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Biology (illness) and Stress Objectives: Discuss physiological aspects of stress. To what extent do biological, cognitive and sociocultural factors influence health-related behavior? Does Stress Cause Illness? A. Smoking i. Wills (1988) Teens a. Stress linked to smoking initiation in adolescence ii. Carey, 1993 Relapse a. Those with higher stress more likely to relapse iii. Gilbert & Spielberger, 1987 a. Stress reliever? B. Alcohol i. Link between negative mood and alcohol consumption ii. Cappel & Greeley, 1987 a. People drink for its tension-releasing properties iii. Negative moods (internal stressor), consequence of external stressor C. Eating i. Greeno & Wing, 1994 (Stress and eating) 1. General effect model: stress changes food intake 2. Individual difference model: predicts stress only causes changes in eating in vulnerable groups/ individuals a. MOST research ii. Stone & Brownell, 1994 1. Stress eating Paradox a. No clear pattern b. Sometimes stress causes overeating and sometimes undereating D. General Behavior Change i. Correlation research 1. Connection between stress and unhealthy lifestyle 2. Connection between stress and health problems ii. Mtandabari, 1997 (medical students) 1. Acute exposure to stress causes changes in health-related behaviors a. Minimal influence on their ability to perform satisfactory 2. Chronic stress may have damaging effects or long term changes in behavior Stress and changes in physiology A. Stress and illness onset B. Stress and illness progression C. Beliefs and physiological changes Which factors mediate the stress-illness link? A. B. C. D. E. F. G. Exercise Gender Coping styles Life events Type-A behavior/Type A personality Social support Actual/ or perceived control Placebo and Health Psychology Definition of Placebo • Inert substances which cause symptom relief – After the sugar pill my headache went away • Substances or actions that cause changes in symptoms not directly attributed to specific drug or operation – After I had my hip operation my headache went away • Any therapy that is deliberately used for its nonspecific psychological or physiological effects – I had a bath and my headache went away Problems with understanding placebos • What are specific/real and nonspecific/unreal effects? – Unreal: unpredicted – Real: it happened – Example: ‘My headache went away after my surgery.’ • Why are psychological factors nonspecific? – Example: I feel relaxed after my surgery, is that a nonspecific effect? • Are there placebo effects in psychological treatments? – Example: ‘I went to cognitive restructuring therapy and just ended up feeling less relaxed. Placebo or real effect?’ • Problem Summary – Distinction between… • Specific and nonspecific • Psychological and physiological History of Placebo • CULTURE – Past and Today still use apparently inert treatments • No apparent medical (active) properties – Faith healers & religious healers • blood of a gladiator Strength • part of a dolphins penis. Virility • Is faith in the healer the placebo? – OR… is there a medical substance that we are not aware of? Modern-day Placebos • Recent studies – Reduce anxiety – Increase cognitive task • Most effective area of study…PAIN – Beecher, 1955 • 30% of chronic pain sufferers experience relief – Using subjective and objective measures – Diamond et al 1960 • Groups: Sham operation and real operation • Results: Pain Reduction EQUAL in both groups • Should they be taken out of the health scenario? Two Theories • Non-interactive – Examine characteristics of… • individual • Treatment • health professionals and facilities • Interactive – Examine the individual PROCESSES, Interaction • Individual • Treatment • professional Non-Interactive 1. Characteristics of an Individual – More susceptible to placebos – Personality • emotional dependency • Level of extroversion – MOST introverted • suggestibility • BUT…little evidence for consistent traits – Some traits are conflicting 2. Characteristics of the treatment – Perceived seriousness, higher placebo rate – Example • Surgery (perceived seriously) Greater Placebo Effect – Strength of Placebo Effect • Surgery • Injection • Two pills • Characteristics of health professional –Higher professional status of individual or institution has higher rate Problems with non-interactive theories • Ignore the interaction between the characteristics –New Theories… •Interactive theories Interactive Theories • • • • • • Experimenter Bias Patient Expectations Reporting Error Conditioning Effects Anxiety Reduction Physiological Theories Interactive Theories • Experimenter Bias (interaction between patient and doctor) – Patient shows change because the doctor expects them to • Gracely et al 1985 (double-blind) – Groups (Patients): reduce, have no effect or increase pain – Doctors: pain killer or no pain killer – Results: • All patients given placebo • Pain killer reduction • No pain killer no reduction – Implications • Interaction between patient and doctor (obvious or not) • Patient expectancies – Ross and Olson, 1981 • All patients attributed spontaneous change to treatment – Why? They want to get better – Park and Covi, 1965 • Sugar pills given to neurotics and told they were sugar pills • Patients showed some reduction in anxiety – Why? Expectations? – Motivation!! (Jensen and Karoly 1991) • Motivation desire to experience some change • Expectation belief that change would occur • Research – Higher motivation = higher placebo effect • Reporting Error – Placebo Latin word ‘I will please’ – Patient expect improvement, want to please the doctor, report inaccurately – Therefore, (doctor or patient) • • • • Error Misrepresentation Misattribution Problems with theory 1. Not all symptoms reported are positive 2. There are objective changes with placebos • Conditioning Effects – Conditioning Theory US Treatment UR Recovery OR US Treatment UR hospital, white coat CR recovery – Example: people feel better before they can digest the pill • More effective when given in a hospital by a doctor • Anxiety Reduction – Placebos decrease anxiety helps recovery – Sternbach, 1978 Gate Control Theory • Anxiety opens the gate and increases pain • Placebos increase the level of perceived control • Break the anxiety-pain cycle • Problems – Many other effects from placebos • Example: increased lung function in asthmatics which is not related to anxiety • Physiological Theories – Levine et al. 1978 • ENDORPHINS (opiate) brains natural pain medication • Evidence: – Placebos can create dependence, withdrawal and tolerance (similar to heroine) – Placebo effects can be blocked by giving naloxone blocks opiate release • Problem • Limited: pain reduction is not the only consequence of placebos Patient Expectations Central Role… • Patient Expectations – Expectancy Theory • I expect to get better – Anxiety Theory • I expect to improve and I am less anxious – Reporting Error • I attribute changes to my treatment – Experimenter Bias • Doctors expect me to get better – Conditioning • Doctors are associated with improvement – Physiological Theory • Changes in Endorphin release • ALL THEORIES FEED INTO PATIENT EXPECTATIONS Ross and Olson (1981) • Summary of placebo effect – Direction of placebo effects parallels the effects of the drug under study – Strength of the placebo effect is proportional to that of the active drug – Reported side-effects of the placebo drug and the active drug are often similar – The time needed for both the placebo and the active drug to become active are often similar • Placebos work because doctor and patient expect them to work Horowitz et al 1990 • Foundational Research – Coronary Drug Project (1982) & Beta-Blocker Heart Attack Trial • CDP adherers had lower mortality rate • BHAT RCT – Participants • 3837 Men and Women (30-69) • Placebo and Beta-blocker – Data • Psychosocial factors – Stress, Social Isolation, Depression, Type A behavior – Health Practices (smoking, alcohol, diet, physical activity) • Adherence – Poor adherers (less than 75%) – Good adherers (more than 75%) • Clinical characteristics • Methodology – Secondary data analysis (meta-analysis) • Results – Poor adherers were TWICE as likely to die by 1 year • Regardless of treatment (beta-blocker or Placebo) – Higher death rate… • • • • Not married High life stress High social isolation Smokers (at baseline) and less likely to quit • Implications – Interaction between individuals – Interaction between individuals and Cognitive Dissonance Cognitive Dissonance • Totman (1976) – Remove patient expectations – Emphasize • Justification (Justify: free from blame or guilt) • Dissonance (lack of harmony or disagreement) – Premise: Faith healing and homeopathic medicines are still used because they WORK Cognitive Dissonance Theory • Placebos work because… – Investment by the individual • • • • • Money Dedication Pain Time Inconvenience – Example: winning a trip to La Palma is not as exciting as winning a trip to Maui Effect of Investment • Two processes 1. Individual needs to adjust behavior 2. Individual needs to see themselves as rational and in control • Justification – – • High Justification Low dissonance: spend money, feel good Low Justification High Dissonance: spendmoney, do not feel good High justification results in low dissonance and low guilt How does justification change symptoms? • State of high dissonance – Unconscious regulating mechanisms cause physical changes that improve health • It is not the expectation of health it is the need for justification – State of cognitive dissonance • Step 1 Premises – Need to justify behavior – Need to see self as rational • Step 2 Behavior – Invest in Treatment • No Effect • Step 3 Low or high Dissonance – LOW • Good Justification ‘I was paid’ • See self as rational – HIGH • Poor justification • I chose to do it/ I am not rational • Step 4 PLACEBO EFFECT – Resolve Dissonance Placebo Effect Treatment Works What evidence exists for justification? • Zimbardo, 1969 (experiment) – 2 groups 1. Do not eat or drink, given $ (low dissonance) 2. Do not eat or dink, given nothing (high dissonance) • Results • When allowed to drink, group two drank less than group 1 • Group 2 rationalized… I did not eat because I was not hungry • Totman, 1987 (Pain Reduction) – Experiment: Placebo (single-blind) – Two Groups 1. Offered pain medication, $ to complete 2. Offered pain medication, no money – Results • • Group 2 experienced less pain following WHY? – Group 2 had high dissonance, low justification • Cause physiological changes that reduced pain – Provided justification – Change state of justification So, how does it work? • Dissonance can be resolved by the placebo having an effect on the individual’s health status by activating unconscious mechanisms Support for Theory 1. Theory can explain all placebo effects, not just pain 2. Theory does not require expectation, but choice – Explains how some individuals still see an affect event though they do not expect to get better 3. Individual investment is needed; time, $ – Explain treatment, individual and therapist characteristics Problems with Theory • Many experiments use $, money may increase their anxiety and therefore increase their pain perception • Persuasion by the experiment may create anxiety • Experiments in labs dealing with pain, is it real life? • You cannot leave expectation out completely, otherwise why would they get involved • Totman does not explain “unconscious mechanisms”