - Mensana Clinic specializing in treatment of chronic pain.

10. http://www.childcancerpain.org/home.cfm - Cancer Pain Management in Children website 11. http://www.painlab.com/ - PainLab website 12. http://www.painresearch.utah.edu/crc/CRCpage/patients.html - Pain resources for patients and their families 13. http://www.painmngt.com/ - Pain Management Online

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TEST QUESTIONS True or False F

1.

In the United States, only 25% of patients experience high levels of pain following surgery.

2.

With chronic pain, one's personality may become dominated by the neurotic triad of hypochondriasis, depression and hysteria.

3.

In a synovectomy, the surgeon disconnects portions of the peripheral nervous system to prevent pain signals from reaching the brain.

4.

Aspirin and acetaminophen are examples of centrally-acting analgesics.

5.

According to operant approaches, placing medications on a fixed administration schedule should reduce requests for medications.

6.

Distraction and guided imagery work best with mild to moderate pain.

7.

The mechanisms that explain how hypnosis works in the reduction of pain are now clearly understood.

8.

Interpersonal therapy is designed to help people deal with chronic pain by changing the way they interact with and perceive their social environments.

9.

Acupuncture effectiveness has been shown to be totally due to psychological factors.

10.

A physical therapist is most likely to apply exercise, massage, traction, heat and cold as treatments for pain.

(334)

T (335)

F (336)

F (337)

T (340)

T (346)

F (348)

T (349)

F (351)

T (352)

378

Matching Match the following with the descriptions in one through five. a. peripherally acting analgesics b. centrally acting analgesics c. epidural block d. biofeedback e. TENS d

1. May involve recording of EMG.

(350)

c

2. Injection of local anesthetic to area surrounding spinal cord.

(338)

a

3. Examples include aspirin and acetaminophen.

(337)

e

4. Involves electrical stimulation.

(350)

b

5. Examples include codeine, morphine and demerol.

(337)

Match the following pain control techniques with the statements in six through ten. a. operant approach b. acupuncture c. distraction d. redefinition e. interpersonal therapy a

6. Changes the consequences of the pain behavior.

(340)

c (344)

7. Whenever she goes to the dentist, Clare counts the ceiling tiles while the dentist works.

d

8. Appears to be most effective with strong pain.

(346)

e (349)

9. May help an individual understand the role of reacting to others as affecting his or her pain.

b

10. Based on the counter-irritation principle.

(351)

379

Multiple Choice c (334)

a (334)

a (334)

c (335)

b (335)

a (336)

1. The term clinical pain refers to a. acute pain only. b. pain experienced only in clinical settings. c. pain that requires or receives professional treatment. d. chronic pain only.

2. According to the book, which of the following is a reason to treat clinical pain? a. It may be a sign of progressive disease. b. It increases contact with medical professionals. c. It provides social contacts. d. It changes important health beliefs.

3. Which of the following is true regarding acute pain? a. It often has no survival value. b. It responds poorly to treatment. c. It rarely is influenced by psychosocial factors. d. It does not hurt as much as chronic pain.

4. Which of the following statements best describes the relationship between psychosocial problems and pain? a. Psychosocial problems are experienced most frequently by acute pain sufferers. b. Psychosocial problems tend to precede rather than follow pain experiences. c. Psychosocial problems are more characteristic of chronic pain than acute pain sufferers. d. Psychosocial problems are not related to pain.

5. Which of the following is not associated of chronic pain syndrome? a. Excessive drug use to relieve pain. b. Enhanced marital satisfaction since families are drawn together more closely during this time. c. Disturbed sleep patterns. d. Increased depression.

6. Chronic and acute pain a. require different pain relief techniques. b. do not respond well to drugs. c. are treated with the same techniques. d. do not present unique problems for treatment programs.

380

a (336)

c (336)

d (336)

d (336)

d (337)

a (338)

7. Common pain relievers in 19th century America were a. alcohol and medicinal elixirs laced with opiates. b. antidepressants and Valium. c. Tylenol and ibuprofen. d. twigs and massage.

8. To relieve her pain, Diana's physician has disconnected portions of her spinal cord. Diana is likely to experience a. long lasting, permanent pain relief. b. paralysis but no immediate pain relief. c. an eventual return of her pain. d. none of these 9. The procedure known as synovectomy is most often used in the treatment of a. low back pain. b. acute pain. c. phantom limb pain. d. arthritis.

10. Under what conditions are surgical pain relief methods likely to be used? a. If the patient lives in the United States. b. If the patient is severely disabled. c. When nonsurgical pain treatments have failed. d. all of the above 11. Which of the following characteristics are likely to influence physicians’ decisions regarding which drug and dosage to administer to a patient for pain relief? a. Intensity, location, and cause of the pain b. Characteristics of the patient c. Sociocultural factors d. all of the above 12. Which of the following patients is most likely to be undermedicated? a. 8 year-old Jamie b. 20 year-old Annette c. 20 year-old Kevin d. 60 year-old Mary

381

d (338)

b (338)

d (338)

a (337)

b (337)

b (338)

13. Research regarding the administration of pain-killers to children shows that a. drugs are given to them less frequently. b. they are given doses below recommended levels. c. their dosages are discontinued earlier than adults. d. all of the above 14. Which of the following is a reason that children are undermedicated? a. The belief that children can't develop addiction. b. Fewer requests for medication from children. c. Concerns that children experience more pain and thus require more medication than is safe. d. Concerns that they are simply seeking attention when they ask for medication.

15. The abbreviation "PRN" refers to a. taking the drug on a fixed schedule. b. a computerized pump that delivers a dose of drug into a vein. c. the practitioner recommending no medication. d. giving the drug as needed to control symptoms.

16. Aspirin is to _____ as morphine is to _____. a. peripheral; central b. central; periperal c. indirect; local d. local; indirect 17. The class of pain reliever most likely to produce increased tolerance and addiction is a. peripherally acting analgesics. b. centrally acting analgesics. c. local anesthetics. d. indirectly acting drugs.

18. Studies with patient-controlled analgesia have shown a. high probabilities of abuse. b. low abuse risk. c. they are not effective with cancer patients. d. patients administer the medication as directed.

382

d (338)

d (338)

c (338)

a (339)

d (338)

b (339)

19. Which group is more likely to self-administer more pain-killers than needed? a. Patients who are relatively young. b. Patients with high levels of anxiety. c. Patients who have low levels of social support. d. all of the above 20. Nadine is dying from cancer. Her physician likely to prescribe what medication for her? a. Acetaminophen. b. Novocaine. c. Sedatives. d. Narcotics.

21. Some research regarding the use of narcotic pain-killers with phantom limb pain indicates that a. addiction usually results. b. increased tolerance usually results. c. pain was reduced without increased tolerance. d. none of the above.

22. Which of the following reflects the clinical caution regarding the use of narcotics for chronic pain? a. Clinical research needs to be done on a wider variety of chronic pain conditions. b. The clinical effects of taking narcotics daily are widely known but seldom considered in treatment. c. Researchers know why low addiction levels occur when such drugs are taken for pain relief but ignore this information. d. Acupuncture is a far more effective treatment.

23. Which of the following is not a frequently cited reason for physicians' preference not to use drugs for long-term pain control? a. Undesirable side effects from these drugs. b. The possibility of physical dependence. c. Drugs' lack of sufficiency in controlling pain. d. Long term expense of the medications.

24. Research using placebos with headache patients reveals that a. placebos do not affect headache patients. b. important psychological processes influence pain control. c. the placebo effect does not occur in instances of chronic pain. d. the placebo effect is only seen in instances of chronic pain.

383

a (339)

b (339)

c (340)

d (340)

c (341)

25. When referring psychological consultations for chronic pain patients, physicians should a. explain the rationale for the referral to the patient. b. turn the treatment completely over to the psychologist to reduce confusion. c. pay as little attention to the patient's discomfort as possible so as not to reinforce it. d. all of the above.

26. Which of the following is not an advantage of group over individual therapy in pain-coping? a. More efficient use of therapist time. b. Increased isolation from others. c. The risk that the patient will stop listening to the therapist altogether. d. A new patient social network.

27. A 4-year-old burn patient is recovering more slowly than expected. A psychologist observes that medical staff is reinforcing some of the child's behaviors and allowing her to avoid uncomfortable activities. She suggests that medical staff ignore the pain behaviors and reinforce the coping behaviors. The psychologist is advocating principles of a. classical conditioning. b. specificity theory. c. operant conditioning. d. gate-control theory.

28. Which of these is a major goal in the operant approach to treating chronic pain patients? a. Keeping pain behaviors from becoming chronic. b. Reducing reliance on medication. c. Reducing accompanying disability. d. all of the above 29. For which type of chronic pain is the operant approach least likely to be successful? a. recurrent b. intractable c. progressive d. it is not successful with any type of chronic pain

384

a (341)

a (342)

b (342)

a (342)

c (344)

b (343)

30. Among the current limitations to the use of operant procedures for chronic are which of the following? a. Patients return to old pain behaviors when intervention is concluded. b. Almost all chronic pain patients benefit from them so there really are no limitations. c. Operant procedures work well regardless of levels of cooperation. d. Disability compensation has no demonstrable effects on behavioral improvements in pain treatment.

31. Tension headaches can be treated with which type of biofeedback? a. EMG. b. Temperature. c. EKG. d. EEG. 32. Most studies on the effectiveness of relaxation and biofeedback have been conducted on a. phantom limb pain. b. headaches. c. arthritis. d. pain associated with cancer.

33. The age group that seems most likely to benefit from biofeedback and relaxation-based pain control is a. children and those who show certain physiological patterns b. young adults. c. middle-aged. d. elderly.

34. When getting an injection at the dentist's office, most children think of a. school. b. pleasant thoughts. c. negative emotions and pain. d. escaping the situation.

35. One of the problems with Blanchard’s longitudinal research on headache is a. the lack of a control group. b. the high rate of participant drop-out. c. the use of ineffective pain reduction techniques. d. the inappropriate use of headache diaries.

385

a (344)

a (344)

c (344)

b (344)

c (344)

a (344)

36. Focusing thoughts on the unpleasant aspects of a painful experience tends to a. make the pain worse. b. lessen the pain. c. lead to hypnotic states. d. have no effect on experienced pain.

37. Which is an example of passive coping with chronic pain? a. Canceling a date and going to bed. b. Calling a friend and chatting. c. Working on a crossword puzzle. d. Building a birdhouse.

38. Who is most likely to use an active coping strategy in dealing with chronic pain? a. Sarah, who believes her doctor doesn't know the source of her pain. b. Tim, who believes his pain will continue indefinitely. c. Trudy, who believes she understands the nature of her condition. d. Rodney, who doesn't know what causes his pain.

39. Rochelle suffers from phantom limb pain, ever since her leg was amputated following a car accident. She deals with the constant pain by focusing on her personal exercise and rehabilitation program, lifting weights and swimming several times a day. This is an example of a. passive coping. b. active coping. c. progressive muscle relaxation. d. EMG biofeedback.

40. One conclusion regarding patients’ beliefs about pain is that a. they have little influence on the pain experience. b. they have little to no relationship to coping with pain. c. physicians need to take these beliefs into consideration when treating pain. d. most thoughts about how to deal with pain are positive.

41. Which of the following is not a class of pain-coping cognitive strategies? a. biofeedback. b. distraction. c. imagery. d. redefinition.

386

c (344)

a (345)

a (345)

c (345)

b (346)

c (346)

42. Distraction efforts at pain control are most effective when the a. pain is strong. b. pain is diffuse. c. pain is mild or moderate. d. the technique commands little attention.

43. Michael thinks about lounging on a beautiful beach to take his mind of the pain of a series of shots at the doctor's office. He is using the cognitive strategy of a. imagery. b. redefinition. c. reflection. d. rejection.

44. Imagery differs from distraction in that it is based upon a. the person's imagination. b. intuitive sense. c. real events. d. real objects.

45. One of the advantages of imagery over distraction is that a. it is successful with severe pain whereas distraction is not. b. it requires little involvement or attention. c. it involves the use of a scene that can be easily carried in one’s head. d. most people are quite adept at imagery.

46. During painful leg-strengthening exercises following knee surgery, Marvin continued to tell himself that, "It hurts, but this must be done if I am to walk without a limp." He was using the cognitive strategy of a. imagery. b. redefinition. c. distraction. d. remission.

47. According to researchers, the most effective cognitive strategy for strong and chronic pain appears to be a. imagery. b. local anesthetic. c. redefinition. d. distraction.

387

b

48. Which of the following is an important determinant in the effectiveness of cognitive methods on pain reduction?

(346)

a. The severity of the pain. b. The type of illness. c. The cognitive method used. d. all of the above b (348)

b (349)

d (349)

c (349)

b (350)

49. Which of the following statements about hypnosis is most accurate? a. Most people can be easily hypnotized. b. Relaxation strategies are as effective as hypnosis in pain reduction among most people. c. Hypnosis simply does not work at an anesthetic. d. Hypnosis works solely by activating endorphins.

50. The concept of a “pain game” refers to a. an operant conditioning treatment approach. b. playing the role of “suffering person.” c. a distraction technique to takes one’s mind off the pain. d. a physical therapy approach that involves exercise and sporting events.

51. Which statement best summarizes the impact of hypnosis in pain control? a. Patients use distraction and redefinition techniques only when told to do so under hypnosis. b. Cognitive strategies produce more pain relief than does hypnosis. c. The deep relaxation that people who are hypnotized experience is the sole reason for the effectiveness of hypnosis in pain relief. d. Regardless of whether a patient receives hypnosis or relaxation therapy, persons who are high in hypnotic suggestibility benefit the most.

52. Interpersonal therapy is incorporated in pain treatment programs because a. patients learn how to play “pain games” with their family members during the course of treatment. b. patients have the opportunity to discover who is causing them the most trouble in their lives and confront them. c. patients gain insight into the motivations for their behaviors and how their behaviors toward others affect their adjustment. d. pain patients tend to experience psychotic symptoms.

53. The basis for stimulation pain-reduction therapies is the principle of a. mental imagery. b. counter-irritation. c. operant conditioning. d. classical conditioning.

388

d (350)

c (351)

b (352)

d (352)

54. Transcutaneous electrical nerve stimulation it based upon the view that counter-irritation works on the principles of a. operant conditioning. b. classical conditioning. c. specificity theory. d. gate-control theory.

55. Which of the following pieces of evidence fails to support the idea that acupuncture works due to the power of suggestion? a. Acupuncture appears to work better in highly suggestible people. b. Patients who benefit from acupuncture are well indoctrinated. c. Analgesia effects can be demonstrated with acupuncture in animals. d. Gate-control theory cannot account for the effects of acupuncture.

56. Enhancing muscular strength and tissue flexibility to restore range of motion in pain patients is an important goal of a. progressive muscle relaxation. b. physical therapy. c. insight therapy. d. EMG biofeedback.

57. Amanda’s pain therapy includes exercise, traction, and massage. Amanda is most probably seeing a person who specializes in a. transcutaneous electrical nerve stimulation. b. acupuncture. c. group psychotherapy. d. physical therapy.

d

58. Studies of the relative effects of physical therapy and behavioral/cognitive (352) programs in the treatment of chronic low back pain have shown that a. neither is very effective. b. only physical therapy is effective. c. only behavioral/cognitive programs are effective. d. both approaches show good effects specific to their area of focus. d (352)

59. Most backaches are due to which of the following? a. Normal wear and tear on joints in the spine. b. Muscle or ligament strains. c. Lack of exercise. d. all of the above

389

d (354)

60. Compared to patients who don’t attend multidisciplinary pain clinics, patients who do a. still have great difficulty with depression. b. are less likely to be working a year after discharge. c. are more likely to play “pain games.” d. experience far less pain at followup.

Short Answer Questions 1. Compare and contrast acute clinical pain with chronic clinical pain.

2. Compare and contrast behavioral versus cognitive methods for pain treatment.

3. Your confused cousin is upset that her son is going away to a pain clinic because she’s heard that all they do there is play “pain games.” Educate your dear cousin on the concept of pain games and how they relate to the pain experience and treatment.

Essay Questions 1. Discuss three issues pertaining to the use of chemicals for acute pain compared to the use of chemicals for chronic pain.

2. Your close friend is debating whether to go to a psychologist who uses biofeedback versus a psychologist who uses hypnosis to treat her chronic back pain. Provide a convincing set of evidence to inform her choice.

3. You have just begun work as a pain specialist in a multidisciplinary program pain clinic. Explain to your closest relative what it is that you do for a living.

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CHAPTER 13 SERIOUS AND DISABLING CHRONIC HEALTH ILLNESSES: CAUSES, MANAGEMENT, AND COPING CHAPTER OUTLINE I. Adjusting to a Chronic Illness A. Initial reactions to having a chronic condition 1. Sequence of reactions a. shock is usually the first reaction after being diagnosed i. phase characterized by feeling stunned/bewildered, behaving in automatic fashion, and feeling detached from situation ii. more pronounced when little warning b. the next phase is a period of emotion focused coping such as denial or grief c. patients tend to come to the reality of their situation and reach some form of adjustment 2. Use of denial and other avoidance strategies a. allow patient to control emotional responses to stressor b. usefulness has limits and may become maladaptive i. gain less information about condition.

B. Influences on coping with a health crisis 1. Initial reactions to acute versus chronic conditions a. first phases in coping are similar regardless of whether the condition is acute or chronic b. unlike acute conditions, chronic problems require patients and families to make permanent behavioral, social, and emotional adjustment 2. Crisis theory describes factors that combine to influence adjustment during crisis. a. factors contributing to coping process i. illness-related factors ii. background and personal factors iii. physical and social environmental factors 3. Illness-related factors a. some illnesses pose a greater threat than others i. may be more disabling, disfiguring, painful or life-threatening ii. annoying or embarrassing changes to body functioning cause difficulty in coping iii. conditions that drawn attention from others can raise feelings of self-consciousness or of being stigmatized b. aspects of treatment regimen i. may be painful or have medications with severe side effects ii. require treatment schedules or time commitments that interfere with their lifestyle and holding a job 391

4. Background and personal factors a. people who cope well with chronic health problems have psychological and behavioral resources to deal with them i. often have hardy or resilient personalities b. other factors that influence coping. i. age ii. gender - men more threatened by conditions that decrease vigor and physical capabilities or place them in a more dependent role iii. social class iv. philosophical or religious commitments v. emotional maturity vi. self-esteem c. timing of health problem in life span i. young children - concerned with restrictions on lifestyle, frightening medical procedures, or being separated from parents. ii. adolescents – can understand illness, but the need to be accepted by peers can lead to difficulty coping iii. early adults - resent not having the chance to develop life in desired direction iv. middle-aged adults - concerned with disruptions to established roles and lifestyles v. older adults - resent not being able to enjoy leisure after a lifetime of work d. impact of self-blame i. higher levels of self-blame for condition are related to poor coping and depression 5. Physical and social environmental factors a. physical aspects of environment i. dull or confining atmosphere of hospital may depress morale/mood ii. home environment may interfere with getting around or lack special equipment needed b. social aspects of environment i. presence of social support generally helps patients cope. ii. sometimes the social network can undermine coping with poor examples or advice iii. primary social support comes from immediate family or friends and neighbors iv. support groups exist for many illnesses C. The coping process 1. Section introduction a. stages in coping process according to crisis theory i. coping begins with cognitive appraisal ii. outcome of appraisal leads to developing array of adaptive 392

tasks and applying coping skills to these tasks 2. The tasks and skills of coping a. two types of adaptive tasks i. tasks related to illness or treatment 1. coping with symptoms/disability 2. adjusting to hospital environment/medical procedures 3. establishing good relationship with physician ii. tasks related to general psychosocial functioning 1. controlling negative feelings/maintaining positive outlook 2. maintaining self-image and sense of competence 3. preserving good relationships 4. preparing for uncertain future b. tasks can be difficult, especially when health problems may lead to disability, disfigurement, or death c. patients adapt well when family members participate in actively, encourage self-sufficiency, and respond to needs in a caring manner c. coping strategies for chronic health problems i. denying or minimizing seriousness of situation ii. seeking information about health problem and treatment procedures iii. learning to provide one’s own medical care iv. setting concrete limited goals v. recruiting instrumental and emotional support vi. considering possible future events vii. gaining a manageable perspective d. some coping skills may be more appropriate for dealing with some tasks than others 3. Long-term adaptation to chronic health problems a. process of adaptation i. defined as making changes to adjust constructively to life’s circumstances and enhance quality of life - quality of life - degree of excellence in one’s life b. effective long-term coping is related to having psychological resources to appropriate coping strategies i. heavy use of avoidance is related to poor adaptation II. Impacts of Different Chronic Conditions A. Asthma 1. What Is asthma? a. clinical characteristics i. a respiratory disorder involving bouts of impaired breathing due to inflamed and obstructed airways

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b. asthma statistics i. 6% of the population suffers from asthma. ii. prevalence higher in children - 1/4th childhood asthma gone by adulthood iii. about 4,000 asthmatics die due to attacks each year - death rates for children higher in African Americans iv. leading cause of short-term disability in US - 14.5 million lost work days,14 million lost school days, 2 million emergency room visits, and 465,000 hospitalizations 2. The physiology, causes, and effects of asthma a. most asthma attacks begin when immune system is activated in allergic response. i. bronchial tubes release histamine which causes bronchial muscles to become inflamed, spasm, and produce mucus. ii. tissue damage leading to greater likelihood for future attacks can occur. b. causes of attacks i. presence of triggers usually prompts attacks - personal factors - respiratory infections; anger or anxiety - environmental conditions - air pollution, pollen, or cold temperature - physical activities - strenuous exercise ii. individual differences in triggers occur iii. main triggers tend to be allergens c. role of immune processes in asthma i. evidence of bone marrow donors transmitting their allergies and asthma to recipients d. factors that cause asthma to develop i. heredity ii. history of respiratory infection iii. exposure to cigarette smoke 3. Medical regimen for asthma a. three components for treatment i. avoiding known triggers ii. using medications such as bronchodilators and antiinflammatories iii. exercising b. treatment regimen tend to combine fitness training and medication. i. adherence to regimen is important - many asthmatics don’t take medication to prevent attacks or take it incorrectly during attacks

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4. Psychosocial factors in asthma a. attacks may be triggered by stress or emotional states b. suggestion may trigger an attack i. evidence - placebo study using graduated strengths of allergen, false feedback of airway obstruction, and placebo asthma medication c. asthma attacks have been related to family maladjustment i. living with asthma may lead to emotional problems in family ii. maladjustment in family may lead to asthmatic episodes B. Epilepsy 1. Section introduction a. clinical characteristics i. recurrent, sudden seizures due to cortical electrical disturbances b. types of epilepsy i. grand mal or tonic clonic attacks begins with a loss of consciousness with progression to muscle spasms. ii. milder forms of seizures involve staring blankly and slight facial twitching c. epilepsy statistics i. prevalence rates are that condition affects 1% of worldwide population - 2.5 million in U.S., 180k new cases a year - many are undiagnosed and untreated ii. 1/3 of epileptics experience first seizure before age 20. iii. risk factors - family history - severe head injury - infections of the central nervous system - stroke

395

d. what to do for a seizure i. prevent injury from falls or flailing ii. do not put anything in the person’s mouth iii. do not restrain the person iv. if the person hasn’t come out of attack within 5 minutes, call ambulance v. when person regains consciousness, describe what happened and see if help is needed 2. Medical regimen for epilepsy a. main medical treatment is anticonvulsant medication i. must be taken regularly to get appropriate serum concentration in blood b. surgical options i. may be used if attacks are frequent and severe and other methods haven’t worked ii. 80% may be symptom-free after surgery 3. Psychosocial factors in epilepsy a. epileptic condition may stigmatize the person among people who don’t understand i. seeing an attack may arouse fear in observers b. having strong seizures may be associated with cognitive and motor impairments that limit eligibility for certain activities or jobs c. how epilepsy is related to other psychosocial factors i. emotional arousal may trigger attacks ii. severe and frequent episodes may result in poor adjustment, anxiety, or depression C. Nervous system injuries 1. The prevalence, causes and physical effects of spinal cord injuries a. clinical characteristics of spinal cord injury i. compression, tear or severing of the spinal cord resulting in loss of motion, control, sensation or reflexes ii. degree of impairment depends on amount of damage and location - quadriplegia/tetraplegia - paralysis resulting from spinal cord damage in the neck region - paraplegia - paralysis in legs when spinal cord damage is lower in spinal column b. spinal cord injury statistics i. 250,000 persons have spinal cord injuries with 11,000 new cases each year ii. majority of cases are males under 30 years of age

396

iii. common causes of spinal cord injuries - automobile and motorcycle accidents - falls - sporting activities - wounds c. physical effects of spinal cord injuries i. long-term effects - full extent of recovery difficult to predict for six months - if spinal cord not severed, considerable recovery may occur over a long time - if spinal cord is severed, autonomic functions may recover, but other functions not d. progress of care i. initial care is directed toward medical needs ii. once condition is stabilized, rehabilitation begins iii. major goal for psychologists during rehabilitation is to help patient adjust to demands and limitations of rehabilitation 2. Physical rehabilitation a. goals of rehabilitation i. regaining as much physical functioning as damage will allow ii. becoming as independent in functioning as possible b. phases of rehabilitation i. initial phase - developing bladder/bowel control and maintaining range of motion ii. intermediate phase - improve function in muscles over which person has control iii. last phase - extend therapy to include activities of daily living 3. Psychosocial aspects of spinal cord injury a. main challenges after spinal cord injury i. average years of life for quadriplegics is 38, 45 for paraplegics ii. need to learn to make most of remaining abilities and lead a full life b. family and friends may influence adjustment i. providing the opportunity for patient to redefine self-concept ii. providing social support without being overprotective c. role changes in wage earning and family responsibilities may occur d. concerns with sexual functioning and fertility vary with gender. i. serious barriers to sexual functioning are psychosocial in nature ii. counseling and education can reduce these barriers e. other psychosocial experiences i. negative thoughts about themselves, future, and relation to others ii. physical barriers in the environment iii. being treated strangely by others may reduce self-esteem, 397

contribute to depression and substance use D. Diabetes 1. Section introduction a. clinical characteristics of diabetes mellitus i. too much glucose in the blood, or hyperglycemia, occurs because of insufficient insulin produced by the pancreas b. prevalence i. prevalent illness worldwide ii. 13 million diagnosed and 5 million undiagnosed cases in US iii. prevalence increases with age iv. women of color are at greater risk 2. The types and causes of diabetes a. Type I or insulin-dependent diabetes mellitus i. typically develops in childhood or adolescence ii. accounts for 5-10% of cases iii. autoimmune processes have destroyed cells of pancreas iv. injections of insulin are required to prevent complications - ketoacidosis - high levels of fatty acids that lead to kidney malfunctions allowing waste buildup which poisons the body b. Type II or non-insulin-dependent diabetes mellitus i. most prevalent form of diabetes ii. pancreas produces some insulin iii. treatment involves special diets and medication iv. usually appears after age 40, in the overweight v. in overweight Type II cases, bodies appear resistant to glucose-reducing action of insulin vi. in normal weight Type II cases, pancreas produces less insulin c. causes of diabetes i. genetic factors found in heredity studies ii. Type I cases are linked to viral infection iii. Type II cases are linked to diets high in fat and sugar, stress, and over-production of protein that impairs metabolism of sugars/carbohydrates 3. Health implications of diabetes a. diabetes as a direct cause of death i. 70,000 deaths are caused by diabetes annually due to acute complications - acute complications can be avoided by following recommended medical regimen

398

b. diabetes as an indirect cause of disabling health problems i. health problems associated with diabetes include neuropathy, blindness, kidney disease, gangrene, heart disease, and stroke ii. indirect effects of diabetes are due to impact on the vascular system 4. Medical regimens for diabetes a. main approaches to treating diabetes i. medication, diet, and regular exercise under medical supervision ii. risks associated with diabetes can be markedly reduced if diabetics carefully follow treatment regimens iii. full extent of reduced risk unclear because long term complications don’t appear for many years 5. Do diabetics adhere to their regimens? a. noncompliance is a major problem in managing diabetes. i. diabetics tend to administer wrong dosage of insulin, test glucose incorrectly, do not follow recommended diets b. adherence to regimen i. diabetics try to adhere but base behaviors on inaccurate perceived symptoms ii. many diabetics can make crude estimates of their glucose, but are not usually very accurate iii. diabetics often have more difficulty following dietary and exercise than the medical aspects 6. Self-managing diabetes a. components of self-care activities i. self-monitoring blood glucose - testing blood for presence of glucose - tests may be done once or several times a day ii. taking insulin and oral medication - medications can increase insulin production or decrease glucose production - insulin injections may be used, the dosage depends upon size, age, food intake, and activity level - insulin pumps may be used to deliver drug continuously - knowing how much insulin to inject is difficult to judge iii. diet and exercise.

- recommended diets focus on reducing sugar and carbohydrates, achieving healthy body weight, and maintaining balanced intake of nutrients - physical activity burns glucose so regular exercise complements dietary efforts

399

7. Psychosocial factors in diabetes care a. compliance to diabetes treatment regimen i. diabetes treatment regimen tend to have all the characteristics that lead to low compliance - complexity - long duration - requiring changes to lifestyle - focus on prevention instead of cure ii. perceived social support and feelings of self-efficacy affect compliance. b. coping processes i. stress affects blood sugar levels.

- directly affects levels of epinephrine and cortisol which cause pancreas to decrease insulin production and liver to increase glucose production ii. indirectly affects blood glucose through effects of nonadherence iii. loss of personal control can lead to severe depression, which can effect glucose control c. life circumstances i. testing glucose levels affected by embarrassment, forgetting, sleeping patterns, poor diet judgments ii. temporary weight gain can occur when glucose is controlled, leading some to stop taking insulin to control weight iii. dietary recommendations may be incompatible to food habits in certain ethnic groups iv. feelings of frustration may occur when diet is followed but glucose targets aren’t met v. if patients don’t feel ill they tend not to follow regimen d. differing patient and doctor goals i. research has revealed that children’s blood glucose levels are more strongly associated with parents’ goal of mild/moderate hyperglycemia than doctor’s goal of normal glucose level 8. When the diabetic is a child or adolescent a. presence of a diabetic child in the family may cause stress and readjustment b. factors that affect child’s experience with diabetes i. little knowledge about the disease ii. aspects of the regimen that sets them apart

400

c. responsibility for following regimen i. parents monitor care during childhood ii. children who are given too much responsibility of poorer glucose control iii. when adolescents assume care, compliance is lower and affected by peer pressure - hormonal changes make controlling blood glucose more difficult - those who are socially competent with high levels of self-esteem and strong parent relationships more likely to adhere E. Arthritis 1. Section introduction a. clinical characteristics i. rheumatic diseases consist of over 100 disorders that affect muscles, joints, and connective tissue near the joints and cause pain, stiffness, and inflammation ii. rheumatic diseases that affect the joints are called arthritis 2. The types and causes of rheumatic diseases a. types of rheumatic diseases i. osteoarthritis - a degeneration of joints associated with wear - risk increases with age, body weight, and occupations that stress the joints ii. fibromyalgia - pain and stiffness in muscles and soft tissue iii. gout - excess uric acid leaves crystalline deposits at the joints iv. rheumatoid arthritis - inflammatory disease of the joints, heart, blood vessels, and lungs, apparently due to an immune response b. mechanism involves autoimmune response attacking bone and tissue of the joint i. causes include genetic factors and viral infections c. trends in prevalence rates i. 70 million Americans suffer from rheumatic disease - arthritis afflicts nearly half of Americans over age 65 ii. observations regarding trend data - mild cases probably are not counted - females more likely to experience osteoarthritis, fibromyalgia, and rheumatoid arthritis; male more likely to have gout - nearly 300,000 children suffer arthritis with many having juvenile rheumatoid arthritis

401

3. The effects and treatment of arthritis a. leading cause of disability in those over age 15, second most cause of work disability b. progress of rheumatoid arthritis i. lubricating fluid leaking out of joints ii. cartilage is destroyed and joint function reduced iii. conversion of organic matter into minerals for bones decreases near joints iv. bone erosion occurs near joints v. joints become deformed c. treatments to manage pain and functional impairment i. medications or surgical procedures - pain relievers such as aspirin and ibuprofen, or prescription - joint replacement. ii. other approaches - maintaining proper body weight - limiting certain foods and alcohol - physical therapy and exercise - use of assistive devices - splints - some alternative medicines/treatments iii. compliance with treatment regimen.

- studies show more compliance when using powerful drugs and less for physical therapy compared to medications 4. Psychosocial factors in arthritis a. vicious circle of stress i. arthritis symptoms produces stress ii. stress is linked to flare-ups b. emotional adjustment levels i. research notes link between arthritis severity and depression and feelings of helplessness/hopelessness ii. research on feelings of personal control - patients believe physicians have more control over disease than they do - patients who believe they have control over daily symptoms show less mood disturbance - patients who are active partners in decisions adjust better - those that believe treatment can help are more likely to follow regimen iii. spouse with higher levels of social support have less depression

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iv. patients who express negative emotions a lot show poorer adjustment and disease status F. Alzheimer’s disease 1. Characteristics of dementia and Alzheimer’s disease a. dementia is a progressive loss of cognitive functioning associated with old age b. Alzheimer’s disease is a deterioration of attention, memory and personality i. incidence increases with age ii. progression of deterioration includes initial losses of attention and memory with eventual personality changes, decline in self-care and disorientation 2. The causes and treatment of Alzheimer’s disease a. causes i. lesions consisting of tangled nerve and protein fibers linked to genetic defects ii. link between Alzheimer’s and strokes iii. regular physical activity and moderate drinking associated with lower risk b. diagnosis and treatment i. tests of cognitive ability and physiological indicators made at specialized centers are 90% accurate ii. no treatments prevent progression of disease, but some medications slow progression and improve symptoms 3. Psychosocial effects of Alzheimer’s disease a. caregiving to Alzheimer’s patients i. most victims are cared for at home by family members. ii. as disease progresses, patients may experience frustration and high levels of helplessness/depression iii. problematic behavior by patients leads to stress in caregivers iv. caregiver health becomes affected by the stress of providing care - caregivers have compromised immune function, poorer health, higher stress hormones, and higher mortality - stress occurs from watching loved one deteriorate over several years III. Psychosocial Interventions for People with Chronic Conditions A. Section introduction 1. Study on perceptions of chronic illnesses a. parent perception of seriousness of illness is related to whether their child has the illness i. view is less negative when one’s own child had the illness

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2. Types of adjustment problems in chronic illness a. physical coping with disability or pain b. vocational coping with revised educational or vocational plans c. self-concept adjustments to changed body image, self-esteem d. social adjustment to losing enjoyable activities and coping with changed relationships e. emotional changes in levels of negative emotions f. compliance with rehabilitation regimen 3. Factors influencing adjustment a. nature of illness i. visibility, level of pain, level of disability, whether lifethreatening b. patient’s age c. interpersonal aspects i. over-protection from family ii. delayed progress in school due to absences that impairs friendships, self-confidence, and self-esteem iii. changes in roles d. treatment approaches i. interdisciplinary teams that work in integrated manner facilitate adjustment B. Educational, social support, and behavioral methods 1. What patients and families need to improve adjustment a. accurate information about disease prognosis and treatment b. community support such as respite centers for Alzheimer’s c. effective support systems i. support groups that provide information, give emotional support, and allow for sharing of feelings 2. Addressing psychosocial factors that contribute to adherence a. improving physician feedback b. use of behavioral methods i. tailoring the regimen ii. using prompts and reminders iii. incorporating rewards 3. Self-management programs combine information with cognitive behavioral methods a. enhance patient’s ability to carry out regimen b. help adapt to new behaviors/life roles c. provide help for coping with emotions d. teaches problem-solving skills to deal with day-to-day circumstances

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C. Relaxation and biofeedback 1. Chronic conditions are aggravated by stress and anxiety a. stress management techniques, such as progressive muscle relaxation and biofeedback, have been used with diabetics and epileptics i. used to help diabetics manage stress and blood glucose ii. epileptics can be taught to recognize sensations before an attack - no way to determine who will benefit from this approach iii. asthma sufferers can learn to control the diameter of the bronchial airways D. Cognitive methods 1. Focus of cognitive approaches a. problem-solving training teaches clients to think through a medical situation and make good choices b. cognitive restructuring helps patient discuss incorrect thoughts/beliefs and learn ways to cope better i. used to alleviate depression in Alzheimer’s or cancer patients and caregivers c. the success of these approaches depend upon how careful and conscientiously they are carried out by the patient E. Interpersonal and family therapy 1. Interpersonal therapy a. designed to change the way patients react to, and interact with, their social environment b. used to help patients gain an understanding of their feelings and behaviors toward others 2. Family therapy a. uses behavioral, cognitive, and insight methods to change patterns of family interactions b. with children, may discuss jealousness of siblings, activities to engage in, how to discuss the illness with friends and relatives and how self-care can be improved F. Collaborative or integrative care approaches 1. Collaborative or integrative care a. combines and integrates perspectives of multiple professionals and providers

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DISCUSSION TOPICS 1. Psychosocial aspects of chronic illness.

Taylor and Aspinwall’s chapter on chronic illness is a comprehensive source for discussion. These authors review the challenge of chronic illness to contemporary health care delivery and highlight psychosocial factors that impact the development, experience, and treatment of chronic illness. Early in the chapter they discuss the principal psychosocial factors that affect health and illness and then discuss specific factors, including potential personality variables, that influence Type A behavior syndrome, cancer, hypertension, rheumatoid arthritis, and diabetes. They provide an overview of the use attitude change efforts, cognitive-behavioral interventions, and relapse intervention. The remainder of the chapter addresses issues related to the role of anxiety and depression in chronic illness, coping approaches, and enhancing quality of life.

Although in many respects the topics presented in the chapter repeat those of the text, I found that it knits together issues raised in previous chapters under the umbrella of chronic illness. For example, the Sarafino text provides ample presentation on enhancing exercise, weight reduction, smoking cessation, and dietary changes. Taylor and Aspinwall draw the link between these intervention efforts and chronic illness. Specfically, they note “since health habits such as smoking, diet, and alcoholism are heavily implicated in the onset of chronic diseases, effective programs to modify these target behaviors are essential in making progress against chronic disease.” (pg.20). This particular statement is, in and of itself, a rich starting point for conversation with students.

Another section of the chapter that might prompt discussion is Taylor and Aspenwall’s discussion of depression and chronic illness on pages 23-27. They note that the assessment of depression in chronically ill people is problematical. Physical signs of depression may also be symptoms of the disease or the treatment used to treat it.

Measurement issues to eliminate this overlap and the development of appropriate diagnostic standards are critical issues. Some expansion of this topic might add to the class discussion.

Source: Taylor, S.E., & Aspinwall, L.G. (1990). Psychosocial aspects of chronic illness. (pp 3-60).

In Herek, G.M., Levy, S.M., Maddi, S.R., Taylor, S.E., & Wertlieb, D.L. (Eds.), Psychological aspects of serious illness: Chronic conditions, fatal diseases, and clinical care. Washington, DC: American Psychological Association.

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2. Psychological approaches to managing chronic illness: The example of diabetes mellitus.

Shillitoe and Christie provide a very thorough overview of issues in treatment of diabetes mellitus with a focus on the psychological aspects of the experience with this disease. After reviewing the various forms of diabetes, these authors provide a tongue-incheck snapshot of a regimen designed to encourage patient nonadherence. They state, “It should be complicated, so that it cannot easily be comprehended; flexible, so that its exact requirements cannot be stated clearly; intrusive and difficult to fit in with the normal routines of family life, work, and social activity. It should be life-long and require alterations of fundamental behaviours, such as eating. Deleterious consequences arising from non-adherence should only become apparent many years later (and then only in a proportion of patients), and should affect some individuals whose self-care practices were good. Contact with health services should be sporadic, impersonal, and inconvenient.

Such a programme would be difficult to distinguish from many diabetes regimens.” (pg.

180).

Many aspects of diabetes regimen clearly are affected by psychological influences.

Dietary restrictions, for example, are subject to cultural, religious, and emotional meanings associated with food and present difficulty when changing eating behavior is required. As a child, learning to competently self-inject insulin may be influenced by stage of cognitive development a la Piaget. As noted in Sarafino’s text, some level of fabrication in logs for self-monitoring of blood glucose has been noted. Lifestyle activities of exercise, smoking, and drinking affect the balance of blood glucose levels in and of themselves but are also influenced by psychological factors as we’ve noted in earlier chapters. Shillitoe and Christie also note that self-care is less conscientious during high stress periods, during negative mood states, and less stable family situations. They conclude their chapter with discussions of patient and physician education, issues of assessment, and delivery of care. Taken as a whole, the chapter provides several extensions of the text’s presentation on diabetes that should prompt some inclass discussion.

Source: Shillitoe, R., & Christie, M. (1990). Psychological approaches to the management of chronic illness: The example of diabetes mellitus.(pp. 177-208). In Bennett, P., Weinman, J., & Spurgeon, P. (Eds.), Current developments in health psychology.

New York: Harwood Academic Publ.

3. Women and alzheimer’s.

This is a brief but highly informative article written by Dr. Zaven Khachaturian, Director of the Alzheimer’s Association’s Ronald &Nancy Reagan Research Institute. In this article Dr. Khachaturian provides an update on gender differences in prevalence for Alzheimer’s disease with greater discussion given to an underlying estrogen link to the disorder. Two demographic trends are interesting here: life expectancies have increased across genders, but more for women than for men. As Alzheimer’s is a disease that increases in prevalence with age, as more women age, greater numbers of women will be at risk for developing Alzheimer’s.

Risk factors for Alzheimer’s include age, genetic predisposition, and gender.

Research has isolated the apolipoprotein E (ApoE) gene as the susceptibility gene for 407

Alzheimer’s. Additionally it appears that when women carry even one copy of APOE4 gene variety, they are at substantial risk for developing early onset Alzheimer’s. Men must carry two copies of this gene to be at similar risk. Although how the gene contributes to disease risk or why gender seems to influence this genetic mechanism is still unclear, continued research in this area is hoped to reveal ways to delay disease onset.

The role of estrogen in memory is discussed in some detail. Noting that Alzheimer’s disease is characterized by loss of memory, Khachaturian notes that research in the 1970s was finding an association between loss of estrogen (via the surgical removal of patients’ ovaries) and memory problems. Small clinical studies done in the 1980s were finding that some Alzheimer’s patients showed significant improvement in attention, orientation, mood and social interactions when estrogen treatment had been employed in a six week intervention. By the 1990s, researchers were reporting that risk for developing Alzheimer’s disease was significantly reduced among women who had received estrogen replacement therapy (ERT). Indeed, one study at Johns Hopkins reported that “women who take estrogen after menopause reduced their risk of developing Alzheimer’s disease by 54 percent.” (pg. 166). A number of studies currently being conducted should clarify the mechanisms through which ERT affect Alzheimer’s. Dr. Khachaturian urges that additional studies should be conducted that compare various forms of estrogen to find optimal treatment programs.

Source: Khachaturian, Z. (1998). At more risk for Alzheimer’s? (pp. 165-167). In Sample, C.J. (Ed.), Perspectives: Women’s health. St. Paul, Mn: Coursewise Publ.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Do You Have Diabetes? Have students complete Handout # 1, which pertains to the symptoms of diabetes.

2. HealthQuest disk. Have students complete the exercises on the HealthQuest disk pertaining to cardiovascular health and cancer. Each section contains an introduction, wellness exercises, and connections.

3. Disability day. In order for the students to develop an appreciation for the disabled, have each “develop” a disability. Obtain if possible several wheelchairs, arm slings and blindfolds. The wheelchairs and arm slings may be borrowed from a local hospital or hospital equipment vendor. The disabilities may be assigned randomly with the students to role-play the disability they are assigned. Disabilities may include blindness, paraplegia, left or right hemiplegia and left or right arm paralysis. If possible survey a few disabled students to devise illustrative tasks on your campus. For example, the students may be assigned a list of such activities as going to the library and finding a book on an upper shelf, or trying to buy food at the cafeteria while carrying their books. In general, with some planning and enough equipment, the effects of the blindness and wheelchair experience can be appreciated within a class period. Arm slings are more effective over a longer period, such as 24 hours. Afterwards, discuss the difficulties encountered, the reactions of other people and campus design flaws. You may wish to have the school’s coordinator for student services present for the discussion.

4. Alzheimer's disease. Students may be interested in attending a local Alzheimer's support group. Most groups will have informational programs available.

A listing of groups across the country may be found by entering your zip code at: http://www.alz.org/findchapter.asp 5. Psychosocial aspects of chronic health problems. Adult diabetics and asthmatics usually have good insights into the demands of their illnesses. Ask one or more of these individuals to come to class to talk about their illness, their treatment, and the way they cope with the illness and their treatment regimens.

6. Adjustment. Have the students describe someone they know with a chronic illness or disability. How does the person cope with their physical limitations? How would they describe the adjustment the person has made? Do the styles of adjustment the class reports vary with the nature of the illness, such as its painfulness or physical limitations? Does the adjustment vary as a function of the social support available? Can the class give examples of positive and negative social support systems?

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Handout #1

Assess Yourself: Do You Have Diabetes?

About half of the people who have diabetes don’t know it. To tell if you might have this disorder, put a check mark in the space preceding each of the following warning signs that are true for you. _____ Very frequent urination. _____ Frequent excessive thrist. _____ Often hungry, even after eating. _____ Unexplained large weight loss. _____ Chronically tired. _____ Occasional blurry vision. _____ Wounds heal very slowly. _____ Tingling or numbness in your feet. _____ Waist measurement greater than half your height.

If you check three or more of these signs, see your doctor—one or two signs alone may not mean anything is wrong. But the more signs you checked, the greater the chance that you have diabetes.

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RESOURCES Suggested Readings: Adjusting to Chronic Illness Lubkin, I.M. (1998). Chronic illness: Impact and intervention. Boston: Jones and Bartlett.

Wright, C. C.; Barlow, J. H.; Turner, A. P., (2003). Self-management training for people with chronic disease: An exploratory study. British Journal of Health Psychology, 8(4), 465-476.

Asthma National Heart, Lung, and Blood Institute. (1997). Facts about controlling your asthma.

Bethesda: author.

Plaut, T.F. (1995). Children with asthma: A manual for parents. Amherst, MA: Pedipress.

United States Department of Health and Human Services. (1990). Check your asthma “IQ”. Bethesda: author.

Epilepsy Bennett, T.L. (1992). The neuropsychology of epilepsy. New York: Plenum Press.

National Institute of Neurological Disorders and Stroke. (2000). Seizures and epilepsy: Hope through research. Bethesda, MD: author.

Schacter, S.C. (1995). The brainstorms companion: Epilepsy in our view. New York: Raven Press.

Taylor, M. P. (2000). Managing epilepsy: A clinical handbook. Oxford: Blackwell Science.

Wyllie, E. (1997). The treatment of epilepsy: Principles and practice. Baltimore: Williams & Wilkins.

Nervous System Injuries Block, A.R., Gatchel, R.J., Deardorff, W.W., et al. (2003). The psychology of spine surgery.

Washington, DC: American Psychological Association.

Diabetes Alberti, K., Zimmet, P., & DeFronzo, R.A. (Eds.). (1997). International textbook of diabetes mellitus. Chichester, NY: Wiley.

Anderson, B.J., & Rubin, R.R. (1996). Practical psychology for diabetes clinicians.

Alexandria, VA: American Diabetes Association.

Haire-Joshu, D. (Ed.). (1996). Management of diabetes mellitus: Perspectives of care across the life span. St. Louis: Mosby-Year Book.

Indian Health Services. (1997). The intimate side of diabetes. Washington, DC: author.

Leahy, J.L., Clark, N.G., & Cefalu, W.T. (2000). Medical management of diabetes mellitus. New York: Dekker.

National Institute of Diabetes and Digestive and Kidney Diseases. (1999). 7 principles for controlling your diabetes for life. Bethesda, MD: author.

Talbot, F., Nouwen, A., Gingras, J., Belanger, A., & Audet, J. (1999). Relations of diabetes intrusiveness and personal control to symptoms of depression among adults with diabetes. Health Psychology, 18(5), 537-542.

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Arthritis Brewerton, D. (1992). All about arthritis: Past, present, future. Cambridge, MA: Harvard University Press.

Cook, A.R. (1999). Arthritis sourcebook. Detroit, MI: Omnigraphics.

Alzheimer’s Hoffman, S. B., & Platt, C.A. (2000). Comforting the confused: Strategies for managing dementia. New York: Springer.

Kumar, V., & Eisdorfer, C. (1998). Advances in the diagnosis and treatment of alzheimer’s disease. New York: Springer.

Whitehouse, P.J., Maurer, K., & Ballenger, J.F. (Eds.) (2000). Concepts of alzheimer’s disease: Biological, clinical, and cultural perspectives. Baltimore: Johns Hopkins University Press.

Wilcock, G.K. (1993). The management of alzheimer’s disease. Bristol, PA: Wrightson.

Psychosocial Interventions for People with Chronic Conditions Christenson, A.J., & Antoni, M.H. (2002). Chronic physical disorders: Behavioral medicine’s perspective. Malden, MA: Blackwell Publishers.

Nicassio, P.M., & Smith, T.W. (1995). Managing chronic illness: a biopsychosocial perspective. Washington, DC: American Psychological Association.

VandenBos, G.R., & Costa, P.T. (Eds.). (1990). Psychological aspects of serious illness.

Washington, DC: American Psychological Association.

Clark, N.M., Becker, M.H., Janz, N.K., Lorig, K., Rakowski, W., & Anderson, L. (1991).

Self-management of chronic disease by older adults: A review and questions for research. Journal of Aging and Health, 3, 3-27.

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Suggested Films and Videos: Asthma 1. Asthma. (2000, Edudex, 26 min). Explores new research and treatment for asthma.

2. Contemporary management of asthma. (1995, Network for Continuing Medical Education, 60 min). Reviews current approaches to treating this illness.

3. Classmates with asthma. (1996, Aquarius Productions, 12 min). Explains the use of nebulizers, peak flow meters, and metered dose inhalers in asthma treatment.

4. Living with asthma. (2000, Edudex, 15 min). A teen and her mother describe ways of living with asthma.

Epilepsy 5. Seizure first aid. (1992, Epilepsy Foundation of America, 12 min). Interviews with several epilepsy patients discuss their seizures and how others can help.

6. When the brain goes wrong. (1992, Fanlight Productions, 45 min). Reviews seven brain disorders including epilepsy.

Nervous System Injuries 7. New techniques in seating and mobility in spinal cord injury. (1991, Regional Learning Resources Services, 71 min). Addresses mobility issues.

Diabetes 8. Asthma in children. (1996, Time Life Medical, 30 min). Discusses diagnosis and treatment of illness, addressing special problems of children.

9. Diabetes. (2000, Edudex, 25 min). Examines the lives to two people living with diabetes.

10. Diabetes: Focus on feelings. (1980, Pyramid Film and Video, 24 min). Diabetics share feelings about living with this chronic illness.

11. Diabetes, the quiet killer. (2004, Films for the Humanities, 26 min). Outlines the symptoms, suspected causes, and treatments of both type-1 and type-2 diabetes.

12. Living with diabetes. (1991, Xenejenex Productions, 40 min). Tips on medical and lifestyle regimen for controlling diabetes.

13. People with diabetes can enjoy healthier lives! (1994, Eli Lilly & Company, 15 min).

Video demonstrates that keeping blood sugar near normal reduces risks for eye, kidney, and nerve damage.

14. Understanding diabetes. (1998, Edudex, 30 min). Explores the medicines used in treatment regimen and lifestyle changes needed.

Arthritis 15. Arthritis. (2002, Films for Humanities and Sciences, 50 min). Looks at conventional and alternative therapies for treating arthritis.

16. Arthritis. (1996, Patient Education Media, 30 min). Created for patients to aid in the understanding of the diagnosis, treatment, and management of arthritis.

17. Kids with arthritis. (1992, Films for the Humanities and Sciences, 30 min). Looks at 413

the lives of children living with arthritis.

18. Pathways to better living with arthritis and related conditions. (1997, Mobility Limited, 52 min). Describes a comprehensive living program designed by exercise and physical therapists.

Alzheimer’s 19. Alzheimer’s: A true story. (Films for the Humanities and Sciences, 75 min). A documentary on the effect of alzheimer’s disease in the life of one couple.

20. Alzheimer’s disease. (1996, Time Life Medical, 30 min). Discusses diagnosis, course of the illness, treatment and management.

21. Alzheimer’s disease. (1997, Aquarius Productions, 28 min). Addresses the lives of alzheimer’s patients and their families.

22. Just for the summer. (1990, Churchill Films, 30 min). A dramatization of a teenager whose grandmother comes to live with his family due to alzheimer’s.

23. The alzheimer’s mystery. (Films for the Humanities and Sciences, 49 min). People coping with alzheimer’s disease and professionals discussing research efforts to find a cure.

24. When the mind fails: A guide to alzheimer’s disease. (Films for the Humanities and Sciences, 59 min). A step-by-step primer for caregivers and patients regarding the signs and treatment for alzheimer’s.

Internet sites of interest: Diabetes 1. http://www.diabetes.org/ - American Diabetes Association 2. http://www.idf.org/ - International Diabetes Foundation 3. http://www.cdc.gov/diabetes - Diabetes homepage at Center for Disease Control Public Health Resource 4. http://www.diabetesmonitor.com/ - Diabetes Monitor – provides information, education, and support for people with diabetes.

5. http://diabetes.niddk.nih.gov/dm/pubs/dictionary - National Diabetes Information Clearinghouse - Diabetes Dictionary 6. http://www.ndei.org/ - National Diabetes Education Initiative – online resource for diabetes treatment and information 7. http://www.diabetes-self-mgmt.com/ - Diabetes Self-Management 8. http://www.jdfc.ca/ - Juvenile Diabetes Research Foundation 9. http://www.nlm.nih.gov/medlineplus/diabetes.html - MEDLINEplus Health information on diabetes

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Arthritis 10. http://www.arthritis.org - Arthritis Foundation 11. http://www.arthritisinformation.net/ - Arthritis Information Center 12. http://www.arc.org.uk/ - Arthritis Research Campaign 13. http://www.mednews.net/arthritis/ - Arthritis News on the Net 14. http://www.painconnection.org/MySupport/LinkDirectory_Arthritis.asp - National Pain Foundation – arthritis link directory Asthma 15. http://www.ginasthma.com - Global Initiative for Asthma 16. http://www.noattack.org - Information on asthma and how to prevent attacks 17. http://www.aaaai.org - The American Academy of Allergy, Asthma, and Immunology 18. http://www.acaai.org - American College of Allergy, Asthma & Immunology online 19. http://www.aanma.org/ - Allergy & Asthma Network 20. http://www.asthma.org.uk/ - Asthma UK website 21. http://www.users.globalnet.co.uk/~aair/ - Asthma & Allergy Information & Research (AAIR) Epilepsy 22. http://www.epilepsyfoundation.org - Epilepsy Foundation 23. http://www.aesnet.org/ - American Epilepsy Society 24. http://www.erf.org.uk/ - Epilepsy Research Foundation Alzheimer’s Disease and Caregiving 25. http://www.alz.org/ - Alzheimer’s Association 26. http://www.alzfdn.org - Alzheimer’s Foundation 27. http://www.alzheimers.org/ - Alzheimer’s Disease Education & Referral Center – Current information and resources from the National Institute on Aging 28. http://www.alz.co.uk/ - Alzheimer’s Disease International Spinal Cord Injury 29. http://www.spinalcord.uab.edu/ - Spinal Cord Injury Information Network 30. http://www.spinalcord.org - National Spinal Cord Injury Association 31. http://www.sonic.net/~spinal/ - Spinal Cord Injury Network International (SCINI) 32. http://www.fscip.org/ - Foundation for Spinal Cord Injury Prevention, Care, & Cure 33. http://www.asia-spinalinjury.org/ - American Spinal Injury Association 34. http://www.spinalinjury.net - Spinal Cord Injury Resource Center 35. http://members.aol.com/scsweb/ - Spinal Cord Society 36. http://www.wheelweb.com/main.shtml - Spinal Cord Injury resources 37. http://www.makoa.org/sci.htm - Spinal cord injury and disease resources

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TEST QUESTIONS True or False F

1.

The initial shock reaction to the diagnosis of a serious illness according to Shontz (1975) is characterized by a rush of emotions and disorganized thinking.

2.

Ron was in an automobile accident which left him with numerous facial scars and paraplegia. We might expect him to have particular difficulty coping with his symptoms.

3.

Research has determined that using one type of coping skill to consistently deal with a chronic illness produces better results than developing a range of coping skills.

4.

One way to treat asthma is to avoid the triggers of attacks.

5.

Most cases of epilepsy are linked to a specific neurological defect.

6.

Harriet, who became quadriplegic at age 40 when her spinal cord was crushed at the waist-level, is typical of such injuries.

7.

If a diabetic follows recommended medical regimen it is less likely that they will die from acute complications.

8.

Although there are over 100 forms of rheumatic disease, they all have the. same underlying pattern of causes.

9.

In Alzheimer’s disease, the initial symptoms noticed are personality changes and disorientation.

10.

Tailoring the treatment regimen to suit the patient’s lifestyle is likely to increase treatment adherence.

(358)

T (359)

F (361)

T (364)

F (365)

F (367)

T (371)

F (375)

F (378)

T (380)

416

MATCHING Match the disorders below with their characteristic in one through five. a. insulin-dependent diabetes mellitus b. non-insulin dependent diabetes mellitus c. rheumatoid arthritis d. asthma e. gout c

1. May result in joint deformities.

(375)

a

2. The main acute complication of this disorder is ketoacidosis.

(370)

d

3. Appears to result mainly from a response to allergens.

(363)

b

4. Two subtypes exist which are based on the person’s weight.

(370)

e

5. Results from an overproduction of uric acid.

(375)

Match the disorders below with their characteristic in six through ten. a. osteoarthritis b. rheumatoid arthritis c. spinal cord injuries d. epilepsy e. Alzheimer’s b

6. May affect not only the joints, but the heart, blood vessels, and lungs as well.

(375)

d

7. Sometimes accompanied by an aura.

(365)

e

8. Characterized by lesions of nerve and protein fibers.

(378)

c

9. Affects predominantly males under 30 years old.

(367)

a

10. Associated with occupations which are physically demanding

(375)

417

MULTIPLE CHOICE a (358)

d (358)

a (358)

d (358)

b (358)

d (359)

1. According to Shontz, the first stage in the sequence following the diagnosis of disabling illness is a. shock. b. encounter reaction. c. reaction formation. d. retreat.

2. Which is not a characteristic of shock? a. It is most pronounced when the crisis comes without warning. b. Feelings of being stunned or bewildered. c. Feeling a sense of detachment from the situation. d. Feelings of loss, grief, despair.

3. Which of the following statements regarding avoidance strategies is true? a. They are used especially when people feel there is nothing they can do to change the situation. b. They are used only by acute pain patients. c. They are always maladaptive. d. They are never maladaptive.

4. The use of avoidance strategies in coping with chronic illness a. often causes patients to gain less information about their illness. b. may be psychologically beneficial early in the coping process. c. may prevent the patient from making important lifestyle changes in fighting their illness. d. all of the above 5. One key difference in chronic health problems vs. short-term difficulties is a. chronic problems are always more painful. b. chronic problems require behavioral, social, and emotional adjustments. c. short-term problems are more painful. d. chronic problems cause less reliance on the medical field.

6. Moos’ theory on adjustment to crises focuses on a. illness factors. b. background and personal factors. c. physical and social environmental factors d. all of the above

418

a (359)

b (359)

7. Wayne is having trouble coping with the embarrassing joint deformities that have resulted from his rheumatoid arthritis. According to Moos, this is a(n) ____ factor. a. illness b. personal c. physical d. background 8. According to Moos, which of the following types of disfigurement is likely to affect coping the most? a. Loss of a limb. b. Severe facial scarring. c. Loss of a breast. d. Loss of the ability to walk.

a 9. Which of the following people are likely to have the most significant problems (359) coping with their treatment regimen? a. Paul, whose treatment is extremely painful. b. Mark, whose medications have minor side effects. c. Frank, whose treatment regimen requires him to take his meds once a day. d. George, whose treatment program is held on nights and weekends. d (359)

d (360)

c (360)

10. People who cope well with chronic illness have __________ personalities. a. passive b. pessimistic c. dependent d. hardy 11. Which of the following are characteristic of people who cope well? a. They have resources to resolve the chronic nature of the situation. b. They find purpose and quality in life. c. They are able to find hope in life. d. all of the above 12. Males differ from females in coping with chronic illness in that a. their greater self-esteem causes them to cope with chronic illness better. b. they are more adherent to treatment regimen. c. they tend to be more threatened by the dependent, passive role they might have to take. d. men suffer fewer chronic illnesses.

419

c (360)

c (360)

d (360)

a (360)

b (360)

b (361)

13. Adolescents are most likely to avoid their treatment regimens for chronic illness because of a. the painful nature of treatment regimen. b. fear of parental separation. c. their desire to avoid appearing different from their friends. d. pre-conceived ideas about illness.

14. For middle-aged patients with chronic illness, which of the following reflects a likely coping difficulty? a. Resentment that they aren’t able to enjoy their leisure time. b. Concern with being viewed as different from their peers. c. Not being able to complete tasks they have begun. d. The frightening nature of medical procedures.

15. Which of the following statements reflects the relationship between selfblame and coping with chronic illness? a. Self-blame may affect coping at first but tends to fade away quickly. b. Self-blame has little impact on coping with a chronic illness. c. Self-blame is linked to more aggressive coping attempts. d. Self-blame is associated with higher levels of depression and poor coping.

16. When adjusting to a chronic illness which of the following represents a physical environmental factor that may occur? a. The lack of assistive devices to increase self-sufficiency. b. The feelings involved in role threat. c. The lack of support networks in the community. d. The complexity of the treatment regimen.

17. The primary source of social support for children and most adults who are ill comes from a. their friends. b. their families. c. their support groups. d. their physicians.

18. Learning and adhering to a medical regimen would be classified by Moos as a. an environmental task. b. an adaptive task. c. a cognitive appraisal. d. a personal factor.

420

d (359)

d (361)

a (362)

b (362)

b (363)

a (364)

d (364)

19. In crisis theory, which of the following is not a task related to general psychosocial functioning? a. Controlling negative feelings. b. Maintaining a satisfactory self-image. c. Preserving good relationships with family and friends. d. Adjusting to the pain.

20. Which is a coping strategy for chronic health problems? a. Learning to provide one’s own medical care. b. Recruiting support from family and friends. c. Denying the seriousness of the illness. d. all of the above 21. The process of making changes in order to adjust constructively to life’s circumstances is called a. adaptation. b. quality of life. c. instrumental support. d. emotional coping.

22. Which of the following is TRUE regarding quality of life? a. Factors that influence quality of life vary a great deal in different countries. b. Around the world, people judge quality of life using similar criteria. c. Quality of life is difficult to measure cross-culturally. d. Making adaptive changes has very little effect on quality of life assessments.

23. Which of the following is NOT true about asthma? a. Most asthmatics first experience symptoms before age 5. b. Death from asthma attacks no longer occurs. c. 25-50% of children with asthma get better by adulthood. d. Prevalence rates are higher for children than adults.

24. The primary site of irritation in the first phase of an asthma attack is a. the bronchial tubes. b. the nostrils. c. the peritoneum. d. the alveoli.

25. Which of the following is a likely trigger of asthma attacks? a. exercise b. weather changes c. psychosocial factors d. all of the above 421

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26. Which of the following is a common treatment for asthma? a. Use of anti-inflammatories. b. Refraining from exercise. c. Gradual exposure to triggers. d. all of the above.

27. Which of the following statements reflects the relationship between maladjustment and asthma? a. Maladjustment has not been linked to asthma conditions. b. The relationship appears to be reciprocal. c. Asthma may lead to maladjustment but not the other way around. d. Maladjustment affects asthma but only if the level of maladjustment is severe.

28. During a recent epileptic attack, Kim lost consciousness and had muscle spasms. She most likely had a. petit mal attack b. grand mal seizure c. absence attack d. psychomotor seizure 29. Which of the following is NOT a risk factor for developing epilepsy? a. Family history. b. Severe head injury. c. Central nervous system infections. d. Low socioeconomic status.

30. Which is the BEST thing to do for an individual suffering an epileptic seizure? a. Call an ambulance immediately. b. Remain calm and protect the epileptic from injury due to falls. c. Lay the person on his or her back. d. Put a spoon in his or her mouth to prevent tongue swallowing.

31. Joshua has been diagnosed with grand mal seizure disorder. He might experience which of the following while trying to adjust to this condition? a. Stigmatized treatment by others. b. Possible cognitive impairments that could limit his memory capabilities. c. Increased seizure activity when emotionally aroused. d. all of the above

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32. Quadriplegia is to _____ spinal cord damage as paraplegia is to _____ spinal cord damage. a. lower; upper b. upper; lower c. minor; severe d. severe; minor 33. Which of the following best described the demographics of spinal cord injuries? a. They are more prevalent in males. b. They are more common under age 30. c. Most result from traffic accidents. d. all of the above 34. The most common cause of death related to spinal cord injury after the spinal shock period is a. heart disease. b. renal failure due to repeated infections. c. stroke. d. suicide.

35. Which of the following statements regarding sexual function and spinal injury below the waist is correct? a. All sexual function is lost. b. Males usually retain fertility. c. Females usually lose fertility due to the injury. d. The greatest barriers to sexual function are psychosocial.

36. Which of the following is TRUE regarding the prevalence of diabetes? a. It is a fairly rare disease worldwide. b. It occurs more frequently in children than in adults. c. It is among the most common chronic conditions in the United States. d. Women of color are very unlikely to develop the disease.

37. For Type I diabetes, the main acute complication that occurs is a. heart disease. b. ketoacidosis. c. hypertension. d. hypoglycemia.

38. Which of the following has been implicated in the development of of diabetes? a. Genetic factors. b. Viral infections. c. Dietary factors. d. all of the above 423

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39. Which of the following ailments is correlated with diabetes? a. Neuropathy. b. Blindness. c. Gangrene. d. all of the above 40. The primary approach to treating diabetes involves a. medicine use only. b. dietary changes only. c. a combination of medicine, dietary changes, and exercise. d. psychosocial intervention only.

41. Research on adherence to diabetes regimen indicates that a. most diabetics carefully administer recommended insulin doses. b. self-report information regarding adherence tends to be fairly accurate. c. adherence to the medical aspects of regimen is higher than that associated with dietary changes. d. people with diabetes often don’t even try to adhere to their regimen.

42. Epinephrine may worsen the effects of diabetes by a. causing the pancreas to decrease insulin production. b. causing the liver to increase glucose production. c. causing the liver to secrete insulin. d. contributing directly to weight gain.

43. Stress has which of the following effects on diabetics? a. It results in increases in insulin release. b. It contributes to increases in blood glucose levels. c. It has only an indirect effect on blood glucose levels. d. It is associated with enhanced vigilance to the medical regimen.

44. Research on parent and physician goals in diabetic treatment suggest a. both parents and physicians are focused on preventing long-term complications. b. parents are concerned with preventing hypoglycemic episodes in their children. c. physicians are primarily concerned with promoting the day-to-day wellbeing and activities of these children. d. physicians and parents have different goals for treatment.

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45. When treatment responsibility for diabetes regimen shifts to adolescents a. adherence increases. b. parents continue to assume primary responsibility. c. adherence is highest in adolescents with high self-esteem and social competence. d. hormonal changes are of little concern in diabetic regimen.

46. Musculoskeletal disorders affecting the joints and connective tissues are called a. gout. b. rheumatic disease. c. congenital disease. d. renal disease.

47. The condition called gout is characterized by an excess of a. peritoneum. b. insulin c. uric acid d. histamine 48. The primary mechanism resulting in the development of osteoarthritis is a. cancer. b. excess uric acid. c. an immune response. d. physical wear and tear.

49. The musculoskeletal disorder most likely to be associated with one’s occupation is a. gout. b. rheumatoid arthritis. c. osteoarthritis. d. fibromyalgia.

50. Common treatment approaches to arthritis include a. use of pain relief medication. b. use of physical therapy. c. use of appropriate assistive devices. d. all of the above.

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51. Research on the relationship between mood and coping with rheumatoid arthritis indicates a. most patients believed they had control over the course of their disease. b. patients who believed they had control over their disease showed high levels of distress. c. patients who saw themselves as active partners in treatment were better adjusted. d. mood did not correlate with adjustment.

52. The progressive loss of cognitive functions, usually in old age, is called a. dementia. b. epilepsy. c. fibromyalgia. d. neuropathy.

53. A common early symptom of Alzheimer’s disease is loss of a. sexual function. b. energy. c. memory. d. motor control.

54. Which of the following statements regarding current treatment approaches for Alzheimer’s disease is accurate? a. Genetic therapy has been shown to be highly effective. b. Administration of beta-amyloid delays progression of the disease. c. Physical therapy reduces the likelihood of muscular deterioration. d. There currently is no effective treatment.

55. Anna is in the early stage of Alzheimer’s disease. Like most victims, she receives her care a. at home from her spouse and children. b. in a nursing home. c. in a hospital. d. in a day-care facility.

56. Research on caregivers of patients with Alzheimer’s disease has found a. emotional and physical effects of caregiving varies widely across different cultures. b. negative health effects are associated with levels of social support and distress. c. emotional distress tends to be short-lived since the disease progresses so quickly. d. negative health effects occur only for those caregivers who had poor health to begin with.

57. According to research, when a parent’s child has a serious disease, 426

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a. they tend to have less negative views of those diseases. b. their views of disease seriousness are exaggerated. c. their views on disease seriousness are no different than those of parents whose children don’t have serious disease. d. their adjustment levels uniformly tend to be poor.

58. Which of the following is included in the type of adjustment problems associated with chronic illness? a. Learning to adjust to changes in one’s self-image. b. Coping with disability or pain. c. Coping with the loss of enjoyable activities or relationships. d. all of the above 59. Regarding the use of biofeedback interventions with patients with epilepsy, research has found a. it works well with most patients. b. it does not work effectively in most cases. c. it is difficult to determine with whom these interventions will be effective. d. it is an inexpensive intervention and thus should be used more frequently.

60. A primary reason to use insight or family therapy in the treatment of chronic illness includes a. changing distorted thoughts about the illness. b. the discussion of reinforcement techniques in intervention. c. the explicit need to increase compliance with treatment regimen. d. addressing anxieties and changes in self-concept and relationships.

Short Answer Questions 1. Discuss 3 of the 7 coping strategies for dealing with chronic illness. How will each affect adjustment?

2. Your cousin is just about to enter rehabilitation for a spinal cord injury due to a motorcycle accident. Outline for him what he should expect during treatment.

3. Compare and contrast the various forms of rheumatic diseases.

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Essay Questions 1. Elliot has just been diagnosed with asthma. Using Moos' crisis theory and the factors of that theory, describe how Elliot is likely to adjust to his disease.

2. Your 8-year-old nephew has just been diagnosed with Type I diabetes. Based on what you've learned from the text, help him understand the disease and what he needs to do in his treatment regimen.

3. Develop and discuss a comprehensive treatment program for patients with chronic illness.

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CHAPTER 14 HEART DISEASE, STROKE, CANCER, AND AIDS: CAUSES, MANAGEMENT AND COPING CHAPTER OUTLINE I. Coping With and Adapting to High‑ Mortality Illness A. Adapting while the prospects seem good 1. Early concerns following diagnosis a. mortality is the main issue that concerns patients and families b. patients often show optimistic attitudes but tentative future plans c. coping often switches from avoidance to problem-focused approaches 2. Developing regular activities a. activities provide a respite from thinking about condition b. patients may over-estimate abilities and become discouraged c. patients need to develop reasonable plans and carry them out 3. Family dynamics a. a cycle of dependence can emerge due to patient helplessness and family nurturance 4. Cognitive adjustments to high-mortality illness a. three themes to cognitive adjustment i. finding meaning in illnesses ii. gaining a sense of control over illness iii. restoring self-esteem, sometimes by comparing themselves with less fortunate people b. effects of cognitive adjustments i. greater positive reappraisal after cancer diagnosis is related to better perceived health and psychosocial functioning ii. many individuals do not achieve high adjustment, particularly when social support is perceived as low B. Adapting in a recurrence or relapse 1. High-mortality diseases are marked by relapses a. relapse presents as an additional crisis i. is perceived as a bad sign ii. patients tend to use similar coping strategies but may be less hopeful II. Heart Disease A. Section introduction 1. Coronary heart disease a. results from narrowing and blocking of coronary arteries b. types of heart disease i. atherosclerosis ‑ blood vessels become narrowed by plaques

ii. angina pectoris - painful cramps caused by brief or incomplete blockage iii. myocardial infarction - part of heart muscle is destroyed by severe or prolonged block - symptoms of heart attack: uncomfortable pressure, fullness, squeezing or pain in the center of chest that lasts for more than a few minutes; pain spreading to shoulders, neck, or arms; chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath - congestive heart failure - condition in which heart is enlarged, pumping capacity is reduced, and person gets shortness of breath upon little exertion - prevalence of heart attack: 1.2 million Americans suffer heart attack each year, 40% of whom die - heart damage increases when patients delay seeking help; 1/3 delay help seeking for 3 or more hours B. Who is at risk of heart disease, and why?

1. Age, gender, and sociocultural risk factors a. age and gender i. risks for heart disease higher for men and those over 45 ii. American men have far higher rates of heart disease than women at all ages b. sociocultural factors i. death rates are three times higher for African-Americans than Asian-Americans, with whites, Native American, and Hispanics being intermediate 2. Lifestyle and biological risk factors a. risk factors i. hypertension ii. family history of heart disease iii. cigarette smoking iv. high blood pressure v. high LDL and total cholesterol levels vi. physical inactivity vii. diabetes viii. obesity ix. stress

b. effects of reducing risk factors i. high LDL and low HDL cholesterol is the strongest risk factor; smoking is the second ii. risk gets cut in half after stopping smoking and reducing cholesterol and blood pressure 3. Negative emotions and heart disease a. research indicates people who experience chronic high levels of hostility, depression, and anxiety are more likely to develop heart disease and hypertension i. have less healthy lifestyles ii. negative emotions have physiological effects that promote heart disease b. type A people have chronically high levels of catecholamines and corticosteroids, especially when under stress i. these chemicals damage heart and blood vessels and increase formation of platelet clots ii. heart attacks are more likely on Monday mornings for those who are working C. Medical treatment and rehabilitation of cardiac patients 1. Section introduction a. many cardiac patients have not had a heart attack, but tests show they have heart disease b. may receive one of two invasive procedures for atherosclerosis i. balloon angioplasty opens the vessel and his held open by a stent ii. bypass surgery shunts blood flow around the diseased section of an artery with a piece of healthy blood vessel 2. Initial treatment for heart attack a. emergency medical treatment i. clot-dissolving medication frees blocked arteries ii. coronary care unit may closely monitor functioning iii. other procedures such as angioplasty or bypass may be necessary b. emotional state of cardiac patients i. high anxiety occurs in first few days of coronary care ii. denial may be used by some patients, who are typically less anxious iii. greatest difficulty coping is seen generally by those who had distress/social problems before attack. iv. excessive denial, depression, anxiety impairs recovery.

3. Rehabilitation for cardiac patients a. programs are designed to promote recovery and reduce risk factors. i. common program features - information provided on symptoms, medications and lifestyle changes - lifestyle change advice includes: quitting smoking, losing weight, exercise, reducing dietary fat and cholesterol, reducing high alcohol consumption, and stress management b. adherence to programs i. some find adherence easy whereas others may resent the restrictions ii. less adherence is found in those with low self-efficacy or who perceive low social support c. exercise as a part of the intervention program i. introduced gradually and tailored to physical capability ii. begins with supervised short-distance walking and becomes more vigorous iii. adherence brings about substantial benefits iii. exercise adherence is related to psychosocial adjustment.

- 50% discontinue in six months - compliance is higher if there is a special place to exercise d. adherence to other lifestyle changes i. dietary changes are difficult due to the impact on family life ii. only 30 - 40% quit smoking iii. higher self-efficacy is related to following cardiac regimen D. The psychosocial impact of heart disease 1. Importance of work a. valued as a sign of recovery i. may need to cut back on work or change jobs ii. negative interpersonal relationships with co-workers due to shift in job capability iii. not going back to work is associated with lasting emotional difficulty 2. Family relationships a. cardiac patients with strong social support recover faster and survive longer b. prior family problems may be exacerbated by the heart attack i. cycle of guilt and blame may develop ii. sexual relations may decline c. families may promote cardiac invalidism i. family members can increase estimates of patient’s physical functioning by personally experiencing the feats they can perform ii. more similar beliefs between spouse and patient about heart disease are related to increased functioning months later d. long-term emotional consequences of heart disease i. most adjust fairly well

ii. poor adaptation, compliance, and greater likelihood of another heart attack occurs if very high levels of anxiety/depression E. Psychosocial interventions for heart disease a. programs with education and psychological counseling i. meta-analysis study results 1. interventions reduced mortality and recurrence of heart problems 2. programs reduced risk factors 3. addressing fear and anxiety led to far greater psychosocial adjustment 4. studies on psychotherapy have had mixed results b. stress-management programs i. programs reduced angina pectoris by 40%, Type A behavior, and lowered blood pressure c. Ornish's multi-component program i. combined dietary, exercise, and stress management approaches ii. program improved atherosclerosis, reports of chest pain, and later cardiac problems III. Stroke A. Section introduction a. definition and prevalence i. damage that occurs in some area of the brain due to deprivation of blood supply and oxygen ii. in US, 600k new or recurrent strokes annually with 160k deaths b. common symptoms of stroke i. sudden weakness or numbness of face, arm, or leg ii. sudden confusion, trouble speaking, or understanding iii. sudden trouble seeing in one or both eyes iv. unexplained dizziness, loss of balance, or fall v. sudden, unexplained, severe headache B. Causes, effects, and rehabilitation of stroke 1. Section introduction a. causes of blood disruption i. ischemic stroked caused by thrombus or embolus in cerebral artery - tends to occur more slowly ii. hemorrhagic stoke is a ruptured blood vessel - tends to occur rapidly and cause loss of consciousness - occurs less frequently but more likely to cause extensive damage and death

2. Age, gender, and sociocultural risk factors for stroke a. incidence rates are higher for men, African Americans, and middleaged persons i. differences probably lies in biological and lifestyle variations 3. Lifestyle and biological risk factors for stroke a. risk factors include: i. smoking ii. hypertension iii. heart disease, diabetes and their risk factors, obesity, physical inactivity, high cholesterol iv. family history v. high red blood cell count vi. occurrence of transient ischemic attacks vii. drinking more than two alcoholic drinks per day b. role of negative emotions i. depression is linked to incidence of stroke and mortality 4. Stroke effects and rehabilitation a. extent and type of impairment depends on amount and location of lesion i. receiving immediate treatment with clot-dissolving medications reduces damage b. although stroke is one of the most disabling chronic illnesses, improvement of deficits is possible, especially for the young, and those with strokes due to hemorrhages i. motor impairment is the most common deficit - biofeedback and physical therapy reduce disability ii. cognitive impairment may include deficits in language, learning, memory, and perception - language disorders include: - receptive aphasia (difficulty understanding verbal information) - expressive aphasia (problems producing language) iii. visual disorders are common with right brain stroke.

- example: visual neglect which results from processing only part of visual field and can be treated by teaching patient to turn head to scan full visual field iv. emotional effects may depend on area of the brain damaged - left hemisphere damage is related to depression - right hemisphere damage is related to interpretation and expression of affect - emotional lability may occur

B. Psychosocial aspects of stroke a. common coping strategies i. denial occurs more than for heart disease or cancer patients b. emotional adjustments i. depressed individuals show less improvement and remain in the hospital longer ii. depression may result when recovery slows and full extent of impairments becomes known c. occupational effects i. less than half of stroke sufferers return to work within 6 months ii. may not be able to return to work at all which may be emotionally and financially stressful d. social effects i. families often do not adjust well, and marital harmony often declines ii. social contacts and activities may decline and be a source of stress IV. Cancer A. Section introduction 1. Fear associated with cancer diagnosis a. anxiety from false positive breast cancer tests can last for months after tests b. physicians recognize patients' fear of cancer, but are becoming more likely to share details about serious medical conditions B. The prevalence and types of cancer 1. Cancer involves unrestricted cell proliferation which may form a malignant neoplasm (tumor). a. cause of growth unclear but may be due to oncogenes, which regulate cell growth 2. Five types of cancer a. carcinomas - malignant neoplasms of skin cells or cells lining body organs i. constitute 85% of human cancers b. melanomas -neoplasims of the skin cells that produce melanin b. lymphomas - cancers of the lymphatic system c. sarcomas - malignant neoplasms of the muscle, bone, or connective tissue d. leukemias - cancers of the blood-forming organs 3. Cancer cells do not adhere as strongly and therefore more easily spread or metastasize through blood or lymph systems.

4. Prevalence a. leading cause of death worldwide i. second leading cause of death in US - 550,000 deaths and 1.4 million new cases annually - 60% of new cases can expect to live at least 5 years, most will be cured - almost all the increase in cancer cases since 1950 is due to lung cancer C. The sites, effects, and causes of cancer 1. Section introduction a. physical effects of cancer i. growth of tumor interferes with normal development and functioning ii. pain may be caused by pressure on normal tissue or nerves or blocking of flow of body fluids b. cancer as a direct or indirect cause of death i. direct cause - spreads to a vital organ and competes for nutrients; causes organ failure ii. indirect cause - weakens victim and, along with treatment, impairs appetite and ability to fight infection 2. Common cancer sites a. skin cancer i. prevalence = 1 million cases annually ii. types of skin cancer - basal cell carcinoma - squamous cell carcinoma - melanoma b. prostate cancer i. prevalence = 230,000 cases annually ii. survival rate can be 100% with early detection c. breast cancer i. prevalence = 217,000 cases annually ii. 5-year survival rate of 97%, 79% if cancer has spread d. lung cancer i. prevalence = 174,000 cases annually ii. 5-year survival rate of 49% if cancer is localized but only 15% overall e. colorectal cancer i. prevalence = 147,000 cases annually ii. 5 year survival rate of 91% when detected early, 62% overall f. uterine and cervical cancer i. prevalence = 51,000 cases annually ii. 5 year survival rates of 92%

3. Prognosis and causes of cancer a. prognosis depends on how early it is detected and its location b. causal agents i. cancer is caused by interplay of genetic and environmental factors ii. environmental factors include stress, smoking, diet, ultraviolet radiation, chemical hazards, and viral infections 4. Age, gender, and sociocultural factors in cancer a. age factor i. risk for cancer quadruples from ages 40-80 b. gender factor i. incidence rates of cancer are much higher in males than females ii. most common diagnoses are prostate cancer in men and breast cancer in women c. sociocultural factors i. cancer incidence and mortality rates highest for African Americans - survival rates are probably lower due to late detection ii. national differences in cancer prevalence occur D. Diagnosing and treating cancer 1. Knowing warning signs for cancer and having regular examinations increases early detection. a. sites for early detection physician or self-examination include breast, skin, colon or rectum, testes, prostate and uterus or cervix b. warning signs for cancer (CAUTION) i. change in bowel or bladder habits ii. a sore that does not heal iii. unusual bleeding or discharge iv. thickening or lump in breast or elsewhere v. indigestion or difficulty swallowing vi. obvious change in wart or mole vii. nagging cough or hoarseness 2. Diagnosis a. typical medical procedures i. blood or urine tests may reveal unusual levels of certain hormones or enzymes ii. radiological imaging, such as X‑ ray, that reveals presence of tumor iii. biopsy to remove and examine suspect tissue

3. Types of Medical Treatment a. goal of treatment is cure i. since possibility of metastasis exists, 5 year survival rate is gauge of treatment success ii. type of treatment determined by size and site of neoplasm, effect of treatment on patient's life, age of patient b. types of treatment i. surgery is a preferred treatment to eliminate localized cancer and may be used to remove portion of large tumors - tissue near neoplasm may be removed due to concern of spreading cancer, although this process is changing - for breast cancer either the entire breast is removed (mastectomy) or just the tumor is removed (lumpectomy) ii. radiation may involve external beam therapy or internal radiation therapy - side effects such as irritation, burns, hair loss, nausea, loss of appetite, sterility, and reduced bone marrow function may occur iii. chemotherapy involves the use of powerful drugs that kill rapidly dividing cells - side effects include reduced immunity, sores in the mouth, hair loss, nausea and vomiting, and damage to internal organs, but most effects are temporary c. treatment side effects i. two common side effects - severe and long-lasting fatigue - nausea during and soon after treatment ii. side effects learned through classical conditioning - anticipatory nausea - learned food aversions d. demands of treatment i. cancer treatment is complex and demanding - requirements to take medications at home - needs to return to clinics for on-going treatments ii. studies of adherence produce mixed findings.

- adults tend to adhere well but adolescents and minority groups have lower adherence E. The psychosocial impact on cancer 1. Cancer involves a series of threats and unique stresses. a. treatment decisions i. must decide between benefits of treatment and side effects ii. adjustment problems may occur if outcomes aren't as expected

b. threat of recurrence i. threat of recurrence is a concern for those in remission ii. if recurrences occurs the distress can be worse than the initial illness c. adjusting to treatment i. medical procedures can be as aversive as disease itself ii. adjustment has medical consequences and affects disease progression iii. high levels of hopelessness and depression are associated with poor prognosis iv. high levels of stress and poor coping are associated with poor immune system activity d. incidence of emotional problems i. less than half of cancer patients show emotional difficulties ii. most problems are transitory iii. patients with cancer often cope by using positive reappraisal iv. study comparing cancer patients and general public found similar levels of depression, happiness, optimism, and perceived health 9 months after diagnosis and treatment 2. Adjustment depends on patients' physical condition and age a. severe depression is associated with disability or pain 3. Site of cancer, age, and gender influence adjustment a. men with prostate cancer react differently depending on age and child-bearing experience b. women with breast, cervical, or uterine cancer affected by degree of disfigurement or impact on sexual functioning 4. Psychosocial problems a. changes in relationships with family and friends may occur. i. withdrawal from social contact because of awkward feelings about discussing disease ii. physical condition and treatment may interfere with social activities iii. others may avoid patient due to fear or own emotions F. Psychosocial interventions for cancer 1. Psychosocial approach begins with physician's diagnostic interview. a. providing information about treatment is helpful 2. Types of psychosocial interventions a. relaxation and systematic desensitization may be used to treat anticipatory nausea b. cancer pain can be treated with relaxation and problem-solving training c. cognitive-behavioral stress management improves adjustment by reducing depression and increasing positive reappraisal strategies d. family therapy and support groups benefit patients and family through education and group discussion G. Childhood cancer 1. Leukemia is the most common cancer in children

a. 2,700 new cases annually b. 5-year survival rate is 78% 2. Treatment programs for leukemia a. phases of treatment i. induction phase - patient receives combinations of high doses of drugs to bring disease into remission, radiation may be used to prevent development in the brain ii. maintenance phase - continued chemotherapy treatment over the next 2-3 years on an out-patient basis b. treatments include extremely painful procedures such as bone marrow transplants i. use of distraction and modeling used as intervention 3. Psychosocial adjustment a. initial trauma is difficult but adjustment improves over time b. adjustment is better with earlier diagnosis and longer survival c. patients may lag behind peers in academic progress due to illness V. AIDS A. Section introduction 1. Ways in which AIDS differs from other high-mortality chronic illnesses a. a new disease that was unknown until 1980 b. an infectious disease caused by HIV and spread through shared contact with blood/semen c. prevalence i. death rate is low in developed countries ii. a worldwide epidemic with high annual mortality and millions of people infected B. Risk factors, effects, and treatment of AIDS 1. Section introduction a. risk factors i. sexual activity that exposes body fluids ii. sharing contaminated needles iii. birth by an infected mother 2. Age, gender, and sociocultural factors in AIDS a. worldwide prevalence is 38 million, 800k are children b. in the US, infection rates are highest among 20-45 year olds c. infection rates are 3 times higher in men, and have constituted 80% of all AIDS cases in the US d. sociocultural i. death rates are many times higher in African Americans and Hispanics ii. largest concentration of cases in sub-Saharan Africa

C. From HIV infection to AIDS 1. Section introduction a. several years may pass following HIV infection before immune system is impaired b. the diagnosis of AIDS i. originally was made following development of opportunistic diseases such as pneumocystis carinii pneumonia or Kaposi's sarcoma ii. current diagnosis includes low level of helper T cells -new blood tests can determine amount of viral load b. AIDS-related complex i. occurs during time of infection and development of AIDS ii. characterized by fever, night sweats, diarrhea, fatigue, and swollen lymph glands 2. Medical treatment for people with HIV/AIDS a. many opportunistic diseases may be treated with antibiotics i. some victims become hypersensitive or allergic to medications ii. many patients develop encephalopathy b. main treatment i. antiretroviral agents - from 1980s to mid-1990s, main drug was azidothymidine (AZT) which suppresses HIV reproduction - from mid 1990s, protease inhibitors used to interfere with HIV reproduction and reduce viral load ii. problems with medicines - regimens may not work on all strains - must strictly adhere to regimen - treatment is expensive - can have serious side effects - adherence low because of treatment complexity and side effects c. survival patterns i. most AIDS victims die within 3 years ii. 5-10% survive for 15 more years with HIV iii. some long survivors explained by genetic processes iv. HIV victims with high reactivity to stress and poor coping show poor immune function and faster disease progression iv. starting treatment early after infection with brief interruptions allows body to develop immune defenses C. The psychosocial impact of AIDS 1. In the mid-1980's, people with AIDS were ostracized.

2. AIDS still arouses fear and discrimination a. many Americans believe it is punishment from God for misbehavior b. often associated with homosexuality and drug abuse c. concern that family, friends, neighbors, and coworkers will reject 3. Health effects of stigma

a. countries that resist acknowledging disease foster its spread b. stigma leads to delay in testing and treatment c. revealing serostatus slows disease progression 3. Adaptation to HIV/AIDS a. adaptation depends on access to medications i. using effective treatment reduces distress ii. as symptoms decrease, adaptation increases b. experiences of those who don't adapt well i. fear of abandonment, pain, debilitation, and disfigurement ii. feelings of hopelessness, helplessness, and depression - treating depression is critical since it related to faster disease progression D. Psychosocial interventions for AIDS 1. Counseling at the time of testing a. information needs i. information is needed to reduce anxiety while waiting for results. ii. for HIV-positive, counseling is needed regarding illness, treatment, and resources 2. Interventions for people living with HIV/AIDS a. intervention needs i. assistance with complex regimen ii. intervention for emotional distress, pain management, and sleep disorders iii. reducing anxiety and depression for those who do not have effective drugs b. studies on intervention effectiveness i. intervention reduces anxiety/depression and enhances immune function ii. HIV patients who wrote about a traumatic experience had lower viral loads than those writing about a neutral topic

VIII. The Survivors: And Life Goes On A. Adapting to bereavement 1. Bereavement is the state of having lost someone through death. a. grief is the characteristic feeling b. mourning is the expression of these feelings B. Physical and psychosocial impact 1. Adapting to bereavement a. each grieving person adjusts at their own rate - no rule of thumb on time needed to adjust - spousal grief is similar before and after death, remains high for about a year, and is greater for middle-aged individuals - individual therapy or group support may help with adjustment 2. Adjusting to bereavement in AIDS cases for gay men. a. many experience long series of bereavements without time to adjust in between

b. gay men who have lost lovers may receive less social support from others

3. Adjusting when a child dies a. death of a child may result in years of grieving for the loss i. the loss of a child is one of the most tragic events that can happen to a family ii. surviving siblings need special attention, it is not uncommon for them to show little grief C. Psychosocial interventions for Bereavement 1. Individual therapy and support a. group discussion and role playing b. systematic densensitization D. Reaching a positive adaption 1. Long-term adjustment a. most people are able to build new lives with social support b. although surviving spouses usually receive a great deal of attention, eventually this changes and they must return to their daily lives c. some bereaved individuals are never able to adjust, but new and enriching lives can be built

DISCUSSION TOPICS

1. Communicating about the HIV/AIDS risk to Hispanic populations Gustavo Yep has reviewed a number of the critical issues to bear in mind when addressing concerns regarding HIV/AIDS with Hispanic populations. First noting the prevalence of HIV/AIDS among Hispanic peoples is higher than would be expected given population distribution, he discusses the need for HIV/AIDS prevention campaigns to be culturally appropriate. Citing an example where one prevention campaign blundered in its promotion condom use ran afoul of the Catholic church, the need for prevention and treatment programs to take into account cultural perceptions of target audiences is highlighted.

Yep uses McGuire’s communication/persuasion model as the basis of how best to deliver HIV prevention messages. Thus, he considers source, message, channel, and receiver factors in his presentation. One particularly interesting section of the chapter reviews the nature of the message in HIV prevention interventions. Yep notes that Marin et al. (1988) strongly caution against translating prevention messages from English to Spanish as the translated message may be too difficult to1 understand, may in fact turn out to be insulting in Spanish, and may be confusing or misleading. Pino (1989) urges that HIV prevention materials need to be “spiritually, culturally, and socially relevant to Latinos.” (pg.

200). The language translation issue extends into dramatic misunderstandings when the focus is on HIV-related terminology. For example, it is common to use the term “sexually active” in English discussions regarding HIV. The Spanish phrase vida sexual active (an active sexual life) connotes prostitution and daily sex and it has been suggested by Marin et al. that the phrase relaciones sexuales (sexual relations) would be culturally more appropriate. These same authors point out that “Spanish terms for vaginal, anal, and oral intercourse carry a high degree of social undesirability.” (pg. 201). Marin & Marin (1991) suggest Hispanic cultural values of allocentrism (collectivism), simpatia (a cultural script that promotes harmonious relationships), familialism (the importance of family), respeto (deference or respect for individuals in authority), and machismo (the expectation that men should be dominant in relationships) must be taken into consideration.

Although the focus of this chapter is on prevention, it would seem that similar themes would come into play in post-diagnosis interventions. One discussion point might be how cultural themes or language used in HIV/AIDS treatment might need to reflect similar cultural sensitivities.

Source: Yep, G.A. (1995). Communicating the HIV/AIDS risk to Hispanic populations: A review and integration. (pp 196-212). In Padilla, A.M. (Ed.), Hispanic psychology: Critical issues in theory and research. Thousand Oaks, CA: Sage.

2. Humanizing death.

The topic of death can produce powerful discussion in a Health Psychology course.

Dr. Sandra Levy, a clinical psychologist with decades of research on cancer control , has written an equally powerful chapter on the role of psychologists working with terminally ill patients. She observes that physicians often rely on a curative orientation to care, even when the course of the disease can no longer be affected. Experimental techniques may be tried, with possible iatrogenic outcome and high costs to patient and family alike. At the same time, patients have often not prepared for their end days…thinking about final care as opposed to cure themselves. The rise in technological sophistication that allows for life to be maintained is often in conflict with other needs of the patient, she says. Cultural countertrends, such as hospice, living wills, and no-code orders, are a growing acknowledgment of those needs.

Levy raises provocative issues in this chapter. In the section, Withdrawing Life Support, she repeatedly emphasizes the needs for thorough preterminal discussions between health professional and patient on their wishes under terminal conditions. She notes, for example, that the practice of CPR carries with it numerous ethical issues. Medical personnel must act quickly to reduce the likelihood of organ damage. At the same time, most patients are not aware of the “aggressive” nature of this procedure and the iatrogenic outcomes of its use. The use of CPR is seldom discussed with patients or families and, as Dr. Levy notes, is the only medical intervention that can actually be performed by a nonphysician without a physician’s order. Physician/patient discussions of other lifesustaining measures are also rarely discussed, according to Levy. Complicated decisions regarding the patients’ decision-making capacity and the use of surrogates for decisionmaking still leave a large portion of the responsibility in the hands of the physician as it appears that relatively few people prepare a living will and/or appoint a surrogate to act for them regarding such decisions.

Providing for the psychological needs of dying patients and their families requires considering the relevant psychosocial stressors and needs of patient and family members alike. Medical staff, Levy observes, tend to under-report levels of depression in the terminally ill. Undiagnosed depression can exacerbate the distress of those already seriously physically ill. Moreover, disease states (esp. in cancers) influence the neurophysiology and contribute to depression. In many cancer patients, the hope that had manifested as a hope for recovery is transformed into other “hopes” – to live to see a certain event or to die peacefully or transferring hopes to other family members’ lives. Feelings of abandonment from friends, family, and even eventually one’s physician, must be confronted. Loss of control and physical loss are linked to “acting out” and mourning or depression. Family members move through experiences of anticipatory grief . The therapeutic approach then works with the dying person as well as the family with a goal, not of attempting provide therapeutic growth as would be done for other mental health concerns, but for helping patients and families build on strengths within their fundamental values. Supportive interventions include appropriate medications for depression and pain, enhancing levels of personal control (environmental factors such as the place to die). Follow-up care with family members remains a critical function of the psychologist.

Levy relays a poignant story of a therapist who provided therapy for four dying friends.

Capturing his experience, Lewis (1982) quoted Walker Percy (1980): “Not once had he been present for his life. So his life had passed like a dream. Is it possible for people to miss their lives in the same way one misses a plane? And how is it that death, the nearness of death,

can restore a missed life?” (pg. 209).

This chapter is relatively brief….students might find it a good source of an in-class discussion on death and dying as an adjunct to the text presentation.

Source: Levy, S.M. (1990). Humanizing death: Psychotherapy with terminally ill patients. (pp 185213). In Herek, G.M., Levy, S.M., Maddi, S.R., Taylor, S.E., & Wertlieb, D.L. (Eds.), Psychological aspects of serious illness: Chronic conditions, fatal diseases, and clinical care. Washington, DC: American Psychological Association.

ACTIVITY SUGGESTIONS 1. Assess Yourself: Your Living Will Choices. Have students complete Handout # 1. A living will is a legal document indicating a person's wishes regarding under what conditions decisions regarding terminating medical treatment may le made. Not every state recognizes the validity of living wills. Contact your local bar association to see if living wills are recognized in your state.

2. The nature of cancer. To help students gain an appreciation that cancer is not one disease but many, assign each student one type of cancer to research. Have them write a report about their assigned cancer and make a class presentation on it.

3. Take the Komen NetQuiz. Have students go to: http://www.komen.org/netquiz/netquiz_popup.html where they will find the Komen NetQuiz. This quiz is not a particularly easy one but is short (i.e., 8 questions) that address detection, risk factors, and treatment.

4. Hospice team presentations - the Hospice Patients Alliance website, www.hospicepatients.org/ , has a very large amount of information (18 topic areas) that students could review and give team presentations in class.

5. Hospice. Contact a local hospice for a speaker on dealing with terminal illness and bereavement. Many larger organizations may have a specialist employed for this purpose.

6. Living with HIV/AIDS. Contact a local AIDS information office or Gay Action office for names of possible speakers who could come to class to talk about living with AIDS. One of the most moving and instructive class discussions ever in my Health Psychology class occurred when I invited a college-aged man with AIDS to come to my class. The young man spoke frankly about high-risk sexual activity and lifestyle and financial problems associated with having AIDS. 7. Psychosocial support for the terminally ill. There are several good videos on this subject. Refer to the Suggested Films & Videos list below. Ask students to debate the pros and cons of home care, hospice, or hospital death for terminally ill cancer patients.

RESOURCES The following organizations may be able to provide local resources as well as lists of publications for sale at a nominal cost and teaching materials.

For Cancer: American Cancer Society 1599 Clifton Rd., N.E. Atlanta, GA. 30329 (404) 320‑ 3333 For Heart Disease and Stroke: American Heart Association 7272 Greenville Ave Dallas, TX 75231 (214) 373‑ 6300 For AIDS: Answers to specific questions or for referrals contact the National AIDS Hotline at 1‑ 800‑ 342‑ 2437. The Hotline is a function of the American Social Health Association.

Their address is: American Social Health Association Dayton, OH 45402 (937) 227‑ 8922 For information on publications, films or books available on any aspect of AIDS, contact National AIDS Information Clearing House P.O. Box 6003 Rockville, MD 20849‑ 6003 (800) 458‑ 5231 Suggested Readings: Coping with and Adapting to High-Mortality Illness Ashe, A., & Rampersad, A. (1993). Days of grace. New York: Knopf.

Stein, M. & Baum, A. (Eds.) (1995). Chronic Diseases. Hillsdale, NJ: Lawrence Erlbaum Associates.

Heart Disease Ayanian, J.Z., & Epstein, A.M. (1991). Differences in the use of procedures between women and men hospitalized for coronary heart disease. The New England Journal of Medicine, 325, 221-225.

Dusseldorp, E., van Elderen, T., Maes, S., Meulman, J., & Kraaij, V. (1999). A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychology, 18(5), 506-519.

Fang, C.Y., & Myers, H.F. (2001). The effects of racial stressors and hostility on

cardiovascular reactivity in African American and Caucasian men. Health Psychology, 20(1), 64-70.

Helgeson, V.S. (2001). Applicability of cognitive adaptation theory to predicting adjustment to heart disease after coronary angioplasty. Health Psychology, 18(6), 561-569.

Johnston, D.W., Johnston, M., Pollard, B., Kinmonth, A., & Mant, D. (2004). Motivation Is Not Enough: Prediction of Risk Behavior Following Diagnosis of Coronary Heart Disease From the Theory of Planned Behavior. Health Psychology, 23(5) 533-538.

Legato, M.J., & Colman, C. (1991). The female heart. New York: Simon & Schuster.

Ornish, D., Brown, S.E., Scherwitz, L.W., Billings, J.H., Armstrong, W.T., Ports, T., McLanahan, S.M., Kirkeeide, R.L., Brand, R.J., & Gould, K.L. (1990). Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 336, 129133.

Sears, S.F., Marhefka, S.L., Rodrigue, J.R., & Campbell, C. (2000). The role of patients' ability to pay, gender, and smoking history on public attitudes toward cardiac transplant allocation: An experimental investigation. Health Psychology, 19(2), 192200.

Stroke National Institute of Neruological and Communicative Disorders and Stroke. (1999).

Stroke: Hope through research. Bethesda, MD: author.

Toole, J.F. (1990). Cerebrovascular disorders. New York: Raven Press.

Cancer Cordova, M.J., Cunningham, L.L.C., Carlson, C.R., & Andrykowski, M.A. (2001).

Posttraumatic growth following breast cancer: A controlled comparison study. Health Psychology, 20(3), 176-185.

Epping-Jordan, J.E., Compas, B.E., Osowiecki, D.M., Oppedisano, G., Gerhardt, C., Primo, K., & Krag, D.N. (1999). Psychological adjustment in breast cancer: Processes of emotional distress. Health Psychology, 18(4), 315-326.

Helgeson, V.S., Cohen, S., Schulz, R., & Yasko, J. (2000). Group support interventions for women with breast cancer: Who benefits from what? Health Psychology, 19(2), 107114.

Messina, C.R., Lane, D.S., Glanz, K., West, D.S., Taylor, V., Frishman, W. & Powell, L. (2004). Relationship of Social Support and Social Burden to Repeated Breast Cancer Screening in the Women's Health Initiative. Health Psychology, 23(6) 582-594.

Pikler, V. & Winterowd, C. (2003). Racial and Body Image Differences in Coping for Women Diagnosed With Breast Cancer. Health Psychology, 22(6) 632-637.

AIDS Catz, S.L., Kelly, J.A., Bogart, L.M., Benotsch, E.G., & McAuliffe, T.L. (2000). Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychology, 19(2), 124-133.

Chesney, M.A. (1993). Health psychology in the 21st century: Acquired immunodeficiency syndrome as a harbinger of things to come. Health Psychology, 12, 259-268.

Chesney, M.A. & Antoni, M.H. (2002). Innovative approaches to health psychology: Prevention and treatment lessons from AIDS. Washington, DC: American Psychological Association.

Crepaz, N., & Marks, G. (2001). Are negative affective states associated with HIV sexual risk behaviors? A meta-analytic review. Health Psychology, 20(4), 291-299.

Gonzalez, J.S., Penedo, F.J., Antoni, M.H., Durán, R.E.; McPherson-Baker, S., Ironson, G., Isabel Fernandez, M., Klimas, N.G., Fletcher, M.A., & Schneiderman, N. (2004).

Social Support, Positive States of Mind, and HIV Treatment Adherence in Men and Women Living With HIV/AIDS. Health Psychology, 23(4) 413-418.

Huber, J.T. (1996). HIV/AIDS community information services: Experiences in serving both at-risk and HIV-infected populations. New York: Haworth Press.

Kalichman, S.C., & Nachimson, D. (1999). Self-efficacy and disclosure of HIV-positive serostatus to sex partners. Health Psychology, 18(3), 281-287.

Mulder, C.L., deVroome, E. M., van Griensven, G.J., Antoni, M.H., & Sandfort, T.G. (1999).

Avoidance as a predictor of the biological course of HIV infection over a 7-year period in gay men. Health Psychology, 19(2), 107-113.

National Institutes of Health. (1996). HIV/AIDS information resources. Bethesda, MD: author.

Vanable, P.A., Ostrow, D.G., McKirnan, D.J., Taywaditep, K.J., & Hope, B.A. (2000). Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men. Health Psychology, 19(2), 134-145.

Adapting to Terminal Illness Rosenburg, L. & Guy, D. (2000). Living in the light of death: On the art of being truly alive.

Boston, MA: Shambhala Publications.

Bertman, S.L. (1991). Facing death: Images, insights, and interventions: A handbook for educators, healthcare professionals, and counselors. Washington, D.C.: Hemisphere Publishing.

Quality of Life and Death deVries, B. (Ed.) (1999). End of life issues: Interdisciplinary and multidimensional perspectives. Thousand Oaks, CA: Sage.

Fagerlin, A., Ditto, P.H., Danks, J.H., Houts, R.M., & Smucker, W.D. (2001). Projection in surrogate decisions about life-sustaining medical treatments. Health Psychology, 20(3), 166-175.

Kastenbaum, R. (2000). The psychology of death. Thousand Oaks, CA: Sage.

Kastenbaum, R. J. (1991). Death, society, and human experience (4th ed.). New York: Merrill.

Power, M., Bullinger, M., Harper, A., & The World Health Organization Quality of Life Group.

(1999). The World Health Organization WHOQOL-100: Tests of the universality of quality of life in 15 different cultural groups worldwide. Health Psychology, 18(5), 495505.

The Survivors Corr, C.A., & Balk, D.E. (Eds.) (1996). Handbook of adolescent death and bereavement.

Thousand Oaks, CA: Sage.

Corr, C.A., & Corr, D.M. (Eds.) (1996). Handbook of childhood death and bereavement.

Thousand Oaks, CA: Sage.

Worden, J.W. (1991). Grief counseling and grief therapy. Thousand Oaks, CA: Sage.

Suggested Films and Videos: Heart Disease 1. Advances in cardiac surgery. (1998, Edudex, 28 min). New techniques in cardiac surgical procedures are presented.

2. Cardiac Psychology. (2003, American Psychological Association, 108 min). Discussion of psychological intervention strategies for patients with high risk of coronary disease.

3. Cardiovascular disease. (1994, Edudex, 20 min). Explores causes of heart attacks and stroke and diagnosis and treatment methods.

Stroke 1. Learning about stroke. (Encyclopedia Britannica Educational Corporation, 19 min).

Describes types of stroke and risk factors.

2. Pathways: moving beyond stroke and aphasia. (1991, Wayne State University Press, 28 min). Examines several case studies of stroke vicitms undergoing rehabilitation.

3. Post-stroke rehabilitation. (1995, Network for Continuing Medical Education, 60 min).

Presents current rehab alternatives for stroke victims.

4. Stroke. (1996, Time-Life Medical, 30 min). Explains diagnosis, pathophysiology, and treatment.

5. Stroke: Brain attack. (Edudex, 30 min). Follows the cases of two people who have had a stroke.

Cancer 1. A significant journey: breast cancer survivors and the men who love them. (1992, Media Productions, Inc, 20 min). Presents several women and their husbands, discussing how they coped with their fears and concerns.

2. Cancer treatment. (1999, Edudex, 28 min). Follows patients through treatment with information provided on chemo - and radiation therapies.

3. Coping with childhood cancer. (1990, Films for the Humanities and Sciences, 28 min).

Interviews five family members of childhood cancer patients, focusing on coping.

4. How will I survive? (1993, Phoenix Films, Inc., 57 min). Interviews women with breast cancer.

5. Men & cancer. (1994, The Institute, 9 min). Discusses cancers that are specific to men, including prostate and testicular cancer.

6. The other epidemic: what every woman needs to know about breast cancer. (1993, MPI Home Video, 43 min). Presents personal stories of survivors of breast cancer, focusing on two women as they are diagnosed and treated for breast cancer.

7. Women and cancer. (1994, The Institute, 8 min). Describes cancers that are specific to women, including uterine, cervical, and breast cancer.

AIDS 1. Beyond life and death. (Films for the Humanities and Sciences, 30 min). Explores how beliefs about death affect how people live.

2. AIDS: Ending the epedemic. (2002, Discovery Communications Inc., 78 min). A look at the current state of AIDS and science behind treatment.

3. AIDS: The modern plague. (Edudex, 30 min). A view of the fight against AIDS and the

effectiveness of prevention and treatment efforts.

4. Heart, soul, and HIV. (1990, Hospital Satellite Network, 60 min). Looks at care alternatives and support programs for victims of AIDS and their families.

5. Medicine at the Crossroads: Pandemic (1993, WNET/BBC-TV, 57 min). Discusses progress in the scientific understanding of AIDS and attempts to prevent the disease.

6. Olga's story. (1993, KCET, 20 min). Describes one Latina's experience with AIDS and its effect on her family.

7. Pathophysiology of AIDS. (1997, Lippincott, 18 min). Shows how a patient's clinical signs and symptoms relate to the progression of AIDS. Adapting to Terminal Illness 1. Living fully until death. (Films for the Humanities and Sciences, 29 min). Focuses on three people who struggle with living fully after receiving a diagnosis of terminal illness.

2. On our own terms: Moyers on dying in America. (Films for the Humanities and Sciences, 90 min ea.) A four film series by Bill Moyers on the US movement to improve care for people who are dying. Titles include: Living with dying, A different kind of care, A death of one's own, and A time for change.

Quality of Life and Death 1. Caregiving. (Films for the Humanities and Sciences, 30 min). Reviews rewards of home health care and caregiving.

2. Every second counts: Living with a heart attack. (2000, Edudex, 23 min). Presents the case of a young doctor with heart disease.

3. Letting go: A hospice journey. (Films for the Humanities and Sciences, 90 min). Shows how hospice care provides solice for dying patients and their families.

The Survivors 1. Grief: The courageous journey. (Films for the Humanities and Sciences, 25 min ea.). A nine-part series on various forms of loss through death, divorce, being fired, and the resulting grief and healing process. Titles include: Understanding grief, Loss of a job, Loss of a family, Loss of a relationship, Loss of a daughter, Loss of a son, Loss of a Spouse, Facing death, and Portraits of grief.

2. Grief and healing. (Films for the Humanities and Science, 30 min). Seven people discuss experiences with loss, grief, and healing.

3. The caring helper: Grief and loss. (1991, Insight Media, 30 min). Portrays stages of grief and intervention techniques.

Internet sites of interest Dying and Terminal Illness 1. http://azaz.essortment.com/medicalsymptom_mal.htm - Coping with a terminal illness – a step by step guide 2. http://www.love-and-light.net - site for book entitled Why Me? Why Not? Living Beyond Terminal Illness.

3. http://www.wma.net/e/policy/i2.htm - World Medical Association Declaration on Terminal Illness 4. http://www.skdesigns.com/internet/spirit/death.html - Spirituality & Alternative Healing: Death, Dying, & Terminal Illness Heart Disease and Stroke 1. http://www.americanheart.org - American Heart Association 2. http://www.strokeassociation.org/ - Stroke Association 3. http://stroke.ahajournals.org/ - Stroke – an American Heart Association journal 4. http://www.strokejournal.org - Journal of Stroke & Cerebrovascular Diseases 5. http://www.stroke.org.uk/ - The Stroke Association (TSA) home page 6. http://neurosurgery.mgh.harvard.edu/paral-r.htm - Spinal Cord Injury, Stroke, and Paralysis Guide to Support Organizations.

7. http://www.stroke-site.org/ - The Brain Attack Coalition – dedicated to reducing the occurrence of disabilities and death associated with stroke Cancer 1. http://hsl.mcmaster.ca/tomflem/breastcancer.html - large list of breast cancer related websites 2. http://www.komen.org/ - Susan G. Komen Breast Cancer Foundation website 3. http://www.cancer.org - American Cancer Society 4. http://www.fhcrc.org/ - Fred Hutchinson Cancer Research Center 5. http://aicr.org/ - American Institute for Cancer Research – Diet, Nutrition, and Cancer Prevention 6. http://www.cancernews.com/ - Cancernews.com website 7. http://nci.nih.gov/ - National Cancer Institute 8. http://www.oncolink.com/ - OncoLink from the University of Pennsylvania Abramson Cancer Center 9. http://www.acor.org/index.html - Association of Cancer Online Resources HIV/AIDS 1. http://www.cdc.gov/hiv/pubs/facts.htm - National Center for HIV, STD, and TB Prevention Divisions of HIV/AIDS Prevention 2. http://www.healingwell.com/AIDS/ - AIDS/HIV Resource Center 3. http://www.aidsresearch.org/index.html - AIDS Research Alliance of America 4. http://www.census.gov/ipc/www/hivaidsd.html - HIV/AIDS Surveillance data base 5. http://www.cdcnpin.org/ - The CDC National Prevention Information Network 6. http://www.fda.gov/oashi/aids/hiv.html - US Food and Drug Administration HIV and AIDS Activities 7. http://hivinsite.ucsf.edu/InSite - HIV InSite homepage from University of California, San Francisco

8. http://www.eatright.org/Public/Other/index_adap0600.cfm - nutrition intervention in the care of people living with HIV/AIDS 9. http://aidsinfo.nih.gov - Information on HIV/AIDS Treatment, Prevention, and Research Hospice and Palliative Care 1. http://www.aahpm.org/ - American Academy of Hospice and Palliative Medicine 2. http://www.hospicefoundation.org/ - Hospice Foundation of America 3. http://www.nahc.org/HAA/home.html - Hospice Association of America 4. http://www.abhpm.org/ - The American Board of Hospice and Palliative Medicine 5. http://www2.edc.org/lastacts/ - International journal from Innovations in End-of-Life Care 6. http://www.hospicecare.com/ - International Association for Hospice & Palliative Care 7. http://www.hospicepatients.org/ - Hospice Patients Alliance 8. http://www.scu.edu/Hospice/ - The Hospice Home Page 9. http://www.hospicenet.org/ - Hospice Net 10. http://www.nahc.org/ - National Association for Home Care 11. http://www.isoqol.org/main.html - International Society for Quality of Life Research 12. http://www.uib.no/isf/people/doc/qol/httoc.htm - Quality of life compendium – contains information and instruments 13. http://www.fmhi.usf.edu/institute/pubs/pdf/abstracts/qol.html - Quality of Life Assessment Manual 14. http://www.wellnessbooks.com/dying/ - Grief & Dying Book Store

Handout #1

Assess Yourself: Your Living Will Choices.

Fill out the Health Care Living Will and Proxy below, indicating what your wishes would be if you were unable to make decisions about medical treatment, such as if you were in a coma. What specific treatments would you want or not want to receive? Whom would you choose as your agent or "proxy" in making decisions if you were unable to make them? This person should be an adult who is familiar with your personal and health care views -- someone you would trust to make the decisions you would make.

Health Care Living Will and Proxy To My Family, Physicians, and Other Concerned Parties: I, _______________, (the principle), being of sound mind, make the following advance directives to be carried out if I become unable to make or communicate decisions about my medical treatment.

Living Will I request the withdrawal or withholding of life sustaining procedures. Consistent with my desire that I be permitted to die naturally if the situation occurs that I am either (1) near death with no reasonable likelihood of recovery or (2) in a coma or vegetative state and my physicians believe that there is no significant possibility of my ever regaining consciousness or higher functions of my brain. Under these circumstances, I specifically: 1. DO NOT want the following treatments I have initialed.

Cardiac resuscitation _____ Artificial respiration _____ Artificial feeding or fluids _____ Other ________________ _____ 2. DO want the following conditions I have initialed.

Medication to relieve pain _____ To die at home, if possible _____ Other ________________ _____ Proxy I designate here (1) a first proxy, _______________ (name), to make decisions in accordance with the wishes and conditions specified above, or as he or she otherwise knows, and (2) a second proxy, ______________ (name), as a substitute if the first proxy is unable, unwilling, or unavailable to act as my health care proxy.

Some living wills are much more complicated than this one, having the person make dozens of choices regarding many different medical procedures that might be considered in very different scenarios. One concern in being so specific is that knowledge about treatments can change: suppose evidence on a treatment's effectiveness changes between the time a patient rejects it in the will and the scenario actually occurs? What then?

TEST QUESTIONS True or False T

1.

Cognitive adjustments patients make to high‑ mortality illnesses include developing positive reappraisals of their life situations , gaining a sense of control, and restoring their self-esteem.

2.

Women are more likely to have heart attacks, but less likely to die from them than men.

3.

50% of patients who begin an exercise program as part of their cardiac rehabilitation discontinue within the first six months.

4.

The vast majority of those smokers who suffer a myocardial infarction quit smoking.

5.

Ischemic strokes are caused when blood supply to the brain is cut off by a blood clot or a plaque.

6.

Aphasias are language disorders that can be caused by stroke in the. left hemisphere of the brain.

7.

Cancer is the most frequent cause of death in the U.S.

8.

The most common site for cancer is the lung

9.

The criteria for diagnosis of AIDS has been changed to include low T-cell counts.

10.

Quality of life has been ruled out as a factor in determining if life-support systems should be used to sustain life.

(388)

F (389)

T (393)

F (393)

T (396)

T (398)

F (400)

F (400)

T (409)

F (413)

Matching Match the following disorders with their descriptions in one through five. a. angina pectoris b. myocardial infarction c. carcinoma d. stroke e. AIDS b

1. The destruction of heart muscle due to lack of blood.

(389)

e (410)

2. May be associated with Pneumocystis carinii pneumonia and eventual encephalopathy.

a

3. Caused by a brief or incomplete blockage of oxygenated blood to the heart.

(389)

d

4. Results in motor or cognitive deficits and possible emotional lability.

(396)

c

5. Characterized by an unrestrained proliferation of cell growth.

(400)

Match the following treatments with their description in six through ten. a. balloon angioplasty b. external beam therapy c. chemotherapy d. lumpectomy e. AZT e

6. May prolong survival, but is not a cure for AIDS

(410)

a

7. Is used to treat blockages in coronary arteries.

(392)

d

8. A treatment for a limited breast cancer

(404)

c

9. Results in anticipatory nausea in 25-50% of those treated.

(404)

b (404)

10. A radiation treatment for cancer.

Multiple Choice d (387)

c (387)

c (387)

b (388)

a (388)

c (388)

1. Which of the following is NOT considered a high-mortality chronic illness? a. cancer b. heart disease c. stroke d. asthma 2. When a person has been diagnosed with a high-mortality disease such as cancer, they a. probably have only a matter of months to live. b. seldom make it to the 5-year survival window. c. may be totally cured. d. are no more likely of dying than a healthy person.

3. During the first few months after diagnosis of a life‑ threatening illness, a. patients usually plan for the future with assurance. b. patients are usually pessimistic. c. more active approaches in coping begin to be utilized. d. the use of avoidance coping grows stronger.

4. The helplessness that a person with a high-mortality illness experiences, coupled with nurturance from his or her family, can lead to ____ on the part of the patient. a. high self esteem b. dependence c. self-efficacy d. hardiness 5. May has dealt with her breast cancer by focusing on the good things in life and living each day to the fullest. This approach best fits what Taylor would categorize as a. finding meaning. b. avoidance. c. restoring self‑ esteem. d. gaining control.

6. Which of the following statements best captures the experience of relapse in high-mortality diseases? a. Relapse is a low occurrence event. b. Patients respond better to relapses than they did to the original diagnosis. c. Relapse is often viewed as a bad sign and that the prognosis is worse. d. Patients use the same coping strategies and continue to experience just as much hope as at the time of the original diagnosis.

b (389)

a (389)

d (389)

c (389)

c (389)

b (389)

7. The painful cramp associated with a brief blockage of oxygenated blood to the heart is called a. myocardial infarction. b. angina pectoris. c. transient ischemic attacks. d. atherosclerosis.

8. Another term for "heart attack" is a. myocardial infarction. b. angina pectoris. c. transient ischemic attacks. d. cerebral infarction.

9. Dan's cardiologist discovers he has an enlarged heart with poor pumping capability which contributes to his shortness of breath when he walks up his apartment stairs. Dan is likely to be diagnosed with a. myocardial infarction. b. angina pectoris. c. transient ischemic attacks. d. congestive heart failure.

10. Which of the following contributes to greater likely of heart damage following a heart attack? a. Getting to the hospital as quickly as possible following onset of symptoms. b. Getting to the hospital within an hour of symptom onset. c. Getting to the hospital within 3 hours of symptom onset. d. The greatest amount of damage occurs immediately – delay seldom affects levels of heart damage.

11. Heart attacks are most common a. among men. b. in the morning. c. in Blacks. d. all of the above.

12. Which is not a biological risk factor for heart disease? a. Family history of the disease. b. Contact with an infected person. c. Hypertension. d. High LDL and total cholesterol levels.

d (390)

a (392)

d (392)

d (393)

b (393)

d (393)

13. Which sociocultural group has the lowest death rates from heart disease? a. African American. b. Hispanic. c. Native American. d. Asian American.

14. Following her recent heart attack Jamie's surgeon placed a balloon in one of her blocked blood vessels and inflated it. This procedure is called a. angioplasty. b. bypass surgery. c. cardiac resuscitation. d. angina pectoris.

15. Which of the following describes the course of anxiety that occurs following a heart attack? a. Anxiety remains high through hospitalization and continues to be higher than non-cardiac patients for years after the event. b. Anxiety is best eliminated through the use of denial. c. Anxiety is natural and rarely affects recovery from heart attack. d. Anxiety levels are high initially but then generally start to decline.

16. Recurrent chest pain following a heart attack a. is uncommon b. indicates a greater risk of heart attack in the near future. c. all of the above d. none of the above 17. Which of the following is least likely to be advised by a physician to a heart attack victim? a. Stop smoking. b. Increase alcohol consumption. c. Lose weight. d. Exercise.

18. Within the first six months of beginning an exercise program about 50% of heart attack victims a. have substantial weight gain. b. have another heart attack c. are re-hospitalized. d. discontinue the program.

d (394)

c (394)

c (394)

b

19. Which of the following describes the role of work following a heart attack? a. It is often viewed as a sign of recovery by patients. b. Most cardiac patients return to work but in a diminished job capacity. c. Returning to work has been linked to long-term well-being. d. all of the above.

20. Following a heart attack, prior family problems a. tend to be viewed as trivial. b. often are worked through more realistically. c. often become worse. d. have no impact on adherence to cardiac rehabilitation regimen.

21. Studies of wives' evaluations of the post‑ heart attack physical abilities of their husbands indicate that wives develop more accurate evaluations by a. having heart attack patients tell them about their capabilities. b. simply observing the physical activity of patients. c. personally participating in patients' activities. d. having physicians tell them what their husbands were capable of doing.

22. Which of the following outcomes is NOT produced by cardiac rehabilitation

(392) programs that include both psychosocial counseling and health/regimen

education? a. Reduced mortality. b. Reduced anxiety and depression. c. Lower recurrence of heart problems. d. Reduced risk factors. a (396)

a (396)

a (397)

23. Wayne had a stroke that occurred very suddenly. His daughter found him unconscious on the living room floor. His stroke was probably caused by a. hemorrhage. b. blood clot. c. a piece of plaque lodged in a cerebral artery. d. shock.

24. Which of the following statements regarding strokes is TRUE? a. Strokes caused by hemorrhages produce the most extensive damage. b. Strokes caused by infarction tend to produce unconsciousness. c. Strokes due to infarctions are less common than strokes due to hemorrage. d. Infarctions cause more death than due hemorrhages.

25. Which sociocultural group has the highest death rates due to stroke? a. African American. b. Hispanic. c. European American. d. Native American.

d (396)

c (396)

b (397)

c (397)

c (397)

a (398)

26. Fred experienced a sudden, severe headache, followed by blindness in one eye and dizziness. These are symptoms of a. a myocardial infarction. b. diabetes. c. AIDS. d. a stroke.

27. Mini-strokes, which may occur one or more times before a full stroke, are called a. myocardial infarctions. b. angina pectoris. c. transient ischemic attacks. d. atherosclerosis.

28. The most common deficits experienced by stroke patients involve a. speech. b. motor action. c. cognitive dysfunction. d. memory loss.

29. Which of the following deficits would be most characteristic of right hemisphere damage from stroke? a. Receptive aphasia. b. Expressive aphasia. c. Visual and emotional disorders. d. Paralysis of the right side of the body.

30. The phenomenon of visual neglect occurs when there is damage in the _____ hemisphere and is characterized by the failure to process information from the _____ visual field. a. right; right b. left; left c. right; left d. left; right 31. The use of denial is most common in which of the following disorders? a. Stroke. b. Heart disease. c. Cancer. d. Diabetes.

d

32. Common forms of effective rehabilitation treatments for victims of stroke

(397) include:

a. speech therapy. b. physical therapy. c. biofeedback. d. all of the above. b (400)

c (400)

a (400)

b (400)

c (400)

a (400)

33. Another common name for a tumor is a. protoplasm. b. neoplasm. c. cytoplasm. d. plasma.

34. Cancers of the blood‑ forming organs are called a. sarcomas. b. lymphomas. c. leukemias. d. carcinomas.

35. The majority of human cancers are a. carcinomas. b. sarcomas. c. lymphomas. d. leukemias.

36. Cancers of the muscle, bone, or connective tissue are called a. carcinomas. b. sarcomas. c. lymphomas. d. leukemias.

37. The spread of cancers to other parts of the body from the primary site through the blood or lymphatic system is called a. osmosis b. leukocytosis c. metastasis d. metamorphosis 38. The increase in cancer death rate since 1950 is attributable to cancer of the a. lung b. liver c. breast d. pancreas

b (400)

d (402)

b (402)

c (403)

d (404)

b (405)

39. _____ is a direct cause of death due to cancer whereas _____ is an indirect cause of death due to cancer. a. Organ failure; painful pressure on organs. b. Organ failure; impaired appetite c. Impaired appetite; organ failure. d. Impaired appetite; reduced immune function.

40. Which of the following is true regarding the demographic characteristics of cancer? a. Incidence rates remain roughly the same across the life span. b. Women and men in the US now have equal incidence rates. c. Native Americans have relatively high levels of cancer compared to persons from other racial-ethnic groups. d. Cancer prevalence varies greatly between countries.

41. The organ most commonly afflicted with cancer in the United States is the a. lung. b. skin. c. prostate. d. breast.

42. The surgical removal and analysis of tissue to detect cancer is called a. radiology. b. anesthetic. c. biopsy. d. imaging.

43. Anticipatory nausea in chemotherapy patients a. is probably learned by classical conditioning. b. occurs in about 25-50% of long‑ time recipients of the treatment. c. contributes to some people stopping treatment and, thus, shortening their lives. d. all of the above 44. What is one way to prevent the learned food aversions associated with chemotherapy? a. Use imaging therapy. b. Provide a scapegoat food prior to chemotherapy. c. Use progressive relaxation techniques. d. Use less powerful chemicals.

c (406)

c (407)

a (408)

d (410)

c (410)

d (410)

45. Which of the following statements about adapting to cancer is TRUE? a. Psychosocial functioning following cancer is often the same, if not better, than before the disease occurred. b. The amount of physical disability is only weakly linked to level of depression. c. Having cancer can significantly interfere with social relationships. d. Some cancers increase sexual functioning.

46. Carmela is experiencing a great deal of pain due to her advanced cancer.

According to research, she is likely to experience the greatest benefits from which of the following? a. Only narcotic drugs will provide her with relief. b. Using systematic desensitization procedures. c. Participation in a tailored cognitive-behavioral program. d. Using guided imagery.

47. During the treatment of childhood leukemia, the inpatient treatment phase is known as the _____ phase whereas the outpatient treatment phase is known as the _____ phase. a. induction; maintenance b. maintenance; induction c. chemotherapy; psychosocial therapy d. psychosocial therapy; chemotherapy 48. An AIDS diagnosis is made based on which of the following symptoms? a. Presence of an "opportunistic" disease. b. Low T-cell count. c. Behavioral history that confirms the person is at risk. d. both a and b.

48. The brain disorder often associated with AIDS is called a. Kaposi's sarcoma. b. nephritis. c. encephalopathy. d. stroke.

49. AIDS may be cured by a. psychotherapy. b. AZT. c. chemotherapy. d. no curative treatment is available at this time.

b (411)

a (411)

d (414)

50. According to the Sarafino text, the stigma associated with AIDS affects health in three ways. Which of the following is NOT one of the three ways mentioned in the text? a. Refusal of societies to acknowledge the disease, therefore allowing its spread. b. It causes some people to believe that if they aren't gay or use drugs, they can't get the disease. c. It causes some people to delay getting tested and, if HIV-positive, get treatment. d. Progression of HIV disease slows down once serostatus is disclosed to others.

51. Studies on the effects of psychosocial interventions with AIDS patients have found a. different intervention needs for those patients with access to antiretroviral regimen than for those without access to these medications. b. stress management is the most important aspect of treatment. c. immune functioning is not affected by psychosocial intervention. d. psychosocial interventions are not as effective as the strict use of antiretroviral regimen.

52. Which of the following is an accurate statement regarding the nature of bereavement? a. Family urging the bereaved to "get on with life" is critical to good adjustment. b. When children seem unconcerned following a death it is most likely due to denial. c. Most bereaved people appreciate the isolation they experience following the death of a loved one. d. Although most people make positive adjustments following a death, some people never adjust to the loss.

Short Answer Questions 1. Briefly discuss the significance of disease recurrence or relapse in patients’ experience with chronic and life-threatening health problems.

2. How is the rehabilitation of cardiac patients influenced by the psychosocial impact of the disease?

3. Discuss the importance of knowing the warning signs of disease in treatment for these diseases.

Essay Questions 1. Discuss differences in adapting to high-mortality illness before and after a relapse.

2. Compare and contrast the intervention needs for high-mortality illnesses discussed in this

chapter with the chronic illnesses discussed in the previous chapter.

3. Compare and contrast the AIDS experience with the other high-mortality illnesses presented in this chapter.

CHAPTER 15 WHAT'S AHEAD FOR HEALTH PSYCHOLOGY? CHAPTER OUTLINE I. Goals for Health Psychology A. Section introduction 1. People are living longer and are more likely to develop chronic disease. a. chronic diseases are aggravated by lifestyle i. medical professionals lack skills and time to address many of these issues ii. health psychologists have training and research to contribute B. Enhancing illness prevention and treatment 1. Section introduction a. efforts to prevent health problems should promote healthprotective activity and reduction of unhealthful behaviors while the person is well b. health psychology has given much attention to health-related behaviors in peoples’ lifestyles i. unhealthful lifestyles are harder to change than prevent ii. cognitive behavioral approaches are effective in producing initial changes but relapse is common c. psychosocial issues also relate to behaviors once an individual has been diagnosed i. individuals often engage in sick-role behaviors ii. individuals may not seek medical attention because they are unaware of the symptoms of a serious illness iii. people are less likely to adhere to complex medical advice 2. Advances in research and theory a. health psychologists will continue to pursue research using new research methods i. ecological momentary assessment allows researchers to examine people’s everyday feelings and behaviors ii. stages of change model is an example of a theory regarding the changing of unhealthful behaviors b. research and theory need to be expanded in two ways i. need to incorporate more biological, psychological, and social factors that relate to health ii. need to give more attention to life-span changes in the nature of health threats

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3. Advances in technology a. technology will play an increasing role in preventing and managing illness i. internet sites providing medical information ii. software designed to help drinkers reduce alcohol intake C. Improving efforts for helping patients cope 1. Major advances in use of psychosocial methods to help people cope. a. stress management and worksite wellness programs have reached nonpatient populations b. use of psychosocial interventions has increased in pain clinics, hospitals, and other medical settings c. psychologists' roles are expanding in hospitals and rehabilitation settings to include training and applying interventions D. Documenting the efficacy and cost-benefit ratio of care 1. Providing psychological services depends on the efficacy and cost-benefit ratio for the services. a. the bottom line is weighed heavily in decisions to offer programs 2. As researchers, psychologists aren't accustomed to analyzing costs & benefits of interventions. a. financial costs are often easily assessed but full range of benefits are not as clear-cut i. benefits could include reduced time in hospitals, less medication, faster recovery, better pain management ii. measuring benefits of psychosocial programs is easier in medical settings 3. Many psychosocial programs provide benefits that far outweigh the costs. a. hospital patients receiving help to cope during medical procedures recover more quickly and use less medication b. the benefits of workplace wellness programs outweigh costs c. health psychologists will give much more attention to cost/benefit analysis in the future D. Enhancing psychologists' acceptance in medical settings 1. Gaining acceptance by the medical professions continues to be a challenge.

2. Historical trends a. psychological services seen as tangential to medical needs b. psychologists not trained in physiological systems, medical illness and treatment, and organization of hospitals 3. Today health psychologists receive appropriate training to work in medical settings and more physicians recognize the psychosocial aspects of health and illness.

4. Strain can occur if one of the functions of a psychologist is to teach medical personnel "people skills."

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a. stylistic differences between psychologists and medical personnel can lead to conflict, but can be resolved b. different ways of communicating about a patient's condition (i.e., charting) may contribute to conflict 5. In 2001, guidelines for medical education require including skills in teamwork and communication with non-medical professionals.

6. Psychologists need to be included as part of a standard team approach to be best accepted by patients.

II. Careers and Training in Health Psychology A. Career opportunities 1. Career opportunities will probably continue to grow. a. psychologists working in health settings doubled from 20,000 in 1974 to 45,000 in 1985 b. some states have passed laws enabling psychologists full staff status in hospitals 2. Health psychologists practice in college and universities, medical schools, HMOs, rehabilitation centers, pain centers, and private practice.

B. Training programs 1. Training is offered at undergraduate, graduate, and postdoctoral levels.

2. Graduate training may be specialized in research or service orientation, but involve a grounding in psychology and health-related courses.

3. Some professionals have recommended greater standardization of health psychologist training.

III. Issues and Controversies for the Future A. Environment, health, and psychology 1. Health psychologists may help assess the effects of exposure to toxic substance, pollutants, or to stress. a. efforts may also be directed toward changing behaviors that produce these problems B. Quality of life 1. Why the focus on quality of life? a. QOL is reduced by becoming and staying sick b. QOL important in prevention efforts i. maintaining good health affects QOL c. life-or-death decisions often come down to judgement of QOL 2. Psychologists and medical personnel will need to make better quality of life assessments. a. quality-adjusted life years i. computed by assessing how long a person is likely to live after receiving treatment, multiplying by treatment QOL and adding together ii. can be used to assess and rank different treatments

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C. Ethical decisions in medical care 1. Section introduction a. bioethics committees have developed in hospitals i. discuss ethical issues in health care ii. make policy iii. recommend action regarding specific cases b. types of issues discussed i. patient's right to choose treatments ii. patient's right to withhold or withdraw treatment iii. patient's right to die 2. Technology and medical decisions a. use of technology and data has raised ethical questions i. example – computer program which gives odds that patient will die in intensive care or after leaving it ii. how will data be used? iii. will these numbers be weighed too heavily by physicians and families? iv. what if insurance companies want the data? b. ethical dilemmas in organ transplants. i. who are the best candidates to cope with stress and behave appropriately to maintain health with a new organ? c. ethical dilemmas in genetics technology. i. since technology now can identify people who may develop genetic diseases, who should be tested and who should have access to results?

3. Assisted dying: suicide and euthanasia a. ending life is a controversial issue in general and in the medical community i. some physicians believe life is sacred and shouldn't be involved in trying to end life ii. others believe if a person is beyond all help and the decision isn't due to depression, they should help b. assisted suicide i. the patient takes the final action with a physician's cooperation c. euthanasia i. the physician ends the life d. legal issues i. some countries and states permit both assisted suicide and/or euthanasia e. role of the psychologist i. could assess the person's emotional status, ability to make sound decisions, likelihood of benefiting from psychosocial interventions IV. Future Focuses in Health Psychology 476

A. Section introduction.

1. Early studies produced narrow view of biopsychosocial influences due to limited subject pool. a. subjects were readily available. b. researchers believed results would generalize. b. recent studies have increased the representativeness of samples.

B. Life-span health and illness 1. From conception to adolescence a. prenatal environments have an effect on health i. health psychologists are studying ways to improve prenatal environments by educating parents b. health beliefs and habits form in childhood and adolescence. i. little research has been done on how these beliefs actually develop ii. efforts to promote healthy behavior such as proper diet, exercise, dental care, and seat belt use needs to begin early iii. later childhood should focus on accident prevention, cigarette and drug use, and unsafe sex 2. Adulthood and old age a. by the time adulthood has been reached, health behaviors are ingrained and difficult to change i. affects chances of developing chronic diseases ii. prolonged emotional difficulties influence future illness b. worldwide aging of the population presents health care challenges i. how will health care system respond to added load? ii. critical to find ways to prevent or change risky lifestyles iii. need to improve ways families cope with caring of elderly relatives C. Sociocultural factors in health 1. We don't exactly know how cultural customs and socioeconomic factors shape lives.

2. Health psychology needs to address understanding and reducing poor health habits of minority groups.

3. Cross-cultural research needs more emphasis. a. few studies examine differences across countries b. countries whose citizens most affected by behavioral risks don't yet recognize principles of health psychology i. research is needed on how to adapt health psychology principles to other cultures

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D. Gender differences and women's health issues 1. Health psychology has neglected women's and gender issues until the 1980s.

2. Current research emphasizes the uniqueness of men and women. a. women and men differ in stress reaction, type A and B behavior patterns, risk of AIDS and heart disease, weight regulation, and tobacco and alcohol use b. special interventions are likely needed to promote health V. Factors Affecting Health Psychology's Future A. Factors influencing amount of research, clinical intervention and health promotion activities.

1. Economic and financial pressures. a. cutbacks in government and private funding may influence financial support b. increasing health care costs may create pressure to increase funding in health psychology areas c. funding may also depend on insurance structuring 2. Education and training a. field of health psychology may influence students in other nonpsychology disciplines and promote importance of research, and psychological interventions 3. Developments in medicine a. new health problems may require psychosocial interventions

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DISCUSSION TOPICS 1. Telemedicine.

As noted in this chapter, the nature of health care delivery has been significantly influenced by technological advances. Although the primary discussion in this chapter has been on how technology has contributed to ethical dilemmas, the development and use of telemedicine has been heralded as an advance that will result in lower medical costs and improved service delivery. For a good introduction into the use of telemedicine, try the following Internet sites: http://trc.telemed.org/telemedicine/primer.asp http://tie.telemed.org/telemed101/topics/telemedicine_history.asp, and http://tie.telemed.org/telemed101/topics/wireless.asp These webpages define and summarize the history and various uses of telemedicine in the United States and globally. Although the term “telemedicine” can be broadly applied to the use of any form of telecommunication locally, regionally, internationally, or even into space, common applications have involved some combination of the use of digital still-images, interactive video or audio transmissions, or the use of the Web. Often telemedicine has been used to link urban specialists or medical personnel with physicians and patients in remote, rural settings. Advantages to the use of telemedicine include reduced travel for patients, real-time or immediate access to medical records for medical personnel, and training opportunities for medical personnel in remote sites. One particularly intriguing hypothetical use of telemedicine use is the development of “Personal Diagnosis Systems” linked to home entertainment systems that could monitor an individual’s health status on a daily basis and “automatically notify a health professional if we become ill.” The topics page on wireless applications may also serve as a good discussion starter for students.

2. Heroic measures in prolonging life.

In this concluding chapter, Sarafino notes several future trends for health psychology that focus on ethical issues. Salvatore Maddi has written a thought provoking chapter on the use of heroic measures in prolonging life that could be the basis for an expanded discussion of this topic. Significant themes in this work include an analysis of definitional difficulties, the ethical issues of trying to save everyone, the meaning of life and death, and the role of the psychologist in helping people resolve the question of the use of heroic measures.

According to Maddi, heroic measures to prolong life include extraordinary, "aggressive" procedures that prolong life when death appears imminent or restore life once death has occurred. Classic examples of these techniques include CPR, transplants, and various forms of dialysis in addition to more controversial techniques such as cryonics.

Maddi notes that although the use of heroic measures tend to be scarce, costly, and invasive, society has quickly moved from viewing them as rare to "accepting them as standard features of everyday life." The use of heroic measures in terminal illness is further complicated by the difficulty in determining that a disease is, in fact, terminal. For example, cancer may or may not result in death and the course and prognosis of the disease is influenced by a wide variety of factors.

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One major theme in this chapter could act as an interesting resource on the ethics and implications of "saving everyone." On pages 159-162, Maddi describes several interesting potential personal and social outcomes of life-sustaining efforts. Whereas the potential negative impact on quality of life as a result of these efforts and the question of who should authorize them seems to be a easily-grasped ethical issues, Maddi's discussion of the social impact raises a number of compelling questions. Practically, he offers, the result of trying to save everyone would an increase in medical services and costs. Socially, these costs would probably be borne by working people, not the poor or elderly. Would this create a working class of people that would challenge the use of these interventions?

Would the poor or elderly need to (re)enter the working world to shoulder the expense?

Would there be a drain on natural resources and increasingly dangerous levels of pollution and crowding as a result? Finally, would there be any "guarantee that the lives prolonged would be worthwhile and sufficiently satisfying to justify the effort"? (pg. 161). The alternative, providing selective treatment, offers no easier answers. On what criteria does one judge who is worthy of saving? Leadership? Brilliance? Creativity? Power?

Affluence? Maddi reviews the use of advisory directives and binding directives in the context of California's Natural Death Act of 1976 which adds to this debate.

In discussing the meaning of life and death, Maddi offers two recurring positions for consideration. First, he suggests that the terminally-ill patient, their families, health professionals, and society at large interpret the meaning of life and death from a hardiness/courage worldview. Specifically, he argues that hardy or courageous individuals are likely to view death as a genuine part of life (rather than deny it) and thus are more likely to courageously face it and, when death appears likely, prepare for it. This theme could be an interesting connection to the earlier discussions of hardiness in previous chapters. Second, Maddi offers that people tend to face death much as they've faced life.

People who have faced life from a nonhardy perspective are likely to struggle with the experience of death.

In the final pages of the chapter, Maddi discusses ways in which the psychologist can help during terminal illness. The psychologist is perhaps better equipped than medical personnel to facilitate communication regarding life and death among family members, to aid in resolution of family conflicts, to work with medical personnel on their own reactions to the outcomes of heroic measures. Maddi contends that existential approaches during this period of a person's life are superior to psychoanalytic or cognitive-behavior approaches since it is during this period where questions of meaning are most likely to arise. Thus, the clinician's therapeutic stance is critical to favorable psychological resolution of patient treatment issues. This observation may be part of a discussion on the choices of psychotherapeutic intervention since various forms of psychosocial intervention have been discussed in such detail in previous chapters.

Source: Maddi, S.R. (1990). Prolonging life by heroic measures: A humanistic existential perspective (pp. 155-178). In Costa, P.T., & VandenBos, G.R. (Eds.), Psychological aspects of serious illness: Chronic conditions, fatal diseases, and clinical care.

Washington, DC: American Psychological Association.

3. Global issues in health care.

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In his book, Culture, health, and illness, Cecil Helman argues that “many of the major threats to human health – such as overpopulation, pollution, global warming, drug abuse and the AIDS epidemic – can no longer be confined, or dealt with solely behind local or national boundaries. In an increasingly mobile and interdependent world, they are truly global in both their origins and their effects.” (pg. 338). As a medical anthropologist, he contends that his discipline needs to no longer consider individual, local, or national level analyses of health issues but, rather, it must move to considering how culture and/or social factors affect “the health of the human species as a whole.” In this chapter he highlights six global health problems: overpopulation, urbanization, AIDS, primary health care, pollution and global warming, and deforestation and species extinction. Since Sarafino raises the issue of cross-cultural research toward the end of Chapter 15, the discussion of cultural (or as Helman puts it, global) aspects of health could be expanded by assigning these six topics to different groups of students and having them lead in-class discussions on their topic.

Source: Helman, C.G. (1994). Medical anthropology and global health, (pp. 338-383). In Helman, C.G., Culture, health, and illness (Third edition). Oxford: Butterworth-Heinemann.

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ACTIVITY SUGGESTIONS 1. Assess Yourself: Some Ethical Dilemmas: What Do You Think? Have students complete Handout # 1. Notice and discuss what factors led to students' beliefs that the right or wrong decision had been made. For example, did behavioral choice influence negative decisions?

2. A career in health psychology. If you didn't do the variation of this activity in Chapter 1, have students go to the Division 38 - Health Psychology webpage (http://www.health-psych.org/) and explore the educational and training programs for becoming a health psychologist.

3. Attitude and behavior change. Now that the course is near its end, have the students reflect on their changed attitudes about their health. Have them describe what attitudes of theirs have changed regarding their role in maintaining health. Have the attitudes which changed instigate behavioral change? Have any changed health risk behaviors discussed such as by losing weight, increasing exercise, eating better, or reducing smoking? Have any behaviors changed? How long do they predict that any effects might last?

4. Life support, physician-assisted suicide, and euthanasia. As your book states, "Medical technology has made it possible to keep some patients alive only in a legal sense, and society has begun to question whether these patients are alive in a humane sense." Increasingly with advances in medical technology some individuals may be able to be kept "alive" by artificial means. The question society must face is how such decisions are to be made. Ask the students to discuss at what point such care should be instituted and when it would be permissible to terminate it. Those not in favor of heroic means might be in favor of the concept of passive euthanasia. Euthanasia comes from Greek words meaning "good death;" and usually implies allowing a painless death for the terminally ill. The administration of something which hastens death is termed active euthanasia by some, and homicide by others. Ask the students for their opinion. If students support euthanasia, ask who should make the decision, and when. Who would they want making such decisions for them? This discussion might be more powerful after viewing one of the right to die films listed in the Suggested Videos section.

5. Psychologists in medical settings. Arrange to have a psychologist who works in a medical setting speak to the class. Be sure to have the guest describe their training and preparation for their position. Was their background in clinical psychology health psychology or some other field? What is their current role? What is their title? Are they members of the medical staff? What privileges do they have? Do they provide services such as testing, counseling to patients, staff education prevention, or program evaluation?

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6. Major approaches in clinical health psychology. Assign several students to each approach listed below and ask them to research the approach and its applications in health psychology. Have them prepare a class presentation and lead a class discussion on their assigned approach to Health Psychology.

Behavioral Approach Cognitive-Behavioral Approach Psychophysiological Approach Clinical Psychology Approach Community Psychology Approach Family Therapy Approach Psychodynamic Approach Insight-Oriented Approach Holistic Approach

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Handout #1

Assess Yourself Some ethical dilemmas: What do you think?

Each of the following cases describes a decision involving an ethical dilemma that is related to health. Circle the Y for "yes" and the N for "no" preceding each case to indicate whether you agree with the decision.

Y

N

A 47-year-old woman developed cirrhosis of the liver as a result of long-term alcoholism. She promised to stop drinking if she could receive a liver transplant. Her request was denied because of likely future drinking.

Y

N

An overweight, chain-smoking, sedentary 51-year-old man with high blood pressure had his first heart attack 7 years ago. His request for a heart transplant was denied because of continuing risk factors.

Y

N

A 28-year-old married woman with a hereditary crippling disease that is eventually fatal decided to become pregnant, knowing that there was a 50% chance that she would pass on her disease to her baby and she would not consider having an abortion.

Y

N

A 37-year-old executive was told by his boss that he would have to pay half of the costs of his employer-provided health insurance if he did not quit smoking and lower his cholesterol.

Y

N

An obese 20-year-old woman who refused to try to lose weight was expelled from nursing school, despite having good grades and clinical evaluations, because it was said she would "set a poor example for patients."

Y

N

A 24-year-old man was denied employment as a bank clerk because was overweight and smoked cigarettes.

Y

N

A 30-year-old woman was denied a promotion to a job that involved working in an area with gases that could harm an embryo if she were to become pregnant.

Y

N

A year after a boy developed leukemia, the company that provided his family's health insurance quadrupled their premium.

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RESOURCES As your text states, career information can be obtained from: Society of Behavioral Medicine 7600 Terrace Avenue, Suite 203 Middleton, WI 53562 American Psychological Association 750 First Street N.E. Washington, DC 20002-4242 The American Psychological Association has a student membership status available.

Information about Health Psychology may be obtained from Division 38, Health Psychology. Other divisions which may be relevant are Division 12, Clinical Psychology, and Division 22, Rehabilitation Psychology.

Suggested Readings: Goals for Health Psychology Aboud, F.E. (1998). Health psychology in global perspective. Thousand Oaks: Sage.

Belar, C.D., & Deardorff, W.W. (1995). Clinical health psychology in medical settings: A practitioner's guidebook. Washington, DC: American Psychological Association.

Gordon, J.S. (1996). Manifesto for a new medicine: Your guide to healing partnerships and the wise use of alternative therapies. Reading, MA: AddisonWesley.

Hafferty, F.W., & McKinlay, J.B. (1993). The changing medical profession: An international perspective. New York: Oxford University Press.

Orlens, C.T. (2000). Promoting the maintenance of health behavior change: Recommendations for the next generation of research and practice. Health Psychology, 19(1), 76-83.

Roth-Roemer, S., Kurpius, S.R., & Carmin, C. (eds.). (1998). The emerging role of counseling psychology in healthcare. New York: W.W. Norton.

Rozensky, R.H., Johnson, N.G., Goodheart, C.D., et al. (2004). Psychology builds a healthy world: Oppurtunities for research and practice. Washington, DC: American Psychological Association.

Smith, T.W., Orleans, C.T. & Jenkins, C.D. (2004). Prevention and Health Promotion: Decades of Progress, New Challenges, and an Emerging Agenda. Health Psychology, 23(2) 126-131.

Taylor, S.E. (1990). Health psychology: The science and the field. American Psychologist, 45, 40-50.

Wing, R.R. (2000). Cross-cutting themes in maintenance of behavior change. Health Psychology, 19(1), 84-88.

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Wolff, S.H., Jonas, S., & Lawrence, R.S. (1996). Health promotion and disease prevention in clinical practice. Baltimore, MD: William & Wilkins.

Careers and Training in Health Psychology Goreczny, A.J. (1995). Handbook of health and rehabilitation psychology. New York: Plenum Press.

Maheu, M.M., Whitten, P., & Allen, A. (2001). E-health, telehealth, and telemedicine: A guide to start-up and success. San Francisco: Jossey-Bass.

Quick, J.C. (1999). Occupation health psychology: Historical roots and future directions. Health Psychology, 18(1), 82-88.

Issues and Controversies for the Future Rosenfeld, B. (2004). Assisted suicide and the right to die: The interface of social science, public policy, and medical ethics. Washington, DC: American Psychological Association.

Sears, S.R., & Stanton, A.L. (2001). Physician-assisted dying: Review of issues and roles for health psychologists. Health Psychology, 20(4), 302.

Future Focuses in Health Psychology Akamatsu, T.J. (1992). Family health psychology. Washington, DC: Hemisphere Publishers.

Gesler, W.M. (1991). The cultural geography of health care. Pittsburgh,PA: University of Pittsburgh Press.

Helman, C. (2000). Culture, health, and illness. Boston: Butterworth-Heinemann.

Jason, L.A., & Glenwick, D.S. (2002). Innovative strategies for promoting health and mental health across the life span. New York: Springer Publishing.

Kato, P.M., & Mann, T. (1996). Handbook of diversity issues in health psychology. New York: Plenum Press.

Loustaunau, M.O., & Sobo, E.J. (1997). The cultural context of health, illness, and medicine. Westport, CN: Bergin & Garvey.

Niven, C.A., & Carroll, D. (1993). The health psychology of women. Langhorne, PA: Harwood Academic.

Resnick, R.J., & Rozensky, R.H. (1996). Health psychology through the lifespan: Practice and research opportunities. Washington, DC: American Psychological Association.

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Suggested Films and Videos: Goals and Future Focuses 1. Medicine at the Crossroads: Conceiving the future. (1993, WNET/BBC-TV, 57 min).

Based on the premise that genetics provides a powerful way to predict health and determine the future of every embryo; explores medical practice in different societies is dealing with these capabilities.

2. Medicine at the Crossroads: Random Cuts (1993, WNET/BBC-TV, 57 min).

Discusses the continued use of medical procedures even after they have been demonstrated to be ineffective.

3. Men's health. (2000, Edudex, 27 min). Examines issues relevant to men including topics such as mid-life crisis, Viagra.

4. Women's health. (2000, Edudex, 18 min). Explores women's health services and presents topics such as maternity and neonatal care and mammograms.

Issues and Controversies for the Future 5. A death of one's own. (Films for the Humanities and Sciences, 90 min). Part of Moyer's On our own terms series, this video pertains to physician-assisted suicides.

6. A time to die. (1990,. MediaWest, 40 min). Discusses the death with dignity movement.

7. Difficult decisions: When a loved one approaches death. (Films for the Humanities and Sciences, 30 min). Two families struggle with life-and-death decisions in an ICU. 8. Life support. (1993, PBS/WNET, 57 min). Considers the medical response to need for care and extending life.

Internet sites of interest: Health Psychology 1. http://www.health-psych.org/ - APA Health Psychology Division 38 2. http://www.health-psych.org/whatis.html - Division 38 page describing activities of a health psychologist 3. http://www.ucm.es/info/Psyap/iaap/spring97.html - International Association of Applied Psychology webpage that contains an address on the global context of health psychology

by Brian Oldenburg.

4. http://www.mdx.ac.uk/www/jhp/index.htmlx - Journal of Health Psychology 5. http://www.apa.org/journals/hea.html - information about Health Psychology 6. http://healthpsych.com - The Health Psychology Library 7. http://venus.uwindsor.ca/courses/psychology/fsirois/HP_articles.html - Health Psychology resources - Online Health Psychology Articles.

8. http://www.ehps.net/ - European Health Psychology Society 9. http://is.dal.ca/~hlthpsyc/hlthhome.htm - The Health Psychology Section of the Canadian Psychological Association 10. http://www.sbm.org -The Society of Behavioral Medicine 487

Various Health Organizations 11. http://www.ahcpr.gov/ - Agency for Healthcare Research and Quality 12. http://www.acoem.org/ - American College of Occupational and Environmental Medicine 13. http://www.apm.org/ - The Academy of Psychosomatic Medicine 14. http://www.rosenthal.hs.columbia.edu/Women.html - Women’s health information resources 15. http://www.pitt.edu/~ejb4/min/ - The Minority Health Network 16. http://www.omhrc.gov/- Office of Minority Health Resource Center 17. http://www.who.int - World Health Organization End of Life 18. http://www.isoqol.org/main.html - International Society for Quality of Life Research 19. http://www.worldrtd.net - The World Federation of Right to Die Societies 20. http://www.finalexit.org/ - Euthanasia Research & Guidance Organization world dictionary 21. http://www.assistedsuicide.org/ - Euthanasia Research & Guidance Organization assisted suicide page 22. http://www.dyingwithdignity.ca/Related_Sites.htm - Links to other choice-in-dying organizations 23. http://www.CompassionInDying.org/ - Site for Compassion in Dying and End of Life Choices 24. http://www.internationaltaskforce.org - International Task Force on Euthanasia and Assisted Suicide

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TEST QUESTIONS True or False F

1.

The cognitive and behavioral approaches psychologists use to change. health behaviors have been found to be relatively ineffective in producing initial change.

2.

In medical settings today, psychologists work mainly on the administration and interpretation of psychological tests.

3.

The "bottom line" issues in deciding whether to offer wellness programs or psychosocial interventions are efficacy and cost-benefit ratio.

4.

Calculating financial costs and benefits of interventions are standard practice for psychologists.

5.

From 1974 to 1985, the number of psychologists working in health care more than doubled.

6.

The quality-adjusted life years scale is useful in determining the value of different treatments.

7.

A patient's right to choose or withdraw treatment may be discussed in a hospital's bioethics committee.

8.

The APACHE III computer program can make the decision about whether a patient should be transferred into an intensive care unit.

9.

Extensive research has been done on how health beliefs and habits develop during childhood and adolescence.

10.

The study of health psychology has been quite active internationally and has influenced health care practice in most countries around the world.

(418)

F (420)

T (420)

F (420)

T (422)

T (424)

T (424)

F (424)

F (426)

F (428)

489

Matching Match the following terms with their descriptions in one through five. a. cost-benefit ratio b. ecological momentary assessment c. bioethics committees d. stages of change model e. quality-adjusted life years scale e

1. Predicts how long a person is likely to live after receiving treatment.

(424)

a (420)

2. Assesses extent to which providing an intervention saves more money than it costs.

d

3. The steps in people's readiness to change health-related behaviors.

(419)

(419)

4. Method which allows researchers to examine people’s behavior and feelings. in daily life.

c

5. Deals with questions regarding the patient’s right to choose treatments.

b

(424)

Match the following groups with the appropriate characteristics listed in six through ten. a. 18 to 60-year-old white American males b. the very young and very elderly c. children and adolescents d. adults and the elderly e. women b

6. Use health services more than other groups.

(426)

c

7. The formation of health beliefs and habits occurs in these groups.

(426)

a

8. Historically, the most frequently recruited subjects in research studies.

(425)

d

9. Possess ingrained and difficult-to-change health related values.

(426)

e

10. Neglected in health research until the 1980s.

(427)

490

Multiple Choice c (418)

d (418)

b (419)

c (420)

b (421)

1. The set of actions which an individual undertakes when an illness is identified and treatment starts are called a. health behaviors b. illness behaviors c. sick-role behaviors d. efficacy behaviors 2. According to the text, which of the following two advances since the mid-1980s are likely to influence future efforts to prevent illness? a. The increase of chronic illness and improved physician-patient interactions. b. Improved community prevention programs and more effective cognitivebehavioral interventions. c. More effective medical interventions and improved cost containment efforts. d. New theories that explain health behaviors and the development of Internet sites that provide medical information.

3. Sarafino suggests the use of telemedicine will a. occur only via the Internet. b. be used for information delivery as well as diagnostic and treatment services. c. be difficult and costly to develop. d. not be useful in the practice of medicine.

4. According to the text, one of the difficulties with deciding whether to administer psychosocial interventions is that a. program efficacy tends not to be assessed. b. agencies tend to be more interested in costs than program efficacy. c. the full benefits of an intervention are often difficult to define and assess. d. the costs of interventions are almost always much higher than the benefits.

5. How is the function of health psychologists in medical settings likely to change in the future? a. They are likely to be restricted to administering and interpreting psychological tests of emotional and cognitive functioning only. b. The number of services and activities in which they engage is likely to expand. c. They will be asked to train medical students and interns to administer coping interventions but will not conduct these programs themselves. d. They are most likely to only be consultants to medical personnel.

491

d (420)

c (420)

b (420)

d (421)

a (421)

6. A weight-loss program at a work-site was discontinued after all of the participants actually gained weight. The reason for its discontinuation would be problems with its a. prevention model. b. stages of change model. c. cost-benefit analysis. d. efficacy.

7. An expensive dental hygiene program at a work-site was discontinued after it was found to be cheaper to just pay for the dental insurance. The reason for its discontinuation was due to a. the prevention model. b. the stages of change model. c. cost-benefit analysis. d. efficacy analysis.

8. Which of the following are recognized as problems encountered by health psychologists when conducting a cost-benefit analysis? a. They have never been trained on how to conduct them. b. Although costs might be more easily assessed, the full benefits of a program are difficult to determine. c. Most psychosocial interventions appear to produce more costs than benefits. d. Health psychologists are unlikely to view this type of analysis as important.

9. Which of the following are among the reasons that, prior to 1970, psychological services were viewed as tangential to the medical needs of patients? a. Psychologists tended to have little training in physiological systems, medical illnesses and treatment. b. The biopsychosocial approach was not recognized by the medical community yet. c. Psychologists had little background with the organization and protocol of hospital settings. d. all of the above 10. Physicians may be resistant to being taught "people skills", according to Christensen and Levinson (1991), because a. they tend to not see such skills as part of medicine. b. such skills are best taught by psychologists. c. "people skills" are considered too time-consuming. d. such efforts are not cost effective.

492

b (421)

d (421)

d (423)

a (424)

d (425)

11. Psychologists may differ from physicians in style of communication in that psychologists a. prefer to communicate through notes in the hospital chart. b. prefer to talk directly to the physician in order to communicate issues regarding patient care. c. are more concerned with tests performed and the results of those tests. d. are more recommendation oriented.

12. Which of the following is not a prominent site of employment for psychologists? a. Colleges and universities. b. Medical schools. c. Health maintenance organizations. d. All of the above are places where psychologists commonly work.

13. Which of the following environmental issues would not be addressed by a psychologist? a. The effects of crowded and noisy environments. b. The reduction of harmful environmental conditions. c. The effects on health of pollutants. d. The development of less toxic industrial by-products.

14. The measurement known as quality-adjusted life years, or QALY's, allows health care planners and patients to a. make decisions regarding the value of different treatments. b. measure past quality of life. c. calculate the number of years a patient is expected to live. d. calculate the cost of treatment.

15. Shirley, who suffered from the final stages of a painful cancer, arranged for someone to purchase carbon monoxide for her, and put a mask attached to the canister over her face. She insisted on turning the dial which released the gas by herself. This situation is best described as a. murder. b. euthanasia. c. a cost-benefit analysis. d. assisted suicide.

493

b (425)

b (426)

d (427)

c (427)

d (428)

16. Which of the following statements regarding euthanasia and physicianassisted suicide is NOT true? a. Euthanasia is legal in the Netherlands. b. In the United States, no laws currently allow for either euthanasia or physician-assisted suicide. c. In the future, psychologists will very likely to be asked to assess patients' emotional status and decision-making capabilities in such cases. d. Concerns over patients' level of depression have been a significant part of the debate in the medical community.

17. The best time to teach behaviors such as proper diets, exercise, dental care and seat belt use is a. prenatal period b. early childhood c. late childhood d. adolescence 18. Which of the following statements regarding sociocultural and crosscultural research is TRUE? a. The mechanisms underlying sociocultural differences in health habits are clearly understood. b. Explicit conclusions can be drawn regarding practices that promote health-protective behaviors. c. A comprehensive body of current research concerning cross-cultural research on health and illness exists. d. Many countries with people who could benefit from changing their behavioral risk factors have not recognized the principles of health psychology.

19. Which statement best describes the status of the study of gender differences in health psychology until the 1980's? a. Most health research focused entirely on women. b. Most health research studied men's and women's issues in equal proportion. c. Health issues relating to women and gender differences were neglected. d. The mechanisms for health behaviors were found to have no gender effect.

20. What factor is likely to have an impact on the future role of health psychology? a. Levels of government and private funding. b. Education and training in health psychology among students in nonpsychology fields. c. Developments in the field of medicine. d. all of the above 494

Short Answer Questions 1. This chapter starts with a section devoted to illness prevention. Summarize the ways that health psychologists contribute to prevention efforts.

2. What differences have or still need to be addressed to increase health psychologists' acceptance in medical settings?

3. Sarafino suggests a number of changes that need to occur in health psychology to increase our understanding of health and illness in different populations. Discuss 2 of his suggestions.

Essay Questions 1. You are an advisor in a psychology department and have an advisee that wants to know more about health psychology. What can you tell this student?

2. Pick one of the controversies described in this chapter and discuss its' relevance to health psychology.

3. As a student in a Health Psychology course, you may have been contemplating a career in this discipline. Using information from this chapter as support (i.e., areas of study, interesting challenges for the discipline), are you inclined to pursue such a career?

495