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Week Two- The Impact of Stress
Eustress and Distress affect the physical functioning of the body in similar ways. What is the difference between these two types of stress? Also discuss the physical stress response. What are stress hormones and what do they do in the human body? Refer to Ch 6 in attached book.

HEALTH
PSYCHOLOGY

Shel ley E . Taylor
10E

HEALTH PSYCHOLOGY

HEALTH PSYCHOLOGY

T E N T H E D I T I O N

SHELLEY E. TAYLOR
University of California, Los Angeles

HEALTH PSYCHOLOGY, TENTH EDITION

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Names: Taylor, Shelley E., author.
Title: Health psychology / Shelley Taylor, University of California, Los Angeles.
Description: Tenth edition. | New York, NY : McGraw-Hill Education, [2018] |
Includes bibliographical references and indexes.
Identifiers: LCCN 2016044904| ISBN 9781259870477 | ISBN 1259870472
Subjects: LCSH: Clinical health psychology. | Medicine, Psychosomatic. | BISAC:
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v

For Nathaniel

vi

SHELLEY E. TAYLOR is Distinguished Professor of Psychology at the
University of California, Los Angeles. She received her Ph.D. in social psychol-
ogy from Yale University. After a visiting professorship at Yale and assistant and
associate professorships at Harvard University, she joined the faculty of UCLA.
Her research interests concern the psychological and social factors that promote
or compromise mental and physical health across the life span. Professor Taylor
is the recipient of a number of awards—most notably, the American Psychological
Association’s Distinguished Scientific Contribution to Psychology Award, a
10-year Research Scientist Development Award from the National Institute of
Mental Health, and an Outstanding Scientific Contribution Award in Health Psy-
chology. She is the author of more than 350 publications in journals and books
and is the author of Social Cognition, Social Psychology, Positive Illusions, and
The Tending Instinct. She is a member of the National Academies of Science and
the National Academy of Medicine.

A B O U T T H E A U T H O R

vii

C O N T E N T S

P A R T 1

PREFACE XV

INTRODUCTION TO HEALTH PSYCHOLOGY 1

C H A P T E R 1

What Is Health Psychology? 2

Definition of Health Psychology 3
Why Did Health Psychology Develop? 3

The Mind-Body Relationship: A Brief History 4
The Rise of the Biopsychosocial Method 5

Psychosomatic Medicine 5
Advantages of the Biopsychosocial Model 5
Clinical Implications of the Biopsychosocial

Model 6
The Biopsychosocial Model: The Case History of

Nightmare Deaths 6
The Need for Health Psychology 6

Changing Patterns of Illness 7
Advances in Technology and Research 8
Expanded Health Care Services 8
Increased Medical Acceptance 9

Health Psychology Research 9
The Role of Theory in Research 9
Experiments 10
Correlational Studies 10
Prospective and Retrospective Designs 10
The Role of Epidemiology in Health Psychology 11
Methodological Tools 11
Qualitative Research 12

What Is Health Psychology Training For? 12

C H A P T E R 2

The Systems of the Body 14

The Nervous System 15
Overview 15
The Brain 15
B O X 2.1 Costs of War to the Brain 17

The Role of Neurotransmitters 17
Disorders of the Nervous System 17

The Endocrine System 19
Overview 19
The Adrenal Glands 19
Disorders Involving the Endocrine System 19

The Cardiovascular System 20
Overview 20
The Heart 20
Disorders of the Cardiovascular System 21
Blood Pressure 22
The Blood 22

The Respiratory System 23
Overview 23
The Structure and Functions of the Respiratory

System 23
Disorders Associated with the Respiratory System 24
Dealing with Respiratory Disorders 25

viii Contents

Genetics and Health 29
Overview 29
Genetics and Susceptibility to Disorders 29

The Immune System 31
Overview 31
Infection 31
The Course of Infection 31
B O X 2.2 Portraits of Two Carriers 32

Immunity 32
Disorders Related to the Immune System 34

The Digestive System and the Metabolism of Food 25
Overview 25
The Functioning of the Digestive System 25
Disorders of the Digestive System 25

The Renal System 27
Overview 27
Disorders of the Renal System 27

The Reproductive System 28
Overview 28
The Ovaries and Testes 28
Fertilization and Gestation 28
Disorders of the Reproductive System 28

P A R T 2

HEALTH BEHAVIOR AND PRIMARY PREVENTION 37

C H A P T E R 3

Health Behaviors 38

An Introduction to Health Behaviors 39
Role of Behavioral Factors in Disease and

Disorder 39
Health Promotion: An Overview 39

Health Behaviors and Health Habits 39
Practicing and Changing Health Behaviors:

An Overview 40
Barriers to Modifying Poor Health Behaviors 41
Intervening with Children and Adolescents 42
Intervening with At-Risk People 43
Health Promotion and Older Adults 44
Ethnic and Gender Differences in Health Risks

and Habits 45
Changing Health Habits 45

Attitude Change and Health Behavior 45
The Health Belief Model 47
The Theory of Planned Behavior 47
Criticisms of Attitude Theories 49
Self Regulation and Health Behavior 49
Self Determination Theory 49
Implementation Intentions 49
Health Behavior Change and the Brain 50

Cognitive-Behavioral Approaches to Health
Behavior Change 50

Cognitive-Behavior Therapy (CBT) 50
Self-Monitoring 50
Stimulus Control 51
The Self-Control of Behavior 51

B O X 3.1 Classical Conditioning 52
B O X 3.2 Operant Conditioning 53
B O X 3.3 Modeling 54

Social Skills and Relaxation Training 54
Motivational Interviewing 54
Relapse Prevention 55
Evaluation of CBT 56

The Transtheoretical Model of Behavior Change 56
Stages of Change 56
Using the Stage Model of Change 57

Changing Health Behaviors Through Social
Engineering 58
Venues for Health-Habit Modification 59

The Practitioner’s Office 59
The Family 59
Self-Help Groups 60
Schools 60
Workplace Interventions 60
Community-Based Interventions 60
The Mass Media 61
Cellular Phones and Landlines 61
The Internet 61

C H A P T E R 4

Health-Promoting Behaviors 64

Exercise 65
Benefits of Exercise 65
Determinants of Regular Exercise 66
Exercise Interventions 67

Contents ix

Evaluation of Cognitive-Behavioral Weight-Loss
Techniques 90

Taking a Public Health Approach 90
Eating Disorders 91

Anorexia Nervosa 91
B O X 5.3 The Barbie Beauty Battle 92

Bulimia 93
Binge Eating Disorder 94

Alcoholism and Problem Drinking 94
The Scope of the Problem 94
What Is Substance Dependence? 95
Alcoholism and Problem Drinking 95
Origins of Alcoholism and Problem Drinking 95
Treatment of Alcohol Abuse 96
Treatment Programs 97
B O X 5.4 After the Fall of the Berlin Wall 97
B O X 5.5 A Profile of Alcoholics Anonymous 98
B O X 5.6 The Drinking College Student 99

Evaluation of Alcohol Treatment Programs 100
Preventive Approaches to Alcohol Abuse 100
Drinking and Driving 101
Is Modest Alcohol Consumption a Health

Behavior? 101
Smoking 101

Synergistic Effects of Smoking 102
A Brief History of the Smoking Problem 102
Why Do People Smoke? 103
Nicotine Addiction and Smoking 105
Interventions to Reduce Smoking 106
Smoking Prevention Programs 109
B O X 5.7 The Perils of Secondhand Smoke 110

Accident Prevention 68
Home and Workplace Accidents 68
Motorcycle and Automobile Accidents 69

Vaccinations and Screening 69
Vaccinations 70
Screenings 70
Colorectal Cancer Screening 71

Sun Safety Practices 71
Developing a Healthy Diet 72

Changing Diet 73
Resistance to Modifying Diet 73

Sleep 75
What Is Sleep? 75
Sleep and Health 75

Rest, Renewal, Savoring 76

C H A P T E R 5

Health-Compromising Behaviors 79

Characteristics of Health-Compromising Behaviors 80
Obesity 81

What Is Obesity? 81
Obesity in Childhood 83
B O X 5.1 The Biological Regulation of Eating 85

SES, Culture, and Obesity 85
Obesity and Dieting as Risk Factors for Obesity 86
Stress and Eating 87
Interventions 87
B O X 5.2 Don’t Diet 88

Cognitive Behavioral Therapy (CBT) 88

P A R T 3

STRESS AND COPING 113

C H A P T E R 6

Stress 114

What Is Stress? 115
What Is a Stressor? 115
Appraisal of Stressors 115

Origins of the Study of Stress 115
Fight or Flight 115
Selye’s General Adaptation Syndrome 115
Tend-and-Befriend 117
How Does Stress Contribute to Illness? 117

The Physiology of Stress 118
Effects of Long-Term Stress 119
Individual Differences in Stress Reactivity 120
Physiological Recovery 121
Allostatic Load 121
B O X 6.1 Can Stress Affect Pregnancy? 122

What Makes Events Stressful? 122
Dimensions of Stressful Events 122
Must Stress Be Perceived as Such to Be Stressful? 123
Can People Adapt to Stress? 124

x Contents

Psychosocial Resources 140
B O X 7.2 Religion, Coping, and Well-Being 142

Resilience 142
Coping Style 143
Problem-Focused and Emotion-Focused Coping 144
B O X 7.3 The Brief COPE 145

Coping and External Resources 146
B O X 7.4 Coping with HIV 146

Coping Outcomes 147
Coping Interventions 147

Mindfulness Meditation and Acceptance/Commitment
Therapy 147

Expressive Writing 148
Self-Affirmation 149
Relaxation Training 149
Coping Skills Training 149

Social Support 151
What Is Social Support? 151
Effects of Social Support on Illness 152
B O X 7.5 Is Social Companionship an Important

Part of Your Life? 153
Biopsychosocial Pathways 153
Moderation of Stress by Social Support 154
What Kinds of Support Are Most Effective? 155
B O X 7.6 Can Bad Relationships Affect Your

Health? 156
Enhancing Social Support 157

P A R T 4

How Has Stress Been Studied? 124
Studying Stress in the Laboratory 124
Must a Stressor Be Ongoing to Be Stressful? 124
Inducing Disease 125
Stressful Life Events 125
B O X 6.2 Post-Traumatic Stress Disorder 126

Daily Stress 127
Sources of Chronic Stress 128

Effects of Early Stressful Life Experiences 128
B O X 6.3 Can an Exciting Sports Event Kill You?

Cardiovascular Events During World Cup
Soccer 128

B O X 6.4 A Measure of Perceived Stress 129
B O X 6.5 The Measurement of Daily Strain 130

Chronic Stressful Conditions 130
Stress in the Workplace 131
B O X 6.6 Can Prejudice Harm Your Health? 132

Some Solutions to Workplace Stressors 134
Combining Work and Family Roles 134

C H A P T E R 7

Coping, Resilience, and Social Support 137

Coping with Stress and Resilience 138
Personality and Coping 138
B O X 7.1 The Measurement of Optimism:

The LOT-R 140

SEEKING AND USING HEALTH CARE SERVICES 159

C H A P T E R 8

Using Health Services 160

Recognition and Interpretation of Symptoms 161
Recognition of Symptoms 161
Interpretation of Symptoms 162
Cognitive Representations of Illness 162
B O X 8.1 Can Expectations Influence Sensations?

The Case of Premenstrual Symptoms 163
Lay Referral Network 164
The Internet 164

Who Uses Health Services? 164
Age 164
Gender 164

Social Class and Culture 165
Social Psychological Factors 165

Misusing Health Services 165
Using Health Services for Emotional

Disturbances 165
Delay Behavior 166
B O X 8.2 The June Bug Disease: A Case of

Hysterical Contagion 167

C H A P T E R 9

Patients, Providers, and Treatments 170

Health Care Services 171
Patient Consumerism 171

Contents xi

Who Uses CAM? 192
Complementary and Alternative Medicine: An

Overall Evaluation 192
The Placebo Effect 193

History of the Placebo 193
What Is a Placebo? 193
Provider Behavior and Placebo Effects 194
B O X 9.6 Cancer and the Placebo Effect 194

Patient Characteristics and Placebo Effects 194
Patient-Provider Communication and Placebo

Effects 195
Situational Determinants of Placebo Effects 195
Social Norms and Placebo Effects 195
The Placebo as a Methodological Tool 196

C H A P T E R 1 0

The Management of Pain and
Discomfort 199

The Elusive Nature of Pain 201
B O X 10.1 A Cross-Cultural Perspective on Pain:

The Childbirth Experience 202
Measuring Pain 202
The Physiology of Pain 204
B O X 10.2 Headache Drawings Reflect Distress and

Disability 204
B O X 10.3 Phantom Limb Pain: A Case History 206
Neurochemical Bases of Pain and Its Inhibition 206

Clinical Issues in Pain Management 207
Acute and Chronic Pain 207
Pain and Personality 209

Pain Control Techniques 209
Pharmacological Control of Pain 210
Surgical Control of Pain 210
Sensory Control of Pain 211
Biofeedback 211
Relaxation Techniques 211
Distraction 212
Coping Skills Training 213
Cognitive Behavioral Therapy 214

Pain Management Programs 214
Initial Evaluation 215
Individualized Treatment 215
Components of Programs 215
Involvement of Family 215
Relapse Prevention 215
Evaluation of Programs 215

Structure of the Health Care Delivery System 171
Patient Experiences with Managed Care 172

The Nature of Patient-Provider Communication 173
Setting 173
Provider Behaviors That Contribute to Faulty

Communication 174
B O X 9.1 What Did You Say?: Language Barriers

to Effective Communication 175
Patients’ Contributions to Faulty Communication 175
Interactive Aspects of the Communication

Problem 176
Results of Poor Patient-Provider Communication 177

Nonadherence to Treatment Regimens 177
Good Communication 177
B O X 9.2 What Are Some Ways to Improve

Adherence to Treatment? 178
Improving Patient-Provider Communication and
Increasing Adherence to Treatment 178

Teaching Providers How to Communicate 178
B O X 9.3 What Can Providers Do to Improve

Adherence? 179
The Patient in the Hospital Setting 180

Structure of the Hospital 181
The Impact of Hospitalization on the Patient 182
B O X 9.4 Burnout Among Health Care

Professionals 183
Interventions to Increase Information in Hospital
Settings 184
The Hospitalized Child 184

B O X 9.5 Social Support and Distress from
Surgery 185

Preparing Children for Medical Interventions 185
Complementary and Alternative Medicine 186

Philosophical Origins of CAM 186
CAM Treatments 188

Dietary Supplements and Diets 188
Prayer 188
Acupuncture 189
Yoga 189
Hypnosis 190
Meditation 190
Guided Imagery 190
Chiropractic Medicine 191
Osteopathy 191
Massage 191

xii Contents

C H A P T E R 1 2

Psychological Issues in Advancing and
Terminal Illness 239

Death Across the Life Span 240
Death in Infancy and Childhood 240
Death in Adolescence and Young Adulthood 243
Death in Middle Age 244
Death in Old Age 244
B O X 12.1 Why Do Women Live Longer Than

Men? 245
Psychological Issues in Advancing Illness 246

Continued Treatment and Advancing Illness 246
B O X 12.2 A Letter to My Physician 247
Psychological and Social Issues Related to

Dying 247
B O X 12.3 Ready to Die: The Question of Assisted

Suicide 248
The Issue of Nontraditional Treatment 249

Are There Stages in Adjustment to Dying? 249
Kübler-Ross’s Five-Stage Theory 249
Evaluation of Kübler-Ross’s Theory 250

Psychological Issues and the Terminally Ill 251
Medical Staff and the Terminally Ill Patient 251
Counseling with the Terminally Ill 253
The Management of Terminal Illness in Children 253

Alternatives to Hospital Care for the Terminally Ill 253
Hospice Care 253
Home Care 254

Problems of Survivors 254
B O X 12.4 Cultural Attitudes Toward Death 255
The Survivor 255
Death Education 257

C H A P T E R 1 3

Heart Disease, Hypertension, Stroke,
and Type II Diabetes 259

Coronary Heart Disease 260
What Is CHD? 260
Risk Factors for CHD 260
Stress and CHD 261
Women and CHD 263
Personality, Cardiovascular Reactivity, and CHD 264

C H A P T E R 1 1

Management of Chronic Health
Disorders 218

Quality of Life 220
What Is Quality of Life? 220
Why Study Quality of Life? 220

Emotional Responses to Chronic Health Disorders 221
Denial 221
Anxiety 222
Depression 222

Personal Issues in Chronic Health Disorders 223
B O X 11.1 A Future of Fear 223
The Physical Self 223
The Achieving Self 224
The Social Self 224
The Private Self 224

Coping with Chronic Health Disorders 224
Coping Strategies and Chronic Health Disorders 224
Patients’ Beliefs About Chronic Health Disorders 225
B O X 11.2 Chronic Fatigue Syndrome and Other

Functional Disorders 226
Comanagement of Chronic Health Disorders 227

Physical Rehabilitation 227
B O X 11.3 Epilepsy and the Need for a Job

Redesign 228
Vocational Issues in Chronic Health Disorders 228
Social Interaction Problems in Chronic Health

Disorders 228
B O X 11.4 Who Works with People with Chronic

Health Disorders? 229
Gender and the Impact of Chronic Health

Disorders 232
Positive Changes in Response to Chronic Health

Disorders 232
When a Child Has A Chronic Health Disorder 232

Psychological Interventions and Chronic Health
Disorders 234

Pharmacological Interventions 234
Individual Therapy 234
Relaxation, Stress Management, and Exercise 235
Social Support Interventions 236
B O X 11.5 Help on the Internet 236
Support Groups 237

P A R T 5

MANAGEMENT OF CHRONIC AND TERMINAL
HEALTH DISORDERS 217

Contents xiii

Negative Affect and Immune Functioning 287
Stress, Immune Functioning, and Interpersonal

Relationships 288
Coping and Immune Functioning 288
Interventions to Improve Immune Functioning 289

HIV Infection and AIDS 290
A Brief History of HIV Infection and AIDS 290
HIV Infection and AIDS in the United States 291
The Psychosocial Impact of HIV Infection 292
Interventions to Reduce the Spread of HIV

Infection 293
Coping with HIV+ Status and AIDS 296
Psychosocial Factors That Affect the Course of HIV

Infection 297
Cancer 298

Why Is Cancer Hard to Study? 299
Who Gets Cancer? A Complex Profile 299
Psychosocial Factors and Cancer 299
Psychosocial Factors and the Course of Cancer 301
Adjusting to Cancer 301
Psychosocial Issues and Cancer 302
Post-traumatic Growth 302
Interventions 303
Therapies with Cancer Patients 304

Arthritis 304
Rheumatoid Arthritis 305
Osteoarthritis 306

Type I Diabetes 306
Special Problems of Adolescent Diabetics 307

B O X 13.1 Hostility and Cardiovascular Disease 265
Depression and CHD 266
Other Psychosocial Risk Factors and CHD 267
Management of Heart Disease 267
B O X 13.2 Picturing the Heart 269
Prevention of Heart Disease 271

Hypertension 272
How Is Hypertension Measured? 272
What Causes Hypertension? 272
Treatment of Hypertension 274
The Hidden Disease 275

Stroke 275
Risk Factors for Stroke 276
Consequences of Stroke 277
Rehabilitative Interventions 277

Type II Diabetes 278
Health Implications of Diabetes 280
Psychosocial Factors in the Development of

Diabetes 280
The Management of Diabetes 281
B O X 13.3 Stress Management and the Control of

Diabetes 281

C H A P T E R 1 4

Psychoneuroimmunology and
Immune-Related Disorders 284

Psychoneuroimmunology 285
The Immune System 285
Assessing Immune Functioning 285
Stress and Immune Functioning 285
B O X 14.1 Autoimmune Disorders 287

P A R T 6

TOWARD THE FUTURE 311

C H A P T E R 1 5

Health Psychology: Challenges
for the Future 312

Health Promotion 314
A Focus on Those at Risk 314
Prevention 314
A Focus on Older Adults 314
Refocusing Health Promotion Efforts 315
Promoting Resilience 315
Health Promotion and Medical Practice 316
Health Disparities 316

Stress and Its Management 318
Where Is Stress Research Headed? 318

Health Services 319
Building Better Consumers 319

Management of Serious Illness 320
Quality-of-Life Assessment 320
The Aging of the Population 320

Trends in Health and Health Psychology 321
The Research of the Future 321
The Changing Nature of Medical Practice 321

xiv Contents

GLOSSARY 328

REFERENCES 338

NAME INDEX 412

SUBJECT INDEX 438

Systematic Documentation of Cost Effectiveness
and Treatment Effectiveness 322

International Health 324
Becoming a Health Psychologist 325

Undergraduate Experience 325
Graduate Experience 325
Postgraduate Work 326
Employment 326

xv

P R E F A C E

When I wrote the first edition of Health Psychology over 30 years ago, the task
was much simpler than it is now. Health psychology was a new field and was
relatively small. In recent decades, the field has grown steadily, and great research
advances have been made. Chief among these developments has been the use and
refinement of the biopsychosocial model: the study of health issues from the stand-
point of biological, psychological, and social factors acting together. Increasingly,
research has attempted to identify the biological pathways by which psychosocial
factors such as stress may adversely affect health and potentially protective factors
such as social support may buffer the impact of stress. My goal in the tenth edition
of this text is to convey this increasing sophistication of the field in a manner that
makes it accessible, comprehensible, and exciting to undergraduates.
Like any science, health psychology is cumulative, building on past research
advances to develop new ones. Accordingly, I have tried to present not only the
fundamental contributions to the field but also the current research on these
issues. Because health psychology is developing and changing so rapidly, it is
essential that a text be up to date. Therefore, I have not only reviewed the recent
research in health psychology but also obtained information about research proj-
ects that will not be available in the research literature for several years. In so
doing, I am presenting a text that is both current and pointed toward the future.
A second goal is to portray health psychology appropriately as being inti-
mately involved with the problems of our times. The aging of the population and
the shift in numbers toward the later years has created unprecedented health needs
to which health psychology must respond. Such efforts include the need for health
promotion with this aging cohort and an understanding of the psychosocial issues
that arise in response to aging and its associated chronic disorders. Because AIDS
is a leading cause of death worldwide, the need for health measures such as con-
dom use is readily apparent if we are to halt the spread of this disease. Obesity
is now one of the world’s leading health problems, nowhere more so than in the
United States. Reversing this dire trend that threatens to shorten life expectancy
worldwide is an important current goal of health psychology. Increasingly, health
psychology is an international undertaking, with researchers from around the
world providing insights into the problems that affect both developing and devel-
oped countries. The tenth edition includes current research that reflects the inter-
national focus of both health problems and the health research community.
Health habits lie at the origin of our most prevalent disorders, and this fact
underscores more than ever the importance of modifying problematic health behav-
iors such as smoking and alcohol consumption. Increasingly, research documents
the importance of a healthy diet, regular exercise, and weight control among other
positive health habits for maintaining good health. The at-risk role has taken on
more importance in prevention, as breakthroughs in genetic research have made
it possible to identify genetic risks for diseases long before disease is evident.
How people cope with being at risk and what interventions are appropriate for
them represent important tasks for health psychology research to address.
Health psychology is both an applied field and a basic research field. Accord-
ingly, in highlighting the accomplishments of the field, I present both the scientific

xvi Preface

progress and its important applications. Chief among these are efforts by clinical
psychologists to intervene with people to treat biopsychosocial disorders, such as
post-traumatic stress disorder; to help people manage health habits that have
become life threatening, such as eating disorders; and to develop clinical interven-
tions that help people better manage their chronic illnesses.
Finding the right methods and venues for modifying health continues to be a
critical issue. The chapters on health promotion put particular emphasis on the
most promising methods for changing health behaviors. The chapters on chronic
diseases highlight how knowledge of the psychosocial causes and consequences
of these disorders may be used to intervene with people at risk—first, to reduce
the likelihood that such disorders will develop, and second, to deal effectively
with the psychosocial issues that arise following diagnosis.
The success of any text depends ultimately on its ability to communicate the
content clearly to student readers and spark interest in the field. In this tenth
edition, I strive to make the material interesting and relevant to the lives of student
readers. Many chapters highlight news stories related to health. In addition, the
presentation of material has been tied to the needs and interests of young adults.
For example, the topic of stress management is tied directly to how students might
manage the stresses associated with college life. The topic of problem drinking
includes sections on college students’ alcohol consumption and its modification.
Health habits relevant to this age group—tanning, exercise, and condom use,
among others—are highlighted for their relevance to the student population. By
providing students with anecdotes, case histories, and specific research examples
that are relevant to their own lives, they learn how important this body of knowl-
edge is to their lives as young adults.
Health psychology is a science, and consequently, it is important to commu-
nicate not only the research itself but also some understanding of how studies
were designed and why they were designed that way. The explanations of par-
ticular research methods and the theories that have guided research appear
throughout the book. Important studies are described in depth so that students
have a sense of the methods researchers use to make decisions about how to gather
the best data on a problem or how to intervene most effectively.
Throughout the book, I have made an effort to balance general coverage of
psychological concepts with coverage of specific health issues. One method of
doing so is by presenting groups of chapters, with the initial chapter offering
general concepts and subsequent chapters applying those concepts to specific
health issues. Thus, Chapter 3 discusses general strategies of health promotion,
and Chapters 4 and 5 discuss those issues with specific reference to particular
health habits such as exercise, smoking, accident prevention, and weight control.
Chapters 11 and 12 discuss broad issues that arise in the context of managing
chronic health disorders and terminal illness. In Chapters 13 and 14, these issues
are addressed concretely, with reference to specific disorders such as heart disease,
cancer, and AIDS.
Rather than adopt a particular theoretical emphasis throughout the book,
I  have attempted to maintain a flexible orientation. Because health psychology is
taught within all areas of psychology (for example, clinical, social, cognitive,
physiological, learning, and developmental), material from each of these areas is
included in the text so that it can be accommodated to the orientation of each
instructor. Consequently, not all material in the book is relevant for all courses.
Successive chapters of the book build on each other but do not depend on each

Preface xvii

other. Chapter 2, for example, can be used as assigned reading, or it can act as a
resource for students wishing to clarify their understanding of biological concepts
or learn more about a particular biological system or illness. Thus, each instruc-
tor can accommodate the use of the text to his or her needs, giving some chapters
more attention than others and omitting some chapters altogether, without under-
mining the integrity of the presentation.

■ NEW TO THIS EDITION

∙ Coverage of qualitative methods, such as how interviews and personal narra-
tives can enrich our understanding of health experiences (Chapter 1)

∙ Discussion of Alzheimer’s disease, its toll, and its increasing importance as
a disease of an aging population (Chapter 2)

∙ New section on the self-regulation of health behaviors, including the impact
of self affirmation on health behavior change (Chapter 3)

∙ Coverage of perceived barriers to health behavior change, one of the most
important reasons why people do not practice better health habits (Chapter 3)

∙ Coverage of the post childbirth period as a teachable moment (Chapter 3)
∙ Discussion of the health risks of being sedentary and sitting for long periods

of time (Chapters 4, 13)
∙ Expanded coverage of vaccinations and ways to overcome resistance to getting

children vaccinated for major diseases (Chapter 4)
∙ Coverage of new research on sleep and health (Chapter 4)
∙ Enhanced coverage of eating disorders, including binge eating disorder

(Chapter 5)
∙ Coverage of the newest research on the obesity epidemic (Chapter 5)
∙ New research on stress in childhood and adolescence (Chapter 6)
∙ Expanded converge on the effects of prejudice and discrimination on health

(Chapter 6)
∙ Expanded coverage of how mindfulness meditation can aid coping with stress

(Chapter 7)
∙ Coverage of dyadic coping, namely how partners can shape each other’s bio-

logical and psychological responses to stress (Chapter 7)
∙ Discussion of how people are using probiotics to enhance the microbiome of

the gut and its potential effects on health (Chapter 9)
∙ Coverage of the epidemic of opioid and heroin abuse and their effects on

health and on suicide (Chapters 10, 12)
∙ Change in orientation from disease and illness to health and chronic health

disorders (Chapters 3, 11)
∙ Discussion of the startling increase in the death rate of middle-aged adults

and the reasons why (Chapter 12)
∙ Intervening in childhood and adolescence to forestall chronic health disorders

in middle age (Chapter 13)
∙ Discussion of psychosocial factors in the development of Type II Diabetes

(Chapter 12)
∙ Coverage of post-traumatic growth (Chapter 14)
∙ Use of technology and the Internet to improve health and to assess and inter-

vene in the course of chronic health disorders (Chapters 1, 3, 13, 15)
∙ Impact of changes in healthcare coverage in the United States (Chapter 15)
∙ The changing face of health psychology (Chapter 15)

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■ ACKNOWLEDGMENTS

My extensive gratitude goes to Emily Iseda, Jesse Solorzano, and Saskia Giebl
for the many hours they put in on the manuscript. I thank my editors at McGraw-
Hill, Jamie Laferrera, Erin Guendelsberger, and Sheila Frank, who devoted much
time and help to the preparation of the book. I also wish to thank the following
reviewers who commented on all or part of the book:

Marie-Joelle Estrada, University of Rochester
Jennifer Grewe, Utah State University
Marguerite D. Kermis, Canisius College
Rhonna Krouse, College of Western Idaho
Jeffrey M. Kunka, Roosevelt University
Max Levine, Siena College
Susan D. Lonborg, Central Washington University
Michelle Loudermilk, Fayetteville Technical Community College
Angelina Stacy MacKewn, University of Tennessee at Martin
H. Russell Searight, Lake Superior State University
Bert Uchino, University of Utah

Shelley E. Taylor

xx Preface

Introduction to Health
Psychology

1P A R T

© Amana Productions Inc./Getty Images RF

2

C H A P T E R 1
C H A P T E R O U T L I N E

Definition of Health Psychology
Why Did Health Psychology Develop?

The Mind-Body Relationship: A Brief History
The Rise of the Biopsychosocial Method

Psychosomatic Medicine

Advantages of the Biopsychosocial Model

Clinical Implications of the Biopsychosocial Model

The Biopsychosocial Model: The Case History of
Nightmare Deaths

The Need for Health Psychology
Changing Patterns of Illness

Advances in Technology and Research

Expanded Health Care Services

Increased Medical Acceptance

Health Psychology Research
The Role of Theory in Research

Experiments

Correlational Studies

Prospective and Retrospective Designs

The Role of Epidemiology in Health Psychology

Methodological Tools

What Is Health Psychology Training For?

What Is Health Psychology?

© McGraw-Hill Education/Ken Karp, photographer

Chapter 1 What Is Health Psychology? 3

Health psychologists focus on health promotion
and maintenance, which includes issues such as how
to get children to develop good health habits, how to
promote regular exercise, and how to design a media
campaign to get people to improve their diets.
Health psychologists study the psychological as-
pects of the prevention and treatment of illness. A
health psychologist might teach people in a high-
stress occupation how to manage stress effectively to
avoid health risks. A health psychologist might work
with people who are already ill to help them follow
their treatment regimen.
Health psychologists also focus on the etiology
and correlates of health, illness, and dysfunction.
Etiology refers to the origins or causes of illness.
Health psychologists especially address the behav-
ioral and social factors that contribute to health,
illness, and dysfunction, such as alcohol consumption,
smoking, exercise, the wearing of seat belts, and ways
of coping with stress.
Finally, health psychologists analyze and attempt
to improve the health care system and the formulation
of health policy. They study the impact of health insti-
tutions and health professionals on people’s behavior to
develop recommendations for improving health care.
In summary, health psychology examines the psy-
chological and social factors that lead to the enhance-
ment of health, the prevention and treatment of illness,
and the evaluation and modification of health policies
that influence health care.

Why Did Health Psychology Develop?
To many people, health is simply a matter of staying
well or getting over illnesses quickly. Psychological
and social factors might seem to have little to contrib-
ute. But consider some of the following puzzles that
cannot be understood without the input of health
psychology:
∙ When people are exposed to a cold virus, some

get colds whereas others do not.
∙ Men who are married live longer than men who

are not married.
∙ Throughout the world, life expectancy is

increasing. But in countries going through
dramatic social upheaval, life expectancy can
plummet.

∙ Women live longer than men in all countries
except those in which they are denied access to

“Life span may be as wide as your smile: The bigger
the smile, the longer the life” (March 29, 2010)
“Epidemic of drug overdose deaths ripples
across America” (January 20, 2016)
“Vaccination is a social responsibility”
( February 4, 2015)
“Smartphone apps help people quit smoking”
(January 23, 2015)
“Risk of concussions from youth sports”
( December 25, 2015)

Every day, we see headlines about health. We are told
that smoking is bad for us, that we need to exercise
more, and that we’ve grown obese. We learn about
new treatments for diseases about which we are only
dimly aware, or we hear that a particular herbal rem-
edy may make us feel better about ourselves. We are
told that meditation or optimistic beliefs can keep us
healthy or help us to get well more quickly. How do
we make sense of all these claims? Health psychology
addresses important questions like these.

■ DEFINITION OF HEALTH
PSYCHOLOGY

Health psychology is an exciting and relatively new
field devoted to understanding psychological influ-
ences on how people stay healthy, why they become
ill, and how they respond when they do get ill. Health
psychologists both study such issues and develop in-
terventions to help people stay well or recover from
illness. For example, a health psychology researcher
might explore why people continue to smoke even
though they know that smoking increases their risk
of cancer and heart disease. Understanding this
poor health habit leads to interventions to help peo-
ple stop smoking.
Fundamental to research and practice in health
psychology is the definition of health. Decades ago,
a forward-looking World Health Organization (1948)
defined health as “a complete state of physical,
mental, and social well-being and not merely the ab-
sence of disease or infirmity.” This definition is at
the core of health psychologists’ conception of
health. Rather than defining health as the absence of
illness, health is recognized to be an achievement
involving balance among physical, mental, and so-
cial well-being. Many use the term wellness to refer
to this optimum state of health.

4 Part One Introduction to Health Psychology

illness. Rather than ascribing illness to evil spirits, they
developed a humoral theory of illness. According to this
viewpoint, disease resulted when the four humors or
circulating fluids of the body—blood, black bile, yellow
bile, and phlegm—were out of balance. The goal of
treatment was to restore balance among the humors. The
Greeks also believed that the mind was important. They
described personality types associated with each of the
four humors, with blood being associated with a pas-
sionate temperament, black bile with sadness, yellow
bile with an angry disposition, and phlegm with a laid-
back approach to life. Although these theories are now
known not to be true, the emphasis on mind and body in
health and illness was a breakthrough at that time.
By the Middle Ages, however, the pendulum had
swung to supernatural explanations for illness. Disease
was regarded as God’s punishment for evildoing, and
cure often consisted of driving out the evil forces by
torturing the body. Later, this form of “therapy” was
replaced by penance through prayer and good works.
During this time, the Church was the guardian of medi-
cal knowledge, and as a result, medical practice assumed
religious overtones. The functions of the physician were
typically absorbed by priests, and so healing and the
practice of religion became virtually indistinguishable.
Beginning in the Renaissance and continuing
into  the present day, great strides were made in
understanding the technical bases of medicine. These

health care. But women are more disabled, have
more illnesses, and use health services more.

∙ Infectious diseases such as tuberculosis, pneumonia,
and influenza used to be the major causes of
illness and death in the United States. Now chronic
diseases such as heart disease, cancer, and diabetes
are the main causes of disability and death.

∙ Attending a church or synagogue, praying, or
otherwise tending to spiritual needs is good for
your health.

By the time you have finished this book, you will
know why these findings are true.

■ THE MIND-BODY
RELATIONSHIP: A BRIEF
HISTORY

During prehistoric times, most cultures regarded the
mind and body as intertwined. Disease was thought to
arise when evil spirits entered the body, and treatment
consisted primarily of attempts to exorcise these spirits.
Some skulls from the Stone Age have small, symmetri-
cal holes that are believed to have been made intention-
ally with sharp tools to allow the evil spirit to leave the
body while the shaman performed the treatment ritual.
The ancient Greeks were among the earliest civili-
zations to identify the role of bodily factors in health and

Sophisticated, though not always successful, techniques for the treatment of illness were

developed during the Renaissance. This woodcut from the 1570s depicts a surgeon

drilling a hole in a patient’s skull, with the patient’s family and pets looking on.

Courtesy National Library of Medicine Prints and Photographs

Chapter 1 What Is Health Psychology? 5

Flanders Dunbar in the 1930s (Dunbar, 1943) and Franz
Alexander in the 1940s (Alexander, 1950). For exam-
ple, Alexander developed a profile of the ulcer-prone
personality as someone with excessive needs for depen-
dency and love.
Dunbar and Alexander maintained that conflicts
produce anxiety, which becomes unconscious and takes
a physiological toll on the body via the autonomic ner-
vous system. The continuous physiological changes
eventually produce an organic disturbance. In the case
of the ulcer patient, for example, repressed emotions
resulting from frustrated dependency and love-seeking
needs were thought to increase the secretion of acid in
the stomach, eventually eroding the stomach lining and
producing ulcers (Alexander, 1950).
Dunbar’s and Alexander’s work helped shape the
emerging field of psychosomatic medicine by offer-
ing profiles of particular disorders believed to be psy-
chosomatic in origin, that is, caused by emotional
conflicts. These disorders include ulcers, hyperthy-
roidism, rheumatoid arthritis, essential hypertension,
neurodermatitis (a skin disorder), colitis, and bron-
chial asthma.
We now know that all illnesses raise psychologi-
cal issues. Moreover, researchers now believe that a
particular conflict or personality type is not sufficient
to produce illness. Rather, the onset of disease is usu-
ally due to several factors working together, which
may include a biological pathogen (such as a viral or
bacterial infection) coupled with social and psycho-
logical factors, such as high stress, low social support,
and low socioeconomic status.
The idea that the mind and the body together deter-
mine health and illness logically implies a model for
studying these issues. This model is called the biopsy-
chosocial model. Its fundamental assumption is that
health and illness are consequences of the interplay of
biological, psychological, and social factors (Keefe,
2011).

Advantages of the
Biopsychosocial Model
How does the biopsychosocial model of health and
illness overcome the disadvantages of the biomedical
model? The biopsychosocial model maintains that
biological, psychological, and social factors are all
important determinants of health and illness. Both
macrolevel processes (such as the existence of social
support or the presence of depression) and microlevel
processes (such as cellular disorders or chemical

advances include the invention of the microscope in the
1600s and the development of the science of autopsy,
which allowed medical practitioners to see the organs
that were implicated in different diseases. As the science
of cellular pathology progressed, the humoral theory of
illness was put to rest. Medical practice drew increas-
ingly on laboratory findings and looked to bodily factors
rather than to the mind as bases for health and illness. In
an effort to break with the superstitions of the past, prac-
titioners resisted acknowledging any role for the mind in
disease processes. Instead, they focused primarily on
organic and cellular pathology as a basis for their diag-
noses and treatment recommendations.
The resulting biomedical model, which has gov-
erned the thinking of most health practitioners for the
past 300 years, maintains that all illness can be explained
on the basis of aberrant somatic bodily processes, such
as biochemical imbalances or neurophysiological
abnormalities. The biomedical model assumes that
psychological and social processes are largely irrele-
vant to the disease process. The problems with the bio-
medical model are summarized in Table 1.1.

TABLE 1.1 | The Biomedical Model: Why Is It
Ill-suited to Understanding Illness?

• Reduces illness to low-level processes such as
disordered cells and chemical imbalances

• Fails to recognize social and psychological processes as
powerful influences over bodily estates—assumes a
mind-body dualism

• Emphasizes illness over health rather than focusing on
behaviors that promote health

• Model cannot address many puzzles that face
practitioners: why, for example, if six people are
exposed to a flu virus, do only three develop the flu?

■ THE RISE OF THE
BIOPSYCHOSOCIAL MODEL

The biomedical viewpoint began to change with the
rise of modern psychology, particularly with Sigmund
Freud’s (1856–1939) early work on conversion hysteria.
According to Freud, specific unconscious conflicts can
produce physical disturbances that symbolize repressed
psychological conflicts. Although this viewpoint is no
longer central to health psychology, it gave rise to the
field of psychosomatic medicine.

Psychosomatic Medicine
The idea that specific illnesses are produced by peo-
ple’s internal conflicts was perpetuated in the work of

6 Part One Introduction to Health Psychology

was consistent with the genetic theory. But how and
why would such a defect be triggered during sleep?
As the number of cases increased, it became evi-
dent that psychological and cultural, as well as bio-
logical, factors were involved. Some family members
reported that the victim had experienced a dream fore-
telling the death. Among the Hmong of Laos, a refu-
gee group that was especially plagued by these
nightmare deaths, dreams are taken seriously as por-
tends of the future. Anxiety due to these dreams, then,
may have played a role in the deaths (Adler, 1991).
Another vital set of clues came from a few men
who were resuscitated by family members. Several of
them said that they had been having a severe night ter-
ror. One man, for example, said that his room had sud-
denly grown darker, and a figure like a large black dog
had come to his bed and sat on his chest. He had been
unable to push the dog off and had become quickly and
dangerously short of breath (Tobin & Friedman,
1983). This was also an important clue because night
terrors are known to produce abrupt and dramatic
physiologic changes.
Interviews with the survivors revealed that many
of the men had been watching violent TV shows
shortly before retiring, and the content of the shows
appeared to have made its way into some of the fright-
ening dreams. In other cases, the fatal event occurred
immediately after a family argument. Many of the
men were said by their families to have been exhausted
from combining demanding full-time jobs with a sec-
ond job or with night school classes to learn English.
The pressures to support their families had been tak-
ing their toll.
All these clues suggest that the pressures of ad-
justing to life in the United States played a role in the
deaths. The victims may have been overwhelmed by
cultural differences, language barriers, and difficul-
ties finding satisfactory jobs. The combination of this
chronic strain, a genetic susceptibility, and an imme-
diate trigger provided by a family argument, violent
television, or a frightening dream culminated in night-
mare death (Lemoine & Mougne, 1983). Clearly, the
biopsychosocial model unraveled this puzzle.

■ THE NEED FOR HEALTH
PSYCHOLOGY

What factors led to the development of health psy-
chology? Since the inception of the field of psychol-
ogy in the early 20th century, psychologists have made

imbalances) continually interact to influence health
and illness and their course.
The biopsychosocial model emphasizes both
health and illness. From this viewpoint, health be-
comes something that one achieves through attention
to biological, psychological, and social needs, rather
than something that is taken for granted (Suls, Krantz &
Williams, 2013).

Clinical Implications of the
Biopsychosocial Model
The biopsychosocial model is useful for people treat-
ing patients as well. First, the process of diagnosis can
benefit from understanding the interacting role of bio-
logical, psychological, and social factors in assessing
a person’s health or illness. Recommendations for
treatment can focus on all three sets of factors.
The biopsychosocial model makes explicit the
significance of the relationship between patient and
practitioner. An effective patient-practitioner rela-
tionship can improve a patient’s use of services, the
efficacy of treatment, and the rapidity with which
illness is resolved.

The Biopsychosocial Model: The Case
History of Nightmare Deaths
To see how completely the mind and body are inter-
twined in health, consider a case study that intrigued
medical researchers for nearly 15 years. It involved the
bewildering “nightmare deaths” among Southeast
Asians.
Following the Vietnam War, in the 1970s, refu-
gees from Southeast Asia, especially Laos, Vietnam,
and Cambodia, immigrated to the United States.
Around 1977, the Centers for Disease Control (CDC)
in Atlanta became aware of a strange phenomenon:
sudden, unexpected nocturnal deaths among male
refugees from these groups. Death often occurred in
the first few hours of sleep. Relatives reported that the
victim began to gurgle and move about in bed rest-
lessly. Efforts to awaken him were unsuccessful, and
shortly thereafter he died. Even more mysteriously,
autopsies revealed no specific cause of death.
However, most of the victims appeared to have a
rare, genetically based malfunction in the heart’s
pacemaker. The fact that only men of particular ethnic
backgrounds were affected was consistent with the
potential role of a genetic factor. Also, the fact that the
deaths seemed to cluster within particular families

Chapter 1 What Is Health Psychology? 7

declined because of treatment innovations and changes
in public health standards, such as improvements in
waste control and sewage.
Now, chronic illnesses—especially heart disease,
cancer, and respiratory diseases—are the main con-
tributors to disability and death, particularly in indus-
trialized countries. Chronic illnesses are slowly
developing diseases with which people live for many
years and that typically cannot be cured but rather are
managed by patient and health care providers. Table 1.3
lists the main diseases worldwide at the present time.
Note how the causes are projected to change over the
next decade or so.
Why have chronic illnesses helped spawn the
field of health psychology? First, these are diseases in
which psychological and social factors are implicated
as causes. For example, personal health habits, such as
diet and smoking, contribute to the development of
heart disease and cancer, and sexual activity is critical
to the likelihood of developing AIDS (acquired im-
mune deficiency syndrome).
Second, because people may live with chronic dis-
eases for many years, psychological issues arise in
their management. Health psychologists help chroni-
cally ill people adjust psychologically and socially to
their changing health state and treatment regimens,
many of which involve self-care. Chronic illnesses af-
fect family functioning, including relationships with a
partner or children, and health psychologists help ease
the problems in family functioning that may result.
Chronic illnesses may require medication use and
self-monitoring of symptoms, as well as changes in

important contributions to health, exploring how and
why some people get ill and others do not, how people
adjust to their health conditions, and what factors lead
people to practice health behaviors. In response to
these trends, the American Psychological Association
(APA) created a task force in 1973 to focus on psy-
chology’s potential role in health research. Partici-
pants included counseling, clinical, and rehabilitation
psychologists, many of whom were already employed
in health settings. Independently, social psycholo-
gists, developmental psychologists, and community/
environmental psychologists were developing concep-
tual approaches for exploring health issues (Friedman &
Silver, 2007). These two groups joined forces, and in
1978, the Division of Health Psychology was formed
within the APA. It is safe to say that health psychol-
ogy is one of the most important developments within
the field of psychology in the past 50 years. What
other factors have fueled the growing field of health
psychology?

Changing Patterns of Illness
An important factor influencing the rise of health psy-
chology has been the change in illness patterns in the
United States and other technologically advanced societ-
ies in recent decades. As Table 1.2 shows, until the
20th century, the major causes of illness and death in
the United States were acute disorders. Acute disor-
ders are short-term illnesses, often result of a viral or
bacterial invader and usually amenable to cure. The
prevalence of acute infectious disorders, such as tu-
berculosis, influenza, measles, and poliomyelitis, has

TABLE 1.2 | What Are the Leading Causes of Death in the United States? A Comparison of 1900 and 2015,
per 100,000 Population

1900 2015

Influenza and pneumonia 202.2 Heart disease 611.1

Tuberculosis, all forms 194.4 Cancer 584.9

Gastroenteritis 142.7 Chronic lower respiratory diseases 149.2

Diseases of the heart 137.4 Accidents (unintentional injuries) 130.6

Vascular lesions of the c.n.s. 106.9 Stroke 129.0

Chronic nephritis 81.0 Alzheimer’s disease 84.8

All accidents 72.3 Diabetes 75.6

Malignant neoplasms (cancer) 64.0 Influenza and pneumonia 57.0

Certain diseases of early infancy 62.6 Nephritis, nephrotic syndrome, and nephrosis 47.1

Diphtheria  40.3 Intentional self-harm (suicide) 41.1

Source: Murphy, 2000; Centers for Disease Control and Prevention, September 2015.

8 Part One Introduction to Health Psychology

under increasing scrutiny, as substantial increases in
health care costs have not brought improvement in
basic indicators of health.
Moreover, huge disparities exist in the United States
such that some individuals enjoy the very best health
care available in the world while others receive little
health care except in emergencies. Prior to the Afford-
able Care Act (known as Obamacare), 49.9 million
Americans had no health insurance at all (U.S. Census
Bureau, 2011). Efforts to reform the health care sys-
tem to provide all Americans with a basic health care
package, similar to what already exists in most
European countries, have resulted.
Health psychology represents an important per-
spective on these issues for several reasons:

∙ Because containing health care costs is so
important, health psychology’s main emphasis
on prevention—namely, modifying people’s
risky health behaviors before they become
ill—can reduce the dollars devoted to the
management of illness.

∙ Health psychologists know what makes people
satisfied or dissatisfied with their health care
(see Chapters 8 and 9) and can help in the design
of a user-friendly health care system.

∙ The health care industry employs millions of
people. Nearly every person in the country has
direct contact with the health care system as a
recipient of services. Consequently, its impact is
enormous.

behavior, such as altering diet and getting exercise.
Health psychologists develop interventions to help peo-
ple learn these regimens and promote adherence to them.

Advances in Technology and Research
New medical technologies and scientific advances
create issues that can be addressed by health psy-
chologists. Just in the past few years, genes have
been uncovered that contribute to many diseases in-
cluding breast cancer. How do we help a college stu-
dent whose mother has just been diagnosed with
breast cancer come to terms with her risk? If she
tests positive for a breast cancer gene, how will this
change her life? Health psychologists help answer
such questions.
Certain treatments that prolong life may severely
compromise quality of life. Increasingly, patients are
asked their preferences regarding life-sustaining mea-
sures, and they may require counseling in these mat-
ters. These are just a few examples of how health
psychologists respond to scientific developments.

Expanded Health Care Services
Other factors contributing to the rise of health psy-
chology involve the expansion of health care ser-
vices. Health care is the largest service industry in
the United States, and it is still growing rapidly.
Americans spend more than $3 trillion annually on
health care (National Health Expenditures, 2014).
In  recent years, the health care industry has come

TABLE 1.3 | What Are the Worldwide Causes of Death?

2014 2030

Projected
Rank Disease or Injury Rank Disease or Injury

1 Ischemic heart disease 1 Ischemic heart disease

2 Stroke 2 Cerebrovascular disease

3 Chronic obstructive pulmonary disease 3 Chronic obstructive pulmonary disease

4 Lower respiratory infections 4 Lower respiratory infections

5 Trachea bronchus, lung cancers 5 Road traffic accidents

6 HIV/AIDS 6 Trachea, bronchus, lung cancers

7 Diarrhoeal diseases 7 Diabetes mellitus

8 Diabetes mellitus 8 Hypertensive heart disease

9 Road injury 9 Stomach cancer

10 Hypertensive heart disease 10 HIV/AIDS

Source: World Health Organization, May 2014.

Chapter 1 What Is Health Psychology? 9

those that target risk factors such as diet or smoking,
have contributed to the decline in the incidence of some
diseases, especially coronary heart disease.
To take another example, psychologists learned
many years ago that informing patients fully about the
procedures and sensations involved in unpleasant medi-
cal procedures such as surgery improves their adjust-
ment (Janis, 1958; Johnson, 1984). As a consequence of
these studies, many hospitals and other treatment cen-
ters now routinely prepare patients for such procedures.
Ultimately, if a health-related discipline is to
flourish, it must demonstrate a strong track record,
not only as a research field but as a basis for interven-
tions as well. Health psychology is well on its way to
fulfilling both tasks.

■ HEALTH PSYCHOLOGY
RESEARCH

Health psychologists make important methodological
contributions to the study of health and illness. The
health psychologist can be a valuable team member by
providing the theoretical, methodological, and statisti-
cal expertise that is the hallmark of good training in
psychology.

The Role of Theory in Research
Although much research in health psychology is
guided by practical problems, such as how to ease the
transition from hospital to home care, about one-third
of health psychology investigations are guided by the-
ory (Painter, Borba, Hynes, Mays, & Glanz, 2008). A
theory is a set of analytic statements that explain a set
of phenomena, such as why people practice poor
health behaviors. The best theories are simple and
useful. Throughout this text, we will see references to
many theories, such as the theory of planned behavior
that predicts and explains when people change their
health behaviors (Chapter 3).
The advantages of theory for guiding research
are several. Theories provide guidelines for how to do
research and interventions (Mermelstein & Revenson,
2013). For example, the general principles of cog-
nitive behavior therapy can tell one investigator what
components should go into an intervention with
breast cancer patients to help them cope with the af-
termath of surgery, and these same principles can
help a different investigator develop a weight loss in-
tervention for obese people.

For all these reasons, then, health care delivery has a
substantial social and psychological impact on people,
an impact that is addressed by health psychologists.

Increased Medical Acceptance
Another reason for the development of health psychol-
ogy is the increasing acceptance of health psychologists
within the medical community. Health psychologists
have developed a variety of short-term behavioral inter-
ventions to address health-related problems, including
managing pain, modifying bad health habits such as
smoking, and controlling the side effects of treatments.
Techniques that may take a few hours to teach can pro-
duce years of benefit. Such interventions, particularly

In the 19th and 20th centuries, great strides were made in the

technical basis of medicine. As a result, physicians looked more

and more to the medical laboratory and less to the mind as a

way of understanding the onset and progression of illness.

© image 100/AGE Fotostock RF

10 Part One Introduction to Health Psychology

trials are the gold standards of health psychology re-
search. However, sometimes it is impractical to study
issues experimentally. People cannot, for example, be
randomly assigned to diseases. In this case, other
methods, such as correlational methods, may be used.

Correlational Studies
Much research in health psychology is correlational
research, in which the health psychologist measures
whether changes in one variable correspond with
changes in another variable. A correlational study, for
example, might reveal that people who are more hos-
tile have a higher risk for cardiovascular disease.
The disadvantage of correlational studies is that it
is difficult to determine the direction of causality un-
ambiguously. For example, perhaps cardiovascular
risk factors lead people to become more hostile. On
the other hand, correlational studies often have advan-
tages over experiments because they are more adapt-
able, enabling us to study issues when variables
cannot be manipulated experimentally.

Prospective and Retrospective Designs
Some of the problems with correlational studies can be
remedied by using a prospective design. Prospective
research looks forward in time to see how a group of
people change, or how a relationship between two vari-
ables changes over time. For example, if we were to find
that hostility develops relatively early in life, but heart
disease develops later, we would be more confident that
hostility is a risk factor for heart disease and recognize
that the reverse direction of causality—namely, that
heart disease causes hostility—is less likely.
Health psychologists conduct many prospective
studies in order to understand the risk factors that re-
late to health conditions. We might, for example, in-
tervene in the diet of one community and not in
another and over time look at the difference in rates
of heart disease. This would be an experimental pro-
spective study. Alternatively, we might measure the
diets that people create for themselves and look at
changes in rates of heart disease, based on how good
or poor the diet is. This would be an example of a cor-
relational prospective study.
A particular type of prospective study is longitudi-
nal research, in which the same people are observed
at multiple points in time. For example, to understand
what factors are associated with early breast cancer in

Theories generate specific predictions, so they can
be tested and modified as the evidence comes in. For
example, testing theories of health behavior change re-
vealed that people need to believe they can change
their behavior, and so the importance of self-efficacy
was incorporated into theories of health behaviors.
Theories help tie together loose ends. Everyone
knows that smokers relapse, people go off their diets,
and alcoholics have trouble remaining abstinent. A
theory of relapse unites these scattered observations
into general principles of relapse prevention that can
be incorporated into diverse interventions. A wise
psychologist once said, “There is nothing so practical
as a good theory” (Lewin, 1946), and we will see this
wisdom repeatedly borne out.

Experiments
Much research in health psychology is experimental. In
an experiment, a researcher creates two or more condi-
tions that differ from each other in exact and predeter-
mined ways. People are then randomly assigned to these
different conditions, and their reactions are measured.
Experiments to evaluate the effectiveness of treatments
or interventions over time are also called randomized
clinical trials, in which a target treatment is compared
against the existing standard of care or a placebo con-
trol, that is, an organically inert treatment.
Medical interventions increasingly are based on
these methodological principles. Evidence-based
medicine means that medical and psychological inter-
ventions go through rigorous testing and evaluation of
their benefits, usually through randomized clinical trials,
before they become the standard of care (Rousseau &
Gunia, 2016). These criteria for effectiveness are also
frequently now applied to psychological interventions.
What kinds of experiments do health psycholo-
gists undertake? To determine if social support groups
improve adjustment to cancer, cancer patients might
be randomly assigned to participate in a support group
or to a comparison condition, such as an educational
intervention. The patients could be evaluated at a sub-
sequent time to pinpoint how the two groups differed
in their adjustment.
Experiments have been the mainstay of science,
because they typically provide more definitive
answers to problems than other research methods.
When we manipulate a variable and see its effects, we
can establish a cause-effect relationship definitively.
For this reason, experiments and randomized clinical

Chapter 1 What Is Health Psychology? 11

But morbidity is important as well. What is the
use of affecting causes of death if people remain ill
but simply do not die? Health psychology addresses
health- related quality of life. Indeed, some researchers
maintain that quality of life and symptom reduction
should be more important targets for our interventions
than mortality and other biological indicators (Kaplan,
1990). Consequently, health psychologists work to
improve quality of life so that people with chronic
disorders can live their lives as free from pain, disability,
and lifestyle compromise as possible.

Methodological Tools
This section highlights some of the methodological
tools that have proven valuable in health psychology
research.

Tools of Neuroscience The field of neurosci-
ence has developed powerful new tools such as func-
tional magnetic resonance imaging (fMRI) that permit
glimpses into the brain. This area of research has also
produced knowledge about the autonomic, neuroen-
docrine, and immune systems that have made a vari-
ety of breakthrough studies possible. For example,
health psychologists can now connect psychosocial
conditions, such as social support and positive beliefs,
to underlying biology in ways that make believers out
of skeptics. The knowledge and methods of neurosci-
ence also shed light on such questions as, how do pla-
cebos work? Why are many people felled by functional
disorders that seem to have no underlying biological
causes? Why is chronic pain so intractable to treat-
ment? We address these issues in later chapters. These
and other applications of neuroscience will help to
address clinical puzzles that have mystified practitio-
ners for decades (Gianaros & Hackman, 2013).

Mobile and Wireless Technologies The rev-
olution in technology has given rise to a variety of
tools to intervene in and assess the health environment
(Kaplan & Stone, 2013). Ecological momentary
interventions (EMI) (Heron & Smyth, 2010) make use
of cell phones, pagers, palm pilots, tablets, and other
mobile technologies to deliver interventions and
assess health-related events in the natural environ-
ment. Interventions using EMI have included studies
of smoking cessation, weight loss, diabetes manage-
ment, eating disorders, healthy diet, and physical ac-
tivity (Heron & Smyth, 2010).

women at risk, we might follow a group of young
women whose mothers developed breast cancer, iden-
tify which daughters developed breast cancer, and
identify factors reliably associated with that develop-
ment, such as diet, smoking, or alcohol consumption.
Investigators also use retrospective designs, which
look backward in time in an attempt to reconstruct the
conditions that led to a current situation. Retrospective
methods, for example, were critical in identifying the
risk factors that led to the development of AIDS. Ini-
tially, researchers saw an abrupt increase in a rare cancer
called Kaposi’s sarcoma and observed that the men who
developed this cancer often eventually died of general
failure of the immune system. By taking extensive his-
tories of the men who developed this disease, researchers
were able to determine that the practice of anal-
receptive sex without a condom is related to the devel-
opment of the disorder. Because of retrospective studies,
researchers knew some of the risk factors for AIDS even
before they had identified the retrovirus.

The Role of Epidemiology
in Health Psychology
Changing patterns of illness have been charted and fol-
lowed by the field of epidemiology, a discipline closely
related to health psychology in its goals and interests.
Epidemiology is the study of the frequency, distribu-
tion, and causes of infectious and noninfectious disease
in a population. For example, epidemiologists study not
only who has what kind of cancer but also why some
cancers are more prevalent than others in particular
geographic areas or among particular groups of people.
Epidemiological studies frequently use two im-
portant terms: “morbidity” and “mortality.” Morbidity
refers to the number of cases of a disease that exist at
some given point in time. Morbidity may be expressed
as the number of new cases (incidence) or as the total
number of existing cases (prevalence). Morbidity sta-
tistics, then, tell us how many people have what kinds
of disorders at any given time. Mortality refers to
numbers of deaths due to particular causes.
Morbidity and mortality statistics are essential to
health psychologists. Charting the major causes of
disease can lead to steps to reduce their occurrence.
For example, knowing that automobile accidents are a
major cause of death among children, adolescents,
and young adults has led to safety measures, such as
child-safety restraint systems, mandatory seat belt
laws, and raising the legal drinking age.

12 Part One Introduction to Health Psychology

individual person talk about his or her health needs and
experiences is, of course, beneficial for planning an in-
tervention for that person, such as help in losing weight.
But more broadly, guided interviews and narratives can
provide insights into health processes that summary
statistics may not provide. For example, interviews
with cancer patients about their chemotherapy experi-
ences may be more helpful in redesigning how chemo-
therapy is administered than are numerical ratings of
how satisfied patients are. Qualitative research can also
supplement insights from other research methods. For
example, surveys of college students can identify rates
of problem drinking, but interviews may be helpful for
identifying how to build responsible drinking skills
(deVisser et al., 2015). Quantitative and qualitative
methods can work hand-in-hand to develop the research
evidence for effective interventions.

■ WHAT IS HEALTH PSYCHOLOGY
TRAINING FOR?

Students who are trained in health psychology on the
undergraduate level go on to many different occupa-
tions. Some students go into medicine, becoming phy-
sicians and nurses. Because of their experience in
health psychology, some of these health care practitio-
ners conduct research as well. Other health psychol-
ogy students go into the allied health professional
fields, such as social work, occupational therapy, di-
etetics, physical therapy, or public health. Social
workers in medical settings, for example, may assess
where patients go after discharge, decisions that are
informed by knowledge of the psychosocial needs of
patients. Dietetics is important in the dietary manage-
ment of chronic illnesses, such as cancer, heart dis-
ease, and diabetes. Physical therapists help patients
regain the use of limbs and functions that may have
been compromised by illness and its treatment.
Students who receive either a Ph.D. in health psy-
chology or a Psy.D. most commonly go into academic
research as faculty members or into private practice,
where they provide individual and group counseling.
Other Ph.D.s in health psychology practice in hospi-
tals and other health care settings. Many are involved
in the management of health care, including business
and government positions. Others work in medical
schools, hospitals and other treatment settings, and
industrial or occupational health settings to promote
healthy behavior, prevent accidents, and help control
health care costs. ∙

People in these studies typically participate through
an apparatus, such as a cell phone, that can provide
on-the-spot administration of a treatment or intervention,
as well as the collection of data. For example, text mes-
sages just before meals can remind people about their
intentions to consume a healthy diet. Short text messag-
ing has also been used to enhance smoking cessation pro-
grams and ensure maintenance to quitting (Berkman,
Dickenson, Falk, & Lieberman, 2011). Activity measures
and sensors can accurately assess how much exercise a
person is getting. Mobile technology can also help people
already diagnosed with disorders. People on medications
may receive reminders from mobile devices to take their
medications. Numerous other applications are likely.
Measuring biological indicators of health has usu-
ally required an invasive procedure such as a blood
draw. Now, however, mobile health technologies can as-
sess some biological processes. Ambulatory blood pres-
sure monitoring devices help people with high blood
pressure identify conditions when their blood pressure
goes up. People with diabetes can monitor their blood
glucose levels multiple times a day with far less invasive
technology than was true just a few years ago.
At present, evidence for the success of mobile
health-based interventions and assessments is mixed
(Kaplan & Stone, 2013), suggesting the need for more
research. But these procedures have greatly improved
health psychologists’ abilities to study health-related
phenomena in real time.

Meta-analysis For some topics in health psy-
chology, enough studies have been done to conduct a
meta-analysis. Meta-analysis combines results from
different studies to identify how strong the evidence is
for particular research findings. For example, a meta-
analysis might be conducted on 100 studies of dietary
interventions to identify which characteristics of these
interventions lead to more successful dietary change.
Such an analysis might reveal, for example, that only
those interventions that enhance self-efficacy, that is,
the belief that one will be able to modify one’s diet,
are successful. Meta-analysis is a particularly power-
ful methodological tool, because it uses a broad array
of diverse evidence to reach conclusions.

Qualitative Research
In addition to the methods just described, there is an
important role for qualitative research in health psy-
chology (Gough & Deatrich, 2015). Listening to an

Chapter 1 What Is Health Psychology? 13

1. Health psychology examines psychological
influences on how people stay healthy, why
they become ill, and how they respond when
they do get ill. The field focuses on health
promotion and maintenance; prevention
and treatment of illness; the etiology and
correlates of health, illness, and disability;
and improvement of the health care system
and the formulation of health policy.

2. The interaction of the mind and the body has
concerned philosophers and scientists for
centuries. Different models of the relationship
have predominated at different times in history.

3. The biomedical model, which has dominated
medicine, is a reductionistic, single-factor model
of illness that treats the mind and the body as
separate entities and emphasizes illness concerns
over health.

4. The biomedical model is currently being
replaced by the biopsychosocial model, which
regards any health disorder as the result of the
interplay of biological, psychological, and social
factors. The biopsychosocial model recognizes
the importance of interacting macrolevel and
microlevel processes in producing health and
illness. Under this model, health is regarded as
an active achievement.

5. The biopsychosocial model guides health
psychologists and practitioners in their research
efforts to uncover factors that predict states of
health and illness and in their clinical
interventions with patients.

6. The rise of health psychology can be tied to
several factors, including the increase in chronic
or lifestyle-related illnesses, the expanding role
of health care in the economy, the realization
that psychological and social factors contribute
to health and illness, the demonstrated
importance of psychological interventions to
improving people’s health, and the rigorous
methodological contributions of health
psychology researchers.

7. Health psychologists perform a variety of tasks.
They develop theories and conduct research
on the interaction of biological, psychological,
and social factors in producing health and
illness. They help treat patients with a variety
of disorders and conduct counseling for the
psychosocial problems that illness may create.
They develop worksite interventions to improve
employees’ health habits and work in medical
settings and other organizations to improve
health and health care delivery.

S U M M A R Y

K E Y T E R M S

acute disorders
biomedical model
biopsychosocial model
chronic illnesses
conversion hysteria
correlational research
epidemiology
etiology

evidence-based medicine
experiment
health
health psychology
longitudinal research
meta-analysis
morbidity
mortality

prospective research
psychosomatic medicine
randomized clinical trials
retrospective designs
theory
wellness

14

Disorders of the Cardiovascular System

Blood Pressure

The Blood

The Respiratory System
Overview

The Structure and Functions of the Respiratory System

Disorders Associated with the Respiratory System

Dealing with Respiratory Disorders

The Digestive System and the Metabolism of Food
Overview

The Functioning of the Digestive System

Disorders of the Digestive System

The Renal System
Overview

Disorders of the Renal System

The Reproductive System
Overview

The Ovaries and Testes

Fertilization and Gestation

Disorders of the Reproductive System

Genetics and Health
Overview

Genetics and Susceptibility to Disorders

The Immune System
Overview

Infection

The Course of Infection

Immunity

Disorders Related to the Immune System

C H A P T E R 2

C H A P T E R O U T L I N E

The Nervous System
Overview

The Brain

The Role of Neurotransmitters

Disorders of the Nervous System

The Endocrine System
Overview

The Adrenal Glands

Disorders Involving the Endocrine System

The Cardiovascular System
Overview

The Heart

The Systems of the Body

© LWA/Dann Tardif/Getty Images RF

Chapter 2 The Systems of the Body 15

Regulation of the autonomic nervous system occurs
via the sympathetic nervous system and the parasympa-
thetic nervous system. The sympathetic nervous system
prepares the body to respond to emergencies, to strong
emotions such as anger or fear, and to strenuous activity.
As such, it plays an important role in reaction to stress.
The parasympathetic nervous system controls the
activities of organs under normal circumstances and acts
antagonistically to the sympathetic nervous system.
When an emergency has passed, the parasympathetic ner-
vous system helps to restore the body to a normal state.

The Brain
The brain is the command center of the body. It re-
ceives sensory impulses from the peripheral nerve
endings and sends motor impulses to the extremities
and to internal organs to carry out movement. The
parts of the brain are shown in Figure 2.2.

The Hindbrain and the Midbrain The hind-
brain has three main parts: the medulla, the pons, and
the cerebellum. The medulla is responsible for the regu-
lation of heart rate, blood pressure, and respiration. Sen-
sory information about the levels of carbon dioxide and
oxygen in the body also comes to the medulla, which, if
necessary, sends motor impulses to respiratory muscles
to alter the rate of breathing. The pons serves as a link
between the hindbrain and the midbrain and also helps
control respiration.
The cerebellum coordinates voluntary muscle move-
ment, the maintenance of balance and equilibrium, and

An understanding of health requires a working knowledge of human physiology, namely the
study of the body’s functioning. Having basic knowl-
edge of physiology clarifies how good health habits
make illness less likely, how stress affects the body,
how chronic stress can lead to hypertension or coro-
nary artery disease, and how cell growth is radically
altered by cancer.

■ THE NERVOUS SYSTEM

Overview
The nervous system is a complex network of intercon-
nected nerve fibers. As Figure 2.1 shows, the nervous
system is made up of the central nervous system, which
consists of the brain and the spinal cord, and the periph-
eral nervous system, which consists of the rest of the
nerves in the body, including those that connect to the
brain and spinal cord. Sensory nerve fibers provide in-
put to the brain and spinal cord by carrying signals from
sensory receptors; motor nerve fibers provide output
from the brain or spinal cord to muscles and other or-
gans, resulting in voluntary and involuntary movement.
The peripheral nervous system is made up of the so-
matic nervous system and the autonomic nervous system.
The somatic, or voluntary, nervous system connects nerve
fibers to voluntary muscles and provides the brain with
feedback about voluntary movement, such as a tennis
swing. The autonomic, or involuntary, nervous system
connects the central nervous system to all internal organs
over which people do not customarily have control.

FIGURE 2.1 | The Components of the Nervous System

The nervous system

Central nervous system
(carries voluntary nerve
impulses to skeletal muscles
and skin; carries involuntary
impulses to muscles and glands)

Brain Spinal cord

Peripheral nervous system

Somatic nervous
system
(controls voluntary
movement)

Autonomic nervous
system
(controls organs that
operate involuntarily)

Sympathetic nervous
system
(mobilizes the body
for action)

Parasympathetic
nervous system
(maintains and
restores
equilibrium)

16 Part One Introduction to Health Psychology

The cerebral cortex consists of four lobes: frontal,
parietal, temporal, and occipital. Each lobe has its own
memory storage area or areas of association. Through
these complex networks of associations, the brain is
able to relate current sensations to past ones, giving the
cerebral cortex its formidable interpretive capabilities.
In addition to its role in associative memory, each
lobe is generally associated with particular functions.
The frontal lobe contains the motor cortex, which co-
ordinates voluntary movement. The parietal lobe con-
tains the somatosensory cortex, in which sensations of
touch, pain, temperature, and pressure are registered
and interpreted. The temporal lobe contains the corti-
cal areas responsible for auditory and olfactory (smell)
impulses, and the occipital lobe contains the visual
cortex, which receives visual impulses.

The Limbic System The limbic system plays an
important role in stress and emotional responses. The
amygdala and the hippocampus are involved in the
detection of threat and in emotionally charged memories,
respectively. The cingulate gyrus, the septum, and areas
in the hypothalamus are related to emotional functioning
as well.
Many health disorders implicate the brain. One
important disorder that was overlooked until recently
is chronic traumatic encephalopathy, whose causes
and consequences are described in Box 2.1.

the maintenance of muscle tone and posture. Damage
to this area can produce loss of muscle tone, tremors,
and disturbances in posture or gait.
The midbrain is the major pathway for sensory
and motor impulses moving between the forebrain and
the hindbrain. It is also responsible for the coordina-
tion of visual and auditory reflexes.

The Forebrain The forebrain includes the
thalamus and the hypothalamus. The thalamus is in-
volved in the recognition of sensory stimuli and the
relay of sensory impulses to the cerebral cortex.
The hypothalamus helps regulate cardiac function-
ing, blood pressure, respiration, water balance, and
appetites, including hunger and sexual desire. It is an
important transition center between the thoughts gener-
ated in the cerebral cortex of the brain and their impact
on internal organs. For example, embarrassment can lead
to blushing via the hypothalamus through the vasomotor
center in the medulla to the blood vessels. Together with
the pituitary gland, the hypothalamus helps regulate the
endocrine system, which releases hormones that affect
functioning in target organs throughout the body.
The forebrain also includes the cerebral cortex,
the largest portion of the brain, involved in higher-
order intelligence, memory, and personality. Sensory
impulses that come from the peripheral areas of the
body are received and interpreted in the cerebral cortex.

FIGURE 2.2 | The Brain (Source: Lankford, 1979, p. 232)

Corpus callosum

Cerebellum

Spinal cord

Pons

Reticular formation

Hypothalamus

Thalamus

Pituitary

Cerebellum

Visual
cortex

Somatosensory cortex
Motor cortex

Temporal lobe

Occipital
lobe

Frontal
lobe

Auditory cortex

Parietal lobe

(a) Surface diagram (b) Cross-sectional diagram

Cerebral
cortex

17

such as coronary artery disease and hypertension,
discussed in greater detail in Chapter 13.
Parasympathetic functioning is a counterregulatory
system that helps restore homeostasis following sympa-
thetic arousal. The heart rate decreases, the heart’s capil-
laries constrict, blood vessels dilate, respiration rate
decreases, and the metabolic system resumes its activities.

Disorders of the Nervous System
Approximately 25 million Americans have some dis-
order of the nervous system. The most common
forms of neurological dysfunction are epilepsy and
Parkinson’s disease. Cerebral palsy, multiple sclerosis,
and Huntington’s disease also affect substantial num-
bers of people.

Epilepsy A disease of the central nervous system
affecting 1 in 26 people in the United States (Epilepsy
Foundation, 2014), epilepsy is often idiopathic, which
means that no specific cause for the symptoms can be
identified. Symptomatic epilepsy may be traced to

The Role of Neurotransmitters
The nervous system functions by means of chemi-
cals, called neurotransmitters, that regulate nervous
system functioning. Stimulation of the sympathetic
nervous system prompts the secretion of two neu-
rotransmitters, epinephrine and norepinephrine, to-
gether termed the catecholamines. These substances
are carried through the bloodstream throughout the
body, promoting sympathetic activation.
The release of catecholamines prompts important
bodily changes. Heart rate increases, the heart’s capil-
laries dilate, and blood vessels constrict, increasing
blood pressure. Blood is diverted into muscle tissue.
Respiration rate goes up, and the amount of air flow-
ing into the lungs is increased. Digestion and urina-
tion are generally decreased. The pupils of the eyes
dilate, and sweat glands are stimulated to produce
more sweat. These changes are critically important in
responses to stressful circumstances. Chronic or recur-
rent arousal of the sympathetic nervous system can
accelerate the development of several chronic disorders,

B O X 2.1Costs of War to the Brain

A 27-year-old former Marine who had done two tours
of Iraq returned home, attempting to resume his fam-
ily life and college classes. Although he had once had
good grades, he found he could not remember small
details or focus his attention any longer. He became
irritable, snapping at his family, and eventually, his
wife initiated divorce proceedings. He developed an
alcohol problem, and a car crash caused him to lose
his driver’s license. When his parents hadn’t heard
from him, they phoned the police, who found him, a
suicide victim of hanging.
Chronic traumatic encephalopathy (CTE) is a de-
generative brain disorder that strikes people who have
had repeated or serious head injuries. Former boxers
and football players, for example, have high rates of
CTE. In CTE, an abnormal form of a protein accumu-
lates and eventually destroys cells in the brain, includ-
ing the frontal and temporal lobes, which are critical
for decision making, impulse control, and judgment.
Autopsies suggest that CTE may also be present
at high levels among returning veterans, and that blasts
from bombs or grenades may have produced these
serious effects, including irreversible losses in mem-
ory and thinking abilities. More than 27,000 cases
of traumatic war injury were reported by the U.S.
military in 2009 alone, and CTE is a likely contributor

(Congressional Research Service, 2010). CTE is sus-
pected in some cases that have been diagnosed as
post-traumatic stress disorder (see Chapter 6).
Whether the military will find ways to reduce expo-
sure to its causes or ways to retard the processes CTE
sets into effect remains to be seen. Health psycholo-
gists can play an important role in addressing the cog-
nitive and social costs of this degenerative disorder.

Source: Kristof, April 25, 2012.

© Ingram Publishing/SuperStock RF

18 Part One Introduction to Health Psychology

The effects of multiple sclerosis result from the
disintegration of myelin, a fatty membrane that sur-
rounds nerve fibers and facilitates the conduction of
nerve impulses. Multiple sclerosis is an autoimmune
disorder, so called because the immune system fails to
recognize its own tissue and attacks the myelin sheath
surrounding nerve fibers.

Huntington’s Disease A hereditary disorder of
the central nervous system, Huntington’s disease is
characterized by chronic physical and mental deterio-
ration. Symptoms include involuntary muscle spasms,
loss of motor abilities, personality changes, and other
signs of mental disintegration.
The disease affects about 30,000 people directly,
and 200,000 more are at risk in the United States (Hun-
tington’s Disease Society of America, 2016). The gene
for Huntington’s has been isolated, and a test is now
available that indicates not only if one is a carrier of the
gene but also at what age (roughly) one will succumb to
the disease. As will be seen later in this chapter, genetic
counseling with this group of at-risk people is important.

Polio Poliomyelitis is a highly infectious viral dis-
ease that affects mostly young children. It attacks the
spinal nerves and destroys the cell bodies of motor
neurons so that motor impulses cannot be carried from
the spinal cord outward to the peripheral nerves or
muscles. Depending on the degree of damage that is
done, the person may be left with difficulties in walk-
ing and moving properly, ranging from shrunken and
ineffective limbs to full paralysis. Polio cases have de-
creased substantially worldwide, although polio is still
a major health issue in Pakistan and Afghanistan.

Paraplegia and Quadriplegia Paraplegia is
paralysis of the lower extremities of the body; it re-
sults from an injury to the lower portion of the spinal
cord. Quadriplegia is paralysis of all four extremities
and the trunk of the body; it occurs when the upper
portion of the spinal cord is severed. People who have
these conditions usually lose bladder and bowel con-
trol and the muscles below the cut area may lose their
tone, becoming weak and flaccid.

Dementia Dementia (meaning “deprived of
mind”) is a serious loss of cognitive ability beyond
what might be expected from normal aging. A history
of brain injuries or a genetically-based propensity may
be involved in long-term decline. Although dementia

harm during birth, severe injury to the head, infec-
tious disease such as meningitis or encephalitis, or
metabolic or nutritional disorders. Risk for epilepsy
may also be inherited.
Epilepsy is marked by seizures, which range from
barely noticeable to violent convulsions accompanied
by irregular breathing and loss of consciousness. Epi-
lepsy cannot be cured, but it can often be controlled
through medication and behavioral interventions de-
signed to manage stress (see Chapters 7 and 11).

Parkinson’s Disease Patients with Parkinson’s
disease have progressive degeneration of the basal
ganglia, a group of nuclei in the brain that control
smooth motor coordination. The result of this deterio-
ration is tremors, rigidity, and slowness of movement.
As many as one million Americans have Parkinson’s
disease, which primarily strikes people age 50 and
older (Parkinson’s Disease Foundation, 2016); men
are more likely than women to develop the disease. Al-
though the cause of Parkinson’s is not fully known, de-
pletion of the neurotransmitter dopamine may be
involved. Parkinson’s patients may be treated with med-
ication, but large doses, which can cause undesirable side
effects, are often required for control of the symptoms.

Cerebral Palsy Currently, more than 764,000
people in the United States have or experience symp-
toms of cerebral palsy (CerebralPalsy.org, 2016). Ce-
rebral palsy is a chronic, nonprogressive disorder
marked by lack of muscle control. It stems from brain
damage caused by an interruption in the brain’s oxy-
gen supply, usually during childbirth. In older chil-
dren, a severe accident or physical abuse can produce
the condition. Apart from being unable to control mo-
tor functions, those who have the disorder may (but
need not) also have seizures, spasms, mental retarda-
tion, difficulties with sensation and perception, and
problems with sight, hearing, and/or speech.

Multiple Sclerosis Approximately 2.3 million
people worldwide have multiple sclerosis (National
Multiple Sclerosis Society, 2016). This degenerative
disease can cause paralysis and, occasionally, blind-
ness, deafness, and mental deterioration. Early symp-
toms include numbness, double vision, dragging of
the feet, loss of bladder or bowel control, speech dif-
ficulties, and extreme fatigue. Symptoms may appear
and disappear over a period of years; after that, dete-
rioration is continuous.

Chapter 2 The Systems of the Body 19

stimulating and inhibiting each other’s activities. The
nervous system is chiefly responsible for fast-acting,
short-duration responses to changes in the body,
whereas the endocrine system mainly governs slow-
acting responses of long duration.
The endocrine system is regulated by the hypothala-
mus and the pituitary gland. Located at the base of the
brain, the pituitary has two lobes. The posterior pituitary
lobe produces oxytocin, which controls contractions dur-
ing labor and lactation and is also involved in social af-
filiation, and vasopressin, or antidiuretic hormone (ADH),
which controls the water-absorbing ability of the kidneys,
among other functions. The anterior pituitary lobe of the
pituitary gland secretes hormones responsible for growth:
somatotropic hormone (STH), which regulates bone,
muscle, and other organ development; gonadotropic hor-
mones, which control the growth, development, and se-
cretions of the gonads (testes and ovaries); thyrotropic
hormone (TSH), which controls the growth, develop-
ment, and secretion of the thyroid gland; and adrenocorti-
cotropic hormone (ACTH), which controls the growth
and secretions of the cortex region of the adrenal glands.

The Adrenal Glands
The adrenal glands are small glands located on top of
each of the kidneys. Each adrenal gland consists of an
adrenal medulla and an adrenal cortex. The hormones
of the adrenal medulla are epinephrine and norepi-
nephrine, which were described earlier.
As Figure 2.4 implies, the adrenal glands are criti-
cally involved in physiological and neuroendocrine re-
actions to stress. Catecholamines, secreted in conjunction
with sympathetic arousal, and corticosteroids are impli-
cated in biological responses to stress. We will consider
these stress responses more fully in Chapter 6.

Disorders Involving the Endocrine System
Diabetes Diabetes is a chronic endocrine disorder
in which the body is not able to manufacture or properly
use insulin. It is the fourth most common chronic illness
in this country and one of the leading causes of death.
Diabetes consists of two primary forms. Type I diabetes
is a severe disorder that typically arises in late childhood
or early adolescence. At least partly genetic in origin,
Type I diabetes is an autoimmune disorder, possibly pre-
cipitated by an earlier viral infection. The immune sys-
tem falsely identifies cells in the islets of Langerhans in
the pancreas as invaders and destroys those cells, com-
promising or eliminating their ability to produce insulin.

is most common among older adults, it may occur at
any stage of adulthood. Memory, attention, language,
and problem solving are affected early in the disorder
and often lead to diagnosis.
The most common form of dementia is Alzheimer’s,
accounting for 60–70% of the cases. In most people,
symptoms appear in their mid-60s, and the disease
progresses irreversibly, due to plaques and tangles in
the progressively shrinking brain. In addition to the
early signs of cognitive decline, especially difficulty
with short term memory, social functioning, and use
of language, are disrupted as the disease progresses.
About 48 million people worldwide have Alzheimer’s
(Alzheimer’s Association, 2016).

■ THE ENDOCRINE SYSTEM

Overview
The endocrine system, diagrammed in Figure 2.3,
complements the nervous system in controlling bodily
activities. The endocrine system is made up of a num-
ber of ductless glands that secrete hormones into the
blood, stimulating changes in target organs. The endo-
crine and nervous systems depend on each other,

FIGURE 2.3 | The Endocrine System

Thyroid

Ovaries

Adrenal glands

Testes

Pituitary gland

20 Part One Introduction to Health Psychology

body. Blood carries oxygen from the lungs to the tissues
and carbon dioxide from the tissues to the lungs. Blood
also carries nutrients from the digestive tract to the indi-
vidual cells so that the cells may extract nutrients for
growth and energy. The blood carries waste products from
the cells to the kidneys, from which the waste is excreted
in the urine. It also carries hormones from the endocrine
glands to other organs of the body and transports heat to
the surface of the skin to control body temperature.

The Heart
The heart functions as a pump, and its pumping action
causes the blood to circulate throughout the body. The
left side of the heart, consisting of the left atrium and
left ventricle, takes in oxygenated blood from the lungs
and pumps it out into the aorta (the major artery leaving
the heart), from which the blood passes into the smaller
vessels (the arteries, arterioles, and capillaries) to reach
the cell tissues. The blood exchanges its oxygen and
nutrients for the waste materials of the cells and is then
returned to the right side of the heart (right atrium and
right ventricle), which pumps it back to the lungs via the
pulmonary artery. Once oxygenated, the blood returns
to the left side of the heart through the pulmonary veins.
The anatomy of the heart is pictured in Figure 2.5.

Type II diabetes, which typically occurs after age
40, is the more common form. In Type II diabetes,
insulin may be produced by the body, but there may
not be enough of it, or the body may not be sensitive
to it. It is heavily a disease of lifestyle, and risk factors
include obesity and stress, among other factors.
Diabetic patients have high rates of coronary heart
disease, and diabetes is the leading cause of blindness
among adults. It accounts for almost 50 percent of all the
patients who require renal dialysis for kidney failure
(National Institute on Diabetes and Digestive and Kidney
Disorders, 2007). Diabetes can also produce nervous
system damage, leading to pain and loss of sensation. In
severe cases, amputation of the extremities, such as toes
and feet, may be required. As a consequence of these
complications, people with diabetes have a considerably
shortened life expectancy. In later chapters, we will con-
sider Type I (Chapter 14) and Type II (Chapter 13) diabe-
tes, and the issues associated with their management.

■ THE CARDIOVASCULAR
SYSTEM

Overview
The cardiovascular system comprises the heart, blood
vessels, and blood and acts as the transport system of the

FIGURE 2.4 | Adrenal Gland Activity in Response to Stress

Secretion of catecholamines
(epinephrine and norepinephrine)
– Heart rate increases and heart capillaries dilate
– Blood pressure increases via vasoconstriction
– Blood is diverted to muscle tissue
– Breathing rate increases
– Digestion slows down
– Pupils of eyes dilate

Secretion of
corticosteroids
– Increases protein and

fat mobilization
– Increases access to

bodily energy storage
– Inhibits antibody

formation and inflammation
– Regulates sodium

retention

Stress

Pituitary
gland

Sympathetic
nervous system

Adrenal
cortex

Adrenal
medulla

Chapter 2 The Systems of the Body 21

defects—that is, defects present at birth—and others,
to infection. By far, however, the major threats to the
cardiovascular system are due to lifestyle factors, in-
cluding stress, poor diet, lack of exercise, and smoking.

Atherosclerosis The major cause of heart dis-
ease is atherosclerosis, a problem that becomes worse
with age. Atherosclerosis is caused by deposits of cho-
lesterol and other substances on the arterial walls,
which form plaques that narrow the arteries. These
plaques reduce the flow of blood through the arteries
and interfere with the passage of nutrients from the cap-
illaries into the cells—a process that can lead to tissue
damage. Damaged arterial walls are also potential sites
for the formation of blood clots, which can obstruct a
vessel and cut off the flow of blood.
Atherosclerosis is associated with several pri-
mary clinical manifestations:
∙ Angina pectoris, or chest pain, which occurs

when the heart has insufficient supply of oxygen
or inadequate removal of carbon dioxide and
other waste products.

∙ Myocardial infarction (MI), or heart attack,
which results when a clot has developed in a
coronary vessel and blocks the flow of blood to
the heart.

The heart performs these functions through regular
rhythmic phases of contraction and relaxation known as
the cardiac cycle. There are two phases in the cardiac
cycle: systole and diastole. During systole, blood is
pumped out of the heart, and blood pressure in the blood
vessels increases. As the muscle relaxes during diastole,
blood pressure drops, and blood is taken into the heart.
The flow of blood into and out of the heart is con-
trolled by valves at the inlet and outlet of each ventri-
cle. These heart valves ensure that blood flows in one
direction only. The sounds that one hears when listen-
ing to the heart are the sounds of these valves closing.
These heart sounds make it possible to time the car-
diac cycle to determine how rapidly or slowly blood is
being pumped into and out of the heart.
A number of factors influence the rate at which
the heart contracts and relaxes. During exercise, emo-
tional excitement, or stress, for example, the heart
speeds up, and the cardiac cycle is completed in a
shorter time. A chronically or excessively rapid heart
rate can decrease the heart’s strength, which may
reduce the volume of blood that is pumped.

Disorders of the Cardiovascular System
The cardiovascular system is subject to a number
of disorders. Some of these are due to congenital

FIGURE 2.5 | The Heart

Tricuspid
valve

Right atrium

Right
ventricle

Aorta

Mitral valve

Left atrium

Aortic valve

Left
ventricle

Pulmonary valve
Pulmonary
artery

Aorta

22 Part One Introduction to Health Psychology

blood (oxygen and nutrients or carbon dioxide and
waste materials). The blood also helps to regulate skin
temperature.
Blood cells are manufactured in the bone marrow
in the hollow cavities of bones. Bone marrow con-
tains five types of blood-forming cells: myeloblasts
and monoblasts, both of which produce particular
white blood cells; lymphoblasts, which produce lym-
phocytes; erythroblasts, which produce red blood
cells; and megakaryocytes, which produce platelets.
Each of these types of blood cells has an important
function.
White blood cells play an important role in heal-
ing by absorbing and removing foreign substances
from the body. They contain granules that secrete di-
gestive enzymes, which engulf and act on bacteria and
other foreign particles, turning them into a form con-
ducive to excretion. An elevated white cell count sug-
gests the presence of infection.
Lymphocytes produce antibodies—agents that
destroy foreign substances. Together, these groups of
cells play an important role in fighting infection and
disease. We will consider them more fully in our dis-
cussion of the immune system in Chapter 14.
Red blood cells are important mainly because
they contain hemoglobin, which is needed to carry
oxygen and carbon dioxide throughout the body.
Anemia, which involves below-normal numbers of
red blood cells, can interfere with this transport
function.
Platelets serve several important functions. They
clump together to block small holes that develop in
blood vessels, and they also play an important role in
blood clotting.

Clotting Disorders Clots (or thromboses) can
sometimes develop in the blood vessels. This is most
likely to occur if arterial or venous walls have been
damaged or roughened because of the buildup of
cholesterol. Platelets then adhere to the roughened
area, leading to the formation of a clot. A clot can
have especially serious consequences if it occurs in
the blood vessels leading to the heart (coronary
thrombosis) or brain (cerebral thrombosis), because
it will block the vital flow of blood to these organs.
When a clot occurs in a vein, it may become de-
tached and form an embolus, which can become
lodged in the blood vessels to the lungs, causing pul-
monary obstruction. Death is a common conse-
quence of these conditions.

∙ Ischemia, a condition characterized by lack of
blood flow and oxygen to the heart muscle. As
many as 3 to 4 million Americans have silent
ischemic episodes without knowing it, and they
may consequently have a heart attack with no
prior warning.

Other major disorders of the cardiovascular system
include the following.
∙ Congestive heart failure (CHF), which occurs

when the heart’s delivery of oxygen-rich blood is
inadequate to meet the body’s needs.

∙ Arrhythmia, irregular beatings of the heart,
which, at its most severe, can lead to loss of
consciousness and sudden death.

Blood Pressure
Blood pressure is the force that blood exerts against
the blood vessel walls. During systole, the force on the
blood vessel walls is greatest; during diastole, it falls
to its lowest point. The measurement of blood pres-
sure includes these two pressures.
Blood pressure is influenced by several factors.
The first is cardiac output—pressure against the arte-
rial walls is greater as the volume of blood flow in-
creases. A second factor is peripheral resistance, or
the resistance to blood flow in the small arteries of the
body (arterioles), which is affected by the number of
red blood cells and the amount of plasma the blood
contains. In addition, blood pressure is influenced by
the structure of the arterial walls: If the walls have
been damaged, if they are clogged by deposits of
waste, or if they have lost their elasticity, blood pres-
sure will be higher. Chronically high blood pressure,
called hypertension, is the consequence of too high a
cardiac output or too high a peripheral resistance. We
will consider the management of hypertension in
Chapter 13.

The Blood
An adult’s body contains approximately 5 liters of
blood, which consists of plasma and cells. Plasma, the
fluid portion of blood, accounts for approximately
55 percent of the blood volume. The remaining
45 percent of blood volume is made up of cells. The
blood cells are suspended in the plasma, which con-
tains plasma proteins and plasma electrolytes (salts)
plus the substances that are being transported by the

Chapter 2 The Systems of the Body 23

The inspiration of air is an active process, brought
about by the contraction of muscles. Inspiration
causes the lungs to expand inside the thorax (the chest
wall). Expiration, in contrast, is a passive function,
brought about by the relaxation of the lungs, which
reduces the volume of the lungs within the thorax.
The lungs fill most of the space within the thoracic
cavity and are very elastic, depending on the thoracic
walls for support. If air gets into the space between
the thoracic wall and the lungs, one or both lungs will
collapse.
Respiratory movements are controlled by a re-
spiratory center in the medulla. The functions of
this center depend partly on the chemical composi-
tion of the blood. For example, if the blood’s carbon
dioxide level rises too high, the respiratory center
will be stimulated and respiration will be increased.
If the carbon dioxide level falls too low, the respira-
tory center will slow down until the carbon dioxide
level is back to normal.
The respiratory system is also responsible for
coughing. Dust and other foreign materials are in-
haled with every breath. Some of these substances are
trapped in the mucus of the nose and the air passages
and are then conducted back toward the throat, where
they are swallowed. When a large amount of mucus
collects in the large airways, it is removed by cough-
ing (a forced expiratory effort).

■ THE RESPIRATORY SYSTEM

Overview
Respiration, or breathing, has three main functions: to
take in oxygen, to excrete carbon dioxide, and to regu-
late the composition of the blood.
The body needs oxygen to metabolize food. Dur-
ing the process of metabolism, oxygen combines
with carbon atoms in food, producing carbon dioxide
(CO2). The respiratory system brings in oxygen
through inspiration; it eliminates carbon dioxide
through expiration.

The Structure and Functions of the
Respiratory System
Air is inhaled through the nose and mouth and then
passes through the pharynx and larynx to the trachea.
The trachea, a muscular tube extending downward
from the larynx, divides at its lower end into two
branches called the primary bronchi. Each bronchus
enters a lung, where it then subdivides into secondary
bronchi, still-smaller bronchioles, and, finally, micro-
scopic alveolar ducts, which contain many tiny clus-
tered sacs called alveoli. The alveoli and the capillaries
are responsible for the exchange of oxygen and carbon
dioxide. A diagram of the respiratory system appears
in Figure 2.6.

FIGURE 2.6 | The Respiratory System (Source: Lankford, 1979, p. 467)

Nasal passages

Larynx
Trachea

Pulmonary artery
Pulmonary vein
Bronchi

Alveoli
Bronchiole

Pharynx

Esophagus

Lobes of
the lung

Diaphragm

24 Part One Introduction to Health Psychology

amounts of mucus are produced in bronchitis, leading
to persistent coughing.
A serious viral infection of the respiratory system
is influenza, which can occur in epidemic form. Flu
viruses attack the lining of the respiratory tract, kill-
ing healthy cells. Fever and inflammation of the respi-
ratory tract may result. A common complication is a
secondary bacterial infection, such as pneumonia.

Bacterial Infections The respiratory system is
also vulnerable to bacterial disorders, including strep
throat, whooping cough, and diphtheria. Usually,
these disorders do not cause permanent damage to the
upper respiratory tract. The main danger is the possi-
bility of secondary infection, which results from low-
ered resistance. However, these bacterial infections
can cause permanent damage to other tissues, includ-
ing heart tissue.

Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD), in-
cluding chronic bronchitis and emphysema, is the
fourth-leading killer of people in the United States.
Some 12 million Americans have COPD (COPD In-
ternational, 2015). Although COPD is not curable, it is
preventable. Its chief cause is smoking, which accounts
for over 80  percent of all cases of COPD (COPD
International, 2015).

Pneumonia There are two main types of pneu-
monia. Lobar pneumonia is a primary infection of the
entire lobe of a lung. The alveoli become inflamed,
and the normal oxygen–carbon dioxide exchange be-
tween the blood and alveoli can be disrupted. Spread
of infection to other organs is also likely.
Bronchial pneumonia, which is confined to the
bronchi, is typically a secondary infection that may oc-
cur as a complication of other disorders, such as a se-
vere cold or flu. It is not as serious as lobar pneumonia.

Tuberculosis and Pleurisy Tuberculosis (TB)
is an infectious disease caused by bacteria that invade
lung tissue. When the invading bacilli are surrounded
by macrophages (white blood cells of a particular
type), they form a clump called a tubercle. Eventually,
through a process called caseation, the center of the
tubercle turns into a cheesy mass, which can produce
cavities in the lung. Such cavities, in turn, can give
rise to permanent scar tissue, causing chronic difficul-
ties in oxygen and carbon dioxide exchange between

Disorders Associated with the
Respiratory System
Asthma Asthma is a severe allergic reaction typi-
cally to a foreign substance, including dust, dog or cat
dander, pollens, or fungi. An asthma attack can also
be touched off by emotional stress or exercise. These
attacks may be so serious that they produce bronchial
spasms and hyperventilation.
During an asthma attack, the muscles surround-
ing air tubes constrict, inflammation and swelling of
the lining of the air tubes occur, and increased mucus
is produced, clogging the air tubes. The mucus secre-
tion, in turn, may then obstruct the bronchioles, reduc-
ing the supply of oxygen and increasing the amount of
carbon dioxide.
Statistics show a dramatic increase in the preva-
lence of allergic disorders, including asthma, in the past
20–30 years. Currently, approximately 235 million peo-
ple worldwide have asthma, 25 million of them in the
United States (Centers for Disease Control and Preven-
tion, May 2011; World Health Organization, May 2011).
The numbers are increasing, especially in industrialized
countries and in urban as opposed to rural areas. Asthma
rates are especially high in low income areas, and
psychosocial stressors may play a role in aggravating
an underlying vulnerability (Vangeepuram, Galvez,
Teitelbaum, Brenner, & Wolff, 2012). However, the
reasons for these dramatic changes are not yet fully
known. Children who have a lot of infectious disorders
during childhood are less likely to develop allergies,
suggesting that exposure to infectious agents plays a
protective role. Thus, paradoxically, the improved hy-
giene of industrialized countries may actually be contrib-
uting to the high rates of allergic disorders currently seen.

Viral Infections The respiratory system is vul-
nerable to infections, especially the common cold, a
viral infection of the upper and sometimes the lower
respiratory tract. The infection that results causes
discomfort, congestion, and excessive secretion of
mucus. The incubation period for a cold—that is, the
time between exposure to the virus and onset of
symptoms—is 12–72 hours, and the typical duration
is a few days. Secondary bacterial infections may
complicate the illness. These occur because the pri-
mary viral infection causes inflammation of the mu-
cous membranes, reducing their ability to prevent
secondary infection.
Bronchitis is an inflammation of the mucosal
membrane inside the bronchi of the lungs. Large

Chapter 2 The Systems of the Body 25

The Functioning of the
Digestive System
Food is first lubricated by saliva in the mouth, where
it forms a soft, rounded lump called a bolus. It passes
through the esophagus by means of peristalsis, a uni-
directional muscular movement toward the stomach.
The stomach produces various gastric secretions, in-
cluding pepsin and hydrochloric acid, to further the
digestive process. The sight or even the thought of
food starts the flow of gastric juices.
As food progresses from the stomach to the duo-
denum (the intersection of the stomach and lower in-
testine), the pancreas becomes involved in the digestive
process. Pancreatic juices, which are secreted into the
duodenum, contain enzymes that break down proteins,
carbohydrates, and fats. A critical function of the pan-
creas is the production of the hormone insulin, which
facilitates the entry of glucose into the bodily tissues.
The liver also plays an important role in metabolism by
producing bile, which enters the duodenum and helps
break down fats. Bile is stored in the gallbladder and is
secreted into the duodenum as needed.
Most metabolic products are water soluble and
can be easily transported in the blood, but some sub-
stances, such as lipids, are not soluble in water and so
must be transported in the blood plasma. Lipids in-
clude fats, cholesterol, and lecithin. An excess of lipids
in the blood is called hyperlipidemia, a condition com-
mon in diabetes, some kidney diseases, hyperthyroid-
ism, and alcoholism. It is also a causal factor in the
development of heart disease (see Chapters 5 and 13).
The absorption of food takes place primarily in
the small intestine, which produces enzymes that
complete the breakdown of proteins to amino acids.
The motility of the small intestine is under the control
of the sympathetic and parasympathetic nervous sys-
tems, such that parasympathetic activity speeds up
metabolism, whereas sympathetic nervous system
activity reduces it.
Food then passes into the large intestine which
acts largely as a storage organ for the accumulation of
food residue and helps in the reabsorption of water.
The entry of feces into the rectum leads to the expul-
sion of solid waste. The organs involved in the me-
tabolism of food are pictured in Figure 2.7.

Disorders of the Digestive System
The digestive system is susceptible to a number of
disorders.

the blood and the alveoli. Once the leading cause of
death in the United States, it has been in decline for
several decades. However, worldwide, it remains
common and deadly, affecting one-third of the world’s
population (Centers for Disease Control, 2015).
Pleurisy is an inflammation of the pleura, the
membrane that surrounds the organs in the thoracic
cavity. The inflammation, which produces a sticky
fluid, is usually a consequence of pneumonia or tuber-
culosis and can be extremely painful.

Lung Cancer Lung cancer is a disease of uncon-
trolled cell growth in tissues of the lung. The affected
cells begin to divide in a rapid and unrestricted man-
ner, producing a tumor. Malignant cells grow faster
than healthy cells. This growth may lead to metasta-
sis, which is the invasion of adjacent tissue and infil-
tration beyond the lungs. The most common symptoms
are shortness of breath, coughing (including coughing
up blood), and weight loss. Smoking is one of the
primary causes.

Dealing with Respiratory Disorders
A number of respiratory disorders can be addressed
by health psychologists. For example, smoking is im-
plicated in both pulmonary emphysema and lung can-
cer. Dangerous substances in the workplace and air
pollution are also factors that contribute to the inci-
dence of respiratory problems.
As we will see in Chapters 3–5, health psycholo-
gists have conducted research on many of these prob-
lems and discussed the clinical issues they raise.
Some respiratory disorders are chronic conditions.
Consequently, issues of long-term physical, voca-
tional, social, and psychological rehabilitation be-
come important. We cover these issues in Chapters
11, 13, and 14.

■ THE DIGESTIVE SYSTEM AND
THE METABOLISM OF FOOD

Overview
Food, essential for survival, is converted through the
process of metabolism into heat and energy, and it
supplies nutrients for growth and the repair of tissues.
But before food can be used by cells, it must be
changed into a form suitable for absorption into the
blood. This conversion process is called digestion.

26 Part One Introduction to Health Psychology

Gastroesophageal reflux disease Gastro-
esophageal reflux disease (GERD), also known as
acid reflux disease, results from an abnormal reflux in
the esophagus. This is commonly due to changes in
the barrier between the esophagus and the stomach.
As much as 60 percent of the U.S. adult population
experiences acid reflux at least occasionally (U.S.
Healthline, 2012).

Gastroenteritis, Diarrhea, and Dysentery
Gastroenteritis is an inflammation of the lining of the
stomach and small intestine. It may be caused by exces-
sive amounts of food or drink, contaminated food or
water, or food poisoning. Symptoms appear approxi-
mately 2–4 hours after the ingestion of food and include
vomiting, diarrhea, abdominal cramps, and nausea.
Diarrhea, characterized by watery and frequent
bowel movements, occurs when the lining of the small
and large intestines cannot properly absorb water or
digested food. Chronic diarrhea may result in serious
disturbances of fluid and electrolyte (sodium, potas-
sium, magnesium, calcium) balance.
Dysentery is similar to diarrhea except that mu-
cus, pus, and blood are also excreted. It may be caused

by a protozoan that attacks the large intestine (amoe-
bic dysentery) or by a bacterial organism. Although
these conditions are only rarely life threatening in in-
dustrialized countries, in developing countries, they
are among the most common causes of death.

Peptic Ulcer A peptic ulcer is an open sore in the
lining of the stomach or the duodenum. It results from
the hypersecretion of hydrochloric acid and occurs
when pepsin, a protein-digesting enzyme secreted in
the stomach, digests a portion of the stomach wall or
duodenum. A bacterium called H. pylori is believed to
contribute to the development of many ulcers. Once
thought to be primarily psychological in origin, ulcers
are now believed to be aggravated by stress, but not
caused by it.

Appendicitis Appendicitis is a common condi-
tion that occurs when wastes and bacteria accumulate
in the appendix. If the small opening of the appendix
becomes obstructed, bacteria can easily proliferate.
Soon this condition gives rise to pain, increased peri-
stalsis, and nausea. If the appendix ruptures and the
bacteria are released into the abdominal cavity or
peritoneum, they can cause further infection (peritoni-
tis) or even death.

Hepatitis Hepatitis means “inflammation of the
liver,” and the disease produces swelling, tenderness,
and sometimes permanent damage. When the liver is
inflamed, bilirubin, a product of the breakdown of he-
moglobin, cannot easily pass into the bile ducts. Conse-
quently, it remains in the blood, causing a yellowing of
the skin known as jaundice. Other common symptoms
are fatigue, fever, muscle or joint aches, nausea, vomit-
ing, loss of appetite, abdominal pain, and diarrhea.
There are several types of hepatitis, which differ
in severity and mode of transmission. Hepatitis A,
caused by viruses, is typically transmitted through
food and water. It is often spread by poorly cooked
seafood or through unsanitary preparation or storage
of food. Hepatitis B is a more serious form, with
2  billion people infected worldwide and 1 million
deaths annually (Hepb.org, 2016). Also known as
serum hepatitis, it is caused by a virus and is transmit-
ted by the transfusion of infected blood, by improperly
sterilized needles, through sexual contact, and through
mother-to-infant contact. It is a particular risk among
intravenous drug users. Its symptoms are similar to
those of hepatitis A but are far more serious.

FIGURE 2.7 | The Digestive System
(Source: Lankford, 1979, p. 523)

Esophagus

Stomach

Pancreas

Transverse
colon

Descending
colon

Jejunum

Sigmoid
colon

Rectum
Ileum

Appendix

Cecum

Ascending
colon

Duodenum

Liver

Gallbladder

Oral cavity

Chapter 2 The Systems of the Body 27

One of the chief functions of the kidneys is to
control the water balance in the body. For example, on
a hot day, when a person has been active and has per-
spired profusely, relatively little urine will be pro-
duced so that the body may retain more water. On the
other hand, on a cold day, when a person is relatively
inactive or has consumed a good deal of liquid, urine
output will be higher so as to prevent overhydration.
Urine can offer important diagnostic clues to many
disorders. For example, an excess of glucose may indi-
cate diabetes, and an excess of red blood cells may in-
dicate a kidney disorder. This is one of the reasons that
a medical checkup usually includes a urinalysis.
To summarize, the urinary system regulates
bodily fluids by removing surplus water, surplus elec-
trolytes, and the waste products generated by the me-
tabolism of food.

Disorders of the Renal System
The renal system is vulnerable to a number of disorders.
Among the most common are urinary tract infections, to
which women are especially vulnerable and which can
result in considerable pain, especially on urination. If
untreated, they can lead to more serious infection.
Nephrons are the basic structural and functional
units of the kidneys. In many types of kidney disease,
such as that associated with hypertension, large num-
bers of nephrons are destroyed or damaged so severely
that the remaining nephrons cannot perform their nor-
mal functions.
Glomerular nephritis involves the inflammation
of the glomeruli in the nephrons of the kidneys that
filter blood. Nephritis can be caused by infections,
exposure to toxins, and autoimmune diseases, espe-
cially lupus. Nephritis is a serious condition linked to
a large number of deaths worldwide.
Another common cause of acute renal shutdown is
tubular necrosis, which involves destruction of the epi-
thelial cells in the tubules of the kidneys. Poisons that
destroy the tubular epithelial cells and severe circulatory
shock are the most common causes of tubular necrosis.
Kidney failure is a severe disorder because the in-
ability to produce an adequate amount of urine will
cause the waste products of metabolism, as well as sur-
plus inorganic salts and water, to be retained in the body.
An artificial kidney, a kidney transplant, or kidney
dialysis may be required in order to rid the body of its
wastes. Although these technologies can cleanse the
blood to remove the excess salts, water, and metabolites,

Hepatitis C, also spread via blood and needles, is
most commonly caused by blood transfusions; 130–150
million people worldwide have the disorder, which ac-
counts for half a million deaths annually. Hepatitis D is
found mainly in intravenous drug users who are also
carriers of hepatitis B, necessary for the hepatitis D
virus to spread. Finally, hepatitis E resembles hepatitis
A but is caused by a different virus.

■ THE RENAL SYSTEM

Overview
The renal system consists of the kidneys, ureters, uri-
nary bladder, and urethra. The kidneys are chiefly
responsible for the regulation of bodily fluids; their
principal function is to produce urine. The ureters con-
tain smooth muscle tissue, which contracts, causing
peristaltic waves to move urine to the bladder, a muscu-
lar bag that acts as a reservoir for urine. The urethra then
conducts urine from the bladder out of the body. The
anatomy of the renal system is pictured in Figure 2.8.
Urine contains surplus water, surplus electrolytes,
waste products from the metabolism of food, and sur-
plus acids or alkalis. By carrying these products out of
the body, urine maintains water balance, electrolyte
balance, and blood pH. Of the electrolytes, sodium
and potassium are especially important because they
are involved in muscular contractions and the conduc-
tion of nerve impulses, among other vital functions.

FIGURE 2.8 | The Renal System
(Source: Lankford, 1979, p. 585)

Kidney

Ureter

Bladder

Urethra

28 Part One Introduction to Health Psychology

hair. Progesterone, which is produced during the sec-
ond half of the menstrual cycle to prepare the body for
pregnancy, declines if pregnancy fails to occur.
In males, testosterone is produced by the intersti-
tial cells of the testes under the control of the anterior
pituitary lobe. It brings about the production of sperm
and the development of secondary sex characteristics,
including growth of the beard, deepening of the voice,
distribution of body hair, and both skeletal and mus-
cular growth.

Fertilization and Gestation
When sexual intercourse takes place and ejaculation
occurs, sperm are released into the vagina. These
sperm, which have a high degree of motility, proceed
upward through the uterus into the fallopian tubes,
where one sperm may fertilize an ovum. The fertilized
ovum then travels down the fallopian tube into the uter-
ine cavity, where it embeds itself in the uterine wall and
develops over the next 9 months into a human being.

Disorders of the Reproductive System
The reproductive system is vulnerable to a number of
diseases and disorders. Among the most common and
problematic are sexually transmitted diseases (STDs),
which occur through sexual intercourse or other forms
of sexually intimate activity. STDs include herpes,

they are highly stressful medical procedures. Kidney
transplants carry many health risks, and kidney dialysis
can be extremely uncomfortable for patients. Conse-
quently, health psychologists have been involved in ad-
dressing these problems.

■ THE REPRODUCTIVE SYSTEM

Overview
The development of the reproductive system is con-
trolled by the pituitary gland. The anterior pituitary
lobe produces the gonadotropic hormones, which
control development of the ovaries in females and the
testes in males. A diagrammatic representation of the
human reproductive system appears in Figure 2.9.

The Ovaries and Testes
The female has two ovaries located in the pelvis. Each
month, one of the ovaries releases an ovum (egg),
which is discharged at ovulation into the fallopian
tubes. If the ovum is not fertilized (by sperm), it re-
mains in the uterine cavity for about 14 days and is
then flushed out of the system with the uterine endo-
metrium and its blood vessels (during menstruation).
The ovaries also produce the hormones estrogen
and progesterone. Estrogen leads to the development
of secondary sex characteristics in females, including
breasts and the distribution of both body fat and body

FIGURE 2.9 | The Reproductive System (Sources: Green, 1978, p. 122; Lankford, 1979, p. 688)

Female

Fallopian tube Uterus

Ovum
Right ovary

Vagina

Cervix

Left ovary

Male

Urinary
bladder

Ejaculatory
duct Seminal vesicle

Prostate
gland

Cowper’s
gland

Urethra

Ductus deferens

Epididymis

Scrotum
TestisSeminiferous

tubules

Prepuce
(foreskin)

Glans
penis

Penis

Chapter 2 The Systems of the Body 29

than protecting against these disorders, HT may actu-
ally increase some of these risks. As a result of this
new evidence, most women and their doctors are re-
thinking the use of HT, especially over the long term.

■ GENETICS AND HEALTH

Overview
The fetus starts life as a single cell, which contains the
inherited information from both parents that will de-
termine its characteristics. The genetic code regulates
such factors as eye and hair color, as well as behav-
ioral factors. Genetic material for inheritance lies in
the nucleus of the cell in the form of 46 chromosomes,
23 from the mother and 23 from the father. Two of
these 46 are sex chromosomes, which are an X from
the mother and either an X or a Y from the father. If
the father provides an X chromosome, a female child
will result; if he provides a Y chromosome, a male
child will result.

Genetics and Susceptibility to Disorders
Genetic studies have provided valuable information
about the inheritance of susceptibility to disease. For
example, scientists have bred strains of rats, mice, and
other laboratory animals that are sensitive or insensitive
to the development of particular diseases and then used
these strains to study illness onset and the course of ill-
ness. For example, a strain of rats that is susceptible to
cancer may shed light on the development of this dis-
ease and what other factors contribute to its occurrence.
The initial susceptibility of the rats ensures that many
of them will develop malignancies when implanted
with carcinogenic (cancer-causing) materials.
In humans, several types of research help demon-
strate whether a characteristic is genetically acquired.
Studies of families, for example, can reveal whether
members of the same family are more likely to de-
velop a disorder, such as heart disease, than are unre-
lated individuals in a similar environment. If a factor
is genetically determined, family members will show
it more frequently than will unrelated individuals.
Twin research is another method for examining
the genetic basis of a characteristic. If a characteristic
is genetically transmitted, identical twins share it more
commonly than do fraternal twins or other brothers
and sisters. This is because identical twins share the
same genetic makeup, whereas other brothers and sisters
have only partially overlapping genetic makeup.

gonorrhea, syphilis, genital warts, chlamydia, and,
most seriously, AIDS.
For women, a risk from several STDs is chronic
pelvic inflammatory disease (PID), which may pro-
duce severe abdominal pain and infections that may
compromise fertility. Other gynecologic disorders to
which women are vulnerable include vaginitis, endo-
metriosis (in which pieces of the endometrial lining of
the uterus move into the fallopian tubes or abdominal
cavity, grow, and spread to other sites), cysts, and fi-
broids (nonmalignant growths in the uterus that may
nonetheless interfere with reproduction). Women are
vulnerable to disorders of the menstrual cycle, includ-
ing amenorrhea, which is the absence of menses, and
oligomenorrhea, which is infrequent menstruation.
The reproductive system is also vulnerable to
cancer, including testicular cancer in men and gyne-
cologic cancers in women. Every 6 minutes, a woman
in the United States is diagnosed with a gynecologic
cancer, including cancer of the cervix, uterus, and
ovaries (American Cancer Society, 2012a). Endome-
trial cancer is the most common female pelvic malig-
nancy, and ovarian cancer is the most lethal.
Approximately 10 percent of U.S. couples experi-
ence fertility problems, defined as the inability to
conceive a pregnancy after 1 year of regular sexual
intercourse without contraception (Centers for Disease
Control and Prevention, June 2011). Although physi-
cians once believed that infertility has emotional ori-
gins, researchers now believe that distress may
complicate but does not cause infertility. Fortunately,
over the past few decades, the technology for treating
infertility has improved. A variety of drug treatments
have been developed, as have more invasive technolo-
gies. In vitro fertilization (IVF) is the most widely used
method of assistive reproductive technology, and the
success rate for IVF can be as high as 40% per cycle
(Resolve: The National Fertility Association, 2013).
Menopause is not a disorder of the reproductive
system; rather, it occurs when a woman’s reproductive
life ends. Because of a variety of noxious symptoms
that can occur during the transition into menopause,
including sleep disorders, hot flashes, joint pain, for-
getfulness, and dizziness, some women choose to take
hormone therapy (HT), which typically includes estro-
gen or a combination of estrogen and progesterone. HT
was once thought not only to reduce the symptoms of
menopause but also to protect against the development
of coronary artery disease, osteoporosis, breast cancer,
and Alzheimer’s disease. It is now believed that, rather

30 Part One Introduction to Health Psychology

health would be fruitless if genes are implicated
(Dar-Nimrod & Heine, 2011). Such erroneous beliefs
may deter health behavior change and information
seeking about one’s risk (Marteau & Weinman, 2006).
Genetic risk information may also evoke defensive pro-
cesses whereby people downplay their risk (Shiloh,
Drori, Orr-Urtreger, & Friedman, 2009). Genetic risks
may also interact with stress or trauma to increase risks
for certain disorders (Zhao, Bremner, Goldberg,
Quyyumi, & Vaccarino, 2013). Accordingly, making
people aware of genetic risk factors should be accom-
panied by educational information to offset these po-
tential problems (Smerecnik et al., 2009).
Another role for health psychologists involves
genetic counseling. Prenatal diagnostic tests permit
the detection of some genetically based disorders, in-
cluding Tay-Sachs disease, cystic fibrosis, muscular
dystrophy, Huntington’s disease, and breast cancer.
Helping people decide whether to be screened and
how to cope with genetic vulnerabilities if they test
positive represents an important role for health psy-
chologists (Mays et al., 2014). For example, belief in a
genetic cause can lead people to take medical actions
that may be medically unwarranted (Petrie et al., 2015).
In addition, people who have a family history of
genetic disorders, those who have already given birth
to a child with a genetic disorder, or those who have
recurrent reproductive problems, such as multiple
miscarriages, often seek such counseling. In some
cases, technological advances have made it possible
to treat some of these problems before birth through
drugs or surgery. However, if the condition cannot be
corrected, the parents often must make the difficult
decision of whether to abort the pregnancy.
Children, adolescents, and young adults some-
times learn of a genetic risk to their health, as research
uncovers such causes. Breast cancer, for example,
runs in families, and among young women whose
mothers, aunts, or sisters have developed breast can-
cer, vulnerability is higher. Families that share genetic
risks may need special attention through family coun-
seling (Mays et al., 2014). Some of the genes that con-
tribute to the development of breast cancer have been
identified, and tests are now available to determine
whether a genetic susceptibility is present. Although
this type of cancer accounts for only 5 percent of
breast cancer, women who carry these genetic suscep-
tibilities are more likely to develop the disease at an
earlier age; thus, these women are at high risk and
need careful monitoring and assistance in making

Examining the characteristics of twins reared to-
gether as opposed to twins reared apart is also informa-
tive regarding genetics. Attributes that emerge for twins
reared apart are suspected to be genetically determined,
especially if the rate of occurrence between twins
reared together and those reared apart is the same.
Finally, studies of adopted children also help iden-
tify which characteristics are genetic and which are en-
vironmentally produced. Adopted children will not
manifest genetically transmitted characteristics from
their adoptive parents, but they may manifest environ-
mentally transmitted characteristics.
Consider, for example, obesity, which is a risk
factor for a number of disorders, including coronary
artery disease and diabetes. If twins reared apart show
highly similar body weights, then we would suspect
that body weight has a genetic component. If, on the
other hand, weight within a family is highly related,
and adopted children show the same weight as their
parents and any natural offspring, then we would look
to the family diet as a potential cause of obesity. For
many attributes, including obesity, both environmental
and genetic factors are involved.
Research like this has increasingly uncovered
the genetic contribution to many health disorders
and behavioral factors that may pose risks to health.
Such diseases as asthma, Alzheimer’s disease, cystic
fibrosis, muscular dystrophy, Tay-Sachs disease, and
Huntington’s disease have a genetic basis. There is
also a genetic basis for coronary heart disease and
for some forms of cancer, including some breast and
colon cancers. This genetic basis does not preclude
the important role of the environment, however.
Genetics will continue to be of interest as the con-
tribution of genes to health continues to be uncovered.
For example, genetic contributions to obesity and alco-
holism have emerged in recent years. Moreover, the
contributions of genetics studies to health psychology
are broadening. Even some personality characteristics,
such as optimism, which is believed to have protective
health effects, have genetic underpinnings (Saphire-
Bernstein, Way, Kim, Sherman, & Taylor, 2011).

Genetics and Health Psychology Health psy-
chologists have important roles to play with respect to
genetic contributions to health disorders. One question
concerns whether people need to be alerted to genetic
risks (Smerecnik, Mesters, de Vries, & de Vries, 2009).
Many people think that genetic risks are immutable and
that any efforts they might undertake to affect their

Chapter 2 The Systems of the Body 31

∙ Mechanical transmission is the passage of a
microbe to an individual by means of a carrier
that is not directly involved in the disease
process. Dirty hands, bad water, rats, mice, and
flies can be implicated in mechanical
transmission. Box 2.2 tells about two people
who were carriers of deadly diseases.

Infection
Once a microbe has reached the body, it penetrates
into bodily tissue via any of several routes, including
the skin, the throat and respiratory tract, the digestive
tract, or the genitourinary system. Whether the invad-
ing microbes gain a foothold in the body and produce
infection depends on three factors: the number of or-
ganisms, the virulence of the organisms, and the
body’s defensive capacities. The virulence of an or-
ganism is determined by its aggressiveness (i.e., its
ability to resist the body’s defenses) and by its toxige-
nicity (i.e., its ability to produce poisons, which invade
other parts of the body).

The Course of Infection
Assuming that the invading organism does gain a
foothold, the natural history of infection follows a spe-
cific course. First, there is an incubation period be-
tween the time the infection is contracted and the time
the symptoms appear.
Next, there is a period of nonspecific symptoms,
such as headaches and general discomfort, which pre-
cedes the onset of the disorder. During this time, the
microbes are actively colonizing and producing tox-
ins. The next stage is the acute phase, when the illness
and its symptoms are at their height. Unless the infec-
tion proves fatal, a period of decline follows the acute
phase. During this period, the organisms are expelled
from the mouth and nose in saliva and respiratory se-
cretions, as well as through the digestive tract and the
genitourinary system in feces and urine.
Infections may be localized, focal, or systemic. Lo-
calized infections remain at their original site and do not
spread throughout the body. Although a local infection
is confined to a particular area, it sends toxins to other
parts of the body, causing other disruptions. Systemic
infections affect a number of areas or body systems.
The primary infection initiated by the microbe
may also lead to secondary infections. These occur be-
cause the body’s resistance is lowered from fighting

treatment-related decisions. With whole genome test-
ing becoming available to individuals, knowledge of
genetic risks may increase (Drmanac, 2012).
Carriers of genetic risks may experience great dis-
tress (Hamilton, Lobel, & Moyer, 2009). Should people
be told about their genetic risks if nothing can be done
to treat them? Growing evidence suggests that people at
risk for treatable disorders benefit from genetic testing
and do not suffer long-term psychological distress (e.g.,
Hamilton et al., 2009). People who are chronically anx-
ious, though, may require special attention and counsel-
ing (Rimes, Salkovskis, Jones, & Lucassen, 2006).
In some cases, genetic risks can be offset by behav-
ioral interventions to address the risk factor. For exam-
ple, one study (Aspinwall, Leaf, Dola, Kohlmann, &
Leachman, 2008) found that being informed that one
had tested positive for a gene implicated in melanoma
(a serious skin cancer) and receiving counseling led to
better skin self-examination practices at a 1-month follow-
up. Thus health psychologists have an important role to
play in research and counseling related to genetic risks,
especially if they can help people modify their risk
status and manage their distress (Aspinwall, Taber,
Leaf, Kohlmann, & Leachman, 2013).

■ THE IMMUNE SYSTEM

Overview
Disease is caused by a variety of factors. In this sec-
tion, we address the transmission of disease by infec-
tion, that is, the invasion of microbes and their growth
in the body. The microbes that cause infection are
transmitted to people in several ways:
∙ Direct transmission involves bodily contact, such

as handshaking, kissing, and sexual intercourse.
For example, genital herpes is typically
contracted by direct transmission.

∙ Indirect transmission (or environmental
transmission) occurs when microbes are passed
to an individual via airborne particles, dust,
water, soil, or food. Influenza is an example of
an environmentally transmitted disease.

∙ Biological transmission occurs when a transmitting
agent, such as a mosquito, picks up microbes,
changes them into a form conducive to growth in
the human body, and passes them on to the
human. Yellow fever, for example, is transmitted
by this method.

32

Natural and Specific Immunity How does im-
munity work? The body has a number of responses to
invading organisms, some nonspecific and others spe-
cific. Nonspecific immune mechanisms are a gen-
eral set of responses to any kind of infection or
disorder; specific immune mechanisms, which are
always acquired after birth, fight particular microor-
ganisms and their toxins.
Natural immunity is involved in defense against
pathogens. The cells involved in natural immunity
provide defense not against a particular pathogen, but
rather against many pathogens. The largest group of
cells involved in natural immunity is granulocytes,
which include neutrophils and macrophages; both are
phagocytic cells that engulf target pathogens. Neutro-
phils and macrophages congregate at the site of an
injury or infection and release toxic substances. Mac-
rophages release cytokines that lead to inflammation
and fever, among other side effects, and promote
wound healing. Natural killer cells are also involved in

the primary infection, leaving it susceptible to other
invaders. In many cases, secondary infections, such as
pneumonia, pose a greater risk than the primary one.

Immunity
Immunity is the body’s resistance to invading organ-
isms. It may develop either naturally or artificially.
Some natural immunity is passed from the mother to
the child at birth and through breast-feeding, although
this type of immunity is only temporary. Natural im-
munity is also acquired through disease. For example,
if you have measles once, you are unlikely to develop it
a second time; you will have built up an immunity to it.
Artificial immunity is acquired through vaccina-
tions and inoculations. For example, most children and
adolescents receive shots for a variety of diseases—
among them, diphtheria, whooping cough, smallpox,
poliomyelitis, and hepatitis—so that they will not con-
tract these diseases, should they be exposed.

Carriers are people who transmit a disease to others
without actually contracting that disease themselves.
They are especially dangerous because they are not ill
and so they can infect dozens, hundreds, or even thou-
sands of people while going about the business of ev-
eryday life.

“TYPHOID MARY”
Perhaps the most famous carrier in history was “Ty-
phoid Mary,” a young Swiss immigrant to the United
States who infected thousands of people during her
lifetime. During her ocean crossing, Mary was taught
how to cook, and eventually, some 100 individuals
aboard the ship died of typhoid, including the cook
who trained her. Once Mary arrived in New York, she
obtained a series of jobs as a cook, continually passing
on the disease to those for whom she worked without
contracting it herself.
Typhoid is precipitated by a salmonella bacte-
rium, which can be transmitted through water, food,
and physical contact. Mary carried a virulent form of
the infection in her body but was herself immune to
the disease. It is believed that she was unaware she
was a carrier for many years. Toward the end of her
life, however, she began to realize that she was
responsible for the many deaths around her.

Mary’s status as a carrier also became known to
medical authorities, and she spent the latter part of her
life in and out of institutions in a vain attempt to iso-
late her from others. In 1930, Mary died not of ty-
phoid but of a brain hemorrhage (Federspiel, 1983).

“HELEN”
The CBS News program 60 Minutes profiled an
equally terrifying carrier: a prostitute, “Helen,” who is
a carrier of HIV, the virus that causes AIDS (acquired
immune deficiency syndrome). Helen has never had
AIDS, but her baby was born with the disease. As a
prostitute and heroin addict, Helen is not only at risk
for developing the illness herself but also poses a
threat to her clients and anyone with whom she shares
a needle.
Helen represents a dilemma for medical and crim-
inal authorities. She is a known carrier of AIDS, yet
there is no legal basis for preventing her from coming
into contact with others. Although she can be arrested
for prostitution or drug dealing, such incarcerations are
usually short-term and have a negligible impact on her
ability to spread the disease to others. For potentially
fatal diseases such as AIDS, the carrier represents a
nightmare, and medical and legal authorities have been
almost powerless to intervene (Moses, 1984).

Portraits of Two CarriersB O X 2.2

Chapter 2 The Systems of the Body 33

increases at the site of inflammation because of the
increased flow of blood. Usually, a clot then forms
around the inflamed area, isolating the microbes and
keeping them from spreading to other parts of the
body. Familiar examples of the inflammatory re-
sponse are the reddening, swelling, discharge, and
clotting that result when you accidentally cut your
skin and the sneezing, runny nose and teary eyes
that result from an allergic response to pollen.
Specific immunity is acquired after birth by
contracting a disease or through artificial means,
such as vaccinations. It operates through the antigen-
antibody reaction. Antigens are foreign substances
whose presence stimulates the production of
antibodies in the cell tissues. Antibodies are pro-
teins produced in response to stimulation by
antigens, which combine chemically with the anti-
gens to overcome their toxic effects.
Specific immunity is slower and, as its name im-
plies, more specific than natural immunity. The lym-
phocytes involved in specific immunity have receptor
sites on their cell surfaces that fit with one, and only
one, antigen, and thus, they respond to only one kind
of invader. When they are activated, these antigen-
specific cells divide and create a population of cells
called the proliferative response.
Essentially, natural and specific immunity work
together, such that natural immunity contains an in-
fection or wound rapidly and early on following the
invasion of a pathogen, whereas specific immunity
involves a delay of up to several days before a full
defense can be mounted. Figure 2.10 illustrates the
interaction between lymphocytes and phagocytes.

natural immunity; they recognize “nonself” material
(such as viral infections or cancer cells) and lyse
(break up and disintegrate) those cells by releasing
toxic substances. Natural killer cells are believed to
be important in signaling potential malignancies and
in limiting early phases of viral infections.
Natural immunity occurs through four main ways:
anatomical barriers, phagocytosis, antimicrobial sub-
stances, and inflammatory responses. Anatomical
barriers prevent the passage of microbes from one
section of the body to another. For example, the skin
functions as an effective anatomical barrier to many
infections, and the mucous membranes lining the nose
and mouth also provide protection.
Phagocytosis is the process by which certain
white blood cells (called phagocytes) ingest microbes.
Phagocytes are usually overproduced when there is a
bodily infection, so that large numbers can be sent to
the site of infection to ingest the foreign particles.
Antimicrobial substances are chemicals produced
by the body that kill invading microorganisms. Inter-
feron, hydrochloric acid, and enzymes such as lyso-
zyme are some antimicrobial substances that help
destroy invading microorganisms.
The inflammatory response is a local reaction to
infection. At the site of infection, the blood capillaries
first enlarge, and a chemical called histamine is re-
leased into the area. This chemical causes an increase
in capillary permeability, allowing white blood cells
and fluids to leave the capillaries and enter the tissues;
consequently, the area becomes reddened and fluids
accumulate. The white blood cells attack the microbes,
resulting in the formation of pus. Temperature

FIGURE 2.10 | Interaction Between Lymphocytes and Phagocytes B lymphocytes release antibodies, which
bind to pathogens and their products, aiding recognition by phagocytes. Cytokines released by T cells activate
phagocytes to destroy the material they have taken up. In turn, mononuclear phagocytes can present antigen to
T cells, thereby activating them. (Source: Roitt, Brostoff, & Male, 1998)

B

T

Lymphocytes Phagocytes

Aid recognition
Antibodies

Cytokines

Activation

Activation

Antigen
presentation

34 Part One Introduction to Health Psychology

Additional discussion of immunity can be found
in Chapter 14, where we consider the rapidly developing
field of psychoneuroimmunology and the role of im-
munity in the development of AIDS.

Disorders Related to the Immune
System
The immune system is subject to a number of disor-
ders and diseases. One very important one is AIDS,
which is a progressive impairment of immunity. An-
other is cancer, which is now believed to depend heavily
on immunocompromise. We defer extended discussion
of AIDS and cancer to Chapter 14.
Lupus affects approximately 1.5 million Amer-
icans, most of them women (WebMD, 2015). The
disease acquired the name lupus, which means
“wolf,” because of the skin rash that can appear on
the face. It leads to chronic inflammation, produc-
ing pain, heat, redness, and swelling, and can be
life-threatening when it attacks the connective tis-
sue of the body’s internal organs. Depending on the
severity of the disease, it may be managed by anti-
inflammatory medications or immunosuppressive
medications.
A number of infections attack lymphatic tissue.
For example, tonsillitis is an inflammation of the ton-
sils that interferes with their ability to filter out bacte-
ria. Infectious mononucleosis is a viral disorder

FIGURE 2.11 | Components of the Immune System (Source: Roitt, Brostoff, & Male, 1998)

Lymphocytes

Leucocytes

Phagocytes Auxiliary cells Other

Cytokines Complement

B cell

Antibodies

T cell

Large
granular

lymphocyte

Interferons,
cytokines

Mononuclear
phagocyte Neutrophil Eosinophil Basophil Mast cell Platelets

Tissue
cells

Inflammatory
mediators

Humoral and Cell-Mediated Immu-
nity There are two basic immunologic reactions—
humoral and cell mediated. Humoral immunity is
mediated by B lymphocytes. The functions of B lym-
phocytes include providing protection against bacte-
ria, neutralizing toxins produced by bacteria, and
preventing viral reinfection. B cells confer immunity
by the production and secretion of antibodies.
Cell-mediated immunity, involving T
lymphocytes from the thymus gland, is a slower-acting
response. Rather than releasing antibodies into the
blood, as humoral immunity does, cell-mediated im-
munity operates at the cellular level. When stimulated
by the appropriate antigen, T cells secrete chemicals
that kill invading organisms and infected cells. Compo-
nents of the immune system are shown in Figure 2.11.

The Lymphatic System’s Role in Immunity
The lymphatic system, which is a drainage system of
the body, is involved in important ways in immune
functioning. There is lymphatic tissue throughout the
body, consisting of lymphatic capillaries, vessels, and
nodes. Lymphatic capillaries drain water, proteins,
microbes, and other foreign materials from spaces be-
tween the cells into lymph vessels. This material is
then conducted in the lymph vessels to the lymph
nodes, which filter out microbes and foreign materials
for ingestion by lymphocytes. The lymphatic vessels
then drain any remaining substances into the blood.

Chapter 2 The Systems of the Body 35

times and was selected because it was adaptive. For
example, among hunter-gatherer societies, natural
selection would have favored people with vigorous
inflammatory responses because life expectancy was
fairly short. Few people would have experienced any
long-term costs of vigorous or long-lasting in-
f lammatory responses, which now seem to play
such an important role in the development of chronic
diseases. Essentially, an adaptive pattern of earlier
times has become maladaptive, as life expectancy
has lengthened.
Autoimmunity occurs when the body attacks the
body’s own tissues. Examples of autoimmune disor-
ders include certain forms of arthritis, multiple sclero-
sis, and lupus, among others.
In autoimmune disease, the body fails to recog-
nize its own tissue, instead interpreting it as a for-
eign invader and producing antibodies to fight it.
Many viral and bacterial pathogens have, over time,
developed the ability to fool the body into granting
them access by mimicking basic protein sequences
in the body. This process of molecular mimicry
eventually fails but then leads the immune system to
attack not only the invader but also healthy tissues.
A person’s genetic makeup may exacerbate this pro-
cess. Stress can aggravate autoimmune disease. Ap-
proximately 50 million Americans suffer from
autoimmune diseases. Women are more likely than
men to be affected (American Autoimmune Related
Diseases Association, 2015). Although the causes
of autoimmune diseases are not fully known, re-
searchers have discovered that a viral or bacterial
infection often precedes the onset of an autoimmune
disease. ∙

marked by an unusually large number of monocytes;
it can cause enlargement of the spleen and lymph
nodes, as well as fever, sore throat, and general lack
of energy.
Lymphoma is a tumor of the lymphatic tissue.
Hodgkin’s disease, a malignant lymphoma, involves
the progressive, chronic enlargement of the lymph
nodes, spleen, and other lymphatic tissues. As a
consequence, the nodes cannot effectively produce
antibodies, and the phagocytic properties of the
nodes are lost. If untreated, Hodgkin’s disease can
be fatal.
Infectious disorders were at one time thought to
be acute problems that ended when their course had
run. A major problem in developing countries, in-
fectious disorders were thought to be largely under
control in developed nations. Now, however, infec-
tious diseases merit closer looks (Morens, Folkers,
& Fauci, 2004). First, as noted in the discussion of
asthma, the control of at least some infectious disor-
ders through hygiene may have paradoxically in-
creased the rates of allergic disorders. A second
development is that some chronic diseases, once
thought to be genetic in origin or unknown in origin,
are now being traced back to infections. For exam-
ple, Alzheimer’s disease, multiple sclerosis, schizo-
phrenia, and some cancers appear to have infectious
triggers, at least in some cases (Zimmer, 2001). The
development of bacterial strains that are resistant to
treatment has raised an alarm. The overuse of anti-
biotics is an active contributor to the development
of increasingly lethal strains. Infectious agents have
also become an increasing concern in the war on ter-
rorism, with the possibility that smallpox and other
infectious agents may be used as weapons.
The inflammatory response that is so protective
against provocations ranging from mosquito bites and
sunburn to gastritis in response to spoiled food is
coming under increasing investigation as a contributor
to chronic disease. The destructive potential of in-
flammation is evident in diseases such as rheumatoid
arthritis and multiple sclerosis, but inflammation also
underlies many other chronic diseases including ath-
erosclerosis, diabetes, Alzheimer’s disease, asthma,
cirrhosis of the liver, some bowel disorders, cystic fi-
brosis, heart disease, depression, and even some can-
cers (Table 2.1).
The inflammatory response, like stress responses
more generally, likely evolved in early prehistoric

TABLE 2.1 | Some Consequences of Chronic
Low-Level Inflammation

Inflammation is believed to play an important role in
several diseases of aging. They include:
• Heart Disease
• Stroke
• Diabetes
• Alzheimer’s Disease (and cognitive decline more

generally)
• Cancer
• Osteoporosis
• Depression

36 Part One Introduction to Health Psychology

1. The nervous system and the endocrine system
act as the control systems of the body, mobilizing
it in times of threat and otherwise maintaining
equilibrium and normal functioning.

2. The nervous system operates primarily through
the exchange of nerve impulses between the
peripheral nerve endings and internal organs and the
brain, thereby providing the integration necessary
for voluntary and involuntary movement.

3. The endocrine system operates chemically via
the release of hormones stimulated by centers in
the brain. It controls growth and development
and augments the functioning of the nervous
system.

4. The cardiovascular system is the transport
system of the body, carrying oxygen and nutrients
to cell tissues and taking carbon dioxide and
other wastes away from the tissues for expulsion
from the body.

5. The heart acts as a pump to control circulation
and is responsive to regulation via the nervous
system and the endocrine system.

6. The heart, blood vessels, and blood are vulnerable
to a number of problems—most notably,
atherosclerosis—which makes diseases of the
cardiovascular system the major cause of death
in this country.

7. The respiratory system is responsible for taking
in oxygen, expelling carbon dioxide, and
controlling the chemical composition of the blood.

8. The digestive system is responsible for producing
heat and energy, which—along with essential
nutrients—are needed for the growth and repair
of cells. Through digestion, food is broken down
to be used by the cells for this process.

9. The renal system aids in metabolic processes by
regulating water balance, electrolyte balance,
and blood acidity-alkalinity. Water-soluble
wastes are flushed out of the system in the urine.

10. The reproductive system, under the control of the
endocrine system, leads to the development of
primary and secondary sex characteristics.
Through this system, the species is reproduced,
and genetic material is transmitted from parents to
their offspring.

11. With advances in genetic technology and the
mapping of the genome has come increased
understanding of genetic contributions to disease.
Health psychologists play important research and
counseling roles with respect to these issues.

12. The immune system is responsible for warding off
infection from invasion by foreign substances. It
does so through the production of infection-fighting
cells and chemicals.

S U M M A R Y

K E Y T E R M S

adrenal glands
angina pectoris
atherosclerosis
autoimmunity
blood pressure
cardiovascular system
catecholamines
cell-mediated immunity
cerebellum
cerebral cortex
endocrine system

humoral immunity
hypothalamus
immunity
ischemia
kidney dialysis
lupus
lymphatic system
medulla
myocardial infarction (MI)
nervous system
neurotransmitters

nonspecific immune mechanisms
parasympathetic nervous system
phagocytosis
pituitary gland
platelets
pons
renal system
respiratory system
specific immune mechanisms
sympathetic nervous system
thalamus

Health Behavior and
Primary Prevention

2P A R T

© Stockbyte/PunchStock RF

38

C H A P T E R 3

C H A P T E R O U T L I N E

An Introduction to Health Behaviors
Role of Behavioral Factors in Disease and Disorder

Health Promotion: An Overview
Health Behaviors and Health Habits

Practicing and Changing Health Behaviors: An
Overview

Barriers to Modifying Poor Health Behaviors

Intervening with Children and Adolescents

Intervening with At-Risk People

Health Promotion and Older Adults

Ethnic and Gender Differences in Health Risks
and Habits

Changing Health Habits
Attitude Change and Health Behavior

The Health Belief Model

Health Behaviors

The Theory of Planned Behavior

Criticisms of Attitude Theories

Self Regulation and Health Behavior

Self Determination Theory

Implementation Intentions

Health Behavior Change and the Brain

Cognitive-Behavioral Approaches to Health
Behavior Change
Cognitive-Behavior Therapy (CBT)

Self Monitoring

Stimulus Control

The Self Control of Behavior

Social Skills and Relaxation Training

Motivational Interviewing

Relapse Prevention

Evaluation of CBT

The Transtheoretical Model of Behavior Change
Stages of Change

Using the Stage Model of Change

Changing Health Behaviors Through Social
Engineering

Venues for Health-Habit Modification
The Practitioner’s Office

The Family

Self-Help Groups

Schools

Workplace Interventions

Community-Based Interventions

The Mass Media

Cellular Phones and Landlines

The Internet

© Getty Images/Blend Images RF

Chapter 3 Health Behaviors 39

health promotion involves teaching people how to
achieve a healthy lifestyle and helping people at risk for
particular health problems offset or monitor those risks.
For the health psychologist, health promotion involves
the development of interventions to help people practice
healthy behaviors. For community and national policy
makers, health promotion involves emphasizing good
health and providing information and resources to help
people change poor health habits.
Successful modification of health behaviors will
have several beneficial effects. First, it will reduce
deaths due to lifestyle-related diseases. Second, it may
delay time of death, thereby increasing life expectancy.
Third and most important, the practice of good health
behaviors may expand the number of years during
which a person may enjoy life free from the complica-
tions of chronic disease. Finally, modification of health
behaviors may begin to make a dent in the more than
$3.0 trillion that is spent yearly on health and illness
(National Health Expenditures, 2014).

Health Behaviors and Health Habits
Health behaviors are behaviors undertaken by people
to enhance or maintain their health. A health habit is a
health behavior that is firmly established and often per-
formed automatically, without awareness. These habits
usually develop in childhood and begin to stabilize
around age 11 or 12 (Cohen, Brownell, & Felix, 1990).
Wearing a seat belt, brushing one’s teeth, and eating a
healthy diet are examples of these behaviors. Although
a health habit may develop initially because it is rein-
forced by positive outcomes, such as parental approval,
it eventually becomes independent of the reinforcement
process. For example, you may brush your teeth auto-
matically before going to bed. As such, habits can be
highly resistant to change. Consequently, it is important
to establish good health behaviors and to eliminate poor
ones early in life.
An illustration of the importance of good health
habits is provided by a classic study of people living
in Alameda County, California, conducted by Belloc
and Breslow (1972). These scientists focused on sev-
eral important health habits:
∙ Sleeping 7 to 8 hours a night
∙ Not smoking
∙ Eating breakfast each day
∙ Having no more than one or two alcoholic drinks

each day

In Chapter 3, we address health behaviors. At the core of this chapter is the idea that good health is
achievable through health behaviors that are practiced
conscientiously.

■ AN INTRODUCTION TO
HEALTH BEHAVIORS

Role of Behavioral Factors in Disease
and Disorder
In the past century, patterns of disease in the United States
have changed substantially. As noted in Chapter 1, there
has been a decline in acute infectious disorders due to
changes in public health standards, but there has been an
increase in the preventable disorders, including lung
cancer, cardiovascular disease, alcohol and drug abuse,
and vehicular accidents. The role of behavioral factors
in the development of these disorders is clear ( Table 3.1).
Nearly half the deaths in the United States are caused by
preventable factors, with smoking, obesity, and problem
drinking being three of the main causes (Centers for
Disease Control and Prevention, 2009a).

■ HEALTH PROMOTION:
AN OVERVIEW

Research on preventable risk factors adopts the per-
spective of health promotion. Health promotion is a
philosophy that has at its core the idea that good health,
or wellness, is a personal and collective achievement.
For the individual, it involves developing a program of
good health habits. For the medical practitioner,

TABLE 3.1 | Risk Factors for the Leading Causes
of Death in the United States

Disease Risk Factors

Heart disease Tobacco, high cholesterol, high
blood pressure, physical inactivity,
obesity, diabetes, stress

Cancer Smoking, unhealthy diet,
environmental factors

Stroke High blood pressure, tobacco,
diabetes, high cholesterol,
physical inactivity, obesity

Accidental injuries On the road (failure to wear seat
belts), in the home (falls, poison, fire)

Chronic lung disease Tobacco, environmental factors
(pollution, radon, asbestos)

Sources: American Cancer Society, 2009a; American Heart Association,
2009a; Centers for Disease Control and Prevention, April 2009.

40 Part Two Health Behavior and Primary Prevention

Values Values affect the practice of health habits.
For example, exercise for women may be considered
desirable in one culture but undesirable in another
(Guilamo-Ramos, Jaccard, Pena, & Goldberg, 2005).

Personal Control People who regard their health
as under their personal control practice better health
habits than people who regard their health as due to
chance. The health locus of control scale (Table 3.2)
(Wallston, Wallston, & DeVellis, 1978) measures the de-
gree to which people perceive their health to be under
personal control, control by the health practitioner, or
chance.

Social Influence Family, friends, and workplace
companions influence health-related behaviors, some-
times in a beneficial direction, other times in an ad-
verse direction (Blumberg, Vahratian, & Blumberg,
2014). For example, peer pressure often leads to
smoking in adolescence but may influence people to
stop smoking in adulthood.

Personal Goals and Values Health habits are
tied to personal goals. If personal fitness is an impor-
tant goal, a person is more likely to exercise.

Perceived Symptoms Some health habits are
controlled by perceived symptoms. For example, a
smoker who wakes up with a smoker’s cough and
raspy throat may cut back in the belief that he or she is
vulnerable to health problems at that time.

Access to the Health Care Delivery System
Access to the health care delivery system affects
health behaviors. For example, obtaining a regular
Pap smear, getting mammograms, and receiving im-
munizations for childhood diseases depend on access
to health care. Other behaviors, such as losing weight
and stopping smoking, may be indirectly encouraged
by the health care system through lifestyle advice.

Knowledge and Intelligence The practice of
health behaviors is tied to cognitive factors, such as
knowledge and intelligence (Mõttus et al., 2014).
More knowledgeable and smarter people typically
take better care of themselves. People who are identi-
fied as intelligent in childhood have better health-
related biological profiles in adulthood, which may be
explained by their practice of better health behaviors
in early life (Calvin, Batty, Lowe, & Deary, 2011).

∙ Getting regular exercise
∙ Not eating between meals
∙ Being no more than 10 percent overweight

The scientists asked nearly 7,000 county residents to
indicate which of these behaviors they practiced. Resi-
dents were also asked about the illnesses they had had,
what their energy level had been, and how disabled they
had been (for example, how many days of work they
had missed) over the previous 6-to-12-month period.
The researchers found that the more good health habits
people practiced, the fewer illnesses they had had, the
better they had felt, and the less disabled they had been.
A follow-up of these people 9–12 years later found
that mortality rates were dramatically lower for people
practicing the seven health habits. Men following these
practices had a mortality rate of only 28 percent and
women had a mortality rate of 43 percent, compared to
men and women who practiced zero to three of these
health habits (Breslow & Enstrom, 1980).

Primary Prevention Instilling good health
habits and changing poor ones is the task of primary
prevention. This means taking measures to combat
risk factors for illness before an illness has a chance
to develop. There are two general strategies of pri-
mary prevention. The first and most common strat-
egy is to get people to alter their problematic health
behaviors, such as helping people lose weight
through an intervention. The second, more recent ap-
proach is to keep people from developing poor health
habits in the first place. Smoking prevention pro-
grams with young adolescents are an example of this
approach, which we will consider in Chapter 5.

Practicing and Changing Health
Behaviors: An Overview
What factors lead one person to live a healthy life and
another to compromise his or her health?

Demographic Factors Younger, more affluent,
better-educated people with low levels of stress and
high levels of social support typically practice better
health habits than people under higher levels of stress
with fewer resources (Hanson & Chen, 2007).

Age Health habits are typically good in childhood,
deteriorate in adolescence and young adulthood, but
improve again among older people.

Chapter 3 Health Behaviors 41

and feel a false sense of security (Halpern-Felsher
et al., 2001).

Instability of Health Behaviors Health habits
are only modestly related to each other. The person
who exercises faithfully does not necessarily wear a
seat belt, for example. Therefore, health behaviors
must often be tackled one at a time. Health habits are
unstable over time. A person may stop smoking for a
year but take it up again during a period of high stress.
Why are health habits relatively independent of
each other and unstable? First, different health habits
are controlled by different factors. For example, smok-
ing may be related to stress, whereas exercise depends
heavily on ease of access to athletic facilities. Second,
different factors may control the same health behavior
for different people. One person’s overeating may be
“social,” and she may eat primarily in the presence of
other people, whereas another person may overeat
only when under stress.
Third, factors controlling a health behavior may
change over the history of the behavior (Costello,
Dierker, Jones, & Rose, 2008). For example, although
peer group pressure (social factors) is important in initi-
ating smoking, over time, smoking may be maintained
because it reduces feelings of stress.
Fourth, factors controlling a health behavior may
change across a person’s lifetime. In childhood,

Barriers to Modifying Poor
Health Behaviors
There is often little immediate incentive for practicing
good health behaviors, however. Health habits de-
velop during childhood and adolescence when most
people are healthy. Smoking, a poor diet, and lack of
exercise have no apparent effect on health for years,
and few children and adolescents are concerned about
what their health will be like when they are 40 or
50 years old (Johnson, McCaul, & Klein, 2002). As a
result, bad habits have a chance to make inroads.

Emotional Factors Emotions may lead to or
perpetuate unhealthy behaviors (Conner, McEachan,
Taylor, O’Hara, & Lawton, 2015). Poor health be-
haviors can be pleasurable, automatic, addictive, and
resistant to change. Moreover, threatening messages
designed to change health behaviors can produce
psychological distress and lead people to respond de-
fensively, distorting risks to their health (Beckjord,
Rutten, Arora, Moser, & Hesse, 2008; Good &
Abraham, 2007). People may perceive a health threat
to be less relevant than it really is, and they may
falsely see themselves as less vulnerable than or dis-
similar to other people with the same habit (Roberts,
Gibbons, Gerrard, & Alert, 2011; Thornton, Gibbons,
& Gerrard, 2002). Continuing to practice a risky be-
havior may itself lead people to minimize their risks

TABLE 3.2 | Health Locus of Control

Health locus of control assesses whether you think you control your health or whether you believe it’s controlled by health care
professionals or by chance. Here are some examples of items that assess health locus of control. For each item, circle the
number that represents the extent to which you agree or disagree with that statement.

1 Strongly Disagree (SD) 4 Slightly Agree (A)

2 Moderately Disagree (MD) 5 Moderately Agree (MA)

3 Slightly Disagree (D) 6 Strongly Agree (SA)

SD MD D A MA SA

1. If I get sick, it is my own behavior that 1 2 3 4 5 6
determines how soon I get well again.

2. Most things that affect my health happen to me 1 2 3 4 5 6
by accident.

3. Whenever I don’t feel well, I should consult a 1 2 3 4 5 6
medically trained professional.

4. I am in control of my health. 1 2 3 4 5 6

5. Health professionals control my health. 1 2 3 4 5 6

6. My good health is largely a matter of good fortune. 1 2 3 4 5 6

7. If I take the right actions, I can stay healthy. 1 2 3 4 5 6

Source: Wallston, Wallston, & DeVellis, 1978; see http://www.vanderbilt.edu/nursing/kwallston/mhlcscales.htm for the complete scale.

42 Part Two Health Behavior and Primary Prevention

Using the Teachable Moment Some times are
better than others for modifying health practices. Health
promotion efforts capitalize on these teachable
moments. Many teachable moments arise in early child-
hood. Parents can teach their children basic safety
behaviors, such as looking both ways before crossing the
street, and basic health habits, such as drinking milk
instead of soda with dinner.
Other teachable moments are built into the health
care system. For example, many infants in the United
States are covered by well-baby care. Pediatricians
can make use of these visits to teach motivated new
parents the basics of accident prevention and home
safety. Many school systems require a physical at the
beginning of the school year and require documenta-
tion of immunizations.
But what can children really learn about health
habits? Surprisingly, quite a bit. Interventions with
children indicate that choosing healthy foods, brushing
teeth regularly, using car seats and seat belts, participat-
ing in exercise, crossing the street safely, and behaving
appropriately in real or simulated emergencies (such as
earthquake drills) are all within the ability of children
as young as age 3 or 4, as long as the behaviors are ex-
plained concretely and the children know what to do
(Maddux, Roberts, Sledden, & Wright, 1986).
Middle school is an important time for learning
several health-related habits. For example, food choices,
snacking, and dieting all crystallize around this time
(Cohen et al., 1990). There is also a window of
vulnerability for smoking and drug use during middle

regular exercise is practiced because it is built into the
school curriculum, but in adulthood, this behavior
must be practiced intentionally.
In summary, health behaviors are elicited and
maintained by different factors for different people,
and these factors change over the lifetime as well as
over the course of the health habit. Consequently,
health habit interventions have focused heavily on
those who may be helped the most—namely, children
and adolescents (Patton et al., 2012).

Intervening with Children and
Adolescents
Socialization Health habits are strongly affected by
early socialization, especially the influence of parents as
both teachers and role models (Morrongiello, Corbett, &
Bellissimo, 2008). Parents instill certain habits in their
children (or not) that become automatic, such as brush-
ing teeth regularly and eating breakfast every day. None-
theless, in many families, even these basic health habits
are not taught. Especially in families in which parents are
separated or there is chronic family stress, health habits
may slip through the cracks (Menning, 2006).
Moreover, as children move into adolescence, they
sometimes ignore the early training they received from
their parents. In addition, adolescents are exposed to
alcohol consumption, smoking, drug use, and sexual
risk taking, particularly if their parents aren’t monitor-
ing them very closely and their peers practice these
behaviors (Andrews, Tildesley, Hops, & Li, 2002).

The foundations for health promotion develop in early childhood, when children are

taught to practice good health behaviors.

© Myrleen Ferguson Cate/Photo Edit

Chapter 3 Health Behaviors 43

for calcium consumption for the prevention of osteo-
porosis. Risk factors of other disorders such as coro-
nary heart disease may also be strongly affected by
health habits in childhood and adolescence as well.

Intervening with At-Risk People
I’m a walking time bomb.

— 37-year-old woman whose female relatives
had breast cancer.

Another vulnerable group is people who are at risk for
particular health problems. For example, people from fam-
ilies with a familial disorder may know that their personal
risk is higher (Glenn et al., 2011). For example, a pediatri-
cian may work with obese parents to control the diet of
their offspring so that obesity in the children can be avoided.

Benefits of Focusing on At-Risk People
Working with at-risk populations can be an efficient
and effective use of health promotion dollars. First,
disease may be prevented altogether. For example,
helping men with a family history of heart disease to
stop smoking can prevent coronary heart disease.
When a risk factor has implications for only some peo-
ple, it makes sense to target those people for whom the
risk factor is relevant. For example, people who have
hypertension that implicates salt sensitivity need to be
especially vigilant about controlling their salt intake.

school, when students are first exposed to these habits
among their peers (D’Amico & Fromme, 1997). Inter-
ventions through the schools may reduce these risks.
Teachable moments are not confined to childhood
and adolescence. Pregnancy is a teachable moment for
stopping smoking and improving diet (Heppner et al.,
2011; Levitsky, 2004). The time period immediately af-
ter giving birth is also a teachable moment for increasing
physical activity and regular exercise, as many new
mothers want to get back to their previous level of fitness
and appearance; but, barriers to physical activity need to
be addressed as well, because new mothers may have
many new responsibilities, leaving little time for behav-
ior seen as optional (Fjeldsoe, Miller, & Marshall, 2013;
Rhodes et al., 2014). Adults with newly diagnosed coro-
nary artery disease are especially motivated to change
contributing health habits such as smoking and poor diet.

Adolescent Health Behaviors and Adult
Health An important reason for intervening with
adolescents is that precautions taken in adolescence
may affect disease risk after age 45 more than do adult
health behaviors. The health habits a person practices
as a teenager or college student may determine which
chronic diseases he or she develops and what the per-
son ultimately dies of in adulthood. For adults who
make changes in their lifestyle, it may already be too
late. This is true for sun exposure and skin cancer and

Adolescence is a window of vulnerability for many poor health habits.

Consequently, intervening to prevent health habits from developing is a high priority

for children in late elementary and middle school.

© Shutterstock/Monkey Business Images RF

44 Part Two Health Behavior and Primary Prevention

Focusing on at-risk people helps to identify other
factors that may increase risk. For example, not every-
one who has a family history of hypertension will de-
velop hypertension, but by focusing especially on
people who are at risk, other factors that contribute to
its development, such as diet, may be identified.

Problems of Focusing on At-Risk People
Clearly, however, there are difficulties in working
with people at risk. People do not always perceive
their risk correctly (Croyle et al., 2006). Most people
are unrealistically optimistic and view their poor
health behaviors as widely shared but their healthy
behaviors as more distinctive. For example, smokers
overestimate the number of other people who smoke.
Sometimes testing positive for a risk factor leads
people into needless worry or hypervigilant behavior
(DiLorenzo et al., 2006). People can become defensive,
minimize the significance of their risk factor, and avoid
using appropriate services or monitoring their condition.

Ethical Issues At what point is it appropriate to
alarm at-risk people if their personal risk is unknown?
Not everyone at risk for a particular disorder will develop
the problem and, in many cases, only many years later.
For example, should adolescent daughters of breast can-
cer patients be alerted to their risk and alarmed at a time
when they are coming to terms with their emerging sexu-
ality and needs for self-esteem? Psychological distress
may be created in exchange for instilling risk reduction
behaviors (Croyle, Smith, Botkin, Baty, & Nash, 1997).
Some people, such as those predisposed to depression,
may react especially poorly to information about their
risks. Moreover, in cases involving genetic risk factors,
there may not be any effective intervention. For example,
alcoholism has a genetic component, particularly among
men, and yet exactly how to intervene with the offspring
of adult alcoholics is not yet clear.
Emphasizing risks that are inherited can raise
complicated issues of family dynamics. For example,
daughters of breast cancer patients may suffer stress
and exhibit behavior problems, due in part to the en-
hanced recognition of their risk (Taylor, Lichtman, &
Wood, 1984a). Intervening with at-risk populations
remains a controversial issue.

Health Promotion and Older Adults
John Rosenthal, 92, starts each morning with a brisk
walk. After a light breakfast of whole wheat toast and
orange juice, he gardens for an hour or two. Later,
he joins a couple of friends for lunch, and if he can

persuade them to join him, they fish during the early
afternoon. Reading a daily paper and always having a
good book to read keeps John mentally sharp. Asked
how he maintains such a busy schedule, John says,
“Exercise, friends, and mental challenge” are the keys
to his long and healthy life.

Rosenthal’s lifestyle is right on target. A chief focus of
recent health promotion efforts has been older adults.
At one time, it was thought that health promotion ef-
forts are wasted in old age. However, policy makers
now recognize that a healthy older adult population is
essential not only for quality of life but also for con-
trolling health care spending.
Health promotion efforts with older adults focus on
several behaviors: maintaining a healthy, balanced diet;
maintaining a regular exercise regimen; taking steps to
reduce accidents; controlling alcohol consumption;
eliminating smoking; reducing the inappropriate use of
prescription drugs; obtaining vaccinations against in-
fluenza; and remaining socially engaged. Often, older
adults have multiple issues or health habits that need
modification, requiring an integrative biopsychosocial
approach to their health care needs (Wild et al., 2014).

Among older adults, health habits are a major determinant of

whether an individual will have a vigorous or an infirmed old age.
© Marcy Maloy/Getty Images RF

Chapter 3 Health Behaviors 45

Exercise keeps older adults mobile and able to
care for themselves, and it does not have to be strenu-
ous. Participating in social activities, running errands,
and engaging in light housework or gardening reduce
the risk of mortality, perhaps by providing social sup-
port or a general sense of self efficacy (Glass, deLeon,
Marottoli, & Berkman, 1999). Among the very old,
exercise has particularly strong benefits (Kahana
et al., 2002).
Controlling alcohol consumption is important for
good health among older adults as well. Some older
adults develop drinking problems in response to age-
related issues, such as loneliness (Brennan & Moos,
1995). Others may try to maintain the drinking habits
they had throughout their lives, which become more
risky in old age. Metabolic changes related to age may
reduce the capacity for alcohol. Moreover, many older
people are on medications that may interact danger-
ously with alcohol, leading to accidents.
Proper medication use is essential to good health.
Older adults who are poor may cut back on their med-
ications to save money. Unfortunately, those who do
are more likely to experience health problems within
the next few years (Reitman, 2004, June 28).
Flu vaccination for older adults is an important
health priority. Flu is a major cause of death among
older adults, and it increases the risk of heart disease
and stroke (Nichol et al., 2003).
Depression and loneliness are problems for older
adults. They compromise health habits, leading to ac-
celerated physical decline. Consequently, addressing
these issues can have effects on physical health
(Newall, Chipperfield, Bailis, & Stewart, 2013).
Related problems of loneliness and social isolation
can take a health toll on older adults, and so interven-
tions to increase social engagement can promote this
important health behavior (Thomas, 2011).
The emphasis on health habits among older
adults is well placed. By age 80, health habits are the
major determinant of whether a person will have a
vigorous or an infirmed old age (McClearn et al.,
1997). Moreover, the efforts to change older adults’
health habits seem to be working: The health of our
older adult population is improving (Lubitz, Cai,
Kramarow, & Lentzner, 2003), and consequently, so
is their well-being (Gana et al., 2013).

Ethnic and Gender Differences in Health
Risks and Habits
Health promotion addresses ethnic and gender differ-
ences in vulnerability to health risks. For example,

African American and Hispanic women get less exer-
cise than do Anglo women and are more likely to be
overweight (Pichon et al., 2007). Anglo and African
American women are more likely to smoke than His-
panic women. Alcohol consumption is a greater prob-
lem among men than women, and smoking is a
somewhat greater problem for Anglo men than for
other groups.
Health promotion efforts with different ethnic
groups need to take account of culturally different social
norms. Culturally appropriate interventions include con-
sideration of health practices in the community, infor-
mal networks of communication that can make
interventions more successful, and language (Barrera,
Toobert, Strycker, & Osuna, 2012; Toobert et al., 2011).
Even efficient low-cost interventions such as text mes-
saging and automated telephone messages can be suc-
cessfully implemented when the messages are culturally
adapted to the target group (Migneault et al., 2012).
Health promotion programs for ethnic groups
also need to take account of co-occurring risk factors.
The combined effects of low socioeconomic status
and a biologic predisposition to particular illnesses,
for example, put certain groups at great risk. Exam-
ples are diabetes among Hispanics and hypertension
among African Americans, which we will consider in
more detail in Chapter 13.

■ CHANGING HEALTH HABITS

Habit is habit, and not to be flung out of the window
by any man, but coaxed downstairs a step at a time.

—Mark Twain

In the remainder of this chapter, we address how
health behaviors can be changed.

Attitude Change and Health Behavior
Educational Appeals Educational appeals
make the assumption that people will change their
health habits if they have good information about their
habits. Early and continuing efforts to change health
habits have consequently focused heavily on educa-
tion and changing attitudes. Table 3.3 lists the charac-
teristics that make health communications especially
persuasive. More recently, though, the fact that atti-
tude change may not lead to behavior change has
prompted research on what additional factors may be
involved (Siegel, Navarro, Tan, & Hyde, 2014). Also,
the important automatic aspect of health habits has
been incorporated into interventions, as unconscious

46 Part Two Health Behavior and Primary Prevention

and nonconscious influences on the practice of health
habits have become increasingly apparent.

Fear Appeals Attitudinal approaches to chang-
ing health habits often make use of fear appeals. This
approach assumes that if people are afraid that a par-
ticular habit is hurting their health, they will change
their behavior to reduce their fear. However, this rela-
tionship does not always hold.
Persuasive messages that elicit too much fear may
actually undermine health behavior change (Becker &
Janz, 1987). Moreover, fear alone may not be suffi-
cient to change behavior. Specific action recommen-
dations, such as where and how one can obtain a flu
shot, may be needed (Self & Rogers, 1990). More-
over, as already noted, fear can increase defensive-
ness, which reduces how effective an appeal will be.

Message Framing A health message can be
phrased in positive or negative terms. For example, a
reminder card to get a flu immunization can stress the
benefits of being immunized or stress the discomfort
of the flu itself (Gallagher, Updegraff, Rothman, &
Sims, 2011). Which of these methods is more success-
ful? Messages that emphasize problems seem to work
better for behaviors that have uncertain outcomes, for
health behaviors that need to be practiced only once,
such as vaccinations (Gerend, Shepherd, & Monday,
2008), and for issues about which people are fearful

TABLE 3.3 | Educational Appeals

• Communications should be colorful and vivid rather
than steeped in statistics and jargon. If possible, they
should also use case histories (Arkes & Gaissmaier,
2012).

• The communicator should be expert, prestigious,
trustworthy, likable, and similar to the audience.

• Strong arguments should be presented at the beginning
and end of a message, not buried in the middle.

• Messages should be short, clear, and direct.
• Messages should state conclusions explicitly.
• Extreme messages produce more attitude change, but

only up to a point. Very extreme messages are
discounted. For example, a message that urges people
to exercise for half an hour a day will be more effective
than one that recommends 3 hours a day.

• For illness detection behaviors (such as HIV testing
or obtaining a mammogram), emphasizing problems if
the behaviors are not undertaken will be most
effective. For health promotion behaviors (such as
sunscreen use), emphasizing the benefits may be
more effective.

• If the audience is receptive to changing a health habit,
then the communication should include only favorable
points, but if the audience is not inclined to accept the
message, the communication should discuss both sides
of the issue.

• Interventions should be sensitive to the cultural norms
of the community to which they are directed. For
example, family-directed interventions may be
especially effective in Latino communities (Pantin
et al., 2009).

Fear appeals often alert people to a health problem but do not necessarily

change behavior.

© McGraw-Hill Education/Christopher Kerrigan photographer

Chapter 3 Health Behaviors 47

are serious. Thus, for example, people may change
their diet to include low cholesterol foods if they value
health, feel threatened by the possibility of heart dis-
ease, and perceive that the personal threat of heart
disease is severe (Brewer et al., 2007).

Perceived Threat Reduction Whether a per-
son believes a health measure will reduce threat has
two subcomponents: whether the person thinks the
health practice will be effective, and whether the cost
of undertaking that measure exceeds its benefits
(Rosenstock, 1974). For example, the man who is con-
sidering changing his diet to avoid a heart attack may
believe that dietary change alone would not reduce his
risk of a heart attack and that changing his diet would
interfere with his enjoyment of life too much to justify
taking the action. So, even if his perceived vulnerabil-
ity to heart disease is great, he would probably not
make any changes. A diagram of the health belief
model applied to smoking is presented in Figure 3.1.

Support for the Health Belief Model Many
studies have used the health belief model to increase
perceived risk and increase perceived effectiveness of
steps to modify a broad array of health habits, ranging
from health screening programs to smoking (e.g.,
Goldberg, Halpern-Felsher, & Millstein, 2002). The
health belief model does, however, leave out an impor-
tant component of health behavior change, and that is
a sense of self efficacy: the belief that one can control
one’s practice of a particular behavior ( Bandura, 1991).
For example, smokers who believe they cannot stop
smoking are unlikely to make the effort.
Other theories of health behavior change use a
similar conceptual analysis of behavior change. For
example, Protection Motivation Theory (Rogers,
1975) examines how people appraise health threats
and how they appraise their abilities to manage
threats. This theory, too, has guided many health in-
terventions (Milne, Sheeran, & Orbell, 2000).

The Theory of Planned Behavior
Health beliefs go some distance in predicting when
people will change their health habits. A theory that
attempts to link health beliefs directly to behavior is
Ajzen’s theory of planned behavior (Ajzen & Madden,
1986; Fishbein & Ajzen, 1975).
According to this theory, a health behavior is the
direct result of a behavioral intention. Behavioral inten-
tions are themselves made up of three components:

(Gerend & Maner, 2011). Messages that stress bene-
fits are more persuasive for behaviors with certain
outcomes (Apanovitch, McCarthy, & Salovey, 2003).
A meta-analysis of 94 studies indicated that messages
stressing benefits are more effective than messages
stressing risks for encouraging health behaviors, such
as skin cancer prevention, smoking cessation, and
physical activity (Gallagher & Updegraff, 2012).
However, negative (loss) framing may stimulate
thought about the health behavior (Bassett-Gunter,
Martin Ginis, & Latimer-Cheung, 2013).
Which kind of message framing will most affect
behavior also depends on people’s personal charac-
teristics (Covey, 2014). For example, people who
have a promotion or approach orientation that empha-
sizes maximizing opportunities are more influenced
by messages phrased in terms of benefits (“calcium
will keep your bones healthy”), whereas people who
have a prevention or avoidance orientation that em-
phasizes minimizing risks are more influenced by
messages that stress the risks of not performing a
health behavior (“low calcium intake will increase
bone loss”) (Updegraff, Emanuel, Mintzer, & Sher-
man, 2015). On the whole, promotion-oriented mes-
sages may be somewhat more successful in getting
people to initiate behavior change, and prevention
messages may be more helpful in getting them to
maintain behavior change over time (Fuglestad, Roth-
man, & Jeffery, 2008).

The Health Belief Model
Attitudinal approaches to health behavior change have
been formalized in several specific theories that have
guided interventions to change health behaviors. An
early influential attitude theory of why people prac-
tice health behaviors is the health belief model
(Hochbaum, 1958; Rosenstock, 1966). According to
this model, whether a person practices a health behav-
ior depends on two factors: whether the person per-
ceives a personal health threat, and whether the person
believes that a particular health practice will be effec-
tive in reducing that threat.

Perceived Health Threat The perception of a
personal health threat is influenced by at least three
factors: general health values, which include interest
in and concern about health; specific beliefs about
personal vulnerability to a particular disorder ( Dillard,
Ferrer, Ubel, & Fagerlin, 2012); and beliefs about the
consequences of the disorder, such as whether they

48 Part Two Health Behavior and Primary Prevention

and the motivation to comply with those normative be-
liefs. Perceived behavioral control is the perception that
one can perform the action and that the action will have
the intended effect; this component of the model is sim-
ilar to self efficacy. These factors combine to produce a
behavioral intention and, ultimately, behavior change.

attitudes toward the specific action, subjective norms
regarding the action, and perceived behavioral control
(Figure 3.2). Attitudes toward the action center on the
likely outcomes of the action and evaluations of those
outcomes. Subjective norms are what a person believes
others think that person should do (normative beliefs)

FIGURE 3.2 | The Theory of Planned Behavior Applied to Adopting a Healthy Diet (Sources: Ajzen & Fishbein, 1980;
Ajzen & Madden, 1986)

Attitudes toward the specific action

— Beliefs about the outcomes of the
behavior (If I change my diet, I will
lose weight, improve my health,
and be more attractive.)

— Evaluations of the outcomes of
the behavior (Being healthy and
looking good are desirable.)

Subjective norms regarding the action

— Normative beliefs (My family and
friends think I should change my diet.)

— Motivation to comply (I want to do
what they want me to do.)

Perceived behavioral control

— (I will be able to change my diet.)

Behavioral
intention
(intending to
change my diet)

Health behavior
(adopting a healthier
diet)

FIGURE 3.1 | The Health Belief Model Applied to the Health Behavior of Stopping Smoking

Belief in health threat

— General health values
(I am concerned about my health.)

— Specific beliefs about vulnerability
(As a smoker, I could get lung cancer.)

— Beliefs about severity of the disorder
(I would die if I developed lung cancer.)

Belief that specific health behavior can reduce threat

— Belief that specific measure can be effective
against specific threat
(If I stop smoking now, I will not develop lung cancer.)

— Belief that benefits of health measure exceed costs
(Even though it will be hard to stop smoking, it is
worth it to avoid the risk of lung cancer.)

Health behavior
(I will stop smoking.)

Chapter 3 Health Behaviors 49

regulation is conscious, designed to meet personal goals
and control thoughts, emotions, and behavior in service
of those goals. Enhancing health behaviors requires ef-
fective self regulation (Mann, de Ridder, & Fujita, 2013)
and interventions may need to be aimed at both the
automatic and the conscious, controlled processes
(Conroy, Maher, Elavsky, Hyde, & Doerksen, 2013).

Self Determination Theory
Self determination theory (SDT), a theory that also
guides health behavior modification, builds on the
idea that people are actively motivated to pursue their
goals (Deci & Ryan, 1985; Ryan & Deci, 2000). The
theory targets two important components as funda-
mental to behavior change, namely autonomous moti-
vation and perceived competence. People are
autonomously motivated when they experience free
will and choice when making decisions. Competence
refers to the belief that one is capable of making the
health behavior change.
Accordingly, if a woman changes her diet because
her physician tells her to, she may not experience a sense
of autonomy and instead may experience her actions as
under another’s control. This may undermine her com-
mitment to behavior change. However, if her dietary
change is autonomously chosen, she will be intrinsically
motivated to persist. SDT has given rise to interventions
that target these beliefs, namely autonomous motivation
and competence, and have shown some success in
changing behaviors including smoking and adherence to
medications (Bruzzese et al., 2014). A meta-analysis of
184 studies indicates support for self-determination the-
ory and the importance of autonomous motivation for
changing health behaviors (Ng et al., 2012).

Implementation Intentions
A theoretical model that emphasizes implementation
intentions (Gollwitzer, 1999) integrates conscious
processing with automatic behavioral enactment
(Gollwitzer & Oettingen, 1998). When a person de-
sires to practice a health behavior, it can be achieved
by making a simple plan that links critical situations
or environmental cues to goal-directed responses. For
example, a person might tell herself, “When I finish
breakfast, I will take out the dog’s leash and walk her.”
The theory underscores the importance of planning ex-
actly how, when, and where to implement a health
behavior. Without these explicit links to action, the
good intention might remain at the intention stage.

To take a simple example, smokers who believe
that smoking causes serious health outcomes, who be-
lieve that other people think they should stop smok-
ing, who are motivated to comply with those normative
beliefs, who believe that they are capable of stopping
smoking, and who form a specific intention to do so
will be more likely to stop smoking than people who
do not hold these beliefs.

Evidence for the Theory of Planned Behavior
The theory of planned behavior predicts a broad array
of health behaviors, and change in health behaviors
(Montanaro & Bryan, 2014; McEachan, Conner,
Taylor, & Lawton, 2011). Its components predict such
behaviors as risky sexual activity among heterosexuals
(Tyson, Covey, & Rosenthal, 2014; Davis et al., 2016),
consumption of soft drinks (Kassem & Lee, 2004) and
food safety practices (Milton & Mullan, 2012). More-
over, communications targeted to particular parts of
the model, such as social norms, have been found to
change behaviors (Reid & Aiken, 2013).

Criticisms of Attitude Theories
Because health habits are often deeply ingrained and
difficult to modify, attitude-change interventions may
provide the informational base for altering health
habits but not always the impetus to take action
(Ogden, 2003). Moreover, attitude change techniques
assume that behavior changes are guided by con-
scious motivation, and these approaches ignore the
fact that some behavior change occurs automatically
and is not subject to awareness. That is, a general
limitation of health behavior change models is the
fact that they heavily emphasize conscious delibera-
tive processes in practicing health behaviors; there is
an important role for implicit automatic processes as
well. Perhaps the most obvious example concerns
health habits that are accomplished automatically in
response to a minimal cue, such as putting on a seat-
belt when one gets into a car.

Self Regulation and Health Behavior
Thus far, we have discussed changing health behaviors
primarily through interventions designed to get people
to alter their behavior. But people also change on their
own. Self regulation refers to the fact that people con-
trol their own actions, emotions, and thoughts (Fiske &
Taylor, 2013). A lot of self regulation is automatic, oc-
curring without awareness or thought. But much self

50 Part Two Health Behavior and Primary Prevention

Harrison, & Lieberman, 2010) gave people persuasive
messages promoting sunscreen use. People who showed
significant activation in two particular brain regions,
the medial prefrontal cortex (mPFC) and posterior cin-
gulate cortex (pCC), in response to the messages in-
creased their sunscreen use. Most important, attitude
change about sunscreen use in response to the persua-
sive message only weakly predicted people’s intentions
to use sunscreen, but activity in these two brain regions
quite strongly predicted sunscreen use, independent of
attitudes and behavioral intentions. In other words, pro-
cesses apparently not accessible to consciousness none-
theless significantly predicted changes in sunscreen use
(Falk, Berkman, Whalen, & Lieberman, 2011).
What this pattern of brain activity means is not yet
fully known. One possibility is that activity in mPFC
and pCC reflects behavioral intentions at an implicit
level that is not consciously accessible (Falk et al.,
2010). Alternatively, activity in mPFC may be related
to behavior change primarily because participants link
the persuasive communication to the self. In any case,
health behavior change can occur unconsciously, but
the brain may detect these processes nonetheless.

■ COGNITIVE-BEHAVIORAL
APPROACHES TO HEALTH
BEHAVIOR CHANGE

Cognitive-Behavior Therapy (CBT)
Cognitive-behavior approaches to health habit modi-
fication focus on the target behavior itself, the condi-
tions that elicit and maintain it, and the factors that
reinforce it (Dobson, 2010). The most effective ap-
proach to health habit modification often comes from
cognitive-behavior therapy (CBT). CBT interven-
tions use several complementary methods to inter-
vene in the modification of a target problem and its
context. CBT may be implemented individually,
through therapy in a group setting, or even on the In-
ternet, and so it is a versatile as well as effective way
of intervening to modify poor health habits.

Self Monitoring
Many programs of cognitive-behavioral modification
use self monitoring as the first step toward behavior
change. The rationale is that a person must understand
the dimensions of the poor health habit before change
can begin. Self monitoring assesses the frequency of a
target behavior and the antecedents and consequences
of that behavior.

A second important feature of the theory is the idea
that, by forming an implementation intention, a person
can delegate the control of goal-directed responses to
situational cues (e.g., completing breakfast), which
may then elicit the behavior automatically (in this case,
the action of taking out the leash to walk the dog). Over
time, the link from the implementation to the goal-
directed response becomes automatic and need not be
brought into conscious awareness to be enacted.
Forming implementation intentions can be a simple
but effective way to promote health behaviors (Martin,
Sheeran, Slade, Wright, & Dibble, 2009). When a person
has a particular health goal, such as remembering to use
sunscreen, he or she can strategically engage automatic
processes in an effort to make good on that goal. So, for
example, a person wanting to practice better sun safety
behaviors might say, “Whenever I am going to the beach,
I will put on sunscreen first.” Having created this imple-
mentation intention, she then delegates the control of
sunscreen use to anticipated situational cues, in this case,
getting ready to go to the beach (Gollwitzer, 1999). Thus,
although the original implementation intention is con-
sciously framed, the relation of the health behavior itself
to the situation in which it is relevant becomes an auto-
matic process (Sheeran, Gollwitzer, & Bargh, 2013).
Adding implementation intentions to attitude models
of health behavior has improved their ability to predict
behavior (Milne, Orbell, & Sheeran, 2002). Results of
a meta-analysis support the idea that changes in inten-
tions lead to changes in behavior (Webb & Sheeran,
2006).

Self Affirmation Self affirmation occurs when
people reflect upon their important values, personal
qualities, or social relationships. When people are self
affirmed, they become less defensive about personally
relevant risk-related information (Schüz, Schüz, & Eid,
2013), which can set the stage for behavior change. A
meta-analysis of 144 studies has shown that inducing
self awareness when people are exposed to persuasive
health information leads to positive changes in inten-
tions and in actual health behaviors (Epton et al., 2015;
Sweeney & Moyer, 2015).

Health Behavior Change and the Brain
Some successful health behavior change in response to
persuasive messages occurs outside of awareness. De-
spite being inaccessible to conscious awareness, this
change may be reflected in patterns of brain activation.
Emily Falk and colleagues (Falk, Berkman, Mann,

Chapter 3 Health Behaviors 51

avoiding eating while engaged in other activities, such
as watching television. Other stimuli might be intro-
duced in the environment to indicate that controlled eat-
ing will now be followed by reinforcement. For example,
people might place signs in strategic locations around
the home, reminding them of reinforcements to be
obtained after successful behavior change.

The Self Control of Behavior
Cognitive-behavior therapy focuses heavily on the be-
liefs that people hold about their health habits. People
often generate internal monologues that interfere with
their ability to change their behavior. For example, a per-
son who wishes to give up smoking may derail the quit-
ting process by generating self doubts (“I will never be
able to give up smoking”). Unless these internal mono-
logues are modified, the person will be unlikely to change
a health habit and maintain that change over time.
Recognition that people’s cognitions about their
health habits are important in producing behavior
change highlights another insight about the behavior
change process: the importance of involving the client
as co-therapist in the behavior-change intervention. Cli-
ents need to actively monitor their own behaviors and
apply the techniques of cognitive-behavioral therapy
to bring about change. As such, CBT emphasizes
self control. The person acts as his or her own therapist
and, together with outside guidance, learns to control
the antecedents and consequences of the target behavior.
Cognitive restructuring trains people to recognize
and modify their internal monologues to promote health
behavior change. Sometimes the modified cognitions
are antecedents to a target behavior. For example, if a
smoker’s urge to smoke is preceded by an internal
monologue that he is weak and unable to control his
smoking urges, these beliefs are targeted for change.
The smoker would substitute a monologue that would
help him stop smoking (for example, “I can do this” or
“I’ll be so much healthier”). Cognitions can also be the
consequences of a target behavior. For example, an
obese woman trying to lose weight might undermine her
weight-loss program by reacting with hopelessness to
every small dieting setback. She might learn, instead, to
engage in self reinforcing cognitions following success-
ful resistance to temptation and constructive self
criticism following setbacks (“Next time, I’ll keep those
tempting foods out of my refrigerator”).

Self Reinforcement Self reinforcement involves
systematically rewarding oneself to increase or decrease

The first step in self monitoring is to learn to dis-
criminate the target behavior. For some behaviors, this
step is easy. A smoker obviously can tell whether he
or she is smoking. However, an urge to smoke may be
less easily discriminated; therefore, the person may be
trained to monitor internal sensations closely so as to
identify the target behavior more readily.
A second stage in self monitoring is charting the
behavior. For example, a smoker may keep a detailed
record of smoking-related events, including when a ciga-
rette is smoked, the time of day, the situation in which the
smoking occurred, and the presence of other people (if
any). She may also record the subjective feelings of crav-
ing that existed prior to lighting the cigarette, the emo-
tional responses that preceded the lighting of the cigarette
(such as anxiety or tension), and the feelings that were
generated by the actual smoking of the cigarette. In this
way, she can begin to get a sense of the conditions under
which she is most likely to smoke. Each of these condi-
tions can be a discriminative stimulus that is capable of
eliciting the target behavior. For example, the sight and
smell of food act as discriminative stimuli for eating. The
sight of a pack of cigarettes or the smell of coffee may act
as discriminative stimuli for smoking. The discrimina-
tive stimulus is important because it signals that a posi-
tive reinforcement will subsequently occur. CBT aims to
eliminate or modify these discriminative stimuli. Al-
though self monitoring is usually only a beginning step
in behavior change, it may itself produce some behavior
change (Quinn, Pascoe, Wood, & Neal, 2010). In fact,
even being asked questions about a health behavior can
launch behavior change (Rodrigues, O’Brien, French,
Glidewell, & Sniehotta, 2015).

Stimulus Control
Once the circumstances surrounding the target behav-
ior are well understood, the factors in the environment
that maintain poor health habits such as smoking,
drinking, and overeating, can be modified. Stimulus-
control interventions involve ridding the environ-
ment of discriminative stimuli that evoke the problem
behavior, and creating new discriminative stimuli,
signaling that a new response will be reinforced.
For example, eating is typically under the control of
discriminative stimuli, including the presence of desir-
able foods and activities (such as watching television).
People desiring to lose weight can be encouraged to
eliminate these discriminative stimuli for eating, such as
ridding their home of rewarding and fattening foods,
restricting their eating to a single place in the home, and

reduction in her smoking as a target (such as 15 ciga-
rettes a day). When that target is reached, she would
administer a reinforcement (the movie or dinner out).
The next step might be reducing smoking to 10 ciga-
rettes a day, at which time she would receive another
reinforcement. The target then might be cut progres-
sively to 5, 4, 3, 2, 1, and none. Through this process,
the target behavior of abstinence would eventually be
reached.
Like self reward, self punishment is of two types.
Positive self punishment involves the administration of
an unpleasant stimulus to punish an undesirable behav-
ior. For example, a person might self administer a mild
electric shock each time he or she experiences a desire

the occurrence of a target behavior. Positive self reward
involves rewarding oneself with something desirable
after successful modification of a target behavior, such
as going to a movie following successful weight loss.
Negative self reward involves removing an aversive fac-
tor in the environment after successful modification of
the target behavior. An example of negative self reward
is taking the Miss Piggy poster off the refrigerator once
regular controlled eating has been achieved.
For example, suppose Mary smokes 20 cigarettes a
day. She might first define a set of reinforcers that can
be administered when particular smoking-reduction
targets are met—reinforcements such as going out to
dinner or seeing a movie. Mary may then set a particular

First described by Russian physiologist Ivan Pavlov in
the early 20th century, classical conditioning is the
pairing of an unconditioned reflex with a new stimu-
lus, producing a conditioned reflex. Classical condi-
tioning is represented in Figure 3.3.
Classical conditioning was one of the first methods
used for health behavior change. For example, consider
its use in the treatment of alcoholism. Antabuse (un-
conditioned stimulus) is a drug that produces extreme
nausea, gagging, and vomiting (unconditioned re-
sponse) when taken in conjunction with alcohol. Over

time, the alcohol becomes associated with the nausea
and vomiting caused by the Antabuse and elicits the
same nausea, gagging, and vomiting response (condi-
tioned response) without the Antabuse being present.
Classical conditioning approaches to health habit
modification do work, but clients know why they
work. Alcoholics, for example, know that if they do not
take the drug they will not vomit when they consume
alcohol. Thus, even if classical conditioning has suc-
cessfully produced a conditioned response, it is heavily
dependent on the client’s willing participation.

B O X 3.1 Classical Conditioning

FIGURE 3.3 | A Classical Conditioning Approach to the Treatment of Alcoholism

Unconditioned
response

(nausea, gagging,
vomiting)

Unconditioned
response

(nausea, gagging,
vomiting)

Conditioned
response

(nausea, gagging,
vomiting)

Phase one Phase two Phase three

The unconditioned stimulus
produces a reflexive response.

The unconditioned stimulus
is paired with a new stimulus.

The conditioned stimulus
evokes the response.

Unconditioned
stimulus

(Antabuse)

Unconditioned
stimulus

(Antabuse)

Conditioned
stimulus
(alcohol)

Conditioned
stimulus
(alcohol)

52

53

to smoke. Negative self punishment consists of with-
drawing a positive reinforcer in the environment each
time an undesirable behavior is performed. For exam-
ple, a smoker might rip up money each time he or she
has a cigarette that exceeds a predetermined quota.
Self punishment is effective only if people actually
perform the punishing activities. If self punishment
becomes too aversive, people often abandon their efforts.
One form of self punishment that is effective in
behavior modification is contingency contracting. In
contingency contracting, an individual forms a contract
with another person, such as a therapist or one’s spouse,
detailing what rewards or punishments are contingent
on the performance or nonperformance of a behavior.
For example, a person who wants to stop drinking
might deposit a sum of money with a therapist and ar-
range to be fined each time he or she has a drink and to
be rewarded each day that he or she abstained.

Behavioral Assignments A technique for in-
creasing client involvement is behavioral assign-
ments, home practice activities that support the goals
of a therapeutic intervention. Behavioral assignments
are designed to provide continuity in the treatment
of a behavior problem. For example, if an early session
with an obese client involved training in self monitoring,
the client would be encouraged to keep a log of his
eating behavior, including the circumstances in which
it occurred. This log could then be used by the thera-
pist and the patient at the next session to plan future

behavioral interventions. Figure 3.4 gives an example
of the behavioral assignment technique. Note that it
includes homework assignments for both client and

B O X 3.2Operant Conditioning

In contrast to classical conditioning, which pairs an
automatic response with a new stimulus, operant con-
ditioning pairs a voluntary behavior with systematic
consequences. The key to operant conditioning is
reinforcement. When a person performs a behavior
and that behavior is followed by positive reinforce-
ment, the behavior is more likely to occur again. Sim-
ilarly, if an individual performs a behavior and
reinforcement is withdrawn or the behavior is pun-
ished, the behavior is less likely to be repeated. Over
time, these contingencies build up those behaviors
paired with positive reinforcement, whereas behaviors
that are punished or not rewarded decline.
Many health habits can be thought of as operant
responses. For example, drinking may be maintained
because mood is improved by alcohol, or smoking

may occur because peer companionship is associated
with it. In these cases, reinforcement maintains the
poor health behavior. Thus, using this principle to
change behavior requires altering the reinforcement.
An important feature of operant conditioning is
the reinforcement schedule. A continuous reinforce-
ment schedule means that a behavior is reinforced
every time it occurs. However, continuous reinforce-
ment is vulnerable to extinction: If the behavior is
occasionally not paired with reinforcement, the indi-
vidual may cease performing the behavior, having
come to anticipate reinforcement each time. Psychol-
ogists have learned that behavior is often more resis-
tant to extinction if it is maintained by a variable or
an intermittent reinforcement schedule than a con-
tinuous reinforcement schedule.

FIGURE 3.4 | Example of a Systematic Behavioral
Assignment for an Obese Client

(Source: Shelton & Levy, 1981, p. 6)

Homework for Tom [client]

Using the counter, count bites taken.

Record number of bites, time,
location, and what you ate.

Record everything eaten for 1 week.

Call for an appointment.

Bring your record.

Homework for John [therapist]

Reread articles on obesity.

and blood pressure and increases oxygenation of the
blood. People typically engage in deep breathing spon-
taneously when they are relaxed. In progressive mus-
cle relaxation, an individual learns to relax all the
muscles in the body progressively to discharge tension
or stress.

Motivational Interviewing
Motivational interviewing (MI) is increasingly used in
health promotion interventions. Originally developed to
treat addiction, the techniques have been adapted to tar-
get smoking, dietary improvements, exercise, cancer
screening, and sexual behavior, among other habits
(Miller & Rose, 2009). Motivational interviewing is a
client-centered counseling style designed to get people
to work through any ambivalence they experience about
changing their health behaviors. It may be especially
effective for people who are initially wary about whether
to change their behavior (Resnicow et al., 2002).
In motivational interviewing, the interviewer
adopts a nonjudgmental, nonconfrontational, encour-
aging, and supportive style. The goal is to help the
client express the positive or negative thoughts he or
she has regarding the behavior in an atmosphere that
is free of negative evaluation (Baldwin, Rothman,
Vander Weg, & Christensen, 2013). Typically, clients
talk at least as much as counselors during MI sessions.
In motivational interviewing, there is no effort to
dismantle the denial or irrational beliefs that often ac-
company bad health behaviors or even to persuade a
client to stop drinking, quit smoking, or otherwise im-
prove health. Rather, the goal is to get the client to
think through and express some of his or her own rea-
sons for and against behavior change. The interviewer
listens and provides encouragement in lieu of giving
advice (Miller & Rose, 2009).

therapist. This technique can ensure that both parties
remain committed to the behavior-change process and
that each is aware of the other’s commitment.
The chief advantages of behavioral assignments
are that (1) the client becomes involved in the treat-
ment process, (2) the client produces an analysis of
the behavior that is useful in planning further inter-
ventions, (3) the client becomes committed to the
treatment process through a contractual agreement to
discharge certain responsibilities, (4) responsibility
for behavior change is gradually shifted to the client,
and (5) the use of homework assignments increases
the client’s sense of self control.

Social Skills and Relaxation Training
Some poor health habits develop in response to the anx-
iety people experience in social situations. For example,
adolescents often begin to smoke to reduce their ner-
vousness in social situations by trying to communicate a
cool, sophisticated image. Drinking and overeating may
also be responses to social anxiety. Social anxiety can
then act as a cue for the maladaptive habit, necessitating
an alternative way of coping with the anxiety.
Consequently, many health habit modification
programs include either social skills training or
assertiveness training, or both, as part of the inter-
vention package. People are trained in methods that
help them deal more effectively with social anxiety.

Relaxation Training Many poor health habits are
caused or maintained by stressful circumstances, and
so managing stress is important to successful behavior
change. A mainstay of stress reduction is relaxation
training involving deep breathing and progressive
muscle relaxation. In deep breathing, a person takes
deep, controlled breaths, which decreases heart rate

Modeling is learning that occurs from witnessing an-
other person perform a behavior (Bandura, 1969). Ob-
servation and subsequent modeling can be effective
approaches to changing health habits. For example, in
one study high school students who observed others
donating blood were more likely to do so themselves
(Sarason, Sarason, Pierce, Shearin, & Sayers, 1991).
Similarity is an important principle in model-
ing. To the extent that people perceive themselves

as similar to the type of person who engages in a
risky behavior, they are likely to do so themselves;
if people see themselves as similar to the type of
person who does not engage in a risky behavior,
they may change their behavior (Gibbons &
Gerrard, 1995). For example, a swimmer may de-
cline a cigarette from a friend because she per-
ceives that most great swimmers do not smoke.

ModelingB O X 3.3

54

Chapter 3 Health Behaviors 55

find themselves in situations where they used to
smoke or drink, such as a party, and relapse at that
vulnerable moment. People with low self efficacy for
the behavior change initially are more likely to re-
lapse. Sometimes, people think they have beaten the
health problem, and so giving in to a temptation would
have few costs (e.g., “a couple drinks would relax
me”).
A potent catalyst for relapse is negative affect
(Witkiewitz & Marlatt, 2004). Relapse is more likely
when people are depressed, anxious, or under stress.
For example, when people are breaking off a relation-
ship or encountering difficulty at work, they are vulner-
able to relapse. Peter Jennings, the national newscaster
who died of lung cancer in 2005, had relapsed to smok-
ing after the September 11, 2001 terrorist attacks.
Figure 3.5 illustrates the relapse process. Because of
the high risk of relapse, behavioral interventions build
in techniques to try to reduce its likelihood.
Relapse prevention should be integrated into
treatment programs from the outset. Enrolling people
who are initially committed and motivated to change
their behavior reduces the risk of relapse and weeds
out people who are not truly committed to behavior
change. Although prescreening people for an

Relapse Prevention
One of the biggest problems faced in health habit
modification is the tendency for people to relapse.
Following initial successful behavior change, people
often return to their old bad habits. Relapse is a par-
ticular problem with the addictive disorders of alco-
holism, smoking, drug addiction, and overeating
(Brownell, Marlatt, Lichtenstein, & Wilson, 1986), but
it can be a problem for all behavior change efforts.
What do we mean by “relapse”? A single cigarette
smoked at a party or the consumption of a pint of ice
cream on a lonely Saturday night need not lead to full-
blown relapse. However, that one cigarette or that sin-
gle pint of ice cream can produce what is called an
abstinence violation effect—that is, a feeling of loss
of control that results when a person has violated self
imposed rules. The result can be a more serious relapse,
as the person’s resolve falters. This is especially true for
addictive behaviors because the person must also cope
with the reinforcing impact of the substance itself.

Reasons for Relapse Why do people relapse?
Initially when people change their behaviors, they are
vigilant, but over time, vigilance fades and the likeli-
hood of relapse increases. For example, people may

Decreased
probability
of relapse

Increased
self efficacy

High-risk
situation

Decreased
self efficacy

and
positive
outcome

expectancies
for effects of

alcohol

Increased
probability
of relapse

Abstinence
violation
effect and
perceived
positive

effects of
alcohol

Ineffective
coping

response

Lapse (initial
use of

alcohol)

Effective coping
response

FIGURE 3.5 | A Cognitive-Behavioral Model of the Relapse Process This figure shows what happens when
a person is trying to change a poor health habit and faces a high-risk situation. With adequate coping responses,
the person may be able to resist temptation, leading to a low likelihood of relapse. Without adequate coping
responses, however, perceptions of self efficacy may decline and perceptions of the rewarding effects of the poor
health behavior may increase, leading to an increased likelihood of relapse. (Source: Larimer, Palmer, & Marlatt, 1999)

56 Part Two Health Behavior and Primary Prevention

situations, and integrate their behavior change into a gen-
erally healthy lifestyle. In a meta-analysis of 26 studies
with more than 9,000 participants treated for alcohol,
tobacco, cocaine, and other substance use, Irvin and
colleagues (Irvin, Bowers, Dunn, & Wang, 1999) con-
cluded that relapse prevention techniques were effective
for reducing substance use and improving psychosocial
functioning.

Evaluation of CBT
The advantages of CBT for health behavior change are
several. First, a carefully selected set of techniques
can deal with all aspects of a problem (van Kessel
et al., 2008): Self observation and self monitoring define
the dimensions of a problem; stimulus control enables
a person to modify antecedents of behavior; self rein-
forcement controls the consequences of a behavior;
and social skills and relaxation training may replace
the maladaptive behavior, once it has been brought
under some degree of control.
A second advantage is that the therapeutic plan
can be tailored to each individual’s problem. Each per-
son’s faulty health habit and personality are different, so,
for example, the particular package identified for one
obese client may not be the same as that developed for
another obese client (Schwartz & Brownell, 1995).
Third, the range of skills imparted by multimodal inter-
ventions may enable people to modify several health
habits simultaneously, such as diet and exercise, rather
than one at a time (Persky, Spring, Vander Wal, Pagoto, &
Hedeker, 2005; Prochaska & Sallis, 2004). Overall,
CBT interventions have shown considerable success in
modifying a broad array of health behaviors.

■ THE TRANSTHEORETICAL
MODEL OF BEHAVIOR CHANGE

Changing a bad health habit does not take place all at
once. People go through stages while they are trying to
change their health behaviors (Prochaska, 1994; Rothman,
2000).

Stages of Change
J. O. Prochaska and his associates (Prochaska, 1994;
Prochaska, DiClemente, & Norcross, 1992) devel-
oped the transtheoretical model of behavior change,
a model that analyzes the stages and processes people
go through in bringing about a change in behavior and

intervention may seem ethically problematic, includ-
ing people who are likely to relapse may demoralize
other participants in a behavior-change program, de-
moralize the practitioner, and ultimately make it more
difficult for the relapser to change his or her behavior.
Relapse prevention techniques include asking peo-
ple to identify the situations that may lead to relapse so
they can help them develop coping skills that will help
them to manage that stressful event. For example, over-
coming the temptation to drink at bars might be fos-
tered by scheduling lunches with friends instead. Or, at
parties, a person might have a sham drink of club soda,
instead of an alcoholic beverage. Mentally rehearsing
coping responses in a high-risk situation can promote
feelings of self efficacy. For example, some programs
train participants to engage in constructive self talk that
will help them talk themselves through tempting situa-
tions (Brownell et al., 1986).
Cue elimination involves restructuring the environ-
ment to avoid situations that evoke the target behavior
(Bouton, 2000). For example, the alcoholic who drank
exclusively in bars can avoid bars. For other habits,
however, cue elimination is impossible. For example,
smokers are usually unable to completely eliminate the
circumstances in their lives that led them to smoke.
Consequently, some relapse prevention programs de-
liberately expose people to situations that evoke the old
behavior to give them practice in using their coping
skills (Marlatt, 1990). Making sure that the new habit
(such as exercise or alcohol abstinence) is practiced in
as many new contexts as possible also ensures that it
endures (Bouton, 2000).

Lifestyle Rebalancing Long-term maintenance of
behavior change can be promoted by leading the person
to make other health-oriented lifestyle changes, a tech-
nique termed lifestyle rebalancing. Lifestyle changes,
such as adding an exercise program or using stress man-
agement techniques, may promote a healthy lifestyle
more generally and help reduce the likelihood of relapse.
The role of social support in maintaining behav-
ior change is equivocal. At present, some studies sug-
gest that enlisting the aid of family members in
maintaining behavior change is helpful, but other
studies suggest not (Brownell et al., 1986). Possibly,
research has not yet identified the exact ways in which
social support may help maintain behavior change.
Overall, relapse prevention is most successful when
people perceive their behavior change to be a long-term
goal, develop coping techniques for managing high-risk

Chapter 3 Health Behaviors 57

successfully. In some cases, they have modified the
target behavior somewhat, such as smoking fewer cig-
arettes than usual, but have not yet made the commit-
ment to eliminate the behavior altogether.

Action The action stage occurs when people mod-
ify their behavior to overcome the problem. Action
requires the commitment of time and energy to mak-
ing real behavior change. It includes stopping the be-
havior and modifying one’s lifestyle and environment
to rid one’s life of cues associated with the behavior.

Maintenance In the stage of maintenance, people
work to prevent relapse and to consolidate the gains they
have made. For example, if a person is able to remain free
of an addictive behavior for more than 6 months, he or she
is assumed to be in the maintenance stage (Wing, 2000).
Because relapse is the rule rather than the excep-
tion with many health behaviors, this stage model is
conceptualized as a spiral. As Figure 3.6 indicates, a
person may take action, attempt maintenance, relapse,
return to the precontemplation phase, cycle through
the subsequent stages to action, repeat the cycle again,
and do so several times until they have eliminated the
behavior (Prochaska et al., 1992).

Using the Stage Model of Change
At each stage, particular types of interventions may
be most appropriate. Specifically, providing people
in the precontemplation stage with information about

suggested treatment goals and interventions for each
stage. Originally developed to treat addictive disor-
ders, such as smoking, drug use, and alcohol addic-
tion, the stage model has now been applied to a broad
range of health habits, including exercising and sun
protection behaviors (Adams, Norman, Hovell,
Sallis, & Patrick, 2009; Hellsten et al., 2008).

Precontemplation The precontemplation stage
occurs when a person has no intention of changing
his or her behavior. Many people in this stage are not
aware that they have a problem, although families,
friends, neighbors, or coworkers may well be. An ex-
ample is the problem drinker who is largely oblivious
to the problems he creates for his family. Sometimes
people in the precontemplative phase seek treatment
if they have been pressured by others to do so. Not
surprisingly, these people often revert to their old be-
haviors and so make poor targets for intervention.

Contemplation Contemplation is the stage in
which people are aware that they have a problem and
are thinking about it but have not yet made a commit-
ment to take action. Many people remain in the con-
templation stage for years. Interventions aimed at
increasing receptivity to behavior change can be help-
ful at this stage (Albarracín, Durantini, Earl, Gunnoe, &
Leeper, 2008).

Preparation In the preparation stage, people in-
tend to change their behavior but have not yet done so

Readiness to change a health habit is a prerequisite to health habit change.

© Getty Images RF

58 Part Two Health Behavior and Primary Prevention

Lack of time, stress, competing goals, and inaccessi-
bility of the health care system may be almost inevi-
table for some people (Gerend et al., 2013; Presseau,
Tait, Johnston, Francis, & Sniehotta, 2013). But
breaking down perceived barriers is paramount to get-
ting people to practice good health behaviors.

■ CHANGING HEALTH
BEHAVIORS THROUGH
SOCIAL ENGINEERING

Much health behavior change occurs not through pro-
grams such as CBT interventions, but through social
engineering. Social engineering modifies the environ-
ment in ways that affect people’s abilities to practice a
particular health behavior. Often, social engineering
solutions are legally mandated. Some examples include
requiring vaccinations for school entry, which has led
to 90 percent of children in the United States receiving
most of the vaccinations they need (Center for the Ad-
vancement of Health, December, 2002). Others include
banning certain drugs, such as heroin and cocaine, and
controlling the disposal of toxic wastes. Still others in-
clude taxation that may reduce, although not eliminate,
poor health habits such as consumption of sugared soft
drinks (The Economist, November 28, 2015).
Social engineering solutions to health problems
can be more successful than individual behavior mod-
ification. For example, lowering the speed limit has
had more impact on death and disability than inter-
ventions to get people to change their driving habits.
Raising the legal drinking age and banning smoking

their problem may move them to the contemplation
phase. To move people from the contemplation phase
into preparation, an appropriate intervention may in-
duce them to assess how they feel and think about the
problem and how stopping it will change them. Inter-
ventions designed to get people to make explicit
commitments as to when and how they will change
their behavior may bridge the gap between prepara-
tion and action. Interventions that emphasize provid-
ing self reinforcement, social support, stimulus
control, and coping skills should be most successful
with individuals moving through the action phase
into long-term maintenance. The transtheoretical
model has also been used to modify multiple health
behaviors simultaneously (Johnson et al., 2014).

Perceived Barriers Perceived barriers are as-
pects of one’s life that interfere with practicing good
health behaviors. The person with two jobs may not
have enough time to sleep 7–8 hours. A woman who
wants to exercise may perceive her neighborhood to
be too unsafe for walking or running. A family with-
out health insurance may not vaccinate their children.
Perceived barriers are a main reason why people
don’t practice good health behaviors (Gerend, Shep-
herd, & Shepherd, 2013), and it can be hard to help
people overcome them. In the case of health insur-
ance, social engineering has stepped in, requiring
people to have insurance and to vaccinate their chil-
dren. For the woman who wants to exercise, driving to
or getting off a bus where there is a park with other
people walking or running may solve the safety issue.

FIGURE 3.6 | A Spiral Model of the Stages of Change (Source: Prochaska et al., 1992)

Precontemplation Contemplation, preparation, action

Contemplation, preparation, action
Precontemplation

Maintenance

Termination

Chapter 3 Health Behaviors 59

individual treatment a person receives makes success
more likely, and second, the intervention can be tailored
to the needs of the particular person. However, only one
person’s behavior can be changed at a time.
Nonetheless, the one-to-one approach reduces
only one person’s risk at a time. Managed care facili-
ties sometimes run clinics to help people stop smok-
ing, change their diet, and make other healthy lifestyle
changes. Advantages are that a number of people can
be reached simultaneously, and there is a direct link
from knowledge of a person’s health risks to the type
of intervention that person receives.

The Family
Increasingly, health practitioners intervene with families
to improve health (Fisher et al., 1998). People from intact
families have better health habits than those who live
alone or in fractured families. Families typically have
more organized, routinized lifestyles than single people
do, so family life can be suited to building in healthy be-
haviors, such as eating three meals a day, sleeping eight
hours each night, and brushing teeth twice daily.
Children learn their health habits from their par-
ents, so committing the entire family to a healthy
lifestyle gives children the best chance at a healthy
start in life. Multiple family members are affected by
any one member’s health habits, and so modifying
one family member’s behavior, such as diet, is likely
to affect other family members.

in the workplace have had major effects on these
health problems. Controlling what is contained in
vending machines at school and controlling advertise-
ment of high fat and high cholesterol products to chil-
dren may help to reduce the obesity epidemic.
Still, most health behavior change cannot be le-
gally mandated, and people will continue to engage in
bad habits even when their freedoms to do so are lim-
ited by social engineering. Consequently, health psy-
chology interventions have a very important role in
health behavior change.

■ VENUES FOR HEALTH-HABIT
MODIFICATION

What is the best venue for changing health habits?
There are several possibilities:

The Practitioner’s Office
Many people have regular contact with a physician or
other health care professional who knows their medi-
cal history and can help them modify their health hab-
its. Physicians are highly credible sources for instituting
health habit change, and their recommendations have
the force of expertise behind them.
Some health-habit modification is conducted by
psychologists and other health practitioners privately on
a one-to-one basis, usually using cognitive- behavioral
techniques. This approach has two advantages. First, the

A stable family life is health promoting, and interventions are increasingly being

targeted to families rather than individuals to ensure the greatest likelihood of

behavior change.

© Ariel Skelly/Blend Images LLC RF

60 Part Two Health Behavior and Primary Prevention

2012). Workplace interventions include on-the-job
health promotion programs that help employees stop
smoking, reduce stress, change their diet, exercise
regularly, lose weight, control hypertension, and limit
drinking, among other problems. Workplace interven-
tions can be linked to those in other sites, for example,
if the workplace frees up parents to participate in
school interventions with their children (Anderson,
Symoniak, & Epstein, 2014). Some workplaces pro-
vide health clubs, restaurants that serve healthy foods,
and gyms that underscore the importance of good
health habits (Figure 3.7). On the whole, workplace
interventions have benefits, including higher morale,
greater productivity, and reduced health care costs to
organizations (Berry, Mirabito, & Baun, 2010).

Community-Based Interventions
There are many kinds of community interventions. A
community-based intervention could be a door-to-
door campaign about a breast cancer screening pro-
gram, a media blitz alerting people to the risks of
smoking, a grassroots community program to en-
courage exercise, a dietary modification program
that recruits through community institutions, or a
mixed intervention involving both media and per-
sonal contact.
There are several advantages of community-
based interventions. First, such interventions reach
more people than individually based interventions or
interventions in limited environments, such as a sin-
gle workplace or classroom. Second, community-based
interventions can build on social support for rein-
forcing adherence to recommended health changes.
For example, if all your neighbors have agreed to
switch to a low-cholesterol diet, you are more likely
to do so as well. Finally, much evidence already shows
that neighborhoods can have profound effects on
health practices, especially those of adolescents.
Monitoring behavior within neighborhoods has been
tied to a lower rate of smoking and alcohol abuse
among adolescents, for example (Chuang, Ennett,
Bauman, & Foshee, 2005).
But community interventions can be expensive
and bring about only modest behavior change
(Leventhal, Weinman, Leventhal, & Phillips, 2008).
Partnering with existing community organizations
such as health maintenance organizations may sus-
tain gains from an initial community intervention and
reduce costs.

Finally, and most important, if behavior change
is introduced at the family level, all family members
are on board, ensuring greater commitment to the
behavior-change program and providing social
support for the person whose behavior is the target.
Family interventions may be especially helpful in
cultures that place a strong emphasis on family.
Latinos, Blacks, Asians, and southern Europeans may
be especially persuaded by health interventions that
emphasize the good of the family (Han & Shavitt,
1994; Klonoff & Landrine, 1999).

Self-Help Groups
Millions of people in the United States modify their
health habits through self-help groups. Self-help
groups bring together people with the same health
habit problem, and often with the help of a coun-
selor, they attempt to solve their problem together.
Some prominent self-help groups include Overeaters
Anonymous and TOPS (Take Off Pounds Sensibly)
for obesity, Alcoholics Anonymous for alcoholics,
and Smokenders for smokers. Many group leaders
employ cognitive-behavioral principles in their pro-
grams. The social support provided in these groups
also contributes to their success. At the present time,
self-help groups constitute the major venue for
health-habit modification in the United States.

Schools
Interventions to encourage good health behaviors can be
implemented through the school system (Facts of Life,
November 2003). The school population is young, and
consequently, we may be able to intervene before
children have developed poor health habits. Schools have
a natural intervention vehicle, namely, classes of approx-
imately an hour’s duration, and many health interven-
tions can fit into this format. Moreover, interventions can
change the social climate in a school regarding particular
health habits in ways that foster behavior change.
Even in college, social networks continue to be
good targets for health interventions. As one or two
people change their behavior, their friends may begin
to do so as well.

Workplace Interventions
Approximately 60 percent of the adult population is
employed, and consequently, the workplace can reach
much of this population (Bureau of Labor Statistics,

Chapter 3 Health Behaviors 61

0%
Gym

membership
discount

20%

40%

60%

80%

Smoking
cessation
program

Web-based
resources

for healthy
living

Wellness
newsletter

Personal
health

coaching

Weight
loss

programs

Classes in
nutrition,
healthy
living

Small Firms Large Firms

FIGURE 3.7 | Percentage of Companies Offering a Particular Wellness Program to Their Employees, by Firm Size, 2011
(Source: Kaiser Family Foundation and Health Research and Education Trust, “Employer Health Benefits: Annual Survey 2011,” September 27, 2011)
Note: “Small firms” are those with 3–199 workers; “large firms” are those with 200 or more workers.

The Mass Media
A goal of health promotion is to reach as many people
as possible, and consequently, the mass media have
great potential. Generally, mass media campaigns
bring about modest attitude change but less long-term
behavior change. Nonetheless, the mass media can
alert people to health risks that they would not other-
wise know about.
Recently, health psychologists have studied the ef-
fects of health behaviors of characters in soap operas,
dramas, and comedies. Characters who smoke, for ex-
ample, can act as role models, increasing the likelihood
that adolescents will begin to smoke (Heatherton &
Sargent, 2009). By contrast, characters who engage in
healthy activities can encourage healthy behavior change
in their viewers.
By presenting a consistent media message over
time, the mass media can also have a cumulative ef-
fect in changing the values associated with health
practices. For example, the cumulative effects of anti-
smoking mass media messages on social norms about
smoking have been substantial.

Cellular Phones and Landlines
Venues for low-cost interventions include cell phones
and landlines (Eakin, Reeves, Winkler, Lawler, &
Owen, 2010). For example, automated phone inter-
ventions can prompt people to maintain health behavior

change (Kaplan & Stone, 2013; King et al., 2014).
Personalized text messages can help smokers quit
(Rodgers et al., 2005), and so texting represents an-
other potentially effective low-cost intervention. Pro-
grams to contact older adults by telephone each day
can make sure their needs are being met, and recent
efforts have incorporated lifestyle advice into these
volunteer programs, such as recommending physical
activity (Castro, Pruitt, Buman, & King, 2011). More-
over, such daily contact can also increase the older
adult’s experience of social support.

The Internet
The Internet provides information and low-cost access
to health interventions for millions of people (Cohen &
Adams, 2011). Websites for smoking cessation (Wang
& Etter, 2004) and other health habits have been de-
veloped (Linke, Murray, Butler, & Wallace, 2007),
and Internet-delivered, computer-tailored lifestyle in-
terventions targeting multiple risk factors simultane-
ously, for example, diet, exercise, and smoking, have
shown some success (Oenema, Brug, Dijkstra, de
Weerdt, & de Vries, 2008). The Internet can also be
used to augment the effectiveness of other interven-
tions, such as school-based smoking cessation pro-
grams (Norman, Maley, Skinner, & Li, 2008) or
interventions with patient groups (Williams, Lynch,
& Glasgow, 2007). Tailored e-coaching that provides

62 Part Two Health Behavior and Primary Prevention

van  Straten, & Andersson, 2008; Mohr et al., 2010).
The Internet also enables researchers to recruit a large
number of participants for studies at relatively low
cost, thus enabling data collection related to health
habits (Lenert & Skoczen, 2002).
The choice of venue for health-habit change is an
important issue. Understanding the particular strengths
and disadvantages of each venue helps to define inter-
ventions that can reach the most people for the least
expense. ∙

individualized feedback can supplement standardized
interventions for health-related behavior change, such
as weight loss (Gabriele, Carpenter, Tate, & Fisher,
2011).
CBT interventions for health habit modification
delivered via the Internet can be as effective as face-to-
face interventions, and they have advantages of low
cost, saving therapists’ time, reducing waitlist and travel
time, and providing interventions to people who might
not seek out a therapist on their own (Cuijpers,

To reach the largest number of people most effectively, researchers are increasingly

designing interventions to be implemented on a community basis through existing

community resources.

© Richard Ellis/Getty Images

Chapter 3 Health Behaviors 63

1. Health promotion enables people to increase
control over and improve their health. It involves
the practice of good health behaviors and the
avoidance of health-compromising ones.

2. Health habits are determined by demographic
factors (such as age and SES), social factors (such
as early socialization in the family), values and
cultural background, perceived symptoms, access
to medical care, and cognitive factors (such as health
beliefs). Health habits are only modestly related to
each other and are highly unstable over time.

3. Health-promotion efforts target children and
adolescents before bad health habits are in place.
They also focus on people at risk for disorders to
prevent those disorders from occurring. A focus
on health promotion among older adults may help
contain the soaring costs of health care late in life.

4. Research based on the health belief model and
the theory of planned behavior have identified
attitudes related to health-habit modification,
including the belief that a threat to health is
severe, that one is personally vulnerable to the
threat, that one is able to perform the response
needed to reduce the threat (self efficacy), that
the response will be effective in overcoming the
threat (response efficacy), and that social norms
support one’s practice of the behavior.

5. Attitudinal approaches to health behavior change
can instill knowledge and motivation. But by
themselves, approaches such as fear appeals and
information appeals can have limited effects on
behavior change.

6. Cognitive-behavioral approaches to health-habit
change use principles of self monitoring, classical
conditioning, operant conditioning, modeling, and
stimulus control to modify the antecedents and
consequences of a target behavior. CBT brings
clients into the treatment process by drawing on
principles of self control and self reinforcement.

7. Social skills training and relaxation training
methods can be incorporated into cognitive-
behavioral interventions to deal with the anxiety or
social deficits that underlie some health problems.

8. Increasingly, interventions focus on relapse
prevention. Practicing coping techniques for
managing high-risk-for-relapse situations is a
major component of such interventions.

9. Successful modification of health habits does not
occur all at once. People go through stages,
which they may cycle through several times.
When interventions are targeted to the stage an
individual is in, they may be more successful.

10. Some health habits are best changed through
social engineering, such as mandated childhood
immunizations or smoking bans in the workplace.

11. The venue for intervening in health habits is
changing. Expensive methods that reach one
individual at a time are giving way to group
methods that are cheaper, including self help
groups, and school and workplace interventions.
The mass media can reinforce health campaigns
by alerting people to health risks. Telephone
interventions, Internet interventions, and texting all
show promise as health behavior change venues.

S U M M A R Y

K E Y T E R M S

abstinence violation effect
assertiveness training
at risk
behavioral assignments
classical conditioning
cognitive-behavior therapy (CBT)
cognitive restructuring
contingency contracting
discriminative stimulus
fear appeals
health behaviors
health belief model
health habit

health locus of control
health promotion
lifestyle rebalancing
modeling
operant conditioning
primary prevention
relapse prevention
relaxation training
self control
self determination theory (SDT)
self efficacy
self monitoring
self regulation

self reinforcement
self talk
social engineering
social skills training
socialization
stimulus-control interventions
teachable moment
theory of planned behavior
transtheoretical model of behavior

change
window of vulnerability

64

C H A P T E R 4

C H A P T E R O U T L I N E

Exercise
Benefits of Exercise

Determinants of Regular Exercise

Exercise Interventions

Accident Prevention
Home and Workplace Accidents

Motorcycle and Automobile Accidents

Vaccinations and Screening
Vaccinations

Screenings

Sun Safety Practices
Developing a Healthy Diet

Changing Diet

Resistance to Modifying Diet

Interventions to Modify Diet

Sleep
What Is Sleep?

Sleep and Health

Rest, Renewal, Savoring

Health-Promoting Behaviors

© RubberBall Productions/Getty Images RF

Chapter 4 Health-Promoting Behaviors 65

Chapter 4 examines how the principles described in Chapter 3 apply to health-promoting behaviors,
including exercise, accident prevention, cancer preven-
tion, healthy diet, and sleep. Each of these important
behaviors has been related to at least one major cause
of illness and death in industrialized countries. As peo-
ple in third-world countries adopt the lifestyles of in-
dustrialized nations, these health habits will assume
increasing importance throughout the world.

■ EXERCISE

A recent headline reads, “Sedentary behavior trumps fat
as a killer” (Healy, 2015). In fact, a recent review of 47
studies found that the risk of several chronic diseases
and early death increases with long periods of sitting
(Alter et al., 2015); even taking breaks from sitting does
not fully offset the risk. Adequate physical fitness
among adolescents is only 42%, with girls worse than
boys (Gahche et al., 2014). Consequently, a high level of
physical activity is an important health behavior.
Exercise helps to maintain mental and physical
health. At one time, scientists believed that only
aerobic exercise has health benefits, but now evi-
dence suggests that any kind of exercise has benefits,
especially for middle-aged and older adults.

Benefits of Exercise
The health benefits of exercise are substantial. A mere
30  minutes of exercise a day can decrease the risk of
several chronic diseases, including heart disease, diabe-
tes, and some cancers. Exercise accelerates wound

healing in those with injuries (Emery, Kiecolt-Glaser,
Glaser, Malarkey, & Frid, 2005), and can be critical to
recovery from disabilities, such as hip fracture (Resnick
et al., 2007). Other health benefits are listed in Table 4.1.
However, over two-thirds of American adults do
not engage in the recommended levels of physical ac-
tivity, and about two-thirds of American adults do not
engage in any regular leisure-time physical activity
(National Center for Health Statistics, 2011). Physical
activity is more common among men than women,
among Whites than African-Americans and Hispan-
ics, among younger than older adults, and among
those with higher versus lower incomes (National
Center for Health Statistics, 2011b).

How Much Exercise? The typical exercise pre-
scription for a normal adult is 30 minutes or more of
moderate-intensity activity on most or all days of the
week or 20 minutes or more of vigorous or aerobic ac-
tivity at least 3 days a week (U.S. Department of Health
and Human Services, 2009). Aerobic exercise is marked
by high intensity, long duration, and the need for endur-
ance, and it includes running, bicycling, rope jumping,
and swimming. A person with low cardiopulmonary
fitness may derive benefits from even less exercise each
week. Even short walks or just increasing activity level
has physical and psychological benefits for older adults
(Ekkekakis, Hall, VanLanduyt, & Petruzzello, 2000;
Schechtman, Ory, & the FICSIT group, 2001).

Effects on Psychological Health Regular exer-
cise improves not only physical health but also mood and
emotional well-being (Gallegos-Carrillo et al., 2013;
Maher et al., 2013). Many people seem to be unaware of
these hidden benefits of exercise (Ruby, Dunn, Perrino,
Gillis, & Viel, 2011). Some of the positive effects of ex-
ercise on mood may stem from factors associated with
exercise, such as social activity or being outside (Dunton,
Liao, Intille, Huh, & Leventhal, 2015). An improved
sense of self-efficacy can also underlie some of the mood
effects of exercise (McAuley et al., 2008).
Because of its beneficial effects on mood and self-
esteem, exercise has even been used as a treatment for
depression (Herman et al., 2002). Several interventions
have now shown that exercise can prevent depression in
women (Babyak et al., 2000; Wang et al., 2011), and
stopping exercise can lead to an increase in symptoms
of depression (Berlin, Kop, & Deuster, 2006).
Health psychologists have also found beneficial
effects of exercise on cognitive functioning, especially

TABLE 4.1 | Health Benefits of Regular Exercise

• Helps you control your weight
• Reduces your risk of cardiovascular disease
• Reduces your risk for Type II diabetes and metabolic

syndrome
• Reduces your risk of some cancers
• Strengthens your bones and muscles
• Decreases resting heart rate and blood pressure and

increases strength and efficiency of heart
• Improves sleep
• Increases HDL (good) cholesterol
• Improves immune system functioning
• Promotes the growth of new neurons in the brain

• Promotes cognitive functioning

Sources: Centers for Disease Control and Prevention, February, 2011;
Hamer & Steptoe, 2007; Heisz & Vandermorris, Wu, McIntosh, &
Ryan, 2015.

66 Part Two Health Behavior and Primary Prevention

(Gagné & Harnois, 2013) as even very young children
start watching TV and using tablets and computers
early in life. Currently, only about half of youth meet
physical activity requirements of 60 minutes a day
(Institute of Medicine, 2013). Children get regular ex-
ercise through required physical education classes in
school, but even these classes have faced budget cut-
backs. Moreover, by adolescence, the practice of regu-
lar exercise has declined substantially, especially
among girls (Davison, Schmalz, & Downs, 2010) and
among boys not involved in formal athletics (Crosnoe,
2002). Adults report lack of time, stress, interference
with daily activities, and fatigue as barriers to obtain-
ing exercise (Kowal & Fortier, 2007).

Who Exercises? People who come from families
in which exercise is practiced, who have positive atti-
tudes toward physical activity, who have a strong sense
of self-efficacy for exercising (Peterson, Lawman,
Wilson, Fairchild, & Van Horn, 2013), who have energy,
and who are extroverted and sociable (Kern, Reynolds,
& Friedman, 2010) are more likely to exercise. People
who perceive themselves as athletic or as the type of
person who exercises (Salmon, Owen, Crawford,
Bauman, & Sallis, 2003), who have social support from
friends to exercise (Marquez & McAuley, 2006), who
enjoy their form of exercise (Kiviniemi, Voss-Humke, &
Seifert, 2007), and who believe that people should take
responsibility for their health are also more likely to get
exercise than people who do not have these attitudes.

Characteristics of the Setting Convenient and
easily accessible exercise settings promote exercise
(Gay, Saunders, & Dowda, 2011). Vigorous walking in
your neighborhood can be maintained more easily than
participation in an aerobics class in a crowded health
club 5 miles from your home. Lack of safe places to do
exercise is a particular barrier for people who live in
low socioeconomic status neighborhoods (Estabrooks,
Lee, & Gyurcsik, 2003; Feldman & Steptoe, 2004).
Improving environmental options for exercise,
such as walking trails and recreational facilities, in-
creases rates of exercise (Siceloff, Coulon, & Wilson,
2014). When people believe their neighborhoods are
safe, when they are not socially isolated, and when
they know what exercise opportunities are available to
them in their area, they are more likely to engage in
physical activity (Hawkley, Thisted, & Cacioppo,
2009; Sallis, King, Sirard, & Albright, 2007; van
Stralen, de Vries, Bolman, Mudde, & Lechner, 2010).

on executive functioning involved in planning and
higher-order reasoning (Heisz & Vandermorris, Wu,
McIntosh, & Ryan, 2015). Exercise appears to promote
memory and healthy cognitive aging (Erickson et al.,
2011; Pereira et al., 2007) and may improve cognitive
functioning and executive control in children as well
(Heisz & Vandermorris, Wu, McIntosh, & Ryan, 2015).
Even modest exercise or increases in activity level can
have these beneficial effects on cognitive functioning.
Exercise may offer economic benefits as well. Em-
ployee fitness programs can reduce absenteeism, increase
job satisfaction, and reduce health care costs, especially
among women employees (Rodin & Plante, 1989).

Determinants of Regular Exercise
Most people’s participation in exercise is erratic.
Starting young, even in preschool, is important

Regular aerobic exercise produces many physical and emo tional

benefi ts, including reduced risk for cardiovascular disease.

© Eliza Snow/Getty Images RF

Chapter 4 Health-Promoting Behaviors 67

as regaining fitness, it can be especially successful
(Hunt, McCann, Gray, Mutrie, & Wyke, 2013).
As is true with other health behaviors, factors that
affect the adoption of exercise are not necessarily the
same as those that predict long-term maintenance of
an exercise program. Believing that physical activity
is important predicts initiation of an exercise program,
whereas barriers, such as no time or few places to get
exercise, predict maintenance (Rhodes, Plotnikoff, &
Courneya, 2008). Self efficacy about one’s ability to
overcome barriers is a predictor of maintenance
(Higgins, Middleton, Winner, & Janelle, 2014).
Family-based interventions designed to induce all
family members to be more active have shown some
success (Rhodes, Naylor, & McKay, 2010). Worksite
interventions to promote exercise have small but posi-
tive effects on increased physical activity (Abraham &
Graham-Rowe, 2009). Even minimal interventions
such as sending mailers encouraging physical exercise
to older adults can increase exercise. Text messaging
also shows success in promoting exercise such as
brisk walking (Prestwich, Perugini, & Hurling, 2010).
The advantages of these interventions, of course, are
low cost and ease of implementation.
Relapse prevention techniques increase long-term
adherence to exercise programs. For example, helping
people figure out how to overcome barriers to obtain-
ing regular exercise, such as stress, fatigue, and a hec-
tic schedule, improves adherence (Blanchard et al.,
2007; Fjeldsoe, Miller, & Marshall, 2012).
Incorporating exercise into a more general pro-
gram of healthy lifestyle change can be beneficial as
well. Motivation to engage in one health behavior can
spill over into another (Mata et al., 2009). For exam-
ple, among adults at risk for coronary heart disease
(CHD), brief behavioral counseling matched to stage
of readiness helped them maintain physical activity,
as well as reduce smoking and fat intake (Steptoe,
Kerry, Rink, & Hilton, 2001). Setting personal goals
for exercise can improve commitment (Hall et al.,
2010), and forming explicit implementation inten-
tions regarding exactly when and how to exercise fa-
cilitates practice as well; planning when to exercise
can facilitate the link between intention and actual
behavior (Conner, Sandberg, & Norman, 2010).
Exercise interventions may promote more general
lifestyle changes. This issue was studied in an intriguing
manner with 60 Hispanic and Anglo families, half of
whom had participated in a 1-year intervention program
of dietary modification and exercise. All the families

Social support can foster exercise. Making a
commitment to another person to meet for exercise
increases the likelihood that it will happen
(Prestwich et al., 2012). People who participate in
group exercise programs such as jogging or walk-
ing say that social support and group cohesion are
two of the reasons why they participate (Floyd &
Moyer, 2010). This support may be especially im-
portant for exercise participation among Hispanics
(Marquez & McAuley, 2006). Even just seeing oth-
ers engaging in exercise around one’s neighborhood
or on a running path can increase how much time a
person puts into exercise (Kowal & Fortier, 2007).
The best predictor of regular exercise is regular ex-
ercise (Phillips & Gardner, 2016). Long-term practice
of regular exercise is heavily determined by habit
(McAuley, 1992). The first 3–6 months appear to be
critical, and people who will drop out usually do so in
that time period (Dishman, 1982). Developing a regular
exercise program, embedding it in regular activities, and
doing it regularly means that it begins to become auto-
matic and habitual. However, habit has its limits. Unlike
such habitual behaviors as wearing a seat belt or brush-
ing teeth, exercise takes willpower and a belief in per-
sonal responsibility in order to be enacted on a regular
basis. In summary, if people participate in activities that
they like, that are convenient, that they are motivated to
pursue, and for which they can develop goals, exercise
adherence will be greater (Papandonatos et al., 2012).

Exercise Interventions

Several types of interventions have shown success in
getting people to exercise. Interventions that incorpo-
rate principles of self-control (enhancing beliefs in
personal efficacy) and that muster motivation can be
successful in changing exercise habits (Conroy, Hyde,
Doerksen, & Riebeiro, 2010). Helping people to form
implementation intentions, and following up with
brief text messages can promote activity as well
(Prestwich, Perugini, & Hurling, 2010). Several stud-
ies confirm the usefulness of the transtheoretical
model of behavioral change (that is, the stages of
change model) for increasing physical activity. Inter-
ventions designed to increase and maintain physical
activity that are matched to stage of readiness are
more successful than interventions that are not
(Blissmer & McAuley, 2002; Dishman, Vandenberg,
Motl, & Nigg, 2010; Marshall et al., 2003). When an
exercise intervention promotes personal values, such

68 Part Two Health Behavior and Primary Prevention

is $518 billion per year (World Health Organization,
2009). Nationally, bicycle accidents cause more than
900 deaths per year, prompt more than 494,000 emer-
gency room visits, and constitute the major cause of
head injury, making helmet use an important issue
(Centers for Disease Control and Prevention, 2015).
Over 2,000 people a day are accidentally poisoned in the
United States, usually by prescription or illegal drugs,
and more than 40,000 people die of poisoning each year
(Centers for  Disease Control and Prevention, March
2012a; Warner, Chen, Makuc, Anderson, & Miniño,
2011). Occupational accidents and their resulting dis-
ability are a particular health risk for working men.

Home and Workplace Accidents
Accidents in the home, such as accidental poisonings
and falls, are the most common causes of death and
disability among children under age 5 (Barton &
Schwebel, 2007). Interventions to reduce home acci-
dents are typically conducted with parents because
they have control over the child’s environment. Put-
ting safety catches and gates in the home, placing poi-
sons out of reach, and teaching children safety skills
are components of these interventions.
Pediatricians and their staff often incorporate such
training into visits with new parents (Roberts & Turner,
1984). Parenting classes help parents to identify the
most common poisons in the home and to keep these
away from young children. Evaluations of interventions
that train parents how to childproof a home (Morrongi-
ello, Sandomierski, Zdzieborski, & McCollam, 2012)
show that such interventions can be successful. Even
young children can learn about safety in the home. For
example, an intervention using a computer game (The
Great Escape) improved children’s knowledge of fire
safety behaviors (Morrongiello, Schwebel, Bell, Stewart,
& Davis, 2012). Virtual environmental training on web-
sites can help children learn to cross the street safely
(Schwebel, McClure, & Severson, 2014).
At one time, workplace accidents were a primary
cause of death and disability. However, statistics sug-
gest that overall, accidents in the workplace have de-
clined since the 1930s. This decline may be due, in
part, to better safety precautions by employers. How-
ever, accidents at home have actually increased. Social
engineering solutions, such as safety caps on medica-
tions and required smoke detectors in the home, have
mitigated the increase, but the trend is worrisome.

Accidents and Older Adults More than 12,800
older adults die each year of fall-related injuries, and

were taken to the San Diego Zoo as a reward for partici-
pating in the program, and while they were there, their
food intake and amount of walking were recorded. Fam-
ilies that had participated in the intervention consumed
fewer calories, ate less sodium, and walked more than
the families in the control condition, suggesting that the
intervention had been integrated into their lifestyle
(Patterson et al., 1988). The family-based approach of
this intervention may have contributed to its success as
well (Martinez, Ainsworth, & Elder, 2008).
Physical activity websites would seem to hold
promise for inducing people to participate in regular ex-
ercise (Napolitano et al., 2003). Of course, if one is on
the Internet, one is by definition not exercising. Indeed,
thus far, the evidence is mixed that physical activity
websites provide the kind of individually tailored rec-
ommendations that are needed to get people to exercise
on a regular basis (Carr et al., 2012) and initial gains
may not be maintained (Carr et al., 2013). However,
automated exercise advice can help maintain a physical
activity program, once it is initiated (King et al., 2014).
Despite the problems health psychologists have en-
countered in getting people to exercise and to do so
faithfully, the exercise level in the U.S. population has
increased substantially in recent decades. A physician’s
recommendation is one of the factors that lead people
to increase their exercise, and trends show that physi-
cians increasingly are advising their patients to begin or
continue exercise (Barnes & Schoenborn, 2012). The
number of people who participate in regular exercise
has increased by more than 50 percent in the past few
decades. Increasingly, it is not just sedentary healthy
adults who are becoming involved in exercise but also
the elderly and chronically ill patients (Courneya &
Friedenreich, 2001). These findings suggest that, al-
though the population may be aging, it may be doing so in
a healthier way than was true in recent past generations.

■ ACCIDENT PREVENTION

No wonder that so many cars collide;
Their drivers are accident prone,
When one hand is holding a coffee cup,
And the other a cellular phone.

—Art Buck

This rhyme captures an important point. Accidents
represent one of the major causes of preventable death,
both worldwide and in the United States. Moreover,
this cause of death is increasing. Worldwide, nearly
1.3 million people die as a result of road traffic
injuries, and the estimated economic cost of accidents

Chapter 4 Health-Promoting Behaviors 69

accidents. These include the way people drive, the
speed at which they drive, and the use of preventive
measures to increase safety, such as interventions to
reduce cell phone usage while driving (Weller, Shack-
leford, Dieckmann, & Slovic, 2013).
For example, many Americans still do not use seat
belts, a problem especially common among adolescents,
which accounts, in part, for their high rate of fatal acci-
dents (Facts of Life, May 2004). Community-wide
health education programs aimed at increasing seat belt
usage and infant restraint devices can be successful. One
such program increased the use from 24 to 41 percent,
leveling off at 36 percent over a 6-month follow-up pe-
riod (Gemming, Runyan, Hunter, & Campbell, 1984).
On the whole, though, social engineering solu-
tions may be more effective. Seat belt use is more
prevalent in states with laws that mandate their use,
and states that enforce helmet laws for motorcycle rid-
ers have reduced deaths and lower health care costs
related to disability due to motorcycle accidents (Wall
Street Journal, 2005, August 9).

■ VACCINATIONS AND SCREENING

Vaccinations and screening represent two ways of
avoiding or detecting early some of the main causes
of death in the United States. Yet many people fail to
use these health resources, which makes behavior
change important for health psychologists.

many more are disabled. At least 25 percent of older
adults may remain hospitalized for at least a year due
to injuries from a fall (Facts of Life, March 2006).
Consequently, strategies to reduce accidents
among older adults have increasingly been a focus of
health psychology research and interventions. Dietary
and medication intervention to reduce bone loss can
affect risk of fracture. Physical activity training involv-
ing balance, mobility, and gait training reduces the risk
of falls. Teaching older adults to make small changes
in their homes that reduce tripping hazards can help,
including nonslip bathmats, shower grab bars, hand
rails on both sides of stairs, and better lighting (Facts
of Life, March 2006). The evidence suggests that fall
prevention programs, often led by health psycholo-
gists, can reduce mortality and disability among older
adults substantially (Facts of Life, March 2006).

Motorcycle and Automobile Accidents
You know what I call a motorcyclist who doesn’t wear
a helmet? An organ donor.

—Emergency room physician

The single greatest cause of accidental death is motor-
cycle and automobile accidents (Centers for Disease
Control and Prevention, 2009a). Although social en-
gineering solutions such as speed limits and seat belts
have major effects on accident rates, psychological
interventions can also address factors associated with

Automobile accidents represent a major cause of death, especially among the young.

Legislation requiring child safety restraint devices has reduced fatalities dramatically.

© Ryan McVay/Getty Images RF

70 Part Two Health Behavior and Primary Prevention

cancer; having genes implicated in breast cancer)
should be monitored. Otherwise, routine PSA screen-
ing is not recommended and a mammogram is recom-
mended every year between ages 45 and 55 and every
other year for women between the ages of 55 and 74.
In older women, the value of the test is less clear.
Why is screening through mammography impor-
tant for high-risk women? The reasons are several:

∙ One in every eight women in the United States
develops breast cancer.

∙ The majority of breast cancers are detected in
women over age 40, and so screening this age
group is cost effective.

∙ Early detection, as through mammograms, can
improve survival rates.

Unfortunately, compliance with mammography
recommendations is low. Fear of radiation, embarrass-
ment over the procedure, anticipated pain, anxiety, fear

Vaccinations
Parents are urged to get their children vaccinated
against measles, polio, diphtheria, whooping cough,
and tetanus, among other childhood diseases. Most
do, because school registration typically requires
these vaccines. However, some do not and instead are
freeriders; that is, if most children are vaccinated, the
minority that is not are protected by those who are
(Betsch, Böhm, & Korn, 2013). In some cases, refus-
ing to get vaccinations for one’s children comes from
the mistaken beliefs that a vaccine actually causes the
disease or that the vaccine causes another disorder,
such as autism. Interventions have attempted to cor-
rect the incorrect beliefs that can undermine vaccina-
tion and stressed the social benefits of vaccination in
the hopes of keeping rates high (Betsch et al., 2013).
Vaccinations of girls and boys against HPV (human
papillomavirus) by age 13 is now recommended by the
National Institutes of Health. HPV is a sexually trans-
mitted virus tied to cervical as well as other cancers. The
Centers for Disease Control and Prevention report, how-
ever, that as of 2016, only 40% of girls and 21% of boys
had received it. This rate compares very unfavorably to
many other countries, including Australia (75%), the
United Kingdom (about 88%) and Rwanda (93%)
(Winslow, 2016). Family-focused messages aimed at
parents and adolescents have been suggested as one fo-
cus of public health interventions to increase vaccina-
tion rates (Alexander et al., 2014), and direct payments
to adolescents in the UK have been tried (Mantzari,
Vogt, & Marteau, 2015). As yet, the most effective way
to encourage this behavior has not been found.

Screenings
The two most common cancers in the United States are
breast cancer in women and prostate cancer in men. Until
recently, routine screening was the frontline against these
cancers. At present, however, routine screening through
mammography for women and the PSA (prostate-
specific antigen) test for men is no longer recommended
for all adults; false positives (when the test falsely sug-
gests the presence of cancer) has led to unnecessary
treatment, including surgeries. Moreover, although diag-
nosed cases from both tests increased, there has been
little to no impact on mortality from these causes.
At present, men who are symptomatic or at high
risk (who have a family history of prostate cancer;
Watts et al., 2014) and women who are symptomatic
or at high risk (having a family history of breast

Mammograms are an important way of detecting breast cancer

in women over 50. Finding ways to reach older women to

ensure that they obtain mammograms is a high priority for

health scientists.

© Getty Images

Chapter 4 Health-Promoting Behaviors 71

to people’s resistance to colorectal screening can
increase the likelihood of obtaining screening as well
(Menon et al., 2011). Hispanics are at particular risk
for colorectal cancer, and so it is especially important
to reach them (Gorin, 2005).
■ SUN SAFETY PRACTICES

The past 30 years have seen a nearly fourfold increase in
the incidence of skin cancer in the United States. Al-
though basal cell and squamous cell carcinomas do not
typically kill, malignant melanoma takes over 9,000
lives each year (Centers for Disease Control and Preven-
tion, August 2015). In the past two decades, melanoma
incidence has risen by 155 percent. Moreover, these
cancers are among the most preventable. The chief risk
factor for skin cancer is well known: excessive exposure
to ultraviolet (UV) radiation. Living or vacationing in
southern latitudes, participating in outdoor activities,
and using tanning salons all contribute to dangerous sun
exposure. Less than one-third of American children ad-
equately protect themselves against the sun, and more
than three-quarters of American teens get at least one
sunburn each summer (Facts of Life, July 2002).
As a result, health psychologists have developed
interventions to promote safe sun practices. Typically,
these efforts begin with educational interventions to
alert people to the risks of skin cancer and to the effec-
tiveness of sunscreen use for reducing risk (Lewis et al.,
2005; Stapleton, Turrisi, Hillhouse, Robinson, & Abar,
2010). However, education alone is not entirely suc-
cessful (Jones & Leary, 1994). Tans are still perceived
to be attractive (Blashill, Williams, Grogan, & Clark-
Carter, 2015), and many people are oblivious to the
long-term consequences of tanning (Orbell &
Kyriakaki, 2008). Many people use sunscreens with an
inadequate sun protection factor (SPF), and few people
apply sunscreen often enough during outdoor activities
(Wichstrom, 1994). Effective sunscreen use requires
knowledge about skin cancer, perceived need for sun-
screen, perceived efficacy of sunscreen as protection
against skin cancer, and social norms that favor sun-
screen use (Stapleton, Turrisi, Hillhouse, Robinson, &
Abar, 2010; Turrisi, Hillhouse, Gebert, & Grimes,
1999). All of these factors change only grudgingly.
Parents play an important role in ensuring that
children reduce sun exposure (Turrisi, Hillhouse,
Robinson, & Stapleton, 2007). Parents’ own sun pro-
tection habits influence how attentive they are to their
children’s practices and what their children do when
they are on their own (Turner & Mermelstein, 2005).

of cancer (Gurevich et al., 2004; Schwartz, Taylor, &
Willard, 2003), and, most importantly, especially among
poorer women, concern over costs act as deterrents to
getting regular mammograms (Lantz, Weigers, &
House, 1997). Lack of awareness of the importance of
mammograms, little time, and lack of available services
also contribute to low screening rates.
Changing attitudes toward mammography can in-
crease the likelihood of obtaining a mammogram. For
example, the theory of planned behavior predicts the
likelihood of obtaining regular mammograms: Women
who have positive attitudes regarding mammography
and who perceive social norms as favoring their ob-
taining a mammogram are more likely to participate
in a mammography program (Montano & Taplin,
1991). Social support predicts use of mammograms
and may be especially important for low-income and
older women (Messina et al., 2004). If your friends
are getting mammograms, you are more likely to do
so  as well. Interventions are more successful if they
are  geared to the stage of readiness of prospective
participants (Champion & Springston, 1999; Lauver,
Henriques, Settersten, & Bumann, 2003).

Colorectal Cancer Screening

In Western countries, colorectal cancer is the second-
leading cause of cancer deaths. In recent years, medi-
cal guidelines have recommended routine colorectal
screening for older adults (Wardle, Williamson,
McCaffery et al., 2003).
Factors that predict the practice of other health
behaviors also predict participation in colorectal can-
cer screening, including self-efficacy, perceived ben-
efits of the procedure, a physician’s recommendation
to participate, social norms favoring participation, and
few barriers to taking advantage of a screening
program (Hays et al., 2003; Manne et al., 2002;
Sieverding, Matterne, & Ciccarello, 2010). As is true
of many health behaviors, beliefs predict the intention
to participate in colorectal screening, whereas life dif-
ficulties (low SES, poor health status) interfere with
actually getting screened (Power et al., 2008).
Community-based programs that use the mass
media, community-based education, interventions
through social networks such as churches, health care
provider recommendations, and reminder notices pro-
mote participation in cancer screening programs and
can attract older adults (Campbell et al., 2004; Curbow
et al., 2004). T elephone-based interventions tailored

72 Part Two Health Behavior and Primary Prevention

needed (Buller, Buller, & Kane, 2005). Nonetheless,
even brief interventions directed to specific sun safety
practices, such as decreasing indoor tanning, can be
effective (Abar et al., 2010).

■ DEVELOPING A HEALTHY DIET

Diet is an important and controllable risk factor for
many of the leading causes of death and disease. For
example, diet is related to serum cholesterol level and
to lipid profiles. The dramatic rise in obesity in the
United States has added urgency to this issue. How-
ever, only about 13 percent of adults get the recom-
mended servings of fruit and only about 9 percent get
the recommended servings of vegetables each day
(Centers for Disease Control and Prevention, July
2015; Table 4.2). Experts estimate that unhealthful
eating contributes to more than 678,000 deaths per
year (U.S. Burden of Disease Collaborators, 2013).
Dietary change is critical for people at risk for or
already diagnosed with chronic diseases such as coro-
nary artery disease, hypertension, diabetes, and can-
cer (Center for the Advancement of Health, 2000f).
These are diseases for which people low in SES are
more at risk, and diet may explain some of the relation
between low SES and these disorders. For example,
supermarkets in high-SES neighborhoods carry more
health-oriented food products than do supermarkets in
low-income areas. Thus, even if the motivation to
change one’s diet is there, the food products may not
be (Conis, 2003, August 4).

Communications to adolescents and young adults
that stress the gains that sunscreen use will bring
them, such as freedom from concern about skin can-
cers or improvements in appearance, may be more
successful than those that emphasize the risks
(Detweiler, Bedell, Salovey, Pronin, & Rothman,
1999; Jackson & Aiken, 2006). When risks are em-
phasized, it is important to stress the immediate ad-
verse effects of rather than the long-term risks of
chronic illness, because adolescents and young adults
are especially influenced by immediate concerns.
In one clever investigation, one group of beachgo-
ers were exposed to a photo-aging intervention that
showed premature wrinkling and age spots; a second
group received a photo intervention that made the
negative appearance-related consequences of UV ex-
posure very salient; a third group received both inter-
ventions; and a fourth group was assigned to a control
condition. Those beachgoers who received the UV
photo information engaged in more sun protective be-
haviors, and the combination of the UV photo with the
photo-aging information led to substantially less
sunbathing over the long-term (Mahler, Kulik,
Gerrard, & Gibbons, 2007; Mahler, Kulik, Gibbons,
Gerrard, & Harrell, 2003). Similar interventions appear
to be effective in reducing the use of tanning salons
(Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005).
Health psychologists have explored Internet-
based strategies as a vehicle for distributing sun safety
materials. Responses have thus far been weak, suggesting
that more personal and aggressive approaches may be

Despite the risks of exposure to the sun, millions of people each year continue to

sunbathe.

© The McGraw-Hill Companies, Inc./Barry Barker, photographer

Chapter 4 Health-Promoting Behaviors 73

Switching from trans fats (as are used for fried and
fast foods) and saturated fats (from meat and dairy
products) to polyunsaturated fats and monounsatu-
rated fats is a healthful change as well (Marsh, 2002,
September 10). Current U.S. government guidelines
for a balanced diet are described in Table 4.2.
Several specific diets, in addition to low-fat diets,
have health benefits. Healthy “Mediterranean” diets
are rich in vegetables, nuts, fruits, and fish and low in
red meat. Low-carbohydrate diets with vegetarian
sources of fat and protein and little bread and other
high-carbohydrate foods can have healthful effects.
Many people like these diets, and so they can be fairly
easily adopted and adhered to over time.

Resistance to Modifying Diet

It is difficult to get people to modify their diet, how-
ever, even when they are at high risk for CHD or when
their physician recommends it. The typical reason that
people switch to a diet low in cholesterol, fats, calo-
ries, and additives and high in fiber, fruits, and vege-
tables is to improve appearance, not to improve health.
Even so, fewer than half of U.S. adults meet the di-
etary recommendations for reducing fat levels and for
increasing fiber, fruit, and vegetable consumption
(Kumanyika et al., 2000).
Rates of adherence to a new diet may be high at first
but fall off over time. Some diets are restrictive, monot-
onous, expensive, and hard to implement. Changes in
shopping, meal planning, cooking methods, and eating
habits may be required. In addition, tastes are hard to
alter. Foods that are high in fat and sugars help turn off
stress hormones, such as cortisol, but they contribute to
an unhealthy diet (Dallman et al., 2003). A preference
for meat, a lack of health consciousness, a limited inter-
est in exploring new foods, and low awareness of the
link between eating habits and illness are all tied to poor
dietary habits.

Stress and Diet Stress has a direct and negative
effect on diet. People under stress eat more fatty foods,
fewer fruits and vegetables, and are more likely to
snack and skip breakfast (O’Connor, Jones, Ferguson,
Conner, & McMillan, 2008). People with low status
jobs, high workloads, and little control at work also
have less healthy diets. When people are under stress,
they are distracted, may fail to practice self-control,
and may not pay much attention to what they are eat-
ing (Devine, Connors, Sobal, & Bisogni, 2003). Thus,
the sheer cognitive burden of daily life can interfere

Changing Diet
The good news is that changing one’s diet can im-
prove health. A diet high in fruits, vegetables, with
some whole grains, peas and beans, poultry, and fish
and low in refined grains, potatoes, and red and pro-
cessed meats lowers the risk of coronary heart disease
(Fung, Willett, Stampfer, Manson, & Hu, 2001).

TABLE 4.2 | Current USDA Recommendations for
a Balanced Diet

The United States Agriculture Department currently
recommends a 2,000-calorie-a-day diet made up of the
following components:

–Dairy (3 cups) –Fruits (2 cups)

–Vegetables (2.5 cups) –Grain (3 oz)

–Meat (6 oz) –Oil (6 tsp)

© Mitch Hrdlicka/
PhotoDisc/Getty
Images RF

© Lex van Lieshout/Image
shop/Alamay RF

© Lex van Lieshout/Image
shop/Alamy RF

© Comstock/
PunchStock RF

© IT Stock/PunchStock RF

© Duncan Smith/Getty
Images RF

74 Part Two Health Behavior and Primary Prevention

shown to be helpful in getting people to increase their
fruit and vegetable intake and otherwise improve their
diets (Ahluwalia et al., 2007; Harris et al., 2014).
Training in self-regulation, including planning skills
and formation of explicit behavioral intentions (Stadler,
Oettingen, & Gollwitzer, 2010), can improve dietary
adherence. Implementation intentions regarding ex-
actly when, where, and what food will be consumed
can also help people bring snacking under intentional
control (Harris et al., 2014). However, much eating
and snacking occurs mindlessly, when people are ex-
erting little self-control. In such cases, simple environ-
mental interventions, such as a sign in a cafe promoting
healthy eating, can help people make good choices
(Allan, Johnston, & Campbell, 2015).
Recent efforts to change the dietary habits of high-
risk people have focused on the family (Gorin et al.,
2013). Eating meals together promotes better eating
habits. In family interventions, family members typi-
cally meet with a dietary counselor to discuss ways to
change the family diet. When all family members are
committed to and participate in dietary change, it is
easier for a target family member (such as a cardiac
patient) to do so as well (Wilson & Ampey-Thornhill,
2001). Children who are involved in these interventions
may practice better dietary habits into adolescence and
adulthood. An intervention with Latino mothers with
Type 2 diabetes and their overweight daughters made
use of this strong social tie to promote weight loss and
healthy eating (Sorkin et al., 2014).
Community interventions aimed at dietary change
have been undertaken. For example, nutrition education
campaigns in supermarkets have shown some success.
In one study, a computerized, interactive nutritional in-
formation system placed in supermarkets significantly
decreased high-fat purchases and somewhat increased
high-fiber purchases (Jeffery, Pirie, Rosenthal, Gerber,
& Murray, 1982; Winett et al., 1991).
Tailoring dietary interventions to ethnic identity
and making them culturally and linguistically appro-
priate may achieve particularly high rates of success
(Eakin et al., 2007; Martinez et al., 2008; Resnicow,
Davis, et al., 2008). In Latino populations, face-to-
face contact with a health adviser who goes through
the steps for successful diet modification may be es-
pecially important, due to the emphasis on personal
contact in Latino culture and communities (Elder
et al., 2005).
Researchers are moving toward interventions that
are cost-effective to alter behavior related to diet and

with the ability to control food consumption by
preventing people from monitoring their eating (Ward
& Mann, 2000).

Who Controls Their Diet? People who are high
in conscientiousness and intelligence do a better job
of adhering to a healthy diet. People who have high
self-control are better able to manage a healthy diet
than people without executive control skills (Hall,
2011). A strong sense of self-efficacy, knowledge
about dietary issues, family support, and the percep-
tion that dietary change has important health benefits
are also critical to developing a healthy diet (Steptoe,
Doherty, Kerry, Rink, & Hilton, 2000).
When people are informed about social norms
regarding diet, they are more likely to make a change
toward those norms (Robinson, Fleming, & Higgs,
2014). For example, if the people around you have
stopped drinking soda because they think it is un-
healthy, you are more likely to do so as well.

Interventions to Modify Diet Recent efforts to
induce dietary change have focused heavily on reduc-
ing portion size, snacking, and sugary drink consump-
tion. Portion size has increased greatly over the past
decades, contributing to obesity. Snacking has also
been tied to obesity. Sugary drinks have been tied to
higher heart disease risk (de Koning et al., 2012) and
are suspected of contributing to the rising rates of type
2 diabetes. Accordingly, interventions have been di-
rected to these issues, as well as to reducing fat and in-
creasing vegetable and fruit consumption. Specific
health risks such as obesity, diabetes, or CHD often
lead people to change their diets, and physicians,
nurses, dieticians, and health psychologists work with
patients to develop an appropriate diet.
Most diet change is implemented through
cognitive-behavioral interventions. Efforts to change
diet begin with education and training in self-monitoring:
Most people are poorly informed about what a healthy
diet is and do not pay sufficient attention to what they
actually eat (O’Brien, Fries, & Bowen, 2000). Addi-
tional components are stimulus control, and contin-
gency contracting, coupled with relapse prevention
techniques for high-risk-for- relapse situations, such as
parties. Drawing on social support for making a dietary
change and increasing one’s sense of self-efficacy are
two critical factors for improving diet (Steptoe,
Perkins-Porras, Rink, Hilton, & Cappuccio, 2004).
Self affirmation and motivational interviewing have

Chapter 4 Health-Promoting Behaviors 75

sound. In stage 2, breathing and heart rates even out,
body temperature drops, and brain waves alternate be-
tween short bursts called sleep spindles and large K-
complex waves. Stages 3 and 4, deep sleep, are marked
by delta waves. These are the phases most important
for restoring energy, strengthening the immune sys-
tem, and prompting the body to release growth hor-
mone. During REM sleep, eyes dart back and forth,
breathing and heart rates flutter, and we often dream
vividly. This stage of sleep is marked by beta waves
and is important for consolidating memories, solving
problems from the previous day, and turning knowl-
edge into long-term memories (Irwin, 2015). All of
these phases of sleep are essential.

Sleep and Health
An estimated 50–70 million Americans suffer from
chronic sleep disorders—most commonly, insomnia
(Centers for Disease Control and Prevention, September
2015). Many other people, such as college students,
choose to deprive themselves of sleep in order to keep
up with all the demands on their time. But sleep is an
important restorative activity, and people who deny
themselves sleep may be doing more harm than they
realize.
Roughly 40 percent of adults sleep less than
7  hours a night on weeknights, one-third of adults

exercise, rather than large-scale CBT interventions.
For example, computer-tailored dietary fat intake in-
terventions can be effective both with adults and with
adolescents (Haerens et al., 2007). Telephone counsel-
ing can achieve beneficial effects (Madlensky et al.,
2008). Such interventions can reach many people at
relatively low cost.
Change is likely to come from social engineering
as well. When children have access to school snack
bars that include sodas, candy, and other unhealthy
foods, it undermines their consumption of healthier
foods (Cullen & Zakeri, 2004).
Some of these interventions may seem heavy-
handed. After all, most people eat what they want
based on their preferences or what is available. Nudg-
ing people in the right direction through subtle mes-
sages may work as well as, or better than, explicit
warnings (Wagner, Howland, & Mann, 2015). Elimi-
nating snack foods from schools, making school
lunch programs more nutritious, making snack foods
more expensive and healthy foods less so, and taxing
products high in sugar or fats (Brownell & Frieden,
2009) will make some inroads into promoting healthy
food choices.

■ SLEEP

Michael Foster, a trucker who carried produce, was
behind in his truck payments. To catch up, he needed
to make more runs each week. To do so, he began
cutting back from 6 hours of sleep a night to 3 or 4,
stretches that he grabbed in his truck between jobs.
On an early-morning run between Fresno and Los
Angeles, he fell asleep at the wheel and his truck
went out of control, hitting a car and killing a family.

What Is Sleep?
Sleep is a vital health habit. It has a powerful effect
on risk of infectious disease, risk of depression,
poor responses to vaccines, and the occurrence and
progression of several chronic disorders, including
cardiovascular disease and cancer (Irwin, 2015).
But sleep is often abused.
There are two broad types of sleep: non–rapid eye
movement (NREM) and rapid eye movement (REM).
NREM sleep consists of four stages. Stage 1, the light-
est and earliest stage of sleep, is marked by theta
waves, when we begin to tune out the sounds around
us, although we are easily awakened by any loud

Scientists have begun to identify the health risks associated

with little or poor-quality sleep.

© Stockbyte/Getty Images RF

76 Part Two Health Behavior and Primary Prevention

adversity (Jarrin, McGrath, & Quon, 2014), who have
high levels of hostility or arousal (Fernández- Mendoza
et al., 2010; Granö, Vahtera, Virtanen, Keltikangas-
Järvinen, & Kivimäki, 2008), who use maladaptive
coping strategies to cope with stress (Fernández-
Mendoza et al., 2010), and who ruminate on the
causes of their stress (Zawadzki, Graham, & Gerin,
2012) have poor sleep quality and report sleep distur-
bances. Stressful events regarded as uncontrollable
can produce insomnia (Morin, Rodrigue, & Ivers,
2003). People who deal with stressful events by rumi-
nating or focusing on them are more prone to insom-
nia than are those who deal with stressful events by
blunting their impact or distracting themselves
(Fernández-Mendoza et al., 2010; Voss, Kolling, &
Heidenreich, 2006; Zoccola, Dickerson, & Lam,
2009). Sleep may have particular significance for peo-
ple low in SES, as low SES is linked to poor subjec-
tive and objective sleep quality (Friedman et al., 2007;
Mezick et al., 2008). Abuse of alcohol is also related
to poor sleep quality (Irwin, Cole, & Nicassio, 2006).
Although the health risks of insufficient sleep are
now well known, less well known is the fact that peo-
ple who habitually sleep more than 7 hours every
night also incur health risks (van den Berg et al.,
2008a). Long sleepers, like short sleepers, also have
more symptoms of psychopathology, including
chronic worrying (Grandner & Kripke, 2004).
Behavioral interventions have been undertaken
for the treatment of insomnia, including mindfulness-
based interventions (Britton, Haynes, Fridel, &
Bootzin, 2010), relaxation therapy, control of sleep-
related behaviors (such as the routine a person engages
in before going to sleep), and cognitive-behavioral
interventions. All these treatments show success in
treating insomnia (Irwin et al., 2006). Table 4.3 lists
some of the recommendations used in interventions to
promote better sleep.

■ REST, RENEWAL, SAVORING

An important set of health behaviors that is only be-
ginning to be understood involves relaxation and re-
newal, the restorative activities that help people
savor the positive aspects of life, reduce stress, and
restore emotional balance (Pressman et al., 2009).
For example, simply not taking a vacation is a risk
factor for heart attack among people with heart dis-
ease (Gump & Matthews, 1998; Steptoe, Roy, &
Evans, 1996). Participating in enjoyable leisure time

experience sleep problems (Stein, Belik, Jacobi, &
Sareen, 2008), and 54 percent of people over age 55
report insomnia at least once a week (Weintraub,
2004). For women, sleep disorders may be tied to hor-
monal levels related to menopause (Manber, Kuo,
Cataldo, & Colrain, 2003). Even children who sleep
too little or too much incur health risks, including risk
of early death (Duggan, Reynolds, Kern, & Friedman,
2014); low socioeconomic status contributes to poor
sleep among children (El-Sheikh et al., 2013).
Insufficient sleep (less than 7 hours a night) af-
fects cognitive functioning, mood, job performance,
and quality of life (Karlson, Gallagher, Olson, &
Hamilton, 2012; Pressman & Orr, 1997). Any of us
who has spent a sleepless night tossing and turning
over some problem knows how unpleasant the follow-
ing day can be. Insomnia compromises well-being on
the short term and quality of life on the long term
(Karlson, Gallagher, Olson, & Hamilton, 2013). Poor
sleep can be a particular problem in certain high-risk
occupations, such as police work, in which officers
are exposed to traumatic events (Irish, Dougall,
Delahanty, & Hall, 2013).
As noted, there are health risks of inadequate
sleep (Leger, Scheuermaier, Phillip, Paillard, &
Guilleminault, 2001). Chronic insomnia can com-
promise the ability to secrete and respond to insulin
(suggesting a link between sleep and diabetes); it in-
creases the risk of coronary heart disease (Ekstedt,
Åkerstedt, & Söderström, 2004); it increases blood
pressure and dysregulates stress physiology (Franzen
et al., 2011); it can affect weight gain (Motivala,
Tomiyama, Ziegler, Khandrika, & Irwin, 2009); it
can reduce the efficacy of flu shots; and it is tied to
adverse immune changes including chronic inflam-
mation (Motivala, 2011). More than 70,000 of the
nation’s annual automobile crashes are accounted for
by sleepy drivers, and 1,550 of these are fatal each
year. In one study of healthy older adults, sleep dis-
turbances predicted all-cause mortality over the next
4–19 years of follow-up (Dew et al., 2003). Children
who do not get enough sleep may show behavioral
problems (Pesonen et al., 2009). By contrast, good
sleep quality can act as a stress buffer (Hamilton,
Catley, & Karlson, 2007).
Who can’t sleep? People who are going through
major stressful life events or traumas, who are suffer-
ing from major depression (Sivertsen et al., 2012),
who are experiencing stress at work (Burgard &
Ailshire, 2009), who are experiencing socioeconomic

Chapter 4 Health-Promoting Behaviors 77

TABLE 4.3 | A Good Night’s Sleep

• Get regular exercise, at least three times a week.
• Keep the bedroom cool at night.
• Sleep in a comfortable bed that is big enough.
• Establish a regular schedule for awakening and going

to bed.
• Develop nightly rituals that can get you ready for bed,

such as taking a shower.
• Use a fan or other noise generator to mask background

sound.
• Don’t consume too much alcohol and don’t smoke.
• Don’t eat too much or too little at night.
• Don’t have strong smells in the room, such as from

incense, candles, or lotions.
• Don’t nap after 3 p.m.
• Cut back on caffeine, especially in the afternoon or

evening.
• If awakened, get up and read quietly in another place,

so that bed is associated with sleep, not sleeplessness.

Sources: Gorman, 1999; S. L. Murphy, 2000.

activities, such as hobbies, sports, socializing, or
spending time in nature, has been tied to lower blood
pressure, lower cortisol, lower weight, and better
physical functioning. Satisfaction with leisure activi-
ties can improve cognitive functioning among the el-
derly (Singh-Manoux, Richards, & Marmot, 2003)
and promote good health behaviors (Kim, Kubzansky,
& Smith, 2015).
Unfortunately, little other than intuition currently
guides our thinking about restorative processes. None-
theless, health psychologists suspect that rest, re-
newal, and savoring—involving activities such as
going home for the holidays, relaxing after exams, and
enjoying a walk or a sunset—have health benefits. ∙

78 Part Two Health Behavior and Primary Prevention

minority and older women, undergo them
because of lack of information, unrealistic fears,
and the high cost and lack of availability of
mammograms. Colorectal screening is also an
important cancer-related health behavior.

7. Dietary interventions involving reductions in
cholesterol, fats, calories, and additives and
increases in fiber, fruits, and vegetables are
widely recommended. Yet long-term adherence
to such diets is limited for many reasons:
Recommended diets are sometimes boring; tastes
are hard to change; and behavior change often
falls off over time.

8. Dietary interventions through the mass media and
community resources have promise. Intervening
with the family is also helpful in promoting and
maintaining dietary change. Cognitive behavioral
therapeutic interventions (CBT) have been
successfully employed to alter diet, although
recent interventions have moved to less costly
formats, such as telephone interventions.

9. Sufficient sleep, rest renewal, and relaxation are
also important health behaviors. Many people
abuse their sleep intentionally or suffer from
insomnia. A variety of behavioral methods that
promote relaxation can offset these risks. In
addition, setting aside time to savor the pleasant
aspects of life and simply taking a vacation may
have health benefits.

1. Health-enhancing behaviors are practiced by
people to improve their current and future health.
Such behaviors include exercise, accident
prevention measures, cancer detection processes,
consumption of a healthy diet, 7–8 hours of sleep
each night, and opportunities for rest and renewal.

2. Exercise reduces risk for heart attack and
improves other aspects of bodily functioning.
Exercise also improves mood and reduces stress.

3. Few people adhere regularly to the standard
exercise prescription of at least 30 minutes at
least three times a week. People are more likely
to exercise when the form of exercise is
convenient and they like it, if their attitudes favor
exercise, and if they come from families in
which exercise is practiced.

4. Cognitive-behavioral interventions, including
relapse prevention components, have been
moderately successful in helping people adhere
to regular exercise programs.

5. Accidents are a major cause of preventable
death, especially among children and
adolescents. Publicity in the mass media,
legislation promoting accident prevention
measures, training of parents by health
practitioners, and interventions to promote safety
measures for children have reduced these risks.

6. Mammograms are recommended for women
over age 50, yet not enough women, especially

S U M M A R Y

K E Y T E R M

aerobic exercise

79

C H A P T E R 5
SES, Culture, and Obesity

Obesity and Dieting as Risk Factors for Obesity

Stress and Eating

Interventions

Cognitive Behavioral Therapy (CBT)

Evaluation of Cognitive-Behavioral Weight-Loss
Techniques

Taking a Public Health Approach

Eating Disorders
Anorexia Nervosa

Bulimia

Alcoholism and Problem Drinking
The Scope of the Problem

What Is Substance Dependence?

Alcoholism and Problem Drinking

Origins of Alcoholism and Problem Drinking

Treatment of Alcohol Abuse

Treatment Programs

Evaluation of Alcohol Treatment Programs

Preventive Approaches to Alcohol Abuse

Drinking and Driving

Is Modest Alcohol Consumption a Health Behavior?

Smoking
Synergistic Effects of Smoking

A Brief History of the Smoking Problem

Why Do People Smoke?

Nicotine Addiction and Smoking

Interventions to Reduce Smoking

Smoking Prevention Programs

Health-Compromising Behaviors

C H A P T E R O U T L I N E

Characteristics of Health-Compromising Behaviors
Obesity

What Is Obesity?

Obesity in Childhood

© Clandestini/Getty Images RF

80 Part Two Health Behavior and Primary Prevention

Some years back, my father went for his annual physical, and his doctor told him, as the doctor did
each year, that he had to stop smoking. As usual, my
father told his doctor that he would stop when he was
ready. He had already tried several times and had been
unsuccessful. My father had begun smoking at age 14,
long before the health risks of smoking were known,
and it was now an integrated part of his lifestyle,
which included a couple of cocktails before a dinner
high in fat and cholesterol and a hectic life that pro-
vided few opportunities for regular exercise. Smoking
was part of who he was. His doctor then said, “Let me
put it this way. If you expect to see your daughter
graduate from college, stop smoking now.”
That warning did the trick. My father threw his
cigarettes in the wastebasket and never had another
one. Over the years, as he read more about health, he
began to change his lifestyle in other ways. He began to
swim regularly for exercise, and he pared down his diet
to one of mostly fish, chicken, vegetables, fruit, and
cereal. Despite the fact that he once had many of the
risk factors for early heart disease, he lived to age 83.

■ CHARACTERISTICS OF
HEALTH-COMPROMISING
BEHAVIORS

In this chapter, we address health-compromising
behaviors—behaviors practiced by people that under-
mine or harm their current or future health. My
father’s problems with stopping smoking illustrate
several important points about these behaviors. Many
health-compromising behaviors are habitual, and sev-
eral, including smoking, are addictive, making them
very difficult habits to break. On the other hand, with
proper interventions, even the most intractable health
habit can be modified. When a person succeeds in
changing a poor health behavior, often he or she will
make other healthy lifestyle changes. The end result is
that risk declines, and a disease-free middle and old
age becomes a possibility.
Many health-compromising behaviors share sev-
eral additional important characteristics. First, there
is a window of vulnerability in adolescence. Behav-
iors such as drinking to excess, smoking, using illicit
drugs, practicing unsafe sex, and taking risks that
can lead to accidents or early death all begin in early
adolescence and sometimes cluster together as
part  of a problem behavior syndrome (Donovan &
Jessor, 1985; Lam, Stewart, & Ho, 2001). In the past,

adolescent boys were more at risk of falling into
these patterns, but girls are catching up (Mahalik et
al., 2013). Not all health-compromising behaviors
develop during adolescence; obesity, for example,
can begin early in childhood. Nonetheless, there is
an unnerving similarity in the factors that elicit and
maintain many health-compromising behaviors.
Many of these behaviors are tied to the peer cul-
ture, as children learn from and imitate their peers, es-
pecially the male peers they like and admire (Bricker
et al., 2009; Gaughan, 2006). Wanting to be attractive
to others becomes very important in adolescence, and
this factor is significant in the development of eating
disorders, alcohol consumption, tobacco and drug use,
tanning, unsafe sexual encounters, and vulnerability to
injury (Shadel, Niaura, & Abrams, 2004). Exposure to
peers’ risky behavior, such as unsafe driving, increases
risk-taking (Simons-Morton et al., 2014).
Many of these behaviors are pleasurable, enhanc-
ing the adolescent’s ability to cope with stressful situa-
tions, and some represent thrill seeking, which can be
rewarding in its own right. However, each of these be-
haviors is also dangerous. Each has been tied to at least
one major cause of death, and several, especially smok-
ing and obesity, are risk factors for more than one major
chronic disease. Adolescents who slip into these pat-
terns are less likely to practice good health habits and
use leisure time for exercise in midlife, setting the stage
for an unhealthy middle and older age (Wichstrøm, von
Soest, & Kvalem, 2013).
Third, these behaviors develop gradually, as the
person is exposed to the behavior, experiments with it,
and later engages in it regularly. As such, many health-
compromising behaviors are acquired through a pro-
cess that makes different interventions important at
the different stages of vulnerability, experimentation,
and regular use.
Fourth, substance abuse of all kinds, whether ciga-
rettes, food, alcohol, drugs, or health-compromising
sexual behavior, are predicted by some of the same
factors (Peltzer, 2010). Adolescents who get involved
in risky behaviors often have conflict with their parents
(Cooper, Wood, Orcutt, & Albino, 2003). Adolescents
with a penchant for deviant behavior and with low self-
esteem also show these behaviors (Duncan, Duncan,
Strycker, & Chaumeton, 2002). Adolescents who try to
combine long hours of employment with school have
an increased risk of alcohol, cigarette, and marijuana
abuse (Johnson, 2004). Adolescents who abuse sub-
stances typically do poorly in school; family problems,

Chapter 5 Health-Compromising Behaviors 81

deviance, and low self-esteem appear to explain this
relationship (Andrews & Duncan, 1997). Reaching pu-
berty early (van Jaarsveld, Fidler, Simon, & Wardle,
2007), and having a low IQ, a difficult temperament,
and deviance-tolerant attitudes predict poor health be-
haviors (Repetti, Taylor, & Seeman, 2002). Good self
control diminishes and poor self-regulation facilitates
vulnerability to substance use (Wills et al., 2013). But
co-occurring mental health disorders, such as depres-
sion or anxiety, may fuel these problem behaviors and
make them harder to treat (Vannucci et al., 2014).
A particular dilemma is that many of these behav-
iors—drinking or cigarette smoking, for example—
may start out as experiments but smoking, drugs,
excessive alcohol consumption, and compulsive eat-
ing can become addictions. There may be common
brain circuitry for all these seemingly different behav-
iors, especially the circuitry that controls reward and
pleasure/pain (Salamone & Correa, 2013; Smith &
Robbins, 2013; Stice, Yokum, & Burger, 2013).
Finally, problem behaviors, including obesity,
smoking, and alcoholism, are more common in the
lower social classes (Fradklin et al., 2015). Lower-
class children and adolescents are exposed more to
problem behaviors and may use these behaviors to
cope with the stressors of low social class (Novak,
Ahlgren, & Hammarstrom, 2007). Practice of these
health- compromising behaviors are one reason that so-
cial class is so strongly related to most causes of dis-
ease and death (Adler & Stewart, 2010).

■ OBESITY

What Is Obesity?
Obesity is an excessive accumulation of body fat.
Generally, fat should constitute about 20–27 percent
of body tissue in women and about 15–22 percent in
men. Table 5.1 presents guidelines from the National
Institutes of Health for calculating your body mass
index and determining whether you are overweight or
obese.
The World Health Organization estimates that
600 million people worldwide are obese and 1.9 bil-
lion are overweight, including 42 million children un-
der age 5 (World Health Organization, January 2015).
Obesity is now so common that it has replaced malnu-
trition as the most prevalent dietary contributor to
poor health worldwide (Kopelman, 2000), and it will
soon account for more diseases and deaths in the
United States than smoking.

The obesity problem is most severe in the United
States. Americans are the fattest people in the world.
At present, 68 percent of the adult U.S. population is
overweight, and about 34 percent is obese (Ogden,
Carroll, Kit, & Flegal, 2012), with women and older
adults somewhat more likely to be overweight or obese
than men and younger adults (Fakhouri, Ogden, Carroll,
Kit, & Flegal, 2012) (Figure 5.1). Although obesity
levels have begun to level off, the trend has not yet
reversed (Kaplan, 2014).
There is no mystery why people in the United
States have become so heavy. The average American’s
food intake rose from 1,826 calories a day in the 1970s
to more than 2,000 by the mid-1990s (O’Connor,
2004, February 6). Soda consumption has skyrock-
eted from 22.2 gallons to 56 gallons per person per
year (Ervin, Kit, Carroll, & Ogden, 2012). Portion
sizes at meals have increased substantially over the
past 20 years (Nielsen & Popkin, 2003). Muffins that
weighed 1.5 ounces in 1957 now average half a pound
each (Raeburn, Forster, Foust, & Brady, 2002, Octo-
ber 21). Snacking has increased more than 60 percent
over the last three decades (Critser, 2003), and easy
access to food through microwave ovens and fast food
restaurants contributes to the increase. The average
American weight gain over the past 20 years is the ca-
loric equivalent of only three Oreo cookies or one can
of soda a day (Critser, 2003), so it does not take vast
quantities of food or sugary drinks to gain weight.

Risks of Obesity Obesity is a risk factor for
many disorders. It contributes to death rates for all
cancers and for the specific cancers of the colon, rec-
tum, liver, gallbladder, pancreas, kidney, and esopha-
gus, as well as non-Hodgkin’s lymphoma and multiple
myeloma. Estimates are that excess weight may ac-
count for 14 percent of all deaths from cancer in men
and 20 percent of all deaths from cancer in women
(Calle, Rodriguez, Walker-Thurmond, & Thun,
2003). Obesity also contributes substantially to
deaths from cardiovascular disease (Flegal, Grau-
bard, Williamson, & Gail, 2007), and it is tied to ath-
erosclerosis, hypertension, Type II diabetes, and
heart failure (Kerns, Rosenberg, & Otis, 2002). Obe-
sity increases risks in surgery, anesthesia administra-
tion, and childbearing (Brownell & Wadden, 1992). It
has been tied to poorer cognitive skills as early as
adolescence, well in advance of any diagnosable
chronic health condition (Hawkins, Gunstad, Calvo,
& Spitznagel, 2016).

82 Part Two Health Behavior and Primary Prevention

Obesity is a chief cause of disability. The number
of people age 30–49 who are too heavy to care for
themselves or perform routine household tasks has
jumped by 50 percent. This increase bodes poorly for
the future. People who are disabled in their 30s and 40s
are more likely to have health care expenses and to
need nursing home care in older age, if they live that
long (Richardson, 2004, January 9). Being obese also
reduces the likelihood that a person will exercise, and
lack of exercise increases obesity; yet obesity and lack
of exercise appear to exert independent adverse effects
on health, leading to greater risks than either risk fac-
tor alone (Hu et al., 2004). One in four people over 50
is obese, and as the population ages, the numbers of
people who will have difficulty performing the basic
tasks of daily living, such as bathing, dressing, or even
walking, will be substantial (Facts of Life, December,
2004). Obesity is tied to poor cognitive functioning as
well (Verstynen et al., 2012).
Obesity is associated with early mortality (Adams
et al., 2006). People who are overweight at age 40 die,
on average, 3 years earlier than people who are thin
(Peeters et al., 2003). Abdominally localized fat, as

opposed to excessive fat in the hips, buttocks, or
thighs, is an especially potent risk factor for cardiovas-
cular disease, diabetes, hypertension, cancer, and de-
cline in cognitive function (Dore, Elias, Robbins,
Budge, & Elias, 2008). People with excessive abdomi-
nal weight (sometimes called “apples,” in contrast to
“pears,” who carry their weight on their hips) are more
psychologically and physiologically reactive to stress
(Epel et al., 2000). Fat tissue produces proinflamma-
tory cytokines, which may exacerbate diseases related to
inflammatory processes (see Chapter 2). Box 5.1 ex-
plores the biological regulation more fully.
Often ignored among the risks of obesity is the
psychological distress that can result. Although there
is a robust stereotype of overweight people as “jolly,”
studies suggest that the obese are prone to neuroticism
and psychiatric conditions, especially depression
(Sutin et al., 2013; Toups et al., 2013).
There are social and economic consequences of
obesity as well. An obese person may have to pay for
two seats on an airplane, have difficulty finding
clothes, endure derision and rude comments, and ex-
perience other reminders that the obese, quite literally,

TABLE 5.1 | Body Mass Index Table

Normal Overweight Obese Obese Extreme Obesity

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Height
(inches) Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

Source: National Heart, Lung & Blood Institute, 2004.

Chapter 5 Health-Compromising Behaviors 83

do not fit. Obesity is stigmatized as a disability whose
fault lies squarely with the obese person (Puhl,
Schwartz, & Brownell, 2005; Wang, Houshyar, &
Prinstein, 2006). Even health care providers may hold
these stereotypes. One woman reported that her phy-
sician told her “I was too fat for a proper exam and to
come back when I’d lost 50 pounds” (Center for the
Advancement of Health, 2008). The resulting effect
of repeated exposure to others’ judgments about their
weight can be heightened biological responses to
stress (Tomiyama et al., 2014), social alienation, and
low self-esteem. As a result, obese people sometimes
become reclusive, and one consequence is that diabe-
tes, heart disease, and other complications of obesity
may be far advanced by the time they seek a physi-
cian. Positive media portrayals of overweight and
obese people can go some distance to mitigate the
stigma (Brochu, Pearl, Puhl, & Brownell, 2014).

Obesity in Childhood

In the United States, approximately 42 million chil-
dren under 5 are overweight or obese (World Health

Organization, 2016). Nearly two-thirds of overweight
and obese children already have risk factors for
cardiovascular disease, such as elevated blood pres-
sure, elevated lipid levels, or hyperinsulemia (Sinha
et al., 2002). African American and Hispanic children
and adolescents are at particular risk. For the first time
in over 200 years, the current generation of children
has a shorter life expectancy than their parents due to
high rates of obesity (Belluck, 2005, March 17).
What causes the high rates of obesity in childhood?
There are genetic contributors to obesity, which com-
bine with risks conferred by low SES, increasing overall
risk to be obese (Dinescu, Horn, Duncan, & Turkheimer,
2016). The impact of genetics on weight may be exerted
in part by a vigorous feeding style that is evident early in
life. There are also genetically based tendencies to store
energy as fat rather than lean tissue. Another important
factor is sedentary lifestyles, involving television, video
games, and the Internet. Consumption of snacks and
sugary drinks during the sedentary activities greatly in-
crease the risks associated with obesity (Ervin & Ogden,
2013). Sugary drinks alone have been tied to 25,000
deaths per year in the U.S. and 180,000 worldwide in

TABLE 5.1 | Body Mass Index Table

Normal Overweight Obese Obese Extreme Obesity

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Height
(inches) Body Weight (pounds) Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

Source: National Heart, Lung & Blood Institute, 2004.

84 Part Two Health Behavior and Primary Prevention

1Significant increasing linear trend by age (p < 0.01). 2Significant increasing linear trend by age (p < 0.001). Note: Estimates were age adjusted by the direct method to the 2000 U.S. Census population using the age groups 20–39, 40 –59, and 60 and over. 0 Pe rc en t 40 35.7 32.6 36.6 39.7 35.5 33.2 37.2 36.6 35.8 31.9 36.0 42.3 30 20 10 50 All1 Men Women2 20 and overAge in years: 20 –39 40 –59 60 and over FIGURE 5.1 | Percentage of Population Overweight and Obese Overweight is BMI over 25 and obese is BMI over 30. (Source: Centers for Disease Control and Prevention, 2011c) More than one-third of the adult population in the United States is overweight, putting them at risk for heart disease, kidney disease, hypertension, diabetes, and other health problems. © Ryan McVay/Getty Images RF 85 adulthood, due to a practice that typically begins in childhood (Healy, July 15, 2015). Children are less likely to be obese if they partici- pate in organized sports or physical activity, but obese children may come from families that do not value or do not have access to exercise facilities (Kozo et al., 2012; Veitch et al., 2011). Children who take in too many calories in infancy and childhood are more likely to become obese adults (Kuhl et al., 2014). Even the family dog is more likely to be overweight in families with large portion sizes and low activity lev- els. By contrast, positive parenting can mitigate poorly controlled eating in children (Connell & Francis, 2014). Figure 5.2 illustrates the high rates of obesity among children. Obesity depends on both the number and the size of an individual’s fat cells. Among moderately obese people, fat cells are typically large, but there is not an unusual number of them. Among the severely obese, there is a large number of fat cells, and the fat cells themselves are exceptionally large (Brownell, 1982). Childhood constitutes a window of vulnerability for obesity because the number of fat cells a person has is typically determined in the first few years of life, by genetic factors and by early eating habits. SES, Culture, and Obesity Additional risk factors for obesity include social class and culture (Gallo et al., 2012). In the United States, women of low socioeconomic status are heavier than high-SES women, and African American women, in particular, are more likely to be obese (Ogden, Lamb, Carroll, & Flegal, 2010). For reasons that remain un- clear, the prevalence of obesity among men is not re- lated to SES. Obesity, thus, may be part of the accumulating disadvantage that women of low SES experience over the lifespan (Zajacova & Burgard, 2010). Values are implicated in obesity. Thinness is valued in women from high-SES levels and from de- veloped countries, which in turn leads to a cultural emphasis on weight control and physical activity (Wardle et al., 2004). Depression and weight gain are linked. People who are depressed are more likely to gain weight, and people who are obese or overweight are more likely to be depressed (Kubzansky, Gilthorpe, & Goodman, 2012; van Reedt Dortland, Giltay, van Veen, Zitman, & Penninx, 2013). People who are high in neuroti- cism, extraversion, and impulsivity and low in consci- entiousness are more likely to be obese (Sutin, Ferrucci, Zonderman, & Terracciano, 2011). Obesity spreads through social networks, al- most like an epidemic. A person’s chances of be- coming obese increase substantially when he or she has a friend, sibling, or partner who has become obese. It may be that obesity changes the social norms associated with obesity, making it more ac- ceptable to become obese (Christakis & Fowler, 2007). Most people seem unaware of the social in- fluences on their eating (Spanos, Vartanian, Her- man, & Polivy, 2014). All animals, including humans, have sensitive and complex systems for regulating food. Taste has been called the chemical gatekeeper of eating. It is an an- cient sensory system and plays an important role in selecting certain foods and rejecting others. An important player in weight control is the pro- tein leptin, which is secreted by fat cells. Leptin signals the neurons of the hypothalamus as to whether the body has sufficient energy stores of fat or whether it needs additional energy. The brain’s eating control center reacts to the signals sent from the hypothalamus to increase or decrease appetite. Leptin inhibits the neurons that stimulate appetite and activates those that suppress appetite. As such, it holds promise as a target for interventions (Morton, Cummings, Baskin, Barsh, & Schwartz, 2006). Ghrelin may play a role in why dieters who lose weight often gain it back so quickly. Ghrelin is secreted by specialized cells in the stomach, spiking just before meals and dropping afterward. When people are given ghrelin injections, they feel extremely hungry. There- fore, blocking ghrelin levels or the action of ghrelin may help people lose weight and keep it off (Grady, 2002, May 23). B O X 5.1The Biological Regulation of Eating 86 Part Two Health Behavior and Primary Prevention Obesity in childhood is one of the fastest growing health concerns in the United States. © Spencer Weiner/Los Angles Times via Getty Images 16 14 12 10 8 6 4 2 0 1963–65 1966–70** 1971–74 1976–80 1988–94 1999–2000 2001–2002 2003–2004 2005–2006 Pe rc en ta ge Age 6–11 Age 12–19* *Excludes pregnant women starting with 1971–74. Pregnancy status not available for 1963–65 and 1966–70. **Data for 1963–65 are for children 6–11 years of age; data for 1966–70 are for adolescents 12–17 years of age, not 12–19 years. 2007–2008 18 20 FIGURE 5.2 | Percentage of Young People Who Are Overweight Overweight is defined as greater than or equal to the 95th percentile of the age- and sex-specific BMI. (Source: National Center for Health Statistics, 2010a) Obesity and Dieting as Risk Factors for Obesity Obesity is a risk factor for becoming even more so. Many obese people have a high basal insulin level, which promotes overeating due to increased hunger. Moreover, the obese have large fat cells, which have a greater capacity for producing and storing fat than do small fat cells. Dieting contributes to the propensity for obesity. Successive cycles of dieting and weight gain, so-called yo-yo dieting, enhance the efficiency of food use and lower the metabolic rate (Bouchard, 2002). When Chapter 5 Health-Compromising Behaviors 87 dieters begin to eat normally again, their metabolic rate may stay low, and it can become easier for them to put on weight again even though they eat less food. Set Point Theory of Weight Evidence has accumulated for a set point theory of weight: the idea that each individual has an ideal biological weight, which cannot be greatly modified (Garner & Wooley, 1991). According to the theory, the set point acts like a thermostat regulating heat in a home. A person eats if his or her weight gets too low and stops eating as the weight reaches its ideal point. Some people have a higher set point than others, leading to a risk for obesity (Brownell, 1982). The theory argues that efforts to lose weight may be compensated for by adjustments in energy expendi- ture, as the body actively attempts to return to its original weight. This theory applies to obese people too. Once obesity is established, it is often stamped in, and the body will defend against efforts to lose weight (Healy, 2015). Stress and Eating Stress affects eating, although in different ways for  different people. About half of people eat more  when they are under stress, and half eat less (Willenbring, Levine, & Morley, 1986). For non- dieting and nonobese normal eaters, stress or anxiety may suppress physiological cues of hunger, leading to lower consumption of food. For overweight and obese people, however, stress and anxiety can disinhibit food consumption, removing the self- control that usually guards against eating (Sinha & Jastreboff, 2013). Whereas men tend to eat less in stressful circumstances, many women eat more (Grunberg & Straub, 1992). Stress also influences what food is consumed. People who eat in response to stress usually consume more low-calorie and salty foods, although when not under stress, stress eaters show a preference for high-calorie foods (Willenbring et al., 1986). Anxiety and depression figure into stress eating as well. One study found that stress eaters experi- ence greater fluctuations in anxiety and depression than do nonstress eaters. Overweight people also have greater fluctuations in anxiety, hostility, and depression than do normal individuals (Lingsweiler, Crowther, & Stephens, 1987). People who eat in re- sponse to negative emotions show a preference for sweet and high-fat foods (Oliver, Wardle, & Gibson, 2000). These “comfort foods,” however, do not actu- ally lift moods (Wagner, Ahlstrom, Redden, Vickers, & Mann, 2014). Interventions More people are treated for obesity in the United States than for all other health habits or conditions combined. More than half a million people attend weight-loss clinics, and Amazon.com lists more than 169,000 book titles that refer to diet or dieting. How- ever, obesity is a very difficult condition to treat. Even initially successful weight-loss programs show a high rate of relapse. Exercise Exercise is critical to reducing weight. It can even change the underlying propensity to gain weight; that is, exercise can help reprogram genes that influence how fat is stored, making obesity less likely (The Economist, July 13, 2013). Sleep Some obese people have an altered sleep pattern, whereby they work when others are sleeping. By working when they are supposed to be asleep, their bodies become used to not expending much energy either during the day or at night, and overall fewer calories are burned (Healy, 2014). Dieting Most weight-loss programs begin with dietary treatment. People are trained to restrict their caloric and/or carbohydrate intake. In some cases, food may be provided to the dieters to ensure that the appropriate foods are being consumed. Generally, weight loss produced through dietary methods is small and rarely maintained for long (Agras et al., 1996). In fact, as Box 5.2 shows, dieting has risks. Very low-carbohydrate or low-fat diets do the best job in helping people lose weight initially, but these diets are the hardest to maintain, and people com- monly revert to their old habits. Reducing caloric intake, increasing exercise, and sticking with an eat- ing plan over the long term are the only factors reli- ably related to staying slim. Beginning as early as preschool, these are the best ways to tackle obesity (Kuhl et al., 2014). Surgery Surgical procedures represent a radical way of controlling extreme obesity. In one common surgical procedure, the stomach is literally stapled up to reduce its capacity to hold food, so that the over- weight individual must restrict his or her intake. In another approach known as lap band surgery, an ad- justable gastric band is inserted surgically around the top of the stomach to create a small pouch in the upper stomach to reduce the stomach’s capacity to take in food. As with all surgeries, there are potential side ef- fects such as gastric and intestinal distress. Conse- quently, this procedure is usually reserved for people who are at least 100 percent overweight, who have failed repeatedly to lose weight through other meth- ods, and who have complicating health problems that make weight loss urgent. Cognitive Behavioral Therapy (CBT) Researchers now believe that the compulsive overeat- ing that leads to obesity shares the same brain cir- cuitry as other addictive disorders, making it a difficult problem to treat, like smoking or drug addiction (Volkow, Wang, Tomasi & Baler, 2013). Many inter- ventions with the obese use CBT to combat maladap- tive eating behavior. Screening Some programs begin by screening applicants for their readiness to lose weight and their motivation to do so. Unsuccessful prior dieting at- tempts, weight lost and regained, high body dissatis- faction, and low self-esteem can all undermine weight loss efforts (Teixeira et al., 2002). Self-Monitoring Obese clients are trained in self-monitoring, to keep careful records of what they eat, when they eat it, how much they eat, and where they eat it. This record keeping simultane- ously defines the behavior, makes clients more aware of their eating patterns, and can lead to begin- ning efforts to lose weight (Baker & Kirschenbaum, 1998). Even online self- monitoring has been tied to weight loss (Krukowski, Harvey-Berino, Bursac, 88 B O X 5.2 Don’t Diet Nearly half of all adults in the United States are trying to lose weight at any given time, and the most popular way is through dieting. Although dieting (or caloric restriction) leads to weight loss on the short term, over the long term, most people gain back at least as much or more weight that they lost when they were dieting (Mann et al., 2007). Why would dieting have exactly the opposite of its intended effects? Health psychologist Janet Tomiyama and her col- leagues set out to answer this question (Tomiyama et al., 2010). Their hypothesis was that diets fail because they increase stress and levels of the stress hormone cortisol. Both of these factors can cause weight gain. Tomiyama reasoned that the stress of monitoring one’s caloric in- take and restricting food consumption enhances stress and cortisol production, leading to the unexpected and paradoxical effect that dieting leads to more weight gain. In their study, 121 young women who wanted to lose weight were assigned to one of four dieting interventions for 3 weeks. They were told either to monitor their diet (or not) and/or to restrict their calories (or not). Tomiyama provided all of the dieters with prepared food, so that everybody consumed the same number of calories. The results showed that the women who restricted their calories (the dieters) had higher cortisol levels, and monitoring calories increased perceived stress. Thus, dieting seems to harm both psychological well- being and biological functioning. The stress of dieting may be one reason why diets usually fail. If dieting does not work, what will? The answer is lifestyle change. Rather than restricting calories, chang- ing one’s diet permanently in a way that involves more fruits and vegetables, less starch (white bread, dinner rolls), and smaller portions, coupled with regular exercise will lead to sustainable weight loss. Adding exercise also helps people take off extra weight and keep it off. © Vstock/UpperCut Images/Getty Images RF Chapter 5 Health-Compromising Behaviors 89 Ashikaga, & West, 2013). Many clients are sur- prised to discover what, when, and how much they actually eat. Monitoring is always important for weight loss, but it becomes especially so at high- risk times, such as during the holidays, when weight gain reliably occurs (Boutelle, Kirschenbaum, Baker, & Mitchell, 1999). Attentional Retaining People who are battling a health issue such as obesity or smoking will often show an attentional bias in favor of cues related to  the issue. For example, an obese person may orient to food cues, such as appealing high-calorie foods, or a store window with rich foods (Kemps, Tiggemann, & Hollitt, 2014). Obese children whose  attention goes to food may also gain weight (Werthmann et al., 2015). Attentional retaining involves breaking or at least moderating this auto- matic attentional bias by distracting one’s self, focusing on other aspects of the environment, or even physical activity. Stimulus Control Clients are trained to modify the stimuli in their environment that have previously elicited and maintained their overeating and to take steps to modify their food consumption. Such steps include purchasing low-calorie foods (such as raw vegetables) and limiting the high-calorie foods kept in the house. Clients are taught to confine eating to one place at particular times of day, and to develop new discriminative stimuli that will be associated with eat- ing, for example, using a particular place setting, such as a special placemat or napkin, and to eat only when those stimuli are present. Keeping portion size modest is also important (Kerameas, Vartanian, Herman, & Polivy, 2015). Controlling Eating The next step is to gain con- trol over the eating process itself. For example, cli- ents may be urged to count each mouthful of food. They may be told to put down eating utensils after every few mouthfuls until the food in their mouths is chewed and swallowed. Longer and longer delays are introduced between mouthfuls so as to encour- age slow eating (which tends to reduce intake). Fi- nally, clients are urged to savor their food—to make a conscious effort to appreciate it while they are eat- ing. The goal is to teach the obese person to eat less and enjoy it more. Self Reinforcement Success can be supported by a positive reinforcement, such as going to a movie or making a facebook message to a friend. Developing a sense of self-control over eating is an important part of behavioral treatment of obesity and can help people overcome temptations. Suc- ceeding in losing weight is tied to greater vitality and psychological well-being (Swencionis et al., 2013), and this can act as another source of self- reinforcement. Controlling Self-Talk Cognitive restructuring is an important part of weight-reduction programs. As noted in Chapter 3, poor health habits can be main- tained through dysfunctional monologues (“I’ll never lose weight—I’ve tried before and failed so many times”). Participants in weight-loss programs are urged to identify the maladaptive thoughts they have regarding weight loss and to substitute positive self- instruction. The formation of explicit implementation inten- tions (Luszczynska, Sobczyk, & Abraham, 2007) and a strong sense of self-efficacy—that is, the belief that one will be able to lose weight—also predicts weight loss (Warziski, Sereika, Styn, Music, & Burke, 2008). The goal of these aspects of interventions is to increase a sense of self- determination, which can enhance intrinsic motiva- tion to continue diet modification and weight loss (Mata et al., 2009). Approximately 500,000 Americans participate in organized weight-reduction programs. Many of these programs include exercise. © AP Photo/Natacha Pisarenko 90 Part Two Health Behavior and Primary Prevention Adding Exercise Exercise is a critical compo- nent of any weight-loss program. As people age, in- creasing physical activity is essential just to maintain weight, let alone avoid gaining it (Jameson, 2004). Stress Management Efforts to lose weight can be stressful (Tomiyama et al., 2010), and so reducing life stress can be helpful. Among the techniques that have been used are mindfulness training and accep- tance and commitment theory (ACT). Social Support Because people with strong so- cial support are more successful at losing weight than those with little social support, most CBT programs include training in eliciting effective support from families, friends, and coworkers. Even supportive messages from a behavioral therapist over the Internet seem to help people lose weight (Oleck, 2001). Au- tonomy support, that is, social support that conveys the belief that the person is an autonomous, responsi- ble agent of his/her own behavior appears to foster self regulation that can lead to more weight loss better than more directive support (Gorin, Powers, Koestner, Wing, & Raynor, 2014). The family environment is critical for weight loss, especially for children and adolescents. Families typi- cally eat together, and so meals, which are usually planned by one person, are consumed by all (Lytle et  al., 2011; Samuel-Hodge et al., 2010). Family- based interventions have shown particular promise for modifying obesity-related health behaviors (Crespo et al., 2012; Gorin et al., 2013). Relapse Prevention Relapse prevention tech- niques are incorporated into treatment programs, in- cluding matching treatments to the eating problems of particular clients, restructuring the environment to remove temptation, rehearsing high-risk situations for relapse (such as parties and holidays), and developing coping strategies to deal with high-risk situations. Moreover, weight loss efforts can fail and lapses are likely, and so people need to be protected against their self-recrimination and tendency to let a lapse turn into a full-blown loss of control. Weight loss programs such as these can be imple- mented successfully, over the Internet (Krukowski, Harvey-Berino, Bursac, Ashikaga, & West, 2013), through workplace weight loss interventions, and through commercial weight loss programs. Indeed, more than 500,000 people each week are exposed to behavioral methods to control obesity through commer- cial programs such as Weight Watchers and Jenny Craig. Evaluation of Cognitive-Behavioral Weight-Loss Techniques Cognitive-behavioral programs typically produce modest success, with weight loss of nearly 2 pounds a week for up to 20 weeks and long-term maintenance over at least 2 years (Brownell & Kramer, 1989). Pro- grams that emphasize diet modification self-direction and exercise and include relapse prevention tech- niques are particularly successful (Jeffery, Hennrikus, Lando, Murray, & Liu, 2000). Interventions with chil- dren and adolescents show particularly good results when parents are involved (Kitzmann et al., 2010). Table 5.2 describes some of the promising leads that current research suggests for enhancing long- term weight loss in cognitive-behavioral programs. Taking a Public Health Approach The increasing prevalence of obesity makes it evident that prevention is essential for combating this problem (Institute of Medicine, 2011d). Prevention with families at risk for having obese children is an important strategy. Parents should be trained early to adopt sensible meal-planning and eat- ing habits that they can convey to their children. Al- though obesity has proven to be very difficult to modify with adults, it is easier to teach children healthy eating and activity habits. Obese children can benefit from lifestyle interventions involving rein- forcements for giving up sedentary activities like tele- vision watching, inducements to engage in sports and other physical activities, and steps to encourage healthier eating practices including avoiding or elimi- nating snacking (Wilfley et al., 2007). School-based interventions directed to making healthy foods avail- able and modifying sedentary behavior will help (Dietz & Gortmaker, 2001). The World Health Organization has argued for sev- eral changes, including food labels that contain more nutrition and serving size information, a special tax on foods that are high in sugar and fat (the so-called junk food tax), and restriction of advertising to children or required health warnings (Arnst, 2004). Some states now control the availability of junk food and sugary drinks in schools, products that have been linked di- rectly to weight in children (Taber, Chriqui, Perna, Chapter 5 Health-Compromising Behaviors 91 Powell, & Chaloupka, 2012). Some of these real or pro- posed changes in food and drink availability have led to bitter battles between food and beverage companies and state, local, and even the Federal government. ■ EATING DISORDERS In pursuit of the elusive perfect body (Box 5.3), many women and an increasing number of men chronically restrict their diet and engage in other weight-loss ef- forts, such as laxative use, cigarette smoking, and chronic use of diet pills (Facts of Life, November 2002). Women ages 15–24 are most likely to practice these behaviors, but cases of eating disorders have been documented in people as young as 7 and as old as their mid-80s (Facts of Life, November 2002). The epidemic of eating disorders suggests that, like obesity, the pursuit of thinness is a major public health threat. Recent years have seen an increase in the incidence of eating disorders, especially among adolescent girls. Chief among these are anorexia ner- vosa and bulimia. Eating disorders have some of the highest disability and mortality rates of all behavioral disorders (Park, 2007). Eating disorders result in death for about 6 percent of those who have them (Facts of Life, November 2002). Suicide attempts are not uncommon (Bulik et al., 2008). Women with eat- ing disorders or tendencies toward them are also more likely to be depressed, anxious, and low in self- esteem and to have a poor sense of mastery. Anorexia Nervosa One of my most jarring memories is of driving down a street on my university campus during Christmas vacation and seeing a young woman clearly suffering from anorexia nervosa about to cross the street. She had obviously just been exercising. The wind blew her sweatpants around the thin sticks that had once been normal legs. The skin on her face was stretched so tight that the bones showed through, and I could make out her skeleton under what passed for flesh. I TABLE 5.2 | Weight-Management Tips Increasing Awareness Keep track of what you eat. Keep track of your weight. Write down when you eat and why. While You’re Eating Pace yourself—eat slowly. Pay attention to your eating process. Pay attention to how full you are. Eat at the same place and at the same time. Eat one portion, and serve yourself before beginning the meal. Shopping for Food Structure your shopping so that you know what you are buying beforehand. Limit the number of already prepared items. Don’t shop when you are hungry. The Eating Environment Make healthy foods more available than unhealthy ones. Do your best to stick to your eating routine when dining out. Think about the limitations and possible adjustments to your eating routine before dining out or eating with other people. Exercise Track your exercise progress: What do you enjoy doing? Incorporate exercise into your lifestyle—become more active in all areas of life. Attitudes Think about your weight-loss goals—make them realistic. Remember that any progress is beneficial and that not reaching your goal does not mean you failed. Think about your desire for foods—manage and work through cravings. Working with Others Incorporate friends and family into your goals and your new lifestyle, including meal preparation and exercise routines. Communicate to them what they can do to help you reach your goals. Nutrition Be informed about nutrition. Know your recommended daily intake of calories, vitamins, and minerals. Know which foods are good sources of vitamins, minerals, proteins, carbohydrates, and healthy fats. Eat a balanced diet. Prepare foods that are both healthy and taste good. 92 realized that I was face-to-face with someone who was shortly going to die. I looked for a place to pull over, but by the time I had found a parking space, she had disappeared into one of the dormitories, and I could not see which one. Nor do I know what I would have said if I had caught up with her. Anorexia nervosa is an obsessive disorder amounting to self-starvation, in which an individual diets and exercises to the point that body weight is grossly below optimum level, threatening health and potentially leading to death. Most sufferers are young women, but gay and bisexual men are also at risk (Blashill, Goshe, Robbins, Mayer, & Safren, 2014). Developing Anorexia Nervosa Genetic fac- tors are clearly implicated, especially genes involving the serotonin, dopamine, and estrogen systems. These systems have been implicated in both anxiety and food intake. Interactions between genetic factors and risks in the environment, such as early exposure to stress, may also play a role (Striegel-Moore & Bulik, 2007), and dysregulated biological stress systems may be involved. Personality characteristics and family interaction patterns may be causal factors in anorexia. Anorexics may experience a lack of control coupled with a need for approval and exhibit conscientious, perfectionistic behavior. Body image distortions are also common among anorexic girls, although it is not clear whether this distortion is a consequence or a cause of the dis- order. For example, these girls still see themselves as overweight when they have long since dropped below their ideal weight (Hewig et al., 2008). Anorexic girls can come from families with psy- chopathology or alcoholism or from families that are extremely close but have poor skills for communicating emotion or dealing with conflict (Garfinkel & Garner, 1983; Rakoff, 1983). Mothers of daughters with eating disorders appear to be more dissatisfied with their fam- ilies, more dissatisfied with their daughters’ appear- ance, and more vulnerable to eating disorders themselves (Pike & Rodin, 1991). Mothers who are preoccupied with their own weight and eating behaviors place their daughters at risk for developing eating prob- lems (Francis & Birch, 2005). More generally, eating disorders have been tied to insecure attachment in rela- tionships, that is, to the expectation of criticism or re- jection from others (Troisi et al., 2006). By the time a young woman or man goes into treatment for anorexia, the behavior may have become a habit that is, conse- quently, much harder to treat (Goode, 2015). B O X 5.3 The Barbie Beauty Battle Health psychologists have criticized the media and the products they popularize for perpetuating false images of feminine beauty. The Barbie doll has come under particular criticism because its popularity with young girls may contribute to excessive dieting and the de- velopment of eating disorders. Using hip measure- ment as a constant, researchers have calculated that for a young, healthy woman to attain the same body proportions as the Barbie doll, she would have to in- crease her bust by 5 inches, her neck length by more than 3 inches, and her height by more than 2 feet while decreasing her waist by 6 inches (Brownell & Napoli- tano, 1995). This clearly unattainable standard may contribute to the false expectations that girls and women develop for their bodies. Consequently, Mat- tel, who makes Barbie dolls, has now added a curvy Barbie with proportions more similar to those of many adolescent girls (Li, 2016). © AP Photo Chapter 5 Health-Compromising Behaviors 93 Treating Anorexia Initially, the chief target of therapy is to bring the patient’s weight back up to a safe level, a goal that often must be undertaken in a residential treatment setting, such as a hospital. To achieve weight gain, most therapies use cognitive- behavioral approaches (Brown & Keel, 2012). However, the standard principles of cognitive be- havioral therapy do not always work well with an- orexics (Brown & Keel, 2012). Motivational issues are especially important, as inducing the anorexic to want to change her behavior is essential (Wilson, Grilo, & Vitousek, 2007). Family therapy may help families learn positive methods of communicating emotion and conflict. During the early phases of treatment, parents are urged to assume control over the anorexic family member’s eating, but as the anorexic family member begins to gain weight and comply with parental au- thority, he or she (usually she) begins to assume more control over eating (Wilson, Grilo, & Vitousek, 2007). Because of the health risks and difficulties in treating anorexia nervosa, research has increasingly moved toward prevention. Some interventions ad- dress social norms regarding thinness directly (Neumark-Sztainer, Wall, Story, & Perry, 2003). For example, one study gave women information about other women’s weight and body type, on the grounds that women who develop eating disorders often wrongly believe that other women are smaller and thinner than they actually are (Sanderson, Darley, & Messinger, 2002). The intervention succeeded in changing women’s estimates of their actual and ideal weight (Mutterperl & Sanderson, 2002). But the factors that may prevent new cases from arising may be quite different from those that lead students who already have symptoms to seek out treat- ment (Mann et al., 1997). One eating disorder preven- tion program had college freshmen meet classmates who had recovered from an eating disorder; they de- scribed their experience and provided information about the disorder. To the researchers’ dismay, following the intervention, the participants had slightly more symptoms of eating disorders than those who had not participated. The program may have in- advertently normalized the problem. Consequently, ideal strategies for prevention may require stressing the health risks of eating disorders, whereas the strate- gies for inducing symptomatic women to seek treat- ment may involve normalizing the behavior and urging them to accept treatment (Mann et al., 1997). Bulimia Bulimia is characterized by alternating cycles of binge eating and purging through such techniques as vomiting, laxative abuse, extreme dieting or fast- ing, and drug or alcohol abuse. Bingeing appears to be caused at least in part by dieting. About half the people diagnosed with anorexia are also bulimic. Bulimia affects 1–3 percent of women (Wisniewski, Epstein, Marcus, & Kaye, 1997) and an increasing number of men (Striegel, Bedrosian, Wang, & Schwartz, 2012), and up to 10 percent of bulimics may have bingeing episodes. Developing Bulimia Whereas many anorexics are thin, bulimics are typically of normal weight or overweight, especially through the hips. The binge phase is regarded as an out-of-control reaction of the body to restore weight, and the purge phase as an ef- fort to regain control over weight. Women prone to bulimia, especially binge eating, appear to have altered stress responses, especially an atypical hypothalamic-pituitary adrenal diurnal pattern (Ludescher et al., 2009). Cortisol levels, especially in response to stress, may be elevated, promoting eating (Gluck et al., 2004). Food can become a constant thought (Blechert, Feige, Joos, Zeeck, & Tuschen-Caffier, 2011). Restrained eating, then, sets the stage for a binge. Bulimia may have a genetic basis, inasmuch as eating disorders cluster in families, and twin studies show a high concordance rate for binge eating (Wade, Bulik, Sullivan, Neale, & Kendler, 2000). Families that place a high value on thinness and ap- pearance are also likely to have bulimic daughters (Boskind-White & White, 1983). Physiological theories of bulimia focus on hor- monal dysfunctions (Monteleone et al., 2001), low leptin functioning (Jimerson, Mantzoros, Wolfe, & Metzger, 2000), hypothalamic dysfunction, food aller- gies, or disordered taste responsivity (Wisniewski et al., 1997), disorder of the endogenous opioid system (Mitchell, Laine, Morley, & Levine, 1986), neurologi- cal disorder, and a combination of these. Treating Bulimia A barrier to treating bulimia is that many women either do not believe that their problem is a serious one, or they do not believe that a medical intervention will overcome it. Accordingly, one of the first steps in treatment is to convince bulim- ics that the disorder threatens their health and that 94 Part Two Health Behavior and Primary Prevention interventions can help them overcome the disorder (Smalec & Klingle, 2000). When bulimia becomes compulsive, outright prevention of the behavior may be required, with the patient placed in a treatment fa- cility. CBT has been moderately successful in treating bulimia (Mitchell, Agras, & Wonderlich, 2007), in ei- ther an individual or group setting (Katzman et al., 2010). Internet interventions may also be somewhat successful in modifying disordered eating and weight gain prevention (Stice, Durant, Rohde, & Shaw, 2014). A combination of medication and cognitive- behavioral therapy appears to be the most effective therapy (Brown & Keel, 2012; Wilson, Grilo, et al., 2007). Typically, this treatment begins with self- monitoring, keeping a diary of eating habits, includ- ing time, place, type of food consumed, and emotions experienced. Simple self-monitoring can produce de- creases in binge-purge behavior. Most therapies combine monitoring with an indi- vidualized or group CBT program to bring eating un- der control (Wilson, Grilo, et al., 2007). Specific techniques include inducing the client to increase the regularity of meals, eat a greater variety of foods, de- lay the impulse to purge as long as possible, and eat favorite foods in new settings not previously associ- ated with binges. Perceptions of self-efficacy facili- tate the success of cognitive-behavioral interventions. Relapse prevention techniques are often added to therapeutic programs. These include learning to identify situations that trigger binge eating and developing cop- ing skills to avoid them. Relaxation and stress manage- ment skills are often added to these programs as well. Binge Eating Disorder Binge eating usually occurs when the individual is alone; it may be triggered by negative emotions pro- duced by stressful experiences (Telch & Agras, 1996). The dieter begins to eat and then cannot stop, and al- though the bingeing is unpleasant, the binger feels out of control, unable to stop eating. Low self esteem is implicated in binge eating and may be a good target for prevention and treatment (Goldschmidt, Wall, Loth, Bucchianeri, & Neumark-Sztainer, 2014). Many people with binge eating disorder also have a mental health disorder, such as anxiety or depression (Kessler et al., 2013). A related eating disorder, termed binge eating disorder, characterizes the many people who engage in recurrent binge eating but do not engage in the compensatory purging behavior to avoid weight gain (Spitzer et al., 1993). Binge eating disorder is a health problem at least on a scale with bulimia. However, many people with the disorder do not seek or obtain treatment (Kessler et al., 2014). Binge eating increases in response to stress, and a rise in ghrelin, which controls the urge to eat, may be responsible (Gluck, Yahav, Hashim, & Geliebter, 2014). People with binge eating disorders are characterized by an excessive concern with body and weight; a preoccupation with dieting; a history of depression, psychopathology, and alcohol or drug abuse; and difficulties with managing work and social settings (Spitzer et al., 1993). Overvaluing body ap- pearance, a larger body mass than is desired, dieting, and symptoms of depression are implicated in trigger- ing binge episodes (Stice, Presnell, & Spangler, 2002). ■ ALCOHOLISM AND PROBLEM DRINKING The Scope of the Problem Alcohol is responsible for approximately 79,000 deaths each year, making it the third-leading cause of preventable death after tobacco and improper diet and exercise. More than 20 percent of Americans drink at levels that exceed government recommenda- tions (Centers for Disease Control and Prevention, September 2008). About 15 million American adults meet criteria for alcohol abuse and dependence (Substance Abuse and Mental Health Services Administration, 2011). As a health issue, alcohol consumption has been linked to high blood pressure, stroke, cirrhosis of the liver, and some forms of cancer. Excessive alcohol consumption has also been tied to brain atrophy and consequent deteriorating cognitive function (Anstey et al., 2006). Alcoholics can have sleep disorders, which, in turn, may contribute to immune alterations that elevate risk for infection (Redwine, Dang, Hall, & Irwin, 2003). Approximately 31 percent of traffic- related deaths are related to alcohol, and it is esti- mated that 50 percent of Americans will be involved in an alcohol-related accident during his or her life- time (National Highway Traffic Safety Administra- tion, 2012). An estimated 15 percent of the national health bill goes to the treatment of alcoholism (Dorgan & Editue, 1995). Economically, the costs of alcohol abuse and Chapter 5 Health-Compromising Behaviors 95 alcoholism are estimated to be approximately $249 bil- lion per year and include the following: ∙ Most of the costs, 73% of the total cost, resulted from losses in the workplace ∙ 11% went to health care expenses to treat problems due to excessive drinking ∙ 10% was spent on law enforcement and criminal justice expenses ∙ 5% of the costs went to losses from motor vehicle crashes (Centers for Disease Control and Prevention, January 2016). In addition to the direct costs of alcoholism through illness, accidents, and economic costs, alcohol abuse contributes to social problems. Alcohol disinhibits aggression, so homicides, suicides, and assaults oc- cur under the influence of alcohol. Alcohol can also facilitate other risky behaviors. For example, among sexually active adults, alcohol leads to more impul- sive sexuality (Weinhardt, Carey, Carey, Maisto, & Gordon, 2001) and poorer skills for negotiating con- dom use (Gordon, Carey, & Carey, 1997). Overall, though, it has been difficult to define the scope of alcoholism. Many problem drinkers keep their problem successfully hidden, at least for a time. By drinking at particular times of day or at particular places, and by restricting contacts with other people during these times, the alcoholic may be able to drink without noticeable disruption in his or her daily activities. What Is Substance Dependence? A person is said to be dependent on a substance when he or she has repeatedly self-administered it, resulting in tolerance, withdrawal, and compulsive behavior (American Psychiatric Association, 2000). Substance dependence can include physical dependence, when the body has adjusted to the substance and incorpo- rates the use of that substance into the normal func- tioning of the body’s tissues. Physical dependence often involves tolerance, the process by which the body increasingly adapts to the use of a substance, requiring larger and larger doses of it to obtain the same effects, and eventually reaching a plateau. Craving is a strong desire to engage in a behavior or consume a substance. It results from physical depen- dence and from a conditioning process: As the sub- stance is paired with environmental cues, the presence of those cues triggers an intense desire for the substance. Addiction occurs when a person has become physically or psychologically dependent on a substance following repeated use over time. Withdrawal refers to the unpleasant symptoms, both physical and psycho- logical, that people experience when they stop using a substance on which they have become dependent. Al- though the symptoms vary, they include anxiety, irrita- bility, intense cravings for the substance, nausea, headaches, tremors, and hallucinations. Alcoholism and Problem Drinking Problem drinking and alcoholism are substance de- pendence disorders that are defined by several spe- cific behaviors. These patterns include the need for daily use of alcohol, the inability to cut down on drinking, repeated efforts to control drinking through temporary abstinence or restriction of alcohol to cer- tain times of the day, binge drinking, occasional con- sumption of large quantities of alcohol, loss of memory while intoxicated, continued drinking despite known health problems, and drinking of nonbeverage alcohol, such as cough syrup. The term alcoholic is usually reserved for some- one who is physically addicted to alcohol. Alcoholics show withdrawal symptoms when they stop drinking, they have a high tolerance for alcohol, and they have little ability to control their drinking. Problem drinkers may not have these symptoms, but they may have so- cial, psychological, and medical problems resulting from alcohol. Physiological dependence can be manifested in stereotypic drinking patterns (particular types of alco- hol in particular quantities at particular times of day), drinking that maintains blood alcohol at a particular level, the ability to function at a level that would inca- pacitate less tolerant drinkers, increased frequency and severity of withdrawal, early-in-the-day and middle-of-the-night drinking, a sense of loss of con- trol over drinking, and a subjective craving for alcohol (Straus, 1988). Origins of Alcoholism and Problem Drinking The origins of alcoholism and problem drinking are complex. Based on twin studies and on the frequency of alcoholism in sons of alcoholic fathers, genetic fac- tors appear to be implicated (Hutchison, McGeary, Smolen, Bryan, & Swift, 2002). Modeling a parent’s drinking is also implicated (van der Zwaluw et al., 2008). Men have traditionally been at greater risk for 96 Part Two Health Behavior and Primary Prevention alcoholism than women (Robbins & Martin, 1993), although younger women and women employed outside the home are catching up (Christie-Mizell & Peralta, 2009; Williams, 2002). Sociodemographic factors, such as low income, also predict alcoholism. Drinking and Stress Drinking occurs, in part, as an effort to buffer the impact of stress. People who have a lot of negative life events, experience chronic stress- ors, and have little social support are more likely to be- come problem drinkers than people without these problems (Brennan & Moos, 1990; Sadava & Pak, 1994). For example, alcohol abuse rises among people who have been laid off from their jobs (Catalano, Dooley, Wilson, & Hough, 1993). Alienation from work, low job autonomy, the sense that one’s abilities are not being used, and lack of participation in decision making at work are associated with heavy drinking (Greenberg & Grunberg, 1995). Financial strain, espe- cially if it produces depression, leads to drinking (Peirce, Frone, Russell, & Cooper, 1994), and a sense of power- lessness in one’s life has also been related to alcohol use and abuse (Seeman, Seeman, & Budros,1988). Many people begin drinking to enhance positive emotions and reduce negative ones (Repetto, Caldwell, & Zimmerman, 2005), and alcohol does reliably lower anxiety and depression and improve self-esteem, at least temporarily (Steele & Josephs, 1990). For many people, drinking is associated with pleasant social oc- casions, and people may develop a social life centered on drinking, such as going to bars or attending parties (Emslie, Hunt, & Lyons, 2013). Thus, there can be psychological rewards to drinking. There are two windows of vulnerability for alco- hol use and abuse. The first, when chemical depen- dence generally starts, is between the ages of 12 and 21 (DuPont, 1988). The other is in late middle age, in which problem drinking may act as a coping method for managing stress (Brennan & Moos, 1990). Late- onset problem drinkers are more likely to control their drinking on their own or be successfully treated, com- pared with people who have more long-term drinking problems (Moos, Brennan, & Moos, 1991). Depression and alcoholism are linked. Alcohol- ism may represent untreated symptoms of depression, or depression may act as an impetus for drinking in an effort to improve mood. Accordingly, in some cases, symptoms of both disorders must be treated simulta- neously (Oslin et al., 2003). Treatment of Alcohol Abuse As many as half of all alcoholics stop or reduce their drinking on their own (Cunningham, Lin, Ross, & Walsh, 2000). This “maturing out” of alcoholism is especially likely in the later years of life (Stall & Biernacki, 1986). Adolescence and young adulthood represent a window of vulnerability to problem drinking and alcoholism. Successful intervention with this age group may reduce the scope of the alcoholism problem. © Image Source RF 97 Cutting back can also be a result of learning just how much they drink, relative to other people (Taylor, Vlaev, Maltby, Brown, & Wood, 2015). In addition, alcoholism can be successfully treated. Nonetheless, as many as 60 percent of the people treated through such programs may return to alcohol abuse (Finney & Moos, 1995). Alcoholics who are high in socioeconomic status (SES) and who are in highly socially stable environments (that is, who have regular jobs, intact families, and a circle of friends) do very well in treatment programs, achieving success rates as high as 68 percent. In contrast, alcoholics of low SES often have success rates of 18 percent or less. With- out employment and social support, the prospects for recovery are dim. Box 5.4 presents an example of these problems. Treatment Programs For hard-core alcoholics, the first phase of treatment is detoxification. Because this process can produce severe symptoms and health problems, detoxification is typically conducted in a carefully supervised and monitored medical setting. Once the alcoholic has at least partly dried out, therapy is initiated. The typical program begins with a short-term, intensive inpatient treatment followed by a period of continuing treatment on an outpatient basis (NIAAA, 2000a). Approximately 745,200 people in the United States received treatment for alcoholism in 2008 (National Institute on Drug Abuse, 2011). A self-help group, especially Alcoholics Anonymous (AA), is the most commonly sought source of help for alcohol- related problems (NIAAA, 2000a) (Box 5.5). Cognitive-Behavioral Treatments Treatment programs for alcoholism and problem drinking typi- cally use cognitive-behavioral therapy (CBT) to treat the biological and environmental factors involved in alcoholism simultaneously (NIAAA, 2000b). The goals of CBT are to decrease the reinforcing properties of alcohol, to teach people new behaviors inconsistent with alcohol abuse, and to modify the environment to include reinforcements for activities that do not involve alcohol. Learning coping techniques for dealing with stress and relapse prevention skills enhance the pros- pects for long-term maintenance. Many CBT programs begin with a self-monitoring phase, in which the alcoholic or problem drinker charts situations that give rise to drinking. Motivational enhancement procedures are often included because the responsibility and the capacity to change rely en- tirely on the client (NIAAA, 2000a). Some programs also include medications for blocking the alcohol- brain interactions that may contribute to alcoholism. When the Berlin Wall came down in 1989, there were celebrations worldwide. In the midst of the jubilation, few fully anticipated the problems that might arise in its wake. Hundreds of thousands of East Germans, who had lived for decades under a totalitarian regime with a relatively poor standard of living, were now free to stream across the border into West Germany, which enjoyed prosperity, high employment rates, and a high standard of living. But for many people, the promise of new opportunities failed to materialize. Employment was less plentiful than had been assumed, and the East Germans were less qualified for the jobs that did exist. East Germans experienced more discrimination and hostility than they expected, and many migrating East Germans found themselves unemployed. Two German researchers, Mittag and Schwarzer (1993), examined alcohol consumption among men who had found employment in West Germany and those who had remained unemployed. In addition, they measured self-efficacy with respect to coping with life’s problems through such items as “When I am in trouble, I can rely on my ability to deal with the problem effectively.” The researchers found that the men with a high sense of self-efficacy were less likely to consume high levels of alcohol. The men who were unemployed and also had a low sense of self-efficacy drank more than any other group. Thus, being male, being unemployed for a long time, and not having a sense of personal agency led to heavy drinking. Although health psychologists cannot provide jobs to the unemployed, perhaps they can empower people to develop a sense of self-efficacy. If one believes that one can control one’s behavior, cope effectively with life, and solve one’s problems, one may be better able to deal effectively with setbacks (Mittag & Schwarzer, 1993). B O X 5.4After the Fall of the Berlin Wall 98 Many treatment programs include stress manage- ment techniques that can be substituted for drinking. Drink refusal skills and the substitution of nonalco- holic beverages in high-risk social situations are also important components of CBT interventions. In some cases, family therapy and group counseling are added. The advantage of family counseling is that it eases the alcoholic’s or problem drinker’s transition back into his or her family (NIAAA, 2000a). Relapse Prevention A meta-analysis of alco- hol treatment outcome studies estimates that more than 50 percent of treated patients relapse within the first 3  months after treatment (NIAAA, 2000a). Ac- cordingly, relapse prevention techniques are essential. Practicing coping skills or social skills for high- risk-for-relapse situations is a mainstay of relapse prevention interventions. In addition, the recogni- tion that people often stop and restart an addictive behavior several times before they are successful has led to the development of techniques for manag- ing relapses. Understanding that an occasional re- lapse is normal helps the problem drinker realize that any given lapse does not signify failure. Over- all, the evidence shows that cognitive behavioral treatments (CBT) to treat alcohol disorders are suc- cessful across a broad range of people and situations (Magill & Ray, 2009). Interventions with heavy- drinking college students have made use of these approaches (Box 5.6). No one knows exactly when Alcoholics Anonymous (AA) began, but it is believed that the organization was formed around 1935 in Akron, Ohio. The first meetings were attended by a few acquaintances who discovered that they could remain sober by attending the services of a local religious group and sharing their problems and efforts to remain sober with other alcoholics. By 1936, weekly AA meetings were tak- ing place around the country. Currently, AA’s membership is estimated to be more than 2 million individuals worldwide (Alcoholics Anonymous, 2015). The sole requirement for participa- tion in AA is a desire to stop drinking. Members come from all walks of life, including all socioeconomic lev- els, races, cultures, sexual preferences, and ages. Members are encouraged to immerse themselves in the culture of AA—to attend “90 meetings in 90 days.” At these meetings, AA members speak about the drink- ing experiences that prompted them to seek out AA and what sobriety has meant to them. Time is set aside for prospective new members to talk informally with long- time members so that they can learn and imitate the coping techniques that recovered alcoholics have used. AA has a firm policy regarding alcohol consump- tion. It maintains that alcoholism is a disease that can be managed but never cured. Recovery means that an indi- vidual must acknowledge that he or she has a disease, that it is incurable, and that alcohol can play no part in future life. Recovery depends completely on staying sober. Is AA successful in getting people to stop drink- ing? AA’s dropout rate is unknown, and success over the long term has not been measured. Moreover, be- cause the organization keeps no membership lists (it is anonymous), it is difficult to evaluate its success. However, AA itself maintains that two out of three people have been able to stop drinking through its pro- gram, and one authorized study reported a 75 percent success rate for a New York AA chapter. AA programs are effective for several reasons. Participation in AA is like a religious conversion ex- perience in which a person adopts a new way of life; such experiences can be powerful in bringing about behavior change. Also, the member who shares his or her experiences develops a commitment to other members. The process of giving up alcohol contrib- utes to a sense of emotional maturity and responsibil- ity, helping the alcoholic accept responsibility for his or her life. AA may also provide a sense of meaning and purpose in a person’s life—most chapters have a strong spiritual or religious bent and urge members to commit themselves to a power greater than them- selves. In addition, the group can provide satisfying personal relationships that help people overcome the isolation that many alcoholics experience. Too, the members provide social reinforcement for each oth- er’s abstinence. AA was one of the earliest self-help programs for people suffering from a health problem; and therefore, has provided a model for self-help organizations. Moreover, in having successfully treated alcoholics for decades, AA has demonstrated that the problem of alcoholism is not intractable. B O X 5.5 A Profile of Alcoholics Anonymous 99 99 Part Six Toward the Future Most U.S. college students drink alcohol, and as many as 40 percent of them are heavy drinkers (O’Malley & Johnston, 2002). Moreover, if you are a college stu- dent who drinks, the odds are 7 in 10 that you have engaged in binge drinking (Wechsler, Seibring, Liu, & Ahl, 2004) (Table 5.3). Many colleges have tried to deal with the heavy- drinking problem by providing educational materials about the harmful effects of alcohol. However, dog- matic alcohol prevention messages may actually in- crease drinking (Bensley & Wu, 1991). Moreover, the information conflicts markedly with the personal ex- periences of many college students who find drinking in a party situation to be enjoyable. Consequently, motivating students even to attend alcohol abuse pro- grams, much less to follow their recommendations, is difficult. Some of the more successful efforts to modify college students’ drinking have encouraged them to gain self-control over drinking rather than trying to get them to eliminate alcohol consumption alto- gether. Cognitive-behavioral interventions help col- lege students gain such control. These programs begin by getting students to monitor their drinking and learn what blood alcohol levels mean and what their effects are. Often, merely monitoring drinking leads to a reduction in drinking. The program in- cludes information about the risks of alcohol con- sumption, the acquisition of skills to moderate alcohol consumption, relaxation training and life- style rebalancing, nutritional information, aerobic exercise, relapse prevention skills designed to help students cope with high-risk situations, assertiveness training, and drink-refusal training. Changing per- ceptions of the drinker from a fun party guy to a loser can foster alcohol reduction and prevention programs with students (Teunissen et al., 2012). Moreover, if the student can alter his or her identity away from the prototype of the drinker, it may reduce alcohol consumption. Many intervention programs include social skills training designed to get students to find alternative ways to relax and have fun in social situations without abusing alcohol. To gain personal control over drink- ing, students are taught controlled drinking skills. For example, one technique involves placebo drinking, namely consuming nonalcoholic beverages or alternat- ing an alcoholic with a nonalcoholic beverage. An evaluation of an 8-week training program with college students involving these components showed moderate success. Students reported signifi- cant reductions in their drinking compared with a group that received only educational materials about the adverse effects of excessive drinking. Moreover, these gains persisted over a year long follow-up period (Marlatt & George, 1988). Lengthy interventions such as this one are ex- pensive and time consuming, and consequently, as is the case with other health habits, efforts have gone B O X 5.6The Drinking College Student TABLE 5.3 | Patterns of College Student Binge Drinking 1999 2001 All students 44.5% 44.4% Men 50.2 48.6 Women 39.4 40.9 Live in dormitory 44.5 45.3 Live in fraternity/sorority house 80.3 75.4 Source: Wechsler et al., 2002. (continued) © PunchStock/Image Source RF 100 into finding briefer interventions that may be suc- cessful (Fried & Dunn, 2012). For example, many college students are now required to attend brief al- cohol interventions incorporated into freshman ori- entation (e.g. DiFulvio, Linowski, Mazziotti, & Puleo, 2012). Even online interventions have been created. AlcoholEdu® is an online alcohol prevention program used by more than 500 college and university cam- puses nationwide. This program is designed to chal- lenge students’ expectations about alcohol while enabling them to make healthy and safe decisions about their personal alcohol consumption. Efforts have also focused on preventing students from getting into a heavy drinking lifestyle in the first place. For example, one intervention (Marlatt et al., 1998) employed motivational interviewing to induce students to question their drinking practices and develop goals for changing their behavior, as drinking to excess has been tied to severe behavioral consequences (see Tables 5.4 and 5.5). Over a two year follow-up, students in the intervention drank significantly less and experi- enced fewer of the consequences of heavy drinking. B O X 5.6 The Drinking College Student (continued ) TABLE 5.4 | Alcohol-Related Problems of College Students Who Had a Drink in the Past Year Drinkers Who Reported Alcohol-Related Problem Problems Had a hangover 51.7% Missed class 27.3 Did something you regret 32.7 Forgot where you were or what you did 24.8 Engaged in unplanned sexual activity 19.5 Got hurt or injured 9.3 Source: Wechsler et al., 2002. TABLE 5.5 | Alcohol Use by U.S. College Students Age 18–24 Alcohol-Related Incidents per Year Deaths: 1,825 Injuries: 599,000 Assaults: 690,000 students assaulted by student who had been drinking Sexual abuses: 97,000 victims of alcohol-related sexual assault or date-rape Academic problems: about 25% of students report academic consequences of their drinking (missing class, falling behind, doing poorly on exams or papers, receiving lower grades overall) Health Problems: 150,000 students develop an alcohol- related health problem Suicide attempts: about 1.2–1.5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use Source: NIAAA, December 2015. Evaluation of Alcohol Treatment Programs Several factors are associated with successful alcohol treatment programs: a focus on factors in the environ- ment that elicit drinking and modifying those factors or instilling coping skills to manage them; a moderate length of participation (about 6–8 weeks); and involv- ing relatives and employers in the treatment process. Interventions that include these components can pro- duce up to a 40 percent treatment success rate (Center for the Advancement of Health, 2000d). Even minimal interventions can make a dent in drinking-related problems. For example, a few ses- sions devoted to a discussion of problem drinking and telephone interventions have shown some suc- cess in reducing drinking (Oslin et al., 2003). Most alcoholics, though, approximately 85 percent, do not receive formal treatment. As a result, social en- gineering approaches such as banning alcohol ad- vertising, raising the drinking age, and enforcing penalties for drunk driving can complement formal intervention efforts. Preventive Approaches to Alcohol Abuse Many researchers believe that a prudent approach to alcohol-related problems is prevention: inducing ado- lescents to avoid drinking altogether or to control their Chapter 5 Health-Compromising Behaviors 101 TABLE 5.6 | U.S. Cigarette Smoking-Related Mortality Disease Deaths Lung cancer 127,700 Chronic obstructive pulmonary disease (COPD) 100,600 Heart disease 99,300 Other cancers 36,000 Other heart disease 25,500 Source: Centers for Disease Control and Prevention, February, 2016. drinking before the problems of alcohol abuse set in. Social influence programs in middle schools are typi- cally designed to teach young adolescents drink- refusal techniques and coping methods for dealing with high-risk situations. Research suggests some success with these pro- grams. First, such programs enhance adolescents’ self-efficacy, which, in turn, may enable them to resist the passive social pressure that comes from seeing peers drink (Donaldson, Graham, Piccinin, & Hansen, 1995). Second, these programs can change social norms that typically foster adolescents’ motivation to begin using alcohol, replacing them with norms stressing abstinence or controlled alcohol consump- tion (Donaldson, Graham, & Hansen, 1994). Third, these programs can be low-cost options for low- income areas, which have traditionally been the most difficult to reach. Drinking and Driving Thousands of vehicular fatalities result from drunk driving each year. Programs such as MADD (Mothers Against Drunk Driving), founded and staffed by the families and friends of those killed by drunk drivers, put pressure on state and local governments for tougher alcohol control measures and stiffer penalties for convicted drunk driver. Moreover, hosts and host- esses are now pressured to assume responsibility for the alcohol consumption of their guests. With increased media attention to the problem of drunk driving, drinkers seem to be developing self-regulatory techniques to avoid driving while drunk. These include limiting drinks to a prescribed number, arranging for a designated driver, getting a taxi, or delaying or avoiding driving after consuming alcohol. Although eliminating drinking altogether is unlikely to occur, the rising popularity of self-regulation to avoid drunk driving may help reduce this serious problem. Is Modest Alcohol Consumption a Health Behavior? Paradoxically, modest alcohol intake may contribute to a longer life. Approximately one to two drinks a day (less for women) reduces risk of a heart attack, lowers risk factors associated with coronary heart disease, and reduces risk of stroke (Britton & Marmot, 2004; Facts of Life, December 2003). These benefits may be especially true for older adults and senior citi- zens. Although many health care practitioners fall short of recommending that people have a drink or two each day, the evidence is mounting that modest drinking may actually reduce the risk for some major causes of death. Nonetheless, this remains an area of controversy. ■ SMOKING Smoking is one of the greatest causes of preventable death. By itself and in interaction with other risk fac- tors, it remains a chief cause of death in developed countries. In the United States, smoking accounts for at least 480,000 deaths each year—smoking is known to be the cause of 9 out of 10 lung cancer deaths in men and women (Centers for Disease Control and Prevention, February 2016) (Table 5.6). Nearly 17% of people in the United States still smoke (Tavernise, 2015), about 42 million people overall. Smoking is related to a fourfold increase in women’s risk of de- veloping breast cancer after menopause (Ambrosone et al., 1996). Smoking also increases the risk for chronic bronchitis, emphysema, respiratory disorders, damage and injuries due to fires and accidents, lower birth weight in offspring, and retarded fetal development (Center for the Advancement of Health, 2000h; Waller, McCaffery, Forrest, & Wardle, 2004). Smoking also increases risk of erectile dysfunction by 50 percent (Bacon et al., 2006). The dangers of smoking are not confined to the smoker. Studies of secondhand smoke reveal that spouses, family members, and coworkers are at risk for a variety of health disorders (Marshall, 1986). Parental cigarette smoking can lower cognitive perfor- mance in adolescents by reducing blood oxygen capacity and increasing carbon monoxide levels (Bauman, Koch, & Fisher, 1989). 102 Part Two Health Behavior and Primary Prevention Synergistic Effects of Smoking Smoking enhances the detrimental effects of other risk factors. For example, smoking and cholesterol in- teract to produce higher rates of heart disease than would be expected from simply adding together their individual risks (Perkins, 1985). Stress and smoking can also interact in dangerous ways. For men, nicotine can increase heart rate reactivity to stress. For women, smoking can reduce heart rate but increase blood pressure responses to stress (Girdler, Jamner, Jarvik, Soles, & Shapiro, 1997). Trauma exposure and post- traumatic stress disorder increase the health risks of smoking (Read et al., 2013). Smoking acts synergisti- cally with low SES as well: Smoking inflicts greater harm among disadvantaged groups than among more advantaged groups (Pampel & Rogers, 2004). Weight and smoking can interact to increase mor- tality. Cigarette smokers who are thin are at increased risk of mortality, compared with average-weight smokers (Sidney, Friedman, & Siegelaub, 1987). Thinness is not associated with increased mortality in people who have never smoked or among former smokers. Smokers engage in less physical activity than nonsmokers, which represents an indirect contri- bution of smoking to ill health. Smoking is more likely among people who are depressed (Pratt & Brody, 2010; Prinstein & La Greca, 2009), and smoking interacts synergistically with depression to increase risk for cancer. Smoking may also be a cause of depression, especially in young people (Goodman & Capitman, 2000), which makes the concern about the synergistic effects of smoking and depression on health more alarming. Smoking is related to anxiety in adolescence; whether smoking and anxiety have a synergistic ef- fect on health disorders is not yet known, but the chances of panic attacks and other anxiety disorders are increased (Johnson et al., 2000). The synergistic health risks of smoking are very important and may be responsible for a substantial per- centage of smoking-related deaths; however, research suggests that the public is largely unaware of the syner- gistic adverse effects of smoking (Hermand, Mullet, & Lavieville, 1997). A Brief History of the Smoking Problem For years, smoking was considered to be a sophisti- cated and manly habit. Characterizations of 19th- and 20th-century gentry, for example, often depicted men retiring to the drawing room after dinner for cigars and brandy. Cigarette advertisements of the early 20th century built on this image, and by 1955, 53 percent of the adult male population in the United States smoked. Women did not begin to smoke in large num- bers until the 1940s, but once they did, advertisers began to tie cigarette smoking to feminine sophistica- tion as well (Pampel, 2001). The risks of smoking are not confined to the smoker. Coworkers, spouses, and other family members of smokers are at risk for many smoking-related disorders. © Shutterstock RF Chapter 5 Health-Compromising Behaviors 103 In 1964, the first surgeon general’s report on smoking came out (U.S. Department of Health, Ed- ucation, and Welfare and U.S. Public Health Ser- vice, 1964), accompanied by an extensive publicity campaign to highlight the dangers of smoking. The good news is that, in the United States, the number of adults who smoke has fallen dramatically to 17  percent. In recent years, however, smoking has increased slightly, and it continues to be a major health problem. Critics argue that the tobacco industry has dispro- portionately targeted minority group members and teens for smoking, and indeed, the rates among cer- tain low-SES minority groups, such as Hispanic men, are especially high (Navarro, 1996). These differences may be due in part to differences in cultural attitudes regarding smoking (Johnsen, Spring, Pingitore, Som- merfeld, & MacKirnan, 2002). At present, 22 percent of high school students smoke (Centers for Disease Control and Prevention, 2008). Table 5.7 presents cur- rent figures on the prevalence of smoking, and Figure 5.3 shows the relation of smoking prevalence to smoking-related historical events. As pressures to reduce smoking among children and adolescents have mounted, tobacco companies have turned their marketing efforts overseas. In devel- oping countries, smoking represents a growing health problem. For example, smoking is reaching epidemic proportions in China. It is estimated that a third of all young Chinese men will die from the effects of to- bacco, more than 3 million deaths each year by 2050 (Reaney, 1998). Why Do People Smoke? Nearly 3 decades of research on smoking have revealed how difficult smoking is to modify. There appear to be genetic influences on smoking (Piasecki, 2006). Genes that regulate dopamine functioning are likely candidates for these heritable influences (Timberlake et al., 2006). Cigarette smokers are generally less health con- scious (Castro, Newcomb, McCreary, & Baezconde- Garbanati, 1989), less educated, and less intelligent than nonsmokers (Hemmingsson, Kriebel, Melin, Allebeck, & Lundberg, 2008). Smoking and drinking often go together, and drinking seems to cue smoking, (Shiffman et al., 1994). Smokers are more impulsive, have more accidents and injuries at work, take off more sick time, and use more health benefits than nonsmokers, thereby representing substantial costs to the economy (Flory & Manuck, 2009; Ryan, Zwerling, & Orav, 1992). Smoking is an entry-level drug in childhood and adolescence for subsequent substance abuse: Trying cigarettes makes one significantly more likely to use other drugs in the future (Fleming, Leventhal, Glynn, & Ershler, 1989). Factors Associated with Smoking in Adolescents At least 46 percent of high school students have tried cigarette smoking. But smoking does not start all at once. There is a period of initial experimentation, during which the adolescent tries out cigarettes, experiences peer pressure to smoke, and de- velops attitudes about what a smoker is like. Following experimentation, only some adolescents go on to be- come heavy smokers (Maggi, Hertzman, & Vaillan- court, 2007). Starting to smoke results from a social conta- gion process through contact with others who smoke (Presti, Ary, & Lichtenstein, 1992). More than 70 percent of all cigarettes smoked by adoles- cents are smoked in the presence of a peer (Biglan, McConnell, Severson, Bavry, & Ary, 1984). Once they begin smoking, adolescents are more likely to prefer the company of peers who smoke (Mercken, Steglich, Sinclair, Holliday, & Moore, 2012). Schools that look the other way or that have poor levels of discipline may inadvertently contribute to regular cigarette use (Novak & Clayton, 2001). As the prevalence of smoking goes up at a particu- lar school, so does the likelihood that additional students will start smoking. Smoking runs in families. Adolescents are more likely to start smoking if their parents smoke, and if their parents smoked early and often (Chassin et al., 2008). If their parents stopped smoking before the child turned approximately 8, smoking cessation TABLE 5.7 | Smoking Prevalence by Age and Sex Percentage of Population Age Males Females 18–24 18.5% 14.8% 25–44 22.9 17.2 45–64 19.4 16.8 65+ 9.8 7.5 Source: Centers for Disease Control and Prevention, November 2015. 104 Part Two Health Behavior and Primary Prevention actually reduces the risk of smoking, presumably because of the family’s anti-smoking attitudes (Wyszynski, Bricker, & Comstock, 2011). Adoles- cents are more likely to start smoking if they are from a lower social class, if they feel social pressure to smoke, and if there has been a major stressor in the family, such as parental separation or job loss (Swaim, Oetting, & Casas, 1996; Unger, Hamilton, & Sussman, 2004). These effects are partly due to the increase in stress and depression that may result (Kirby, 2002; Unger et al., 2004). Even watching people smoke in movies and on television contrib- utes to high rates of adolescent smoking (Sargent & Heatherton, 2009) (Figure 5.4). Once adolescents begin to smoke, the risks they perceive from smoking decline, and so smoking itself reduces perceptions of risk (Morrell, Song, & Halpern- Felsher, 2010). Smoking clusters in social networks, almost as an infectious disease might (Christakis & Fowler, 2008). Although smoking has declined overall, clusters of smokers who know each other increase the likelihood that a friend or relative will continue to smoke. The good news is that these geographic clusters also appear to spread quitting: The likeli- hood that someone will stop smoking increases by two-thirds if their spouse has stopped smoking, by 25 percent if a sibling has quit, and by 36 percent if a friend has quit. Even smoking cessation by a co- worker decreases the likelihood that one will con- tinue to smoke by 34 percent. Smoking, like so many other risky behaviors, spreads through social ties (Christakis & Fowler, 2008). Self-Identity and Smoking The image of one’s self is a significant factor in beginning smoking (Tombor et al., 2015). Low self-esteem, dependency, feelings of powerlessness, and social isolation all in- crease the tendency to imitate others’ behavior, and smoking is no exception (Ennett & Bauman, 1993). Feelings of being hassled, angry, or sad increase the likelihood of smoking (Whalen, Jamner, Henker, & FIGURE 5.3 | Adult per Capita Cigarette Consumption (Thousands per Year) and Major Smoking and Health Events, United States (Source: U.S. Department of Agriculture, 2007) 1900 5 19901910 1920 1930 1940 1950 1960 1970 1980 2000 2010 4 3 2 1 0 Great Depression End of WW II U.S. surgeon general’s first report Broadcast advertising ban Federal cigarette tax doubles Nonsmokers’ rights movement begins Fairness Doctrine messages on television and radio First medical reports linking smoking and cancer Chapter 5 Health-Compromising Behaviors 105 Delfino, 2001; Wills, Sandy, & Yaeger, 2002). Feel- ings of self-efficacy and good self-control skills help adolescents resist temptations to smoke (Wills et al., 2010). Self-identity is also important for stopping smoking. Identifying oneself as a smoker impedes the ability to quit smoking, whereas identifying oneself as  a quitter can promote it (Van den Putte, Yzer, Willemson, & de Bruijn, 2009). Nicotine Addiction and Smoking Smoking is an addiction, reported to be harder to stop than heroin addiction or alcoholism (see Table 5.8). Only so-called chippers are able to smoke casually without showing signs of addiction. However, the exact mechanisms underlying nicotine addiction are unknown (Grunberg & Acri, 1991). People smoke to maintain blood levels of nico- tine and to prevent withdrawal symptoms. In es- sence, smoking regulates the level of nicotine in the body, and when plasma levels of nicotine depart from the ideal levels, smoking occurs. Nicotine al- ters levels of neuroregulators, including acetylcho- line, norepinephrine, dopamine, endogenous opioids, and vasopressin. Nicotine may be used by smokers to engage these neuroregulators because they produce temporary improvements in performance or affect. Acetylcholine, norepinephrine, and vasopressin appear to enhance memory, and acetylcholine and beta endorphins can reduce anxiety and tension. Alterations in dopamine, norepinephrine, and opioids FIGURE 5.4 | Percentage of High School Students Who Smoke (Source: Centers for Disease Control and Prevention, 2010) 50 40 30 20 10 0 1991 27.5% 1993 30.5% 1995 34.8% 1997 36.4% 1999 34.8% 2001 28.5% 2003 21.9% 2005 23.0% 2007 20.0% 2009 19.5% Year/Yearly Average White, non-Hispanic male White, non-Hispanic female Hispanic male Hispanic female Black, non-Hispanic male Black, non-Hispanic female Pe rc en t TABLE 5.8 | Why Is Smoking So Hard to Change? Relapse rates among smoking quitters are very high. Why is smoking such a hard habit to change? • Tobacco addiction typically begins in adolescence, when smoking is associated with pleasurable activities. • Smoking patterns are highly individualized, and group interventions may not address all the motives underlying any particular smoker’s smoking. • Stopping smoking leads to short-term unpleasant withdrawal symptoms such as distractibility, nausea, headaches, constipation, drowsiness, fatigue, insomnia, anxiety, irritability, and hostility. • Smoking is mood elevating and helps to keep anxiety, irritability, and hostility at bay. • Smoking keeps weight down, a particularly significant factor for adolescent girls and adult women. • Smokers are unaware of the benefits of remaining abstinent over the long term, such as improved psychological well-being, higher energy, better sleep, higher self-esteem, and a sense of mastery (Piper, Kenford, Fiore, & Baker, 2012). Sources: Hertel et al., 2008; Stewart, King, Killen, & Ritter, 1995. 106 Part Two Health Behavior and Primary Prevention improve mood. Smoking among habitual smokers improves concentration, recall, alertness, arousal, psychomotor performance, and the ability to screen out irrelevant stimuli, and consequently smoking can improve performance. Habitual smokers who stop smoking report that their concentration is reduced; their attention becomes unfocused; their memory suf- fers; and they experience increases in anxiety, tension, irritability, craving, and moodiness. However, this is not a complete picture. In studies that alter nicotine level in the bloodstream, smokers do not alter their smoking behavior enough to com- pensate for these manipulations. Moreover, smoking is responsive to rapidly changing forces in the envi- ronment long before such forces can affect blood plasma levels of nicotine. High rates of relapse are found among smokers long after plasma nicotine lev- els are at zero. Thus, the role of nicotine in addiction may be more complex. Interventions to Reduce Smoking Changing Attitudes Toward Smoking The mass media have been effective in providing the edu- cational base for anti-smoking attitudes. Most people now view smoking as an addiction with negative so- cial consequences. Antismoking media messages have also been effective in discouraging adults and adoles- cents from beginning to smoke (Hersey et al., 2005). However, education provides only a base and by itself may nudge people closer to the desire to quit but not to quitting itself. Nicotine Replacement Therapy Many thera- pies begin with some form of nicotine replacement, such as nicotine patches, which release nicotine in steady doses into the bloodstream. Nicotine replace- ment therapy significantly increases initial smoking cessation (Cepeda-Benito, 1993; Hughes, 1993). E-cigarettes, which work by turning a nicotine-infused liquid into a vapor, are based on this principle. Whether e-cigarettes are safe, however, is unclear (The Econo- mist, March 23, 2013). Finding the answer to this ques- tion is important, because more youngsters now smoke e-cigarettes than traditional ones (Esterl, 2015). The Therapeutic Approach to the Smoking Problem Accordingly, health psychologists have moved to a therapeutic approach to the smoking problem. Attentional retaining involves helping smokers reorient their attention away from smoking-related cues, both internal and in the environment. It can be a first step in a stopping smoking intervention to help reduce craving and orienting toward smoking-related cues (Kerst & Waters, 2014). Exercise is also a method of reducing attentional bias toward smoking-related cues (Oh & Taylor, 2014). Many smoking intervention programs have used the stages of change model as a basis for intervening. Interventions to move people from the precontempla- tion to the contemplation stage center on changing atti- tudes, emphasizing the adverse health consequences of smoking and the negative social attitudes that most people hold about smoking. Motivating a readiness to quit may, in turn, increase a sense of self-efficacy that one will be able to do so, contributing further to read- iness to quit (Baldwin et al., 2006). Moving people from contemplation to action re- quires that the smoker develop implementation inten- tions to quit, including a timetable for quitting, a program for how to quit, and an awareness of the difficulties associated with quitting (Armitage, 2008). Moving people to the action phase employs many of the cognitive- behavioral techniques that have been used to modify other health habits. As this account suggests, smoking would seem to be a good example of how the stage model might be applied. However, interventions matched to the stage of smoking are inconsistent in their effects (Quinlan & McCaul, 2000; Segan, Borland, & Greenwood, 2004; Stotts, DiClemente, Carbonari, & Mullen, 2000). Social Support and Stress Manage- ment As is true for other health habit interven- tions, would-be ex-smokers are more likely to be successful over the short term if they have a support- ive partner and nonsmoking supportive friends. The presence of smokers in one’s social network is a hindrance to maintenance and predicts relapse (Mermelstein, Cohen, Lichtenstein, Baer, & Kamarck, 1986). Consequently, couple-based interventions have been developed that seem to be especially ef- fective (Khaddouma et al., 2015). Stress management training is helpful for suc- cessful quitting (Yong & Borland, 2008). Because smoking is relaxing for so many people, teaching smokers how to relax in situations in which they might be tempted to smoke provides an alternative method Chapter 5 Health-Compromising Behaviors 107 for coping with stress or anxiety (Manning, Catley, Harris, Mayo, & Ahluwalia, 2005). Lifestyle rebal- ancing through changes in diet and exercise also helps people cut down on smoking or maintain abstinence after quitting. Image is also important in helping people stop. Specifically, people who have a strong sense of them- selves as nonsmokers do better in treatment than those who have a strong sense of themselves as smokers (Gibbons & Eggleston, 1996; Shadel & Mermelstein, 1996). Interventions with young women who smoke must take into account appearance-related issues, as young women often fear that if they stop smoking, they will put on weight (Grogan et al., 2011). Interventions with Adolescents Earlier, we noted how important the image of the cool, sophisticated smoker is in getting teenagers to start smoking. Several interventions to induce adolescents to stop smoking have made use of self-determination theory. Because adolescents often begin smoking to shore up their self-image with a sense of autonomy and control, self- determination theory targets those same cognitions— namely, autonomy and self-control—but from the opposite vantage point; that is, they target the behavior of stopping smoking instead (Williams, McGregor, Sharp, Kouides, et al., 2006). Relapse Prevention Relapse prevention tech- niques are typically incorporated into smoking cessa- tion programs (Piasecki, 2006). Relapse prevention is important because the ability to remain abstinent shows a steady month-by-month decline, such that, within 2 years after smoking cessation, even the best programs do not exceed a 50 percent abstinence rate (Piasecki, 2006). Relapse prevention techniques begin by preparing people for withdrawal, including cardiovascular changes, increases in appetite, variations in the urge to smoke, increases in coughing and discharge of phlegm, and increases in irritability. These problems occur inter- mittently during the first 7–11 days. Relapse prevention also focuses on the ability to manage high-risk situa- tions that lead to a craving for cigarettes, such as drink- ing coffee or alcohol (Piasecki, 2006) and on coping techniques for dealing with stressful interpersonal situa- tions. Some relapse prevention approaches include con- tingency contracting, in which the smoker pays a sum of money that is returned only on the condition of cutting down or abstaining. Like most addictive health habits, smoking shows an abstinence violation effect, whereby a single lapse reduces perceptions of self-efficacy, increases nega- tive mood, and reduces beliefs that one will be suc- cessful in stopping smoking (Shadel et al., 2011). Stress-triggered lapses lead to relapse more quickly than do other kinds (Shiffman et al., 1996). Conse- quently, smokers need to remind themselves that a single lapse is not necessarily worrisome, because many people lapse on the road to quitting. Sometimes, buddy systems or telephone counseling procedures can help quitters avoid turning a single lapse or Smoking has been represented by the tobacco industry as a glamorous habit, and one task of interventions has been to change attitudes about smoking. Courtesy State of Health Products, www.buttout.com 888-428-8868 108 Part Two Health Behavior and Primary Prevention temptation into a full-blown relapse (Lichtenstein, Glasgow, Lando, Ossip-Klein, & Boles, 1996). Evaluation of Interventions How successful have smoking interventions been? Adult smokers are well served by cognitive behavioral interventions that include self-monitoring, modification of the stimuli that elicit and maintain smoking, reinforcing success- ful smoking cessation, and relapse prevention tech- niques such as rehearsing alternative coping techniques in high-risk situations. However, these ap- proaches may be less successful with adolescents. What may be needed instead are inexpensive, effi- cient, short-term interventions (McVea, 2006). Pro- grams that include a motivation enhancement component, a focus on self-efficacy, stress manage- ment, and social skills training can be successful and can be delivered in school clinics and classrooms (Sussman, Sun, & Dent, 2006; Van Zundert, Ferguson, Shiffman, & Engels, 2010). Virtually every imaginable combination of thera- pies for getting people to stop has been tested. Typi- cally, these programs show high initial success rates for quitting, followed by high rates of return to smok- ing, sometimes as high as 90 percent. Those who re- lapse are more likely to be young and dependent on nicotine. Those who relapse often have a low sense of self-efficacy, concerns about gaining weight after stopping smoking, more previous quit attempts, and more slips (occasions when they used one or more cigarettes) (Lopez, Drobes, Thompson, & Brandon, 2008; Ockene et al., 2000). Although the rates of relapse suggest some pes- simism, it is important to consider the cumulative effects of smoking cessation programs. Any single effort to stop smoking yields only a 20 percent suc- cess rate, but with multiple efforts to quit, eventually the smoker may become an ex-smoker (Lichtenstein & Cohen, 1990). In fact, hundreds of thousands of smokers have quit, albeit not necessarily the first time they tried. Over time, people may amass enough techniques and the motivation to persist. People who quit on their own are typically well- educated and have good self-control skills, self- confidence in their ability to stop, and a perception that the health benefits of stopping are substantial (McBride et al., 2001). Stopping on one’s own is eas- ier if one has a supportive social network that does not smoke and if one is able to distance oneself from the typical smoker and identify with nonsmokers instead (Gerrard, Gibbons, Lane, & Stock, 2005). Stopping is also more successful following an acute or chronic health threat, such as a diagnosis of heart disease, es- pecially among middle-aged smokers (Falba, 2005). A list of guidelines for people who wish to stop on their own appears in Table 5.9. Brief Interventions Brief interventions by physicians and other health care practitioners can bring about smoking cessation and control relapse (Vogt, Hall, Hankins, & Marteau, 2009). Provid- ing smoking cessation guidelines during medical visits may improve the quit rate (Williams, Gagne, Ryan, & Deci, 2002). One health maintenance or- ganization targeted the adult smokers in their pro- gram with telephone counseling and newsletters that offered quitting guidelines; the program achieved its goal of reducing the smoking, and, most notably, it reached smokers who otherwise would not have participated in cessation programs (Glasgow et al., 2008). The state of Massachusetts TABLE 5.9 | Quitting Smoking Here are some steps to help you prepare for your Quit Day: • Pick the date and mark it on your calendar. • Tell friends and family about your Quit Day. • Stock up on oral substitutes—sugarless gum, carrot sticks, and/or hard candy. • Decide on a plan. Will you use nicotine replacement therapy? Will you attend a class? If so, sign up now. • Set up a support system. This could be a group class, Nicotine Anonymous, or a friend who has successfully quit and is willing to help you. On your Quit Day, follow these suggestions: • Do not smoke. • Get rid of all cigarettes, lighters, ashtrays, and any other items related to smoking. • Keep active—try walking, exercising, or doing other activities or hobbies. • Drink lots of water and juice. • Begin using nicotine replacement if that is your choice. • Attend a stop-smoking class or follow a self-help plan. • Avoid situations where the urge to smoke is strong. • Reduce or avoid alcohol. • Use the four “A’s” (avoid, alter, alternatives, activities) to deal with tough situations. Source: American Cancer Society, 2014. Chapter 5 Health-Compromising Behaviors 109 Public health approaches to reducing smoking be- gin with warning labels on cigarette packs, billboards, and other places where they are likely to be noticed. These warnings help raise concerns, which can lead to quit attempts (Yong et al., 2014). More broad-based approaches initially focused on community interven- tions combining media blitzes with behavioral inter- ventions directed especially at high-risk people, such as people with other risk factors for CHD. However, such interventions are often expensive, and long-term follow- ups suggest limited long-term effects (Facts of Life, July 2005). Ultimately, banning cigarette smoking from workplaces and public settings and raising cigarette taxes have been most successful in reducing smoking (Orbell et al., 2009; The Economist, July 11, 2015). Smoking Prevention Programs The war on smoking also focuses on keeping potential smokers from starting. These smoking prevention programs aim to catch potential smokers early and attack the underlying motivations that lead people to smoke (Ary et al., 1990). Typically, these programs are implemented through the school system. They are inexpensive and efficient because little class time is needed and no training of school personnel is required. The central components of social influence inter- ventions are: ∙ Information about the negative effects of smoking is carefully constructed to appeal to adolescents. ∙ Materials are developed to convey a positive image of the nonsmoker (rather than the smoker) as an independent, self-reliant individual. ∙ The peer group is used to foster not smoking rather than smoking. Evaluation of Social Influence Pro- grams Do these programs work? Overall, social influence programs can reduce smoking rates (Resnicow, Reddy, et al., 2008) for as long as 4 years (Murray, Davis-Hearn, Goldman, Pirie, & Luepker, 1988). However, experimental smoking may be af- fected more than regular smoking, and experimental smokers may stop on their own anyway (Flay et al., 1992). What is needed are programs that will reach the child destined to become a regular smoker, and as yet, we know less about what helps to keep these youngsters from starting to smoke. began offering free stop smoking treatment to poor residents in 2006 and achieved a remarkable decline in smoking from 38 to 28 percent, suggest- ing that incorporating brief interventions into Medicaid programs can be successful (Goodnough, 2009, December 17). Workplace Initially, workplace interventions were thought to hold promise in smoking cessation efforts. To date, however, workplace interventions are not more effective than other intervention programs (Facts of Life, July 2005). However, when workplace environments are entirely smoke free, employees smoke much less (Facts of Life, July 2005). Commercial Programs and Self-Help A variety of self-help aids and programs have been developed for smokers to quit on their own. These include nicotine patches, as well as more intensive self-help programs. Cable television programs de- signed to help people stop initially and to maintain their resolution have been broadcast in some cities. Although it is difficult to evaluate self-help pro- grams formally, studies suggest that initial quit rates are lower but that long-term maintenance rates are just as high as with more intensive behavioral inter- ventions. Because self-help programs are inexpen- sive, they represent an important attack on the smoking problem for both adults and adolescents (Lipkus et al., 2004). Quitlines provide telephone counseling to help peo- ple stop smoking and are quite successful (Lichtenstein, Zhu, & Tedeschi, 2010). People can call in when they want to get help for quitting or if they are worried about relapse. Most such programs are based on principles derived from CBT. Both adults and younger smokers can benefit from this kind of telephone counseling (Rabius, McAlister, Geiger, Huang, & Todd, 2004). Internet interventions are a recent approach to the smoking problem that has several advantages: People can seek them out when they are ready to and without regard to location. They can deal with urges to smoke by getting instant feedback from an Internet service. In a randomized control trial sponsored by the Ameri- can Cancer Society, an Internet program for smoking cessation was significantly more helpful to smokers trying to quit than a control condition. Moreover, the effects lasted longer than a year, suggesting the long- term efficacy of Internet interventions for smoking cessation (Seidman et al., 2010). 110 Norma Broyne was a flight attendant with American Airlines for 21 years. She had never smoked a ciga- rette, and yet, in 1989, she was diagnosed with lung cancer, and part of a lung had to be removed. Broyne became the center of a class-action suit brought against the tobacco industry, seeking $5 billion on behalf of 60,000 current and former nonsmoking flight attendants for the adverse health effects of the smoke they inhaled while performing their job re- sponsibilities prior to 1990, when smoking was le- gal on most flights (Collins, 1997, May 30). Norma Broyne finally saw her day in court. The tobacco companies that she and other flight attendants sued agreed to pay $300 million to set up a research foun- dation on cancer. Passive smoking, or secondhand smoke, is the third-leading cause of preventable death in the United States, killing more than 41,000 nonsmokers every year (Table 5.10). It causes about 3,000 cases of lung cancer annually, as many as 62,000 heart disease deaths, and exacerbation of asthma in 1 million chil- dren (California Environmental Protection Agency, 2005). Babies with prenatal exposure to secondhand smoke have a 7 percent lower birth weight (Environ- mental Health Perspectives, 2004). Exposure to secondhand smoke also increases the risk of depres- sion (Bandiera et al., 2010). In a dramatic confirmation of the problems associ- ated with workplace smoking, the state of Montana imposed a ban on public and workplace smoking in June 2002 and then overturned it 6 months later. Two physicians charted the number of heart attacks that occurred before the ban, during it, and afterward. Heart attack admissions dropped 40 percent when the workplace ban on smoking was in place but im- mediately bounced back when smoking resumed. What is remarkable about the Montana study is its demonstration of its immediate impact on a major health outcome—heart attacks—in such a short time (Glantz, 2004). Overall, the best way to reduce smoking is to tax tobacco products, restrict where people can smoke, and deliver cost effective cognitive behavioral inter- ventions with relapse prevention techniques to people who are already smokers (Federal Tax Increase, 2009). ∙ B O X 5.7The Perils of Secondhand Smoke TABLE 5.10 | The Toll of Secondhand Smoke Disease Annual Consequences Lung cancer 7,330 deaths Heart disease 33,950 deaths Sudden infant death syndrome 430 deaths Buildup of fluid in the middle ear 790,000 doctor’s office visits Asthma in children 202,000 asthma flare-ups Lower respiratory infection 150,000–300,000 Source: American Lung Association, 2016. © Trevor Benbrook/123RF Chapter 5 Health-Compromising Behaviors 111 1. Health-compromising behaviors are those that threaten or undermine good health. Many of these behaviors cluster and first emerge in adolescence. 2. Obesity has been linked to cardiovascular disease, kidney disease, diabetes, some cancers, and other chronic conditions. 3. Causes of obesity include genetic predisposition, early diet, a family history of obesity, low SES, little exercise, and consumption of large portions of high calorie food and drinks. Ironically, dieting may contribute to the propensity for obesity. 4. Obesity has been treated through diets, surgical procedures, drugs, and cognitive-behavioral (CBT) approaches. CBT includes monitoring eating behavior, modifying the environmental stimuli that control eating, gaining control over the eating process, and reinforcing new eating habits. Relapse prevention skills help in long-term maintenance. 5. Cognitive-behavioral techniques can produce weight losses of 2 pounds a week for up to 20 weeks, maintained over a 2-year period. 6. Increasingly, interventions are focusing on weight-gain prevention with children in obese families and with high-risk adults. 7. Eating disorders, especially anorexia nervosa, bulimia, and bingeing are major health problems, especially among adolescents and young adults, and health problems, including death, commonly result. 8. Alcoholism accounts for thousands of deaths each year through cirrhosis, cancer, fetal alcohol syndrome, and accidents connected with drunk driving. 9. Alcoholism has a genetic component and is tied to sociodemographic factors such as low SES. Drinking also arises in an effort to buffer the impact of stress and appears to peak between ages 18 and 25. 10. Residential treatment programs for alcoholism begin with an inpatient “drying out” period, followed by the use of cognitive-behavioral change methods including relapse prevention. However, most programs are outpatient and use principles of CBT. 11. The best predictor of success is the patient. Alcoholics with mild drinking problems, little abuse of other drugs, and a supportive, financially secure environment do better than those without such supports. 12. Smoking accounts for more than 480,000 deaths annually in the United States due to heart disease, cancer, and lung disorders. 13. Theories of the addictive nature of smoking focus on nicotine and nicotine’s role as a neuroregulator. 14. Attitudes toward smoking have changed dramatically for the negative, largely due to the mass media. Attitude change has kept some people from beginning smoking, motivated many to try to stop, and kept some former smokers from relapsing. 15. Many programs for stopping smoking begin with some form of nicotine replacement, and use CBT to help people stop smoking. Inter- ventions also include social skills training pro- grams and relaxation therapies. Relapse prevention is an important component of these programs. 16. Smoking is highly resistant to change. Even after successfully stopping for a short time, most people relapse. Factors that contribute to relapse include addiction, lack of effective coping techniques for dealing with social situations, and weight gain. 17. Smoking prevention programs are designed to keep youngsters from beginning to smoke. Many of these programs use a social influence approach and teach youngsters how to resist peer pressure to smoke and help adolescents improve their coping skills and self-image. 18. Social engineering approaches to control smoking have also been used, in part, because secondhand smoke harms others in the smoker’s environment. S U M M A R Y 112 Part Two Health Behavior and Primary Prevention addiction alcoholism anorexia nervosa binge eating disorder bingeing bulimia controlled drinking craving detoxification obesity passive smoking physical dependence placebo drinking problem drinking secondhand smoke self-help aids set point theory of weight smoking prevention programs stress eating tolerance withdrawal yo-yo dieting K E Y T E R M S Stress and Coping 3P A R T © Stockbyte/Getty Images RF 114 C H A P T E R 6 C H A P T E R O U T L I N E What Is Stress? What Is a Stressor? Appraisal of Stressors Origins of the Study of Stress Fight or Flight Selye’s General Adaptation Syndrome Tend-and-Befriend How Does Stress Contribute to Illness? The Physiology of Stress Effects of Long-Term Stress Individual Differences in Stress Reactivity Physiological Recovery Allostatic Load What Makes Events Stressful? Dimensions of Stressful Events Must Stress Be Perceived as Such to Be Stressful? Can People Adapt to Stress? Must a Stressor Be Ongoing to Be Stressful? How Has Stress Been Studied? Studying Stress in the Laboratory Inducing Disease Stressful Life Events Daily Stress Sources of Chronic Stress Effects of Early Stressful Life Experiences Chronic Stressful Conditions Stress in the Workplace Some Solutions to Workplace Stressors Combining Work and Family Roles Stress © Grant V. Faint/Getty Images RF Chapter 6 Stress 115 than adequate to deal with a difficult situation, he or she may feel little stress and experience a sense of challenge instead. When the person perceives that his or her resources will probably be sufficient to deal with the event but only with a lot of effort, he or she may feel a moderate amount of stress. When the per- son perceives that his or her resources will probably not be sufficient to overcome the stressor, he or she may experience a great deal of stress. Stress, then, is determined by person-environment fit (Lazarus & Folkman, 1984; Lazarus & Launier, 1978). It results from the process of appraising events (as harmful, threatening, or challenging), of assessing potential resources, and of responding to the events. To see how stress researchers have arrived at this current understanding, we examine the origins of stress research. ■ ORIGINS OF THE STUDY OF STRESS Fight or Flight The earliest contribution to stress research was Walter Cannon’s (1932) description of the fight-or-flight response. Cannon proposed that when an organism perceives a threat, the body is rapidly aroused and mo- tivated via the sympathetic nervous system and the endocrine system. This concerted physiological re- sponse mobilizes the organism to attack the threat or to flee; hence, it is called the fight-or-flight response. At one time, fight or flight literally referred to fighting or fleeing in response to stressful events such as attack by a predator. Now, more commonly, fight refers to aggressive responses to stress, such as get- ting angry or taking action, whereas flight is reflected in social withdrawal or withdrawal through substance use or distracting activities. On the one hand, the fight-or-flight response is adaptive because it enables the organism to respond quickly to threat. On the other hand, it can be harmful because stress disrupts emotional and physiological functioning, and when stress continues unabated, it lays the groundwork for health problems. Selye’s General Adaptation Syndrome Another important early contribution to stress was Hans Selye’s (1956, 1976) work on the general adap- tation syndrome. Selye exposed rats to a variety of stressors, such as extreme cold and fatigue, and ■ WHAT IS STRESS? Most of us have more firsthand experience with stress than we care to remember. Stress is being stopped by a police officer after accidentally running a red light. It is waiting to take a test when you are not sure that you have studied enough or studied the right material. It is missing a bus on a rainy day full of important appointments. Stress is a negative emotional experience accom- panied by predictable biochemical, physiological, cognitive, and behavioral changes that are directed either toward altering the stressful event or accommo- dating to its effects. What Is a Stressor? Initially, researchers focused on stressful events them- selves, called stressors. In the United States, for ex- ample, people report that money, the economy, work, family health problems, and family responsibilities are  their top five stressors (American Psychological Association, 2008). But an experience may be stressful to some peo- ple but not to others. If “noise” is the latest rock music playing on your radio, then it will probably not be stressful to you, although it may be to your neighbor. Appraisal of Stressors Stress is the consequence of a person’s appraisal pro- cesses: primary appraisal occurs as a person is try- ing to understand what the event is and what it will mean. Events may be appraised for their harm, threat, or challenge. Harm is the assessment of the damage that has already been done, as for example being fired from a job. Threat is the assessment of possible future damage, as a person anticipates the problems that loss of income will create for him and his family. But events may also be appraised in terms of their challenge, that is, the potential to overcome or even profit from the event. For example, a man who lost his job may regard his unemployment as an opportu- nity to try something new. Challenge assessments lead to more confident expectations that one can cope with the stressful event, more favorable emo- tional reactions to the event, and lower blood pres- sure, among other benefits (Blascovich, 2008). Secondary appraisals assess whether personal resources are sufficient to meet the demands of the environment. When a person’s resources are more 116 Part Three Stress and Coping comes mobilized to meet the threat. In the second phase, resistance, the person makes efforts to cope with the threat, as through confrontation. The third phase, exhaustion, occurs if the person fails to over- come the threat and depletes physiological resources in the process of trying. These phases are pictured in Figure 6.1. Criticisms of the General Adaptation Syn- drome Selye’s model has been criticized on several grounds. First, it assigns a very limited role to psycho- logical factors, and researchers now believe that the psychological appraisal of events is critical to experi- encing stress (Lazarus & Folkman, 1984). A second criticism concerns the fact that not all stressors pro- duce the same biological responses (Kemeny, 2003). How people respond to stress is influenced by their personalities, emotions, and biological constitutions observed their physiological responses. To his sur- prise, all stressors, regardless of type, produced es- sentially the same pattern of physiological changes. They all led to an enlarged adrenal cortex, shrinking of the thymus and lymph glands, and ulceration of the stomach and duodenum. From these observations, Selye (1956) developed the general adaptation syndrome. He argued that when a person confronts a stressor, it mobilizes itself for ac- tion. The response itself is nonspecific with respect to the stressor; that is, regardless of the cause of the threat, the person will respond with the same physio- logical pattern of reactions. (As will be seen, this par- ticular conclusion has now been challenged.) Over time, with repeated or prolonged exposure to stress, there will be wear and tear on the system. The general adaptation syndrome consists of three phases. In the first phase, alarm, the person be- FIGURE 6.1 | The Three Phases of Selye’s General Adaptation Syndrome Hans Selye, a pioneering stress researcher, formulated the General Adaptation Syndrome. He proposed that people go through three phases in response to stress. The first is the alarm phase, in which the body reacts to a stressor with diminished resistance. In the second stage, the stage of resistance that follows continued exposure to a stressor, stress responses rise above normal. The third phase, exhaustion, results from long-term exposure to the stressor, and at this point, resistance will fall below normal. Time Alarm Resistance Exhaustion St re ss R es po ns es Chapter 6 Stress 117 (Taylor, 2002). In addition, animals and humans with high levels of oxytocin are calmer and more relaxed, which may contribute to their social and nurturant behavior. Research supports some key components of the theory. Women are indeed more likely than men to respond to stress by turning to others (Luckow, Reifman, & McIntosh, 1998; Tamres, Janicki, & Helgeson, 2002). Mothers’ responses to offspring during times of stress also appear to be different from those of fathers in ways encompassed by the tend-and-befriend theory. Nonetheless, men, too, show social responses to stress, and so elements of the theory apply to men as well. How Does Stress Contribute to Illness? These early contributions to the study of stress have helped researchers identify the pathways by which stress leads to poor health. The first set of pathways involves direct effects on physiology. As both Can- non and Selye showed, stress alters biological func- tioning. The ways in which it does so and how it interacts with existing risks or genetic predisposi- tions to illness determine what illnesses a person will develop. Direct physiological effects include such processes as elevated blood pressure, a decreased ability of the immune system to fight off infection, and changes in lipid levels and cholesterol, among other changes. We explore these more fully in the next sections. A second set of pathways concern health behav- iors (Chapters 3–5). People who live with chronic stress have poorer health habits than people who do not, and acute stress, even when it is short-term, of- ten compromises health habits. These poor health hab- its can include smoking, poor nutrition, little sleep, little exercise, and use of substances such as drugs and alcohol. Over the long-term, each of these poor health habits contributes to specific illnesses. For ex- ample, smoking can cause lung disease. Even in the short-term, changes in these health habits may in- crease the risk for illness and set the stage for longer term adverse health outcomes. Third, stress affects psychosocial resources in ways that can adversely affect health (Chapter 7). Supportive social contacts are protective of health, but stress can make a person avoid these social contacts or, worse, behave in ways that drive others away. Op- timism, self-esteem, and a sense of personal control (e.g., Moons, Eisenberger, & Taylor, 2010). A third criticism concerns whether exhaustion of physiologi- cal resources or their chronic activation is most impli- cated in stress; research suggests that continued activation (the second phase) may be most important for accumulating damage to physiological systems, rather than exhaustion. Finally, Selye assessed stress as an outcome, that is, the endpoint of the general adapta- tion syndrome. In fact, people experience many debili- tating effects of stress after an event has ended and even in anticipation of its occurrence. Despite these limitations and reservations, Selye’s model remains a cornerstone in the field. Tend-and-Befriend In response to stress, people (and animals) do not merely fight, flee, and grow exhausted. They also af- filiate with each other, whether it is the herding be- havior of antelope in response to a predator or the coordinated responses to a stressor that a community shows when it is under the threat of a hurricane. S. E. Taylor and colleagues (Taylor, Klein, et al., 2000) de- veloped a theory of responses to stress termed tend- and-befriend. The theory maintains that, in addition to fight or flight, people and animals respond to stress with social affiliation and nurturant behavior toward offspring. These responses to stress may be especially true of women. During the time that responses to stress evolved, men and women faced somewhat different adaptive challenges. Whereas men were responsible for hunting and protection, women were responsible for foraging and child care. These activities were largely sex segre- gated, with the result that women’s responses to stress would have evolved so as to protect not only the self but offspring as well. These responses are not distinctive to humans. The offspring of most species are immature and would be unable to survive, were it not for the atten- tion of adults. In most species, that attention is provided by the mother. Tend-and-befriend has an underlying biological mechanism, in particular, the hormone oxytocin. Oxytocin is a stress hormone, rapidly released in re- sponse to some stressful events, and its effects are especially influenced by estrogen, suggesting a par- ticularly important role in the responses of women to stress. Oxytocin acts as an impetus for affiliation in both animals and humans, and oxytocin increases af- filiative behaviors of all kinds, especially mothering 118 Part Three Stress and Coping ■ THE PHYSIOLOGY OF STRESS Stress engages psychological distress and leads to changes in the body that may have short- and long- term consequences for health. Two interrelated systems are heavily involved in the stress response. They are the sympathetic-adrenomedullary (SAM) system and the hypothalamic-pituitary-adrenocortical (HPA) axis. Sympathetic Activation When events are per- ceived as harmful or threatening, they are identified as such by the cerebral cortex in the brain, which, in turn, sets off a chain of reactions mediated by these apprais- als. Information from the cortex is transmitted to the hypothalamus, which initiates one of the earliest responses to stress—namely, sympathetic nervous system arousal. Sympathetic arousal stimulates the also contribute to good health, yet many stressors un- dermine these beneficial beliefs. To the extent that time, money, and energy must be put into combating the stressor, these external resources are compromised as well, falling especially hard on people who have very little of those resources. A fourth set of pathways by which stress adversely affects health involves the use of health services and adherence to treatment recommendations. People are less likely to adhere to a treatment regimen when they are under stress, and they are more likely to delay seek- ing care for disorders that should be treated. Alterna- tively, they may not seek care at all. These pathways are addressed primarily in Chapters 8 and 9. These four routes—physiology, health behaviors, psychosocial resources, and use of health services— represent the most important pathways by which stress affects health (see Figure 6.2). FIGURE 6.2 | Stress and Mental and Physical Health Stress contributes to mental and physical health disorders. This figure shows some of the routes by which these effects may occur. (Source: Cohen, Kessler, & Gordon, 1995) Increased risk of psychological disorders Increased risk of physical disease Benign appraisal Perceived stress Physiological arousal; poor health behaviors Negative emotions Appraisal of environmental demands and personal resources Environmental demands (stress) Chapter 6 Stress 119 do our current stressful events require these kinds of adjustments. That is, job strain, commuting, family quarrels, and money worries are not the sorts of stress- ors that demand this dramatic mobilization of physi- cal resources. Nonetheless, people still experience sudden elevations of circulating stress hormones in response to current-day stressors, and this process, in certain respects, does not serve the purpose for which it originally developed. Over the long term, excessive discharge of epineph- rine and norepinephrine can lead to suppression of immune function; produce adverse changes such as increased blood pressure and heart rate; provoke varia- tions in normal heart rhythms, such as ventricular ar- rhythmias, which can be a precursor to sudden death; and produce neurochemical imbalances that may con- tribute to the development of psychiatric disorders. The catecholamines may also have effects on lipid levels and free fatty acids, which contribute to the development of atherosclerosis, as was seen in Chapter 2. Corticosteroids have immunosuppressive ef- fects, which can compromise the functioning of the immune system. Prolonged cortisol secretion has also been related to the destruction of neurons in the hippocampus, which can lead to problems with verbal functioning, memory, and concentration (Starkman, Giordani, Brenent, Schork, & Schteingart, 2001) and may be one of the mechanisms leading to senility. Pronounced HPA activation is common in depression, with episodes of cortisol secretion being more frequent and longer among depressed than nondepressed people. Storage of fat in central vis- ceral areas (i.e., belly fat), rather than in the hips, is another consequence of prolonged HPA activation. This accumulation leads to a high waist-to-hip ratio, which is used by some researchers as a marker for chronic stress (Bjorntorp, 1996). Which of these responses to stress have implica- tions for disease? The health consequences of HPA axis activation may be more significant than those of sympathetic activation (Blascovich, 1992; Dientsbier, 1989; Jamieson, Mendes, & Nock, 2013). Sympa- thetic arousal in response to stress by itself may not be a pathway for disease; HPA activation may be required as well. This reasoning may explain why exercise, which produces sympathetic arousal but not HPA activation, is protective for health rather than health compromising. However, unlike exercise, stressors can be experienced long after a stressful event has terminated, and cardiovascular activation may persist medulla of the adrenal glands, which, in turn, secrete the catecholamines epinephrine (EP) and norepineph- rine (NE). These effects result in the cranked-up feel- ing we usually experience in response to stress: increased blood pressure, increased heart rate, in- creased sweating, and constriction of peripheral blood vessels, among other changes. The catecholamines modulate the immune system as well. Parasympathetic functioning may also become dysregulated in response to stress. For example, stress can affect heart rate variability. Parasympathetic mod- ulation is an important restorative aspect of sleep, and so, changes in heart rate variability may both repre- sent a pathway to disturbed sleep and help to explain the relation of stress to illness and increased risk for mortality. HPA Activation The hypothalamic-pituitary adrenal (HPA) axis is also activated in response to stress. The hypothalamus releases corticotrophin- releasing hormone (CRH), which stimulates the pitu- itary gland to secrete adrenocorticotropic hormone (ACTH), which, in turn, stimulates the adrenal cortex to release glucocorticoids. Of these, cortisol is espe- cially significant. It acts to conserve stores of carbo- hydrates and helps reduce inflammation in the case of an injury. It also helps the body return to its steady state following stress. Repeated activation of the HPA axis in response to chronic or recurring stress can ultimately compro- mise its functioning. Daily cortisol patterns may be altered. Normally, cortisol levels are high upon wak- ing in the morning, but decrease during the day (although peaking following lunch) until they flatten out at low levels in the afternoon. People under chronic stress, however, can show any of several deviant pat- terns: elevated cortisol levels long into the afternoon or evening, a general flattening of the daily rhythm, an exaggerated cortisol response to a challenge, a pro- tracted cortisol response following a stressor, or, alter- natively, no response at all (McEwen, 1998). Any of these patterns is suggestive of compromised ability of the HPA axis to respond to and recover from stress (McEwen, 1998; Pruessner, Hellhammer, Pruessner, & Lupien, 2003) (Figure 6.3). Effects of Long-Term Stress Although physiological mobilization prepared hu- mans to fight or flee in prehistoric times, only rarely 120 Part Three Stress and Coping Poor sleep can be a consequence of chronic stress. Because sleep represents a vital restorative activity, this mechanism, too, represents a pathway to disease (Edwards, Hucklebridge, Clow, & Evans, 2003). Individual Differences in Stress Reactivity People vary in their reactivity to stress. Reactivity is the degree of change that occurs in autonomic, neuroendo- crine, and/or immune responses as a result of stress. Some people are predisposed by their genetic makeup, prenatal experiences, and/or early life experiences to be more biologically reactive to stress than others and, con- sequently, they may be especially vulnerable to adverse for hours, days, weeks, or even years after an initial stressful event has occurred, even without awareness (Pieper, Brosschot, van der Leeden, & Thayer, 2010). Such wear and tear on the cardiovascular system may foster illness. Stress may also compromise immune function- ing (Chapter 14). Among these changes is impair- ment of the immune system’s ability to terminate inflammation, which is an early response to stress. Chronic inflammation, even low-level chronic in- flammation, is implicated in many diseases including coronary artery disease (Rohleder, 2014) (See Chap- ter 2), and so the impaired ability to terminate in- flammation may be an important pathway by which stress affects illness outcomes. FIGURE 6.3 | How Does Stress Cause Illness? Direct physiological effects result from sympathetic nervous system and/or HPA activation. In addition, as this figure shows, stress may affect health via behaviors, first, by influencing health behavior, second, by affecting the use of psychosocial resources and, third, by interfering with treatment and the use of health services. Health care ∙ Decreased adherence to treatment ∙ Increased delay in seeking care ∙ Obscured symptom profile ∙ Decreased likelihood of seeking care Psychosocial resources ∙ Threatened social support ∙ Reduced optimism ∙ Threats to self-esteem ∙ Lower sense of mastery Direct physiological effects ∙ Elevated lipids ∙ Elevated blood pressure ∙ Decreased immunity ∙ Increased hormonal activity Health behavior changes ∙ Increased smoking, alcohol use ∙ Decreased nutrition ∙ Decreased sleep ∙ Increased drug use ∙ Poor diet, little exercise Stress Chapter 6 Stress 121 In one intriguing study (Perna & McDowell, 1995), elite athletes were divided into those who were experiencing a high versus a low amount of stress in their lives, and their cortisol response was measured following vigorous training. Those athletes under more stress had a protracted cortisol response. Stress may, accordingly, widen the window of susceptibility for illness and injury among competitive athletes by virtue of its impact on cortisol recovery. Allostatic Load Multiple physiological systems within the body fluc- tuate to meet demands from stress, as we have seen. The concept of allostatic load has been developed to refer to the physiological costs of chronic exposure to the physiological changes that result from repeated or chronic stress (McEwen, 1998). Allostatic load can begin to accumulate in childhood, affecting multiple disease risks across the lifespan (Doan, Dich, & Evans, 2014). The buildup of allostatic load can be assessed by a number of indicators, including increas- ing weight and higher blood pressure (Seeman, Singer, Horwitz, & McEwen, 1997). More of these indicators are listed in Table 6.1. Many of these changes occur normally with age, so to the extent that they occur early, accumulating al- lostatic load may be thought of as accelerated aging in response to stress. Over time, this kind of wear and tear can lead to illness and increased risk of death (Gallo, Fortmann, & Mattei, 2014). The damage due to chronic stress is made worse if people also cope with stress via a high-fat diet, infrequent exercise, alcohol abuse, and health consequences due to stress (Boyce et al., 1995; Jacobs et al., 2006). For example, S. Cohen and colleagues (2002) found that people who reacted to laboratory stress- ors with high cortisol responses and who also had a high level of negative life events were especially vulnerable to upper respiratory infections when ex- posed to a virus. People who reacted to laboratory stressors with low immune responses were espe- cially vulnerable to upper respiratory infection only if they were also under high stress. High immune reactors, in contrast, did not show differences in up- per respiratory illness as a function of the stress they experienced, perhaps because their immune systems were quick to respond to the threat that a potential infection posed (see also Cohen, Janicki-Deverts, & Miller, 2007). Studies like these suggest that psychobiological reactivity to stress is an important factor that influ- ences the stress-illness relationship. As will be seen in Chapter 13, differences in reactivity are believed to contribute to the development of hypertension and coronary artery disease. Physiological Recovery Recovery following stress is also important in the physiology of the stress response. The inability to recover quickly from a stressful event may be a marker for the cumulative damage that stress has caused. Researchers have paid special attention to the cortisol response, particularly, prolonged cortisol responses that occur under conditions of high stress. Stressful events such as being stuck in traffic produce agitation and physiological arousal. © Getty Images RF TABLE 6.1 | Indicators of Allostatic Load • Decreases in cell-mediated immunity • The inability to shut off cortisol in response to stress • Lowered heart rate variability • Elevated epinephrine levels • A high waist-to-hip ratio (reflecting abdominal fat) • Hippocampal volume (which can decrease with repeated stimulation of the HPA) • Problems with memory (an indirect measure of hippocampal functioning) • Elevated blood pressure Source: Seeman, Singer, Horwitz, & McEwen, 1997. 122 Negative Events Negative events produce more stress than do positive events. Shopping for the holi- days, coping with an unexpected job promotion, and getting married are all positive events that draw off time and energy. Nonetheless, these positive experi- ences are less stressful than negative or undesirable events, such as getting a traffic ticket, trying to find a job, coping with a death in the family, getting divorced or experiencing daily conflict (Tobin et al., 2015). Rejection targeted at you specifically by an- other person or group is particularly toxic (Murphy, Slavich, Chen, & Miller, 2015). Negative events produce more psychological distress and physical symptoms than positive ones do (Sarason, Johnson, & Siegel, 1978). smoking, all of which stress can encourage (Doan et al., 2014). The relationship of stress to both acute disorders, such as infection, and chronic disorders, such as heart disease, is now well known. We explore these processes more fully with heart disease and hypertension in Chap- ter 13 and cancer and arthritis in Chapter 14. Stress can even affect the course of pregnancy, as Box 6.1 shows. ■ WHAT MAKES EVENTS STRESSFUL? Dimensions of Stressful Events Although events are not necessarily inherently stress- ful, some characteristics of events make them more likely to be appraised as stressful. B O X 6.1 Can Stress Affect Pregnancy? Common wisdom has long held that pregnant women should be treated especially well and avoid major stressors in their lives. Research now supports that wisdom by showing that stress can actually endanger the course of pregnancy and childbirth. Stress affects the immune and endocrine sys- tems in ways that directly affect the growing fetus. These changes are potentially dangerous because they can lead to spontaneous abortion (Wainstock, Lerner-Geva, Glasser, Shoham-Vardi, & Anteby, 2013), and preterm birth and low birth weight, among other adverse outcomes (Glynn, Dunkel- Schetter, Hobel, & Sandman, 2008; Tegethoff, Greene, Olsen, Meyer, & Meinlschmidt, 2010). African American women and acculturated Mexican American women appear to be especially vulnerable, due in large part to the stress they experience (D’Anna-Hernandez et  al., 2012; Hilmert et al., 2008). The mother’s elevated cortisol levels in re- sponse to stress act as a signal to the fetus that it is time to be born, leading to preterm birth (Mancuso, Dunkel-Schetter, Rini, Roesch, & Hobel, 2004). Are there any factors that can protect against adverse birth outcomes due to stress? Social support, especially from a partner, protects against adverse birth outcomes (Feldman, Dunkel-Schetter, Sandman, & Wadhwa, 2000). Psychosocial resources such as mastery, self- esteem, and optimism may also help guard against adverse birth outcomes (Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999). Pregnancy-specific stress can elevate birth risks as well (Cole-Lewis et al., 2014). The anxiety that can accompany stress and the prenatal period exacer- bates cortisol levels and increases the likelihood of an adverse birth outcome, and so interventions to reduce anxiety may be helpful as well (Mancuso et al., 2004). But the old adage about taking it easy during pregnancy and the more dire warnings about the high risks for adverse birth outcomes in disadvantaged groups make it clear that pregnancy is an especially important time to avoid stress and to draw on one’s psychological and social resources. © Terry Vine Photography/Blend Images LLC RF Chapter 6 Stress 123 perception that one is responsible for doing too much in too short a time. Which Stressors? People are more vulnerable to stress in central life domains than in peripheral ones, because important aspects of the self are heavily in- vested in central life domains (Swindle & Moos, 1992). For example, one study of working women for whom parental identity was very important found that strains associated with the parent role, such as feeling that their children did not get the attention they needed, took a toll (Simon, 1992). To summarize, then, events that are negative, un- controllable, ambiguous, or overwhelming or that in- volve central life goals are experienced as more stressful than events that are positive, controllable, clear-cut, or manageable or that involve peripheral life tasks. Must Stress Be Perceived as Such to Be Stressful? The discussion of stress thus far has emphasized the importance of perception, that is, the subjective expe- rience of stress. However, objective stressors can have effects independent of the perceived stress they cause. For example, in a study of air traffic control- lers, Repetti (1993b) assessed their subjective per- ceptions of stress on various days and also gathered objective measures of daily stress, including the weather conditions and the amount of air traffic. She Uncontrollable Events Uncontrollable or un- predictable events are more stressful than controllable or predictable ones especially if they are also unex- pected (Cankaya, Chapman, Talbot, Moynihan, & Duberstein, 2009). When people feel that they can predict, modify, or terminate an aversive event or feel they have access to someone who can influence it, they experience less stress, even if they actually can do nothing about it (Thompson, 1981). Feelings of control not only mute the subjective experience of stress but also influence biochemical reactions to it, including catecholamine levels and immune responses (Brosschot et al., 1998). Ambiguous Events Ambiguous events are more stressful than clear-cut events. When a potential stressor is ambiguous, a person cannot take action, but must instead devote energy to trying to understand the stressor, which can be a time-consuming, resource- sapping task. Clear-cut stressors, on the other hand, let the person get on with finding solutions and do not leave him or her stuck at the problem definition stage. The ability to take confrontative action is usually as- sociated with less distress and better coping (Billings & Moos, 1984). Overload Overloaded people experience more stress than people with fewer tasks to perform (Cohen & Williamson, 1988). For example, one of the main sources of work-related stress is job overload, the Events such as crowding are experienced as stressful to the extent that they are appraised that way. Some situations of crowding make people feel happy, whereas other crowding situations are experienced as aversive. © momcilog/Getty Images RF © blvdone/Shutterstock found that both subjective and objective measures of stress independently predicted psychological distress and health complaints. Even when the air traffic con- trollers reported that they were not under stress, if air traffic was heavy and weather conditions poor, they were more likely to show evidence of stress, both physiologically and behaviorally. Can People Adapt to Stress? If a stressful event becomes a permanent or chronic part of the environment, will people eventually habit- uate to it, or will they develop chronic strain? The answer to this question depends on the type of stressor, the subjective experience of stress, and the indicator of stress. Most people are able to adapt psychologically to moderate or predictable stressors. At first, any novel or threatening situation can produce stress, but such reactions subside over time. For example, research on the effects of environmental noise (Nivison & Endresen, 1993) and crowding (Cohen, Glass, & Phillip, 1978) indicates few or no long-term adverse physiological or psychological effects, suggesting that most people simply adapt to this chronic stressor. However, vulnerable populations, such as chil- dren, the elderly, and the poor, show little adaptation to chronic stressors (Cohen et al., 1978). One reason is that these groups already experience little control over their environments and, accordingly, may already be at high levels of stress; the addition of an environmen- tal stressor may push their resources to the limits. Most people, then, can adapt to mildly stressful events; however, it may be difficult or impossible to adapt to highly stressful events, and already-stressed people may be unable to adapt to even moderate stressors. Moreover, even when psychological adap- tation may have occurred, physiological changes in response to stress may persist. Chronic stress can im- pair cardiovascular, neuroendocrine, and immune system recovery from stressors and, through such ef- fects, contribute to an increased risk for diseases such as cardiovascular disorders (Matthews, Gump, & Owens, 2001). Must a Stressor Be Ongoing to Be Stressful? One of the wonders and curses of human beings’ sym- bolic capacities is the ability to anticipate things before they materialize. We owe our abilities to plan, invent, and reason abstractly to this skill, but we also get from it our ability to worry. We do not have to be exposed to a stressor to suffer stress. Anticipating Stress The anticipation of a stressor can be as stressful as its actual occurrence, and sometimes more so (Wirtz et al., 2006). Consider the strain of anticipating a confrontation with one’s partner or worrying about an upcoming test. Sleepless nights and days of distracting anxiety attest to the hu- man being’s capacity for anticipatory distress. In one study that illustrates this point, medical students’ blood pressure was assessed on an unstress- ful lecture day, on the day before an important exami- nation, and during the examination itself. Although the students had stable blood pressure on the lecture day, blood pressure on the preexamination day, when the students were worrying about the exam, was as high as that seen during the examination (Sausen, Lovallo, Pincomb, & Wilson, 1992). Aftereffects of Stress Adverse aftereffects of stress often persist long after the stressful event itself is no longer present. These aftereffects include a short- ened attention span and poor performance on intellec- tual tasks as well as ongoing psychological distress and physiological arousal. Cognitive disruptions such as difficulty concentrating are common, and social be- havior is affected as well; people seem to be less will- ing to help others when they are suffering from the aftereffects of stress. Worry or rumination, even when one is not aware that one is doing it, can keep heart rate, blood pressure, and immune markers at high lev- els (Zoccola, Figueroa, Rabideau, Woody, & Benencia, 2014). Box 6.2 profiles a particular kind of aftereffect of stress, post-traumatic stress disorder. ■ HOW HAS STRESS BEEN STUDIED? Health psychologists have used several different meth- ods for studying stress and assessing its effects on psy- chological and physical health. Studying Stress in the Laboratory A common way to study stress is to bring people into the laboratory, expose them to short-term stressful 124 Part Three Stress and Coping they get. For example, S. Cohen and colleagues (1999) measured levels of stress in a group of adults, infected them with an influenza virus by swabbing their nose with cotton soaked in a viral culture, and measured their respiratory symptoms, the amount of mucus they produced, and immune responses to stress. They found that people experiencing more stress are more likely to get sick and mount a stron- ger immune response than people exposed to the virus whose lives were less stressful. This approach has also been used to study factors that protect against stress, such as social support (e.g., Cohen et al., 2008). Stressful Life Events Another line of stress research assesses stressful life events. Two pioneers in stress research, T. H. Holmes and R. H. Rahe (1967), maintained that when a person must adjust to a changing environment, the likelihood of stress increases. They created an inventory of stressful life events (Table 6.2) by developing ratings of stressful events based on the amount of change those events cause. Thus, for example, if one’s spouse dies, virtually every aspect of life is disrupted. On the other hand, getting a traffic ticket may be annoying but is unlikely to produce much change in one’s life. events, and observe the impact of that stress on their physiological, neuroendocrine, and psychological re- sponses. This acute stress paradigm consistently finds that when people perform stressful tasks (such as counting backward quickly by 7s or delivering an impromptu speech to an unresponsive audience), they become psychologically distressed and show physio- logical arousal (Kirschbaum, Klauer, Filipp, & Hellhammer, 1995; Ritz & Steptoe, 2000). The acute stress paradigm has been helpful for identifying who is most vulnerable to stress (Pike et  al., 1997). For example, people who are chroni- cally stressed react more during these laboratory stressors as do people who are high in hostility ( Davis, Matthews, & McGrath, 2000). Box 6.3 provides an example of how an acutely stressful event can lead to dramatic health consequences. These methods have also shown that when people experience stress in the presence of a supportive partner or even a stranger, their stress responses can be reduced ( Ditzen et al., 2007). Inducing Disease Another way of studying the effects of stress has involved intentionally exposing people to viruses and then assessing whether they get ill and how ill TABLE 6.2 | The Social Readjustment Rating Scale Here are some examples of items from the Social Readjustment Rating Scale, including some that are viewed as very taxing and others, much less so. Rank Life Event Mean Value 1 Death of a spouse 100 2 Divorce 73 4 Detention in jail or other institution 63 5 Death of a close family member 63 6 Major personal injury or illness 53 8 Being fired at work 47 Here are some of the smaller stressful events that nonetheless can aggravate accumulating stress as well. Rank Life Event Mean Value 41 Vacation 13 42 Chiristmas 12 43 Minor violations of the law (e.g., traffic tickets, jaywalking, disturbing the peace) 11 Source: T. H. Holmes & Rahe, 1967. Chapter 6 Stress 125 126 B O X 6.2 Post-Traumatic Stress Disorder An Iraq War veteran and his wife headed out to the movies one summer night. As they took their seats, the veteran scanned the rows for moviegoers who might be wired with explosives. A man who appeared to be Middle Eastern, wearing a long coat with bulg- ing pockets, sat down in the same row. The Iraq War veteran instructed his wife to get low to the ground. Moments later, he heard a metal jangling as the man reached into his pocket, and he lunged at the man, sure that he was a suicide bomber about to strike. As he jerked away, the man dropped the deadly weapon—a can of Coke (Streisand, 2006, October 9). When a person has experienced intense stress, symptoms of the stress experience may persist long af- ter the event is over and affect health long afterwards as well (Litcher-Kelly et al., 2014; Lowe, Willis, & Rhodes, 2014). In the case of major traumas, these stressful aftereffects may go on intermittently for months or years. Such long-term reactions are espe- cially likely following combat exposure, as occurred in Iraq and Afghanistan (McNally, 2012). But they may also occur in response to assault, rape, domestic abuse, a violent encounter with nature (such as an earthquake or flood), a disaster (such as 9/11) (Fagan, Galea, Ahern, Bonner, & Vlahov, 2003), being a hostage (Vila, Porche, & Mouren-Simeoni, 1999), or having a child with a life-threatening disease (Cabizuca, Marques- Portella, Mendlowicz, Coutinho, & Figueria, 2009). Particular occupations such as being a police officer in a high-crime city (D. Mohr et al., 2003) or having re- sponsibility for clearing up remains following war, di- saster, or mass death (McCarroll, Ursano, Fullerton, Liu, & Lundy, 2002) increase the risk of trauma. Post- traumatic stress disorder (PTSD) can be the result. Symptoms of PTSD include psychic numbing, re- duced interest in once-enjoyable activities, detach- ment from friends, or constriction in emotions. The person may relive aspects of the trauma, as the Iraq War veteran did. Other symptoms include excessive vigilance, sleep disturbances, feelings of guilt, im- paired memory and concentration, an exaggerated startle response to loud noise (Lewis, Troxel, Kravitz, Bromberger, Matthews, & Hall, 2013), and even sui- cidal behavior. Sometimes the onset of symptoms is delayed, necessitating following people at risk over time (O’Donnell et al., 2013). PTSD can lead to greater and more severe conflict in couples and with other family members and friends (Caska et al., 2014). PTSD can produce temporary and permanent changes in stress regulatory systems (Minassian et al., 2014). People with PTSD show cortisol dysregulation (Mason et al., 2002), alterations in immune function- ing (Boscarino & Chang, 1999), and chronically higher levels of norepinephrine, epinephrine, and tes- tosterone (Lindauer et al., 2006; O’Donnell, Creamer, Elliott, & Bryant, 2007). PTSD leads to poor health, especially cardiovas- cular and lung disorders (Kubzansky, Koenen, Jones, & Eaton, 2009; Pietrzak, Goldstein, Southwick, & Grant, 2011), and early mortality, especially from heart disease (Dedert, Calhoun, Watkins, Sherwood, & Beckham, 2010). It also is tied to life-threatening health habits such as problem drinking and smoking, which contribute to poor health (Dennis et al., 2014), and to worsening symptoms of already existing disor- ders such as asthma (Fagan et al., 2003). Nearly half of adults in the United States experi- ence at least one traumatic event in their lifetime, but only 10  percent of women and 5 percent of men de- velop PTSD (Ozer & Weiss, 2004). Who is most likely to develop PTSD? People who have poor cognitive skills (Gilbertson et al., 2006) or catastrophic thinking about stress (Bryant & Guthrie, 2005), and people who have a preexisting emotional disorder such as anxiety (Dohrenwend, Yager, Wall, & Adams, 2013) are vulnerable. People who use avoidant coping, have low levels of social support, have a history of chronic National Archives and Records Administration (NWDNS-111-SC-347803) 127 Although all people experience at least some stressful events, some people will experience a lot, and it is this group, according to Holmes and Rahe, that is most vulnerable to illness. Although scores on life event inventories pre- dict illness, the relation is quite modest. Why is this the case? First, some of the items on the list are vague; for example, “personal injury or illness” could mean anything from the flu to a heart attack. Second, because events have preassigned point val- ues, individual differences in how events are expe- rienced are not taken into account. For example, a divorce may mean welcome freedom to one partner but a collapse in living standard or self-esteem to the other. Third, inventories include both positive and nega- tive events, as well as events that people choose, such as getting married, and events that simply happen, such as the death of a close friend. As noted, sudden, negative, unexpected, and uncontrollable events are reliably more stressful. Fourth, researchers typically do not as- sess whether stressful events have been successfully resolved, which mutes adverse effects (Thoits, 1994; Turner & Avison, 1992). Life event inventories may pick up chronic strains and also personality factors that influence how intensely a person experiences an event. Many people believe that stress causes illness, and so if they have been ill, they may remember more events in their lives as having been stressful. A final difficulty concerns the time between stress and illness. Usually, in these studies, stress over a 1-year period is related to the most recent 6 months of illness bouts. Yet, January’s crisis is unlikely to have caused June’s cold and April’s financial prob- lems are unlikely to have produced a malignancy de- tected in May. Obviously, these cases are extreme, but they illustrate some of the problems in studying the stress-illness relationship over time. For all these rea- sons, life event inventories are no longer used as much and some researchers have turned instead to perceived stress (Box 6.4). Daily Stress In addition to major stressful life events, researchers have studied minor stressful events, or daily hassles, and their cumulative impact on health and illness. Such hassles include being stuck in traffic, waiting in a line, doing household chores, having difficulty mak- ing small decisions, and daily conflict (Tobin et al., 2015). Daily minor problems produce psychological B O X 6.2Post-Traumatic Stress Disorder (continued) stress, have preexisting heightened reactivity to trauma-related stimuli (Suendermann, Ehlers, Boellinghaus, Gamer, & Glucksman, 2010), and are generally negative all have increased risk of develop- ing PTSD in the wake of a traumatic stressor (Gil & Caspi, 2006; Widows, Jacobsen, & Fields, 2000). Characteristics of the trauma matters, too. Sol- diers who had combat experience, who observed atrocities, and who participated in atrocities are most likely to experience PTSD (Dohrenwend et al., 2013). The more traumas one is exposed to, the greater the risk of PTSD, and the greater the health risk that may result (Sledjeski, Speisman, & Dierker, 2008). Can PTSD be alleviated? Cognitive-behavioral ther- apies are used to treat PTSD (Harvey, Bryant, & Tarrier, 2003; Nemeroff et al., 2006). Perhaps counterintuitively, repeated exposure to the trauma through imagined expo- sure and discussion of thoughts and feelings related to the trauma can reduce symptoms of PTSD and enhance emotional processing of the traumatic event (Reger et al., 2011). Exposure therapy early after the trauma may be best (Rothbaum et al., 2012). Virtual reality exposure therapy after or even before exposure to wartime trauma has been used as well (Rizzo et al., 2009). The goals of repeated exposure involve isolating the trauma as a dis- crete event, habituating to it and reducing overwhelming distress. In turn, this repeated exposure can foster new interpretations of the event and its implications, reduce anxiety, and build a sense of mastery (Harvey et al., 2003). Once habituation is achieved, cognitive restruc- turing is added to integrate the trauma into the client’s self-view and worldview. Anxiety management training is often included so that the patient can recognize and deal with intrusive traumatic memories (Harvey et al., 2003). Interventions such as these have been success- fully used with military veterans (Monson et al., 2006) and women who were sexually abused as children (McDonagh et al., 2005) among other groups. 128 distress, adverse physiological changes, physical symptoms, and use of health care services (Gouin, Glaser, Malarkey, Beversdorf, & Kiecolt-Glaser, 2012; Sin, Graham-Engeland, Ong, & Almeida, 2015). An example of how daily hassles can be mea- sured is shown in Box 6.5. Minor hassles affect physical and psychological health in several ways. First, the cumulative impact of small stressors may wear a person down, leading to illness. Second, such events may aggravate reactions to major life events or chronic stress to produce dis- tress or illness (Marin, Martin, Blackwell, Stetler, & Miller, 2007; Serido, Almeida, & Wethington, 2004). Although useful for identifying the smaller has- sles of life, measure of daily strain have some of the same problems as the measurement of major stressful life events. For example, people who report a lot of hassles may be anxious or neurotic. ■ SOURCES OF CHRONIC STRESS Earlier, we posed the question of whether people can adapt to chronically stressful events. The answer is that people can adapt to a degree but continue to show signs of stress in response to severe chronic strains in their lives. Indeed, chronic stress may be more impor- tant than major life events for developing illness. Effects of Early Stressful Life Experiences Early life adversity in childhood can affect not only health in childhood (e.g., Marin, Chen, Munch, & Miller, 2009), but also health across the lifespan into adulthood and old age (McCrory, Dooley, Layte, & Kenny, 2015; Miller, Chen, & Parker, 2011). Some of New York City traffic enforcement agents who have social support from coworkers are better able to deal with these stressful working conditions (Karlan, Brondolo, & Schwartz, 2003). © Adam Gault/Getty Images RF B O X 6.3 Can an Exciting Sports Event Kill You? Cardiovascular Events During World Cup Soccer Everyone knows that fans get worked up during excit- ing sports matches. Near misses by one’s own team, questionable calls by referees, and dirty plays can all rouse fans to fever pitch. But do these events actually have health effects? To examine this question, Wilbert- Lampen and colleagues (2008) studied acute cardio- vascular events in 4,279 Germans when the German national team played in World Cup soccer events. On days with matches involving the German team, car- diac emergencies were nearly three times as likely as on days when they did not play. Nearly half of these people, mostly men, had previously been diagnosed with coronary heart disease. The study concluded that viewing a stressful soc- cer match, or indeed any other exciting sports event, may more than double the risk of a heart attack or stroke. This increased risk falls especially hard on people who have already been diagnosed with heart disease. So if someone you care about has a cardiovas- cular disorder and is a sports fan, that person may want to rethink whether exciting matches are worth the risk. © Cultural Limited/SuperStock RF Chapter 6 Stress 129 129 this work grew out of the allostatic load view of stress, which argues that major, chronic, or recurrent stress dysregulates stress systems, which, over time, pro- duce accumulating risk for disease (Slatcher & Robles, 2012). These early risks include low socioeconomic status, exposure to violence, living in poverty-stricken neighborhoods, and other community level stressors (Blair & Raver, 2012). Physical or sexual abuse in childhood increases health risks (Midei, Matthews, Chang, & Bromberger, 2013) because abuse can result in intense, chronic stress that taxes physiological systems (Wegman & Stetler, 2009) and difficulties regulating emotions (Broody et al., 2014). Even more modest family stress can increase risk for disease. Repetti and colleagues (2002) found that “risky families”—that is, families that are high in conflict or abuse and low in warmth and nurturance—produce offspring whose stress re- sponses are compromised. These difficulties include problems with emotion regulation, social skills, and health habits (Schrepf, Markon, & Lutgendorf, 2014). Children who grow up in harsh families do not learn how to recognize other people’s emotions and respond to them appropriately or regulate their own emotional responses to situations. As a result, they may overre- act to mild stressors (Hanson & Chen, 2010). These adverse reactions can be compounded by low socioeconomic status (Appleton et al., 2012) and by exposure to trauma (Schrepf et al., 2014). Children who grow up in risky families also have difficulty forming good social relationships. These def- icits in emotion regulation and social skills can persist across the lifespan long into adulthood, compromising the ways in which people from risky families cope with stress (Raposa, Hammen, Brennan, O’Callaghan, & Najman, 2014; Taylor, Eisenberger, Saxbe, Lehman, & Lieberman, 2006). Physiological systems are affected Work strains, like the argument between these coworkers, are common sources of stress that compromise well-being and physical health. © Ingram Publishings RF B O X 6.4A Measure of Perceived Stress Because people vary so much in what they consider to be stressful, many researchers measure perceived stress instead. S. Cohen and his colleagues (1983) de- veloped a measure of perceived stress, some items of which follow. Perceived stress predicts a broad array of health outcomes (Kojima et al., 2005; Young, He, Genkinger, Sapun, Mabry, & Jehn, 2004). ITEMS ON THE PERCEIVED STRESS SCALE For each question, choose from the following alternatives: 0 Never 1 Almost never 2 Sometimes 3 Fairly often 4 Very often 1. In the last month, how often have you been upset because of something that happened unexpectedly? 2. In the last month, how often have you felt nervous and stressed? 3. In the last month, how often have you found that you could not cope with all the things that you had to do? 4. In the last month, how often have you been angered because of things that happened that were outside your control? 5. In the last month, how often have you found yourself thinking about things that you had to accomplish? 6. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? If your score is high, you may want to try to reduce the stress in your life. 130 as well (Miller, Chen, & Parker, 2011). Children from risky families can develop heightened sympathetic re- activity to stress, exaggerated cortisol responses lead- ing to health risks, and/or an immune profile marked by chronic inflammation (Miller & Chen, 2010; Schreier & Chen, 2012). For example, in a retrospective study, V. J. Felitti and colleagues (1998) asked adults to complete a ques- tionnaire regarding their early family environment that inquired, among other things, how warm and supportive the environment was versus how cold, critical, hostile, or conflictridden it was. The more negative characteris- tics these adults reported from their childhood, the more vulnerable they were in adulthood to many disorders, including depression, lung disease, cancer, heart dis- ease, and diabetes (Loucks, Almeida, Taylor, & Matthews, 2011). Because children from risky families often have poor health habits, some enhanced risk for disease may come from smoking, poor diet, and lack of exercise. Stress in adolescence also affects health both during adolescence (Schreier, Roy, Frimer, & Chen, 2014), and into adulthood (Quon & McGrath, 2014). For example, social disadvantage in adolescence is linked to increased body weight, to inflammation (Pietras & Goodman, 2013), and to high-blood pressure and poor blood pressure recovery from stress (Evans, Exner-Cortens, Kim & Bartholomew, 2013). Perceived financial stress is especially strongly related to multiple health markers and outcomes, attesting again to the ad- verse health effects of low SES (Quon & McGrath, 2014). Good parenting can mitigate these effects (Brody, Yu, Chen, & Miller, 2014). Are these effects reversible? At present it is un- known whether early life stress permanently programs stress systems or whether some of these effects are re- versible. However, some factors, such as maternal nur- turance in a high poverty environment, can be protective against the health risks usually found in high-stress ar- eas (Miller et al., 2011). Interventions undertaken early in childhood may have health payoffs across the life- span (Puig, Englund, Simpson, & Collins, 2012). Chronic Stressful Conditions Sometimes, chronic stress is long-term and grinding, such as living in poverty, being in a bad relationship, or remaining in a high-stress job. Chronic stress is also an important contributor to psychological distress and physical illness (Kahn & Pearlin, 2006). In an early community study of 2,300 people, L. I. Pearlin and C. Schooler (1978) found that people who re- ported chronic stress in marriage, parenting, house- hold functioning, or their jobs were more likely to be psychologically distressed. Uncontrollable stressors may be particularly virulent (McGonagle & Kessler, 1990). Even something as mundane as commuting can affect daily cortisol levels and perceived stress, affecting the over 100 million Americans who com- mute to work every weekday (Evans & Wener, 2006). Research relating chronic stress to health out- comes is difficult to conduct, though, because it is hard to show that a particular chronic stressor is the factor that caused illness. Second, unlike life events, which can often be assessed objectively, chronic stress B O X 6.5 The Measurement of Daily Strain INSTRUCTIONS Each day, we experience minor annoyances as well as major problems or difficulties. Indicate how much of a strain each of these annoyances has been for you in the past month. Severity 0 Did not occur 1 Mild strain 2 Somewhat of a strain 3 Moderate strain 4 Extreme strain Hassles 1. A quarrel or problems with a neighbor 0 1 2 3 4 2. Traffic congestion 0 1 2 3 4 3. Thoughts of poor health 0 1 2 3 4 4. An argument with a romantic partner 0 1 2 3 4 5. Concerns about money 0 1 2 3 4 6. A parking ticket 0 1 2 3 4 7. Preparation of meals 0 1 2 3 4 Chapter 6 Stress 131 Revolution was agricultural production, which in- volves physical labor. As people have moved into sed- entary office jobs, the amount of exercise they get in their work lives has declined substantially. Even jobs that require high levels of physical exertion, such as construction work and firefighting, may include so much stress that the benefits of exercise are eliminated. Because activity level is related to health, this change in the nature of work increases vulnerability to illness. Overload Work overload is a chief factor produc- ing high levels of occupational stress. Workers re- quired to work too long and too hard at too many tasks feel more stressed, have poorer health habits, and have more health risks than do workers not suffering from overload (Lumley et al., 2014). The chronic neuroen- docrine activation and cardiovascular activation asso- ciated with overcommitment can contribute to cardiovascular disease (Steptoe, Siegrist, Kirschbaum, & Marmot, 2004; Von Känel, Bellingrath, & Kudielka, 2009). An old rock song states, “Monday, Monday, can’t trust that day.” Monday may indeed be one of the most stressful days of the week. Weekdays more generally are associated with more worry and chronic work over- load than weekends, resulting in altered cortisol levels (Schlotz, Hellhammer, Schulz, & Stone, 2004). Unfor- tunately, many people, particularly in the United States, don’t use their weekends to recover and instead work through the weekend. Then they dump the work they did over the weekend onto their coworkers on Monday. Incomplete recovery from work contributes to death from cardiovascular disease (Kivimäki et al., 2006). So well established is the relation between work overload and poor health that Japan, a country notori- ous for its long working hours, long work weeks, little sleep, and lack of vacations, has a term, karoshi, that refers to death from overwork. One study found that men who worked more than 61 hours a week experi- enced twice the risk of a heart attack as those working 40 hours or less; sleeping 5 hours or less at least 2 days a week increased this risk by two to three times (Liu & Tanaka, 2002). Under Japanese law, families are enti- tled to compensation if they can prove that the bread- winner died of karoshi (Los Angeles Times, March 1993). As a result, work hours have declined in Japan over the past 20 years. Ambiguity and Role Conflict Role conflict and role ambiguity are associated with stress. Role can be more difficult to measure objectively. Third, as in the measurement of life events, inventories that as- sess chronic strain may also tap psychological distress and neuroticism. Nonetheless, the evidence indicates that chronic stress is related to illness (Matthews, Gallo, & Taylor, 2010). Box 6.6 focuses on a particular type of chronic stress, namely, prejudice, and its rela- tion to poor health. Research showing social class differences in death from all causes, including cancers and cardio- vascular disease, also attests to the relationship be- tween chronic stress and health (Grzywacz, Almeida, Neupert, & Ettner, 2004). Poverty, exposure to crime, neighborhood stress, and other chronic stressors vary with SES and are all tied to poor health outcomes (Adler, Boyce, Chesney, Folkman, & Syme, 1993). People who are low in SES typically have low- prestige occupations, which may expose them to greater inter- personal conflict and stress at work. Chronic SES- related stress has also been related to alterations in cortisol patterns, catecholamines, and inflammation (Friedman & Herd, 2010; Kumari et al., 2010). Even children in low SES circumstances suffer health risks, including sleep problems (El-Sheikh et al., 2013), weight gain (Puterman et al., 2016), and increases in allostatic load (Doan, Dich, & Evans, 2014). At least some of the health risks tied to low SES may be re- versible if circumstances improve (Kiviruusu, Huurre, Haukkala, & Aro, 2013). Stress in the Workplace Workplace stress is estimated to cost $300 billion a year (American Institute of Stress, n.d.). Studies of stress in the workplace are important for several additional reasons: ∙ They help identify some of the most common stressors of everyday life. ∙ They provide evidence for the stress-illness relationship. ∙ Work stress may be one of our preventable stressors and so provide possibilities for intervention. ∙ Stress-related physical and mental health disorders account for a growing percentage of disability and social security payments to workers. Work and Sedentary Lifestyle The most com- mon work that people undertook before the Industrial 132 B O X 6.6Can Prejudice Harm Your Health? A young African American father pulled up in front of a house in a largely white neighborhood to pick up his daughter from a birthday party. Because he was early and the party had not ended, he sat waiting in the car. Within 8 minutes, a security car had pulled up behind him; two officers approached him and asked him to  exit his vehicle. Neighbors had reported seeing a suspicious-looking African American man casing their neighborhood. Prejudice and racism adversely affect health (Klonoff, 2014). It has long been known that African Americans experience greater health risks than the rest of the popula- tion. Life expectancy for African American men is about 5  years less than for white men, and life expectancy for African American women is 3 years less than for white women (National Vital Statistics Reports, 2016). For ex- ample, African American men and women die of cardio- vascular disease at nearly one and a half times the rate for white men and women. Many of these differences can be traced to differ- ences in SES and social status (Major, Mendes, & Dovidio, 2013; Myers, 2009). Poverty, lower educa- tional attainment, imprisonment, and unemployment are more prevalent among blacks than whites (Brown- ing & Cagney, 2003). The day-in, day-out grinding strain associated with poor housing, little available em- ployment, poor schools, and poor neighborhoods also contributes to stress through chronic exposure to vio- lence and an enduring sense of danger (Ross & Mirowsky, 2011). Discrimination can erode personal resources, such as social support and the ability to reg- ulate emotions effectively (Gibbons et al., 2014). Med- ical services in minority areas are often inadequate. African Americans are less likely to receive preventive services and more likely to experience delayed medi- cal attention (Institute of Medicine, 2002). Racism and racial discrimination also contribute to disease risk, especially risk of cardiovascular dis- ease (Brondolo, ver Halen, Pencille, Beatty, & Contrada, 2009; Williams & Mohammed, 2009). One may be treated badly by a store clerk or stopped by the police for no reason (driving while black). The ad- verse effects of prejudice and discrimination on health are explained in part by the higher anxiety, depres- sion, and hostility that people develop in response to their experiences of prejudice and discrimination (Brondolo et al., 2011). There are physiological effects of racism as well. Perceived racism coupled with inhibited angry responses to it are related to high blood pressure, con- tributing to the high incidence of hypertension among African Americans (Smart Richman, Pek, Pascoe, & Bauer, 2010). Blood pressure usually falls when a per- son goes to sleep, but African Americans are less likely to experience a dip in blood pressure at night (Tomfohr, Cooper, Mills, Nelesen, & Dimsdale, 2010). Racism may also help to explain the high levels of depression (Turner & Avison, 2003) and back pain (Edwards, 2008) in the African American population. Chronic exposure to racism has been tied to problem drinking and to poor sleep quality (Lewis, Troxel, Kravitz, Bromberger, Matthews, & Hall, 2013). Racism is not the only form of prejudice that con- tributes to poor health. Sexism predicts poor physical and mental health for women (Ryff, Keyes, & Hughes, 2003). Women have the best health in states in which their earnings, employment, and political participation are highest and the worst health in those states in which they score lowest on these indices (Jun, Subramanian, Gortmaker, & Kawachi, 2004). Discrimination against mothers is particularly rampant and difficult to combat (Biernat, Crosby, & Williams, 2004). Negative stereotypes about aging may compro- mise health among older adults. In one study, simply exposing older adults to negative aging stereotypes in- creased cardiovascular responses to stress (Levy, Hausdorff, Hencke, & Wei, 2000). Suicide rates among ethnic immigrant groups have been tied to the amount of hate speech directed toward those groups (Mullen & Smyth, 2004) and the strain of trying to adjust to a new culture can produce adverse changes in stress-related biomarkers (Fang, Ross, Pathak, Godwin, & Tseng, 2014). Perceived discrimination is linked to substance abuse among Native American children (Whitbeck, Hoyt, McMorris, Chen, & Stubben, 2001) and to de- pression among Native American adults (Whitbeck, McMorris, Hoyt, Stubben, & LaFromboise, 2002). Exposure to stress and prejudice can adversely affect LGBT young adults (Hatzenbuehler, Slopen, & McLaughlin, 2014), and exposure to weight stigma can affect biomarkers of stress (Schvey, Pulh, & Bronwell, 2014). Converging evidence like this indicates clearly that the stressors associated with discrimination, rac- ism, and prejudice can adversely affect health. Chapter 6 Stress 133 who consequently did not have much social contact were more likely to become ill and to experience an accidental injury than were people who enjoyed and contributed to a more satisfying social climate (Niemcryk, Jenkins, Rose, & Hurst, 1987). Social relationships not only combat stress in their own right, they also buffer other job stressors, such as low control over one’s work. Control Lack of control over one’s work life is a major stressor. It predicts dissatisfaction at work and absenteeism as well as physiological arousal that pre- dicts disease. Lack of control at work has been tied to greater risk of coronary artery disease (Bosma et al., 1997) and to all-cause mortality. Job control, by con- trast, can improve health (Smith, Frank, Bondy, & Mustard, 2008). R. Karasek and his associates (1981) developed a model of job strain that helps to explain its adverse ef- fects on health. They maintain that high psychological demands on the job with little decision latitude (such as low job control) causes job strain, which, in turn, can lead to the development of coronary artery disease. Re- search generally supports this idea (Emeny et al., 2013). The chronic anger that can result from high strain jobs may further contribute to coronary artery disease risk (Fitzgerald, Haythornthwaite, Suchday, & Ewart, 2003). When high demands and low control are com- bined with little social support at work, in what has been termed the demand-control-support model, risk for coronary artery disease is greater (Hintsanen et al., 2007; Muhonen & Torkelson, 2003). The perception that one’s effort at work is insufficiently rewarded (effort-reward imbalance) is also associated with health risks, especially coronary heart disease (Aboa- Éboulé et al., 2011). Unemployment Unemployment is a major life stressor. It increases psychological distress (Burgard, Brand, & House, 2007), physical symptoms, physical illness (Hamilton, Broman, Hoffman, & Renner, 1990), alcohol abuse (Catalano et al., 1993), difficulty achieving sexual arousal, low birth weight of offspring (Catalano, Hansen, & Hartig, 1999), elevated inflam- mation (Janicki-Deverts, Cohen, Matthews, & Cullen, 2008), and compromised immune functioning (Cohen et al., 2007; Segerstrom & Miller, 2004). For example, in a study of SES-related decline in the wake of Hurricane Katrina, those who suffered trauma or who lost their jobs and experienced other ambiguity occurs when a person has no clear idea of what to do and no idea of the standards used for evalu- ating work. Role conflict occurs when a person re- ceives conflicting information about work tasks or standards from different individuals. For example, if a college professor is told by one colleague to publish more articles, is advised by another colleague to pub- lish fewer papers but of higher quality, and is told by a third to improve teaching ratings, the professor may experience role ambiguity and conflict. Chronically high blood pressure and elevated heart rate have been tied to role conflict and role ambiguity (French & Ca- plan, 1973). When people receive clear feedback about the nature of their performance, they report lower lev- els of stress (Cohen & Williamson, 1988). Social Relationships The inability to develop satisfying social relationships at work has been tied to job stress (House, 1981), to psychological distress at work (Buunk, Doosje, Jans, & Hopstaken, 1993), and to poor physical and mental health (Repetti, 1993a; Shirom, Toker, Alkaly, Jacobson, & Balicer, 2011). Having a poor relationship with one’s supervisor pre- dicts job distress and may increase a worker’s risk for coronary heart disease (Davis, Matthews, Meilahn, & Kiss, 1995; Repetti, 1993a). To a degree, having an amicable social environ- ment at work depends on being an amicable coworker. A study of air traffic controllers found that people who were not particularly well liked by their coworkers and Research shows that workers with high levels of job strain and low levels of control over their work are under great stress and may be at risk for coronary heart disease. © David Woolley/Getty Images RF 134 Part Three Stress and Coping and because mothers take on more household tasks and child care than fathers (Emmons et al., 1990), home and work responsibilities may conflict with each other, increasing stress. Working women who have children at home have higher levels of corti- sol, higher cardiovascular reactivity, and more home strain than those without children at home (Frankenhaeuser et al., 1989; Luecken et al., 1997). Single women raising children on their own are most at risk for health problems (Hughes & Waite, 2002), whereas women who are happily married are less likely to show these negative effects (Saxbe, Repetti, & Nishina, 2008). Protective Effects of Multiple Roles Despite the potential for working mothers to suffer role conflict and overload, there can be positive effects of combin- ing home and work responsibilities (e.g., Janssen et al., 2012). Combining motherhood with employment can be beneficial for women’s health and well-being, deprivations showed enduring health effects (Joseph, Matthews, & Meyers, 2014). Uncertainty over employment and unstable employment have also been tied to physical illness (Heaney, Israel, & House, 1994). For example, a study found that men who had held a series of unrelated jobs were at greater risk of dying than were men who re- mained in the same job or in the same type of job (Pavalko, Elder, & Clipp, 1993). Being stably employed is protective of health (Rushing, Ritter, & Burton, 1992). Other Occupational Outcomes Stress shows up in ways other than illness that may be extremely costly to an organization. Workers who cannot partici- pate actively in decisions about their jobs show higher rates of absenteeism, job turnover, tardiness, job dis- satisfaction, sabotage, and poor performance on the job. Workers may take matters into their own hands and reduce stress by not working as long, as hard, or as well as their employers expect (Kivimäki, Vahtera, Ellovainio, Lillrank, & Kevin, 2002). Some Solutions to Workplace Stressors A blueprint for change has been offered by several organizational stress researchers (for example, Kahn, 1981) (Table 6.3). Combining Work and Family Roles Much of the stress that people experience results not from one role in their lives but from the combination of several roles. As adults, most of us will be workers, partners, and parents. Each of these roles entails heavy obligations, and stress can result when one is attempt- ing to combine multiple roles. Women and Multiple Roles These problems are particularly acute for women. More than half of married women with young children are currently employed (U.S. Bureau of Labor Statistics, 2014). Managing multiple roles is most difficult when both work and family responsibilities are heavy (Emmons, Biernat, Teidje, Lang, & Wortman, 1990), and having many responsibilities at home has health risks of its own (Thurston, Sherwood, Matthews, & Blumenthal, 2011). Because conces- sions to working parents are rarely made at work TABLE 6.3 | Reducing Stress at Work Because work is such an important and time-consuming part of life, it can contribute to the joy but also to the stress that people experience each day. How can stress on the job be reduced? 1. Minimize physical work stressors, such as noise, harsh lighting, crowding, or temperature extremes. 2. Minimize unpredictability and ambiguity in expected tasks and standards of performance. When workers know what they are expected to do, they are less distressed. 3. Involve workers as much as possible in the decisions that affect their work. 4. Make jobs as interesting as possible. 5. Provide workers with opportunities to develop or promote meaningful social relationships. 6. Reward workers for good work, rather than focusing on punishment for poor work. 7. Look for signs of stress before stress has an opportunity to do significant damage. Supervisors can watch for negative affect, such as boredom, apathy, and hostility, because these affective reactions often precede more severe reactions to stress, such as poor health or absenteeism. 8. Add workplace perks that enhance quality of life. Some organizations, such as Google, go so far as to permit pets at work and provide high-quality food continuously throughout the day (Cosser, 2008). Chapter 6 Stress 135 stress and its psychological and physical costs (Ten Brummelhuis & Bakker, 2012). Men and Multiple Roles Men experience stress as they attempt to combine multiple roles as well. Studies show that men are more distressed by finan- cial strain and work stress, whereas women are more distressed by adverse changes in the home (Barnett, Raudenbush, Brennan, Pleck, & Marshall, 1995). Combining employment and marriage is protec- tive for men’s health and mental health (Burton, 1998), just as it is for women who have enough help. But multiple roles can take their toll on men, too. R. L. Repetti (1989) studied workload and interper- sonal strain and how they affected fathers’ interac- tions with the family at the end of the day. She found that after a demanding day at work (high workload strain) fathers were more withdrawn in their interac- tions with their children. After stressful interper- sonal events at work (high interpersonal strain), conflict with children increased. Employed, unmar- ried fathers may be especially vulnerable to psycho- logical distress (Simon, 1998). For both men and women, the research on mul- tiple roles is converging on the idea that stress is lower when one finds meaning in one’s life. The pro- tective effects of employment, marriage, and parent- ing on psychological distress and the beneficial effects of social support on health attest to the bene- ficial effects of social roles (Burton, 1998). When these sources of meaning and pleasure in life are challenged, as through role conflict and role over- load, health may suffer (Stansfeld, Bosma, Hemingway, & Marmot, 1998). Children Children and adolescents also experi- ence stress that can make home life stressful (Repetti, Wang, & Saxbe, 2011). One study found that social and academic failure experiences at school, such as being rejected by a peer or having difficulty with schoolwork, significantly increased a child’s demand- ing and aversive behavior at home—specifically, act- ing out and making demands for attention (Repetti & Pollina, 1994). Children are also affected by their par- ents’ work and family stressors, with consequences for the children’s academic achievement and acting out in adolescence (Menaghan, Kowaleski-Jones, & Mott, 1997). Stress in children leads to adoption of an un- healthy lifestyle (Michels et al., 2015). ∙ improving self-esteem, feelings of self-efficacy, and life satisfaction (Verbrugge, 1983; Weidner, Boughal, Connor, Pieper, & Mendell, 1997). Being a parent also confers resistance to colds (Sneed, Cohen, Turner, & Doyle, 2012). Having control and flexibility over one’s work environment (Lennon & Rosenfield, 1992), having a good income (Rosenfield, 1992), having someone to help with the housework (Krause & Markides, 1985), having adequate child care (Ross & Mirowsky, 1988), having a partner (Ali & Avison, 1997), and having a supportive, helpful partner (Klumb, Hoppmann, & Staats, 2006) all reduce the likelihood that multiple role demands will lead to Many women hold multiple roles, such as worker, homemaker, and parent. Although these multiple roles can provide much satisfaction, they also make women vulnerable to role conflict and role overload. © Terry Vine/Blend Images LLC RF 136 Part Three Stress and Coping 1. Events are perceived as stressful when people believe that their resources (such as time, money, and energy) may not be sufficient to meet the harm, threat, or challenge posed by the stressor. 2. Whether an event is stressful depends on how it is appraised. Events that are negative, uncontrollable or unpredictable, ambiguous, overwhelming, and threatening to central life tasks are especially likely to be perceived as stressful. 3. Early research on stress examined how a person mobilizes resources to fight or flee from threatening stimuli (the fight-or-flight response). Selye proposed the General Adaptation Syndrome, maintaining that reactions to stress go through three phases: alarm, resistance, and exhaustion. Recent efforts have focused on social responses to stress, that is, the ways in which people tend-and-befriend others in times of stress. 4. The physiology of stress implicates the sympathetic adrenomedullary (SAM) system and the hypothalamic-pituitary-adrenocortical (HPA) axis. Over the long term, repeated activation of these and other physiological systems can lead to cumulative damage, termed allostatic load, which represents the premature physiological aging that chronic or recurrent stress can produce. 5. Usually, people can adapt to mild stressors, but severe stressors may cause chronic health problems. Stress can have disruptive aftereffects, including persistent physiological arousal, psychological distress, poor task performance, and, over time, declines in cognitive capabilities. Vulnerable populations—such as children, the elderly, and the poor—may be particularly adversely affected by stress. 6. Researchers study stress in the laboratory and through experimental research that manipulates exposure to pathogens. Research on stressful life events indicates that any event that forces a person to make a change increases stress and the likelihood of illness. Chronic stress, as well as the daily hassles of life, also affect health adversely. 7. Studies of occupational stress suggest that work hazards, work overload, work pressure, role conflict and ambiguity, inability to develop satisfying job relationships, inability to exert control in one’s job, and unemployment can lead to increased illness, job dissatisfaction, absenteeism, tardiness, and turnover. Some of these job stresses can be prevented or offset through intervention. 8. Combining multiple roles, such as those related to work and home life, can create role conflict and role overload, producing psychological distress and poor health. On the other hand, such role combinations may confer meaning and enhance well-being. Which of these effects depend, in large part, on available resources, such as time, money, and social support? S U M M A R Y K E Y T E R M S acute stress paradigm aftereffects of stress allostatic load chronic strain daily hassles demand-control-support model fight-or-flight response general adaptation syndrome person–environment fit primary appraisal reactivity role conflict secondary appraisal stress stressful life events stressors tend-and-befriend 137 C H A P T E R 7 C H A P T E R O U T L I N E Coping with Stress and Resilience Personality and Coping Psychosocial Resources Resilience Coping Style Problem-Focused and Emotion-Focused Coping Coping and External Resources Coping Outcomes Coping Interventions Mindfulness Meditation and Acceptance/Commitment Therapy Expressive Writing Self-Affirmation Relaxation Training Coping Skills Training Social Support What Is Social Support? Effects of Social Support on Illness Biopsychosocial Pathways Moderation of Stress by Social Support What Kinds of Support Are Most Effective? Enhancing Social Support Coping, Resilience, and Social Support © Jack Hollingsworth/Getty Images RF 138 Part Three Stress and Coping A second important aspect of coping is its breadth. Emotional reactions, including anger or depression, are part of the coping process, as are actions that are volun- tarily undertaken to confront the event. Figure 7.1 presents a diagram of the coping process. Personality and Coping The personality characteristics that each person brings to a stressful event influence how he or she will cope with that event. Negativity, Stress, and Illness Some people experience stressful events especially strongly, which increases their psychological distress, their physical symptoms, and their likelihood of illness. Research has especially focused on negative affectivity (Watson & Clark, 1984), a pervasive negative mood marked by anxiety, depression, and hostility. People high in negative affectivity (also called neuroticism) express distress, discomfort, and dissatisfaction in many situations. Negative affectivity or neuroticism is related to poor health, including such chronic disorders as ar- thritis, diabetes, chronic pain, and coronary artery dis- ease (Charles, Gatz, Kato, & Pedersen, 2008; Friedman & Booth-Kewley, 1987; Goodwin, Cox, & Clara, 2006; Shipley, Weiss, Der, Taylor, & Deary, 2007). Negative affectivity is also related to all-cause mortality (Grossardt, Bower, Geda, Colligan, & Rocca, 2009). Taken together, this research suggests that psychological distress involving depression, an- ger, hostility, and anxiety may form the core of a “disease-prone personality” that predisposes people high in negative affect to illness (Friedman & Booth- Kewley, 1987). Neuroticism coupled with social inhi- bition and isolation (sometimes referred to as the Type D or “distressed” personality) is an especially toxic combination for health (Denollet, 2000; Hausteiner et al., 2010). What links chronic negative affect to illness? Negative affectivity is related to elevated levels of stress indicators such as cortisol (Polk, Cohen, Doyle, Skoner, & Kirschbaum, 2005), heart rate (Daly, Delaney, Doran, Harmon, & MacLachlan, 2010), in- flammation (Roy et al., 2010), and risk factors for coronary heart disease (Midei & Matthews, 2009). A second link is poor health habits. For example, people high in negative affect are more likely to drink heavily and use drugs (Frances, Franklin, & In June 2012, wildfires swept through Colorado. Thousands of people were evacuated, and many lost their homes and personal property. Those whose homes survived intact often moved back into neigh- borhoods that were otherwise devastated. Even in cases where peoples’ losses seemed similar, however, not everyone was affected the same way. Consider four families, all of whom lost the better part of their homes and possessions to the fires. One family, newly arrived from Mexico, who had not yet found friends or employment, lost everything. They were devastated psychologically, uncertain whether to return to Mexico or remain. An older man with a heart condition succumbed to a heart attack, leaving his elderly wife behind. A third family, with financial resources and relatives in the area, were quickly taken in and began looking for another home. A young cou- ple, wiped out by the experience, responded with re- silience, determined to make a new start in Denver. What these accounts illustrate is the degree to which stress is moderated by personal and circum- stantial factors. People with many resources, such as money or social support, may find a stressful expe- rience to be less so. Others, without resources or coping skills, may cope poorly. We term these factors stress moderators because they modify how stress is experienced and the effects it has. Moderators of the stress experience may have an impact on stress itself, on the relation between stress and psychological responses, on the relation between stress and illness, and on the degree to which a stressful experience intrudes into other aspects of life. ■ COPING WITH STRESS AND RESILIENCE Coping is defined as the thoughts and behaviors used to manage the internal and external demands of situa- tions that are appraised as stressful (Folkman & Mos- kowitz, 2004; Taylor & Stanton, 2007). Coping has several important characteristics. First, the relation- ship between coping and a stressful event is a dy- namic process. Coping is a series of transactions between a person who has a set of resources, values, and commitments and a particular environment with its own resources, demands, and constraints (Folk- man & Moskovitz, 2004). Thus, coping is not a one- time action that someone takes but rather a set of responses, occurring over time, by which the environ- ment and the person influence each other. Chapter 7 Coping, Resilience, and Social Support 139 Flavin, 1986). People high in negative affectivity also respond to treatment more poorly, which may hasten the course of illness or death (Duits, Boeke, Taams, Passchier, & Erdman, 1997). Although negative affectivity can compromise health, it can also create a false impression of poor health when none exists. People who are high in nega- tive affectivity report more physical symptoms, such as headaches and other pains, especially under stress (Watson & Pennebaker, 1989). One reason may be that negative affect leads people to worry, be more aware of their symptoms, and attribute their symp- toms to poor health (Mora, Halm, Leventhal, & Ceric, 2007). But in other cases, there is no evidence of an underlying physical disorder (Diefenbach, Leventhal, Leventhal, & Patrick-Miller, 1996). People high in negative affectivity may, nonetheless, use health ser- vices during stressful times more than people who are more positive (Cohen & Williamson, 1991). To sum- marize, people who are high in negative affect are more likely to get sick, but they also are distressed, experience physical symptoms, and seek medical at- tention even when they are not sick. Positivity and Illness Positive emotional func- tioning promotes better mental and physical health (Cohen & Pressman, 2006; Wiest, Schüz, Webster, & Wurm, 2011) and a longer life (Xu & Roberts, 2010). FIGURE 7.1 | The Coping Process (Sources: Cohen & Lazarus, 1979; Hamburg & Adams, 1967; Lazarus & Folkman, 1984; Moos, 1988; Taylor, 1983) Coping outcomes Psychological functioning Resumption of usual activities Physiological changes, including illness Coping tasks To reduce harmful environmental conditions To tolerate or adjust to negative events or realities To maintain a positive self-image To maintain emotional equilibrium To continue satisfying relationships with others Coping responses and strategies for problem solving and emotional regulation (e.g., information seeking, direct action, inhibition of action, intrapsychic responses, turning to others) Appraisal and interpretation of the stressor Primary appraisal Existing harm or loss Future threat Degree of challenge Secondary appraisal Evaluation of coping resources and options The stressful event, its stage, and anticipated future course External resources or impediments Other life stressors, such as major life events and daily hassles Social supportTangible resources, such as money and time Other personality factors that influence selection of coping responses and strategies Usual coping style(s) Internal resources or impediments 140 Part Three Stress and Coping 140 Positive emotional states have been tied to lower levels of stress indicators such as cortisol and better immune responses to challenges such as exposure to a flu virus (Low, Matthews, & Hall, 2013; Steptoe, Demakakos, de Oliveira, & Wardle, 2012). When people are feeling positive, they also invest time and effort to overcome obstacles in pursuit of their goals (Haase, Poulin, & Heckhausen, 2012), which may accordingly affect their mood and lower their stress levels. In addition to pro- moting general well-being, positivity promotes several specific psychological resources that improve coping (Taylor & Broffman, 2011), to which we next turn. Psychosocial Resources Optimism An optimistic nature can help people cope more effectively with stress and reduce their risk for illness (Scheier, Carver, & Bridges, 1994). M. F. Scheier and colleagues developed a measure of dispo- sitional optimism that identifies generalized positive expectations about the future. Box 7.1 lists the items on this measure, the Life Orientation Test (LOT-R). Exactly how might optimism exert a positive im- pact on symptom expression, psychological adjustment, and health outcomes? Optimists have better physiologi- cal stress profiles on indicators such as cortisol, blood pressure, and inflammation (Endrighi, Hamer, & Steptoe, 2011; Jobin, Wrosch, & Scheier, 2014; Roy et al., 2010; Segerstrom, 2006b; Segerstrom & Sephton, 2010). Optimism also promotes active and persistent coping efforts, which improves long-term prospects for psychological and physical health (Segerstrom, Casta- ñeda, & Spencer, 2003). Optimism fosters a sense of personal control, which has beneficial effects on physi- cal functioning (Ruthig & Chipperfield, 2007). Opti- mists use problem-focused coping, seek social support from others, and emphasize the positive aspects of stressful situations (Scheier, Weintraub, & Carver, 1986). As noted in Chapter 1, meta-analysis is a particu- larly strong form of evidence because it includes many studies. A meta-analysis of 83 studies concerning the relation of optimism to physical health found effects not only on a broad array of health outcomes, but also on the physiological indicators that can predict them (Rasmus- sen, Scheier, & Greenhouse, 2009). Optimism is usually beneficial for coping. But because optimists are persistent in pursuing their goals, they sometimes experience short-term physio- logical costs (Segerstrom, 2001). When optimists’ ex- pectations are not met, they may feel stressed, and compromised immune functioning may be a short- term consequence (Segerstrom, 2006a). Overall, though, optimism is a potent and valuable resource. Psychological Control Psychological control is the belief that one can determine one’s own behav- ior, influence one’s environment, and bring about de- sired outcomes. The belief that one can exert control over stressful events has long been known to help people cope with stress (Taylor, Helgeson, Reed, & B O X 7.1The Measurement of Optimism: The LOT-R People vary in whether they are fundamentally opti- mistic or pessimistic about life. M. F. Scheier, C. S. Carver, and M. W. Bridges (1994) developed a scale of dispositional optimism to measure this pervasive individual difference. Items from the Life Orientation Test are as follows. (For each item, answer “true” or “false.”) 1. In uncertain times, I usually expect the best. 2. It’s easy for me to relax. 3. If something can go wrong for me, it will. 4. I’m always optimistic about my future. 5. I enjoy my friends a lot. 6. It’s important for me to keep busy. 7. I hardly ever expect things to go my way. 8. I don’t get upset too easily. 9. I rarely count on good things happening to me. 10. Overall, I expect more good things to happen to me than bad. Scoring Sum how many “trues” you indicated for items 1, 4, and 10 and how many “falses” you indicated for items 3, 7, and 9 to obtain an overall score. Items 2, 5, 6, and 8 are filler items only. Copyright © 1994 by the American Psychological Association. Reproduced with permission. Chapter 7 Coping, Resilience, and Social Support 141 Skokan, 1991; Thompson, 1981). Perceived control is closely related to self-efficacy, which is a more narrow belief that one’s actions to obtain a specific outcome in a specific situation will be successful (Bandura, 1977). A related construct is secondary control (or collective control), which maintains that through collaboration with family and friends (Hou & Wan, 2012) or with medical practitioners, one may successfully cope with a stressful event. Thus control need not be personal to be adaptive: the perception that other people have con- trol or that control is shared with significant other peo- ple in one’s life can be beneficial (Hou & Wan, 2012). Many studies show that the belief that one can exert control in stressful situations improves emotional well-being, coping with a stressful event, health behav- iors (Gale, Batty, & Deary, 2008), physiological stress indicators such as immune functioning and cardiovas- cular risk factors (Paquet, Dubé, Gauvin, Kestens, & Daniel, 2010) and health (Infurna, Gerstorf, Ram, Schupp, & Wagner, 2011). Perceived control fosters physical activity, which may be one reason why it contributes to good health (Infurna & Gerstorf, 2014). So powerful are the effects of psychological control that they are the basis for interventions to promote good health habits (Chapters 4 and 5), to help people cope with stressful events, such as surgery and noxious medi- cal procedures (Chapter 8), and to improve treatment effectiveness (Geers, Rose, Fowler, Rasinski, Brown, & Helfer, 2013). People going through unpleasant medical procedures, such as gastroendoscopic exams (Johnson & Leventhal, 1974), childbirth (Leventhal, Leventhal, Schacham, & Easterling, 1989), and chemotherapy (Burish & Lyles, 1979), have all benefitted from control-enhancing interventions. These interventions use information, relaxation, and cognitive-behavioral techniques, such as learning to think differently about the unpleasant sensations of a procedure, to reduce anxiety, improve coping, and promote recovery. Like optimism, control is not a panacea for all aversive situations. People who desire control espe- cially benefit from control-based interventions (Thompson, Cheek, & Graham, 1988). But control may actually be aversive if it gives people more responsibility than they want (Chipperfield & Perry, 2006). Nonetheless, the benefits of perceived control, especially in treatment settings, are clear. Self-Esteem High self-esteem is tied to effective coping. It seems to be most protective at low levels of stress; at higher levels of stress, the stressful events themselves can overwhelm the benefits of self-esteem (Whisman & Kwon, 1993). Nonetheless, typically self-esteem is associated with lower levels of stress indicators, such as HPA axis activity (Seeman et al., 1995), which may be the root by which self-esteem affects illness. In addition, people with stronger self- related resources have better health habits, being somewhat less likely to smoke or use alcohol to ex- cess, for example (Friedman et al., 1995). Additional Psychosocial Resources Con- scientiousness is a psychosocial resource that has health benefits. One study (Friedman et al., 1993) as- sessed young people in the early 1920s to see if differ- ences in personality in childhood predicts who lived longer. Those people who were highly conscientious as children were more likely to live to an old age (Friedman et al., 1995; Costa, Weiss, Duberstein, Friedman, & Siegler, 2014; Hampson, Edmons, Gold- berg, Dubanoski, & Hillier, 2013; Turiano, Chapman, Gruenwald, & Mroczek, 2015). Conscientious people may be more successful at avoiding harmful situa- tions, they may think more about their health (Hill, Turiano, Hurd, Mroczek, & Roberts, 2011), they may be more adherent to treatment recommendations (Hill & Roberts, 2011), they practice good health habits (Hampson, Edmons, Goldberg, Dubanoski, & Hillier, 2015), and they use their cognitive abilities effectively (Hampson et al., 2015). They may consequently have lower stress-related biomarkers (Booth et al., 2014; Bogg & Slatcher, 2015; Mõttus, Luciano, Starr, Pollard, & Deary, 2013; Taylor et al., 2009). Being self-confident and having an easygoing disposition also facilitate coping (Holahan & Moos, 1990, 1991). Nonetheless, oddly, cheerful people die sooner than people who are not cheerful (Friedman et al., 1993). It may be that cheerful people grow up being more careless about their health and, as a result, experience health risks (Martin et al., 2002). Being smart is good for you. More intelligent people have better physiological profiles across the lifespan (Calvin, Batty, Lowe, & Deary, 2011; Morozink, Friedman, Coe, & Ryff, 2010) and live longer (Wrulich, Brunner, Stadler, Schalke, Keller, & Martin, 2014). Emotional stability also predicts longev- ity (Terracciano, Löckenhoff, Zonderman, Ferrucci, & Costa, 2008; Weiss, Gale, Batty, & Deary, 2009). To summarize, coping resources are important because they help people manage the demands of daily stressful events with less emotional distress, 142 Part Three Stress and Coping 142 fewer health risks, better health habits, and a higher quality of life. As such, coping resources are espe- cially helpful to vulnerable populations, especially people low in socioeconomic status (Kiviruusu, Huurre, Haukkala, & Aro, 2013; Schöllgen, Huxhold, Schüz, & Tesch-Römer, 2011). These features are at the core of a health-prone personality, characterized by positivity, optimism, a sense of control, conscien- tiousness, and self-esteem. Resilience Psychological resources such as these not only enable people to confront and cope with stressors. They also help them bounce back from bad experiences and adapt flexibly to the changing demands of stressful situations (Fredrickson, Tugade, Waugh, & Larkin, 2003). This is called resilience (Dunkel Schetter & Dolbier, 2011). A sense of coherence about one’s life (Haukkala, Konttinen, Lehto, Uutela, Kawachi, & Laatikainen, 2013), a sense of purpose or meaning in one’s life (Visotsky, Hamburg, Goss, & Lebovitz, 1961), a sense of humor (Cousins, 1979), trust in others (Barefoot et al., 1998), a sense that life is worth living (Sone et al., 2008), and religious beliefs (Folkman & Moskowitz, 2004) (Box 7.2) are also resources that promote resilience, effective coping, and health. B O X 7.2Religion, Coping, and Well-Being I just prayed and prayed and God stopped that thing just before it would have hit us. —Tornado survivor People going through stressful events have long turned to their faith and to God for solace, comfort, and insight. The majority of people in the United States believe in God (80 percent), attend church services at least once a month (55 percent), and say that religion is important in their personal lives (80 percent) (Gallup, 2009). Reli- gion is especially important to women and to African Americans (Holt, Clark, Kreuter, & Rubio, 2003). Religion (or spirituality, independent of orga- nized religion) can promote well-being (Kashdan & Nezlek, 2012; McIntosh, Poulin, Silver, & Holman, 2011). People with strong spiritual beliefs have greater life satisfaction, greater personal happiness, fewer negative consequences of traumatic life events, and, for some disorders, a slower course of illness (George, Ellison, & Larson, 2002; Ironson et al., 2011; Romero et al., 2006). Surveys find that nearly half of people in the United States use prayer to deal with health prob- lems (Zimmerman, 2005, March 15), and it seems to work. For example, surgery patients with stronger re- ligious beliefs experienced fewer complications and had shorter hospital stays than people with less strong religious beliefs (Contrada et al., 2004). Religion (or spirituality) may be helpful for coping with stress for several reasons. First, it provides a belief system and a way of thinking about stressful events that can lessen distress and enable people to find meaning in these events (Cheadle, Schetter, Lanzi, Vance, Sahadeo, Shalowitz, & the Community Child Health Network, 2015). Second, spiritual beliefs can lead to better health practices (Hill, Ellison, Burdette, & Musick, 2007). Third, organized religion can provide a sense of group identity for people because it provides a network of supportive individuals who share their beliefs (Gebauer, Sedikides, & Neberich, 2012; George et al., 2002). Fourth, religion has been tied to better health. For example, attending religious services has been tied to lower blood pressure (Gillum & Ingram, 2006) and fewer complications from surgery (Ai, Wink, Tice, Bolling, & Shearer, 2009), and few adverse health symptoms (Berntson, Norman, Hawkley, & Cacioppo, 2008). Religion can lower cardiovascular, neuroendo- crine, and immune responses to stressful events (Maselko, Kubzansky, Kawachi, Seeman, & Berkman, 2007; Seeman, Dubin, & Seeman, 2003). Religious beliefs are not an unqualified blessing, however. Prayer itself does not appear to have health benefits (Masters & Spielmans, 2007; Nicholson, Rose, & Bobak, 2010). Moreover, if people see their health disorders as punishments from God, or if their health problems lead them to struggle with their faith, psychological and physical distress can be worsened (Park, Wortmann, & Edmondson, 2011; Sherman, Plante, Simonton, Latif, & Anaissie, 2009). Nonethe- less, typically religion is not only a meaningful part of life but can offer emotional and physical health bene- fits as well (George et al., 2002; Powell, Shahabi, & Thoresen, 2003). Chapter 7 Coping, Resilience, and Social Support 143 In addition to these personality resources, taking opportunities for rest, relaxation, and renewal help people cope more effectively with stressors (Ong, Bergeman, Bisconti, & Wallace, 2006). Taking joy in positive events and celebrating them with other peo- ple improves mood not only immediately but also over the long term (Langston, 1994). Even taking a short vacation can be restorative (de Bloom, Geurts, & Kompier, 2012). Being able to feel positive emotions, even when going through intense stressors, is a coping method that resilient people draw on (Tugade & Fredrickson, 2004). Coping Style A seriously ill cancer patient was asked how she man- aged to cope with her disease so well. She responded, “I try to have cracked crab and raspberries every week.” People have their favorite ways of coping, as this cancer patient described, but there are also gen- eral styles of coping that characterize most people. Coping style is a propensity to deal with stressful events in a particular way. Approach Versus Avoidance Some people cope with a threatening event with an avoidant (min- imizing) coping style, whereas others use an approach (confrontative, vigilant) coping style, by gathering information or taking direct action. Al- though each style can have advantages, on the whole, approach-related coping is more successful than avoidant coping, and it is tied to better mental and physical health outcomes (Taylor & Stanton, 2007). People who cope with threatening events through approach may pay a short-term price in anxiety and physiological reactivity as they confront stressful events, but be better off in the long-term (Smith, Ruiz, & Uchino, 2000). Thus, the avoider or minimizer may cope well with a trip to the dentist but cope poorly with ongoing job stress. In contrast, the vigilant coper may fret over the visit to the dentist but take active efforts to reduce job stress. Whether avoidant or approach-related coping is successful also depends on how long term the stressor is. People who cope with stress by minimizing or avoiding threatening events may deal effectively with short-term threats (Wong & Kaloupek, 1986). How- ever, if stress persists over time, avoidance is not as successful. For example, much of the American population reported high levels of post-traumatic stress disorder symptoms following the 9/11 attacks. Those who coped through avoidant coping strategies fared worse psychologically over the long term, com- pared to those who used more active coping strategies (Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002). People who cope using avoidance may not Religion promotes psychological well-being, and people with religious faith may be better able to cope with aversive events. © Kristy-Anne Glubish/Design Pics RF 144 Part Three Stress and Coping make enough cognitive and emotional efforts to an- ticipate and manage long-term problems (Suls & Fletcher, 1985; Taylor & Stanton, 2007). Problem-Focused and Emotion-Focused Coping Another useful distinction is between problem-focused and emotion-focused coping (cf. Folkman, Schaefer, & Lazarus, 1979; Leventhal & Nerenz, 1982; Pearlin & Schooler, 1978). Problem-focused coping involves attempts to do something constructive about the stress- ful conditions that are harming, threatening, or chal- lenging an individual. Emotion-focused coping involves efforts to regulate emotions experienced due to the stressful event. Typically people use both problem- focused and emotion-focused coping to manage stress- ful events, suggesting that both types of coping are useful (Folkman & Lazarus, 1980). The nature of the event also contributes to which coping strategies will be used (Vitaliano et al., 1990). For example, work-related problems benefit from problem-focused coping, such as taking direct action or seeking help from others. Health problems, in con- trast, lead to more emotion-focused coping, perhaps because health threats often must be tolerated but may not be amenable to direct action. Overall, situations in which something constructive can be done will favor problem-focused coping, whereas those situations that simply must be accepted favor emotion-focused coping (Zakowski, Hall, Klein, & Baum, 2001). People who are able to shift their coping strate- gies to meet the demands of a situation cope better with stress than those who do not (Chen, Miller, Lach- man, Gruenewald, & Seeman, 2012). This point is, of course, suggested by the fact that the problem-solving and emotional approaches may work better for differ- ent stressors. Overall, research suggests that people who are flexible copers may cope especially well with stress (Cheng, 2003). Emotional Approach Coping An important type of emotional coping is emotional-approach coping, which involves clarifying, focusing on, and working through the emotions experienced in re- sponse to a stressor (Stanton, 2010). Emotional- approach coping improves adjustment to many chronic conditions, including chronic pain (Smith, Lumley, & Longo, 2002) and medical conditions such as preg- nancy (Huizink, Robles de Medina, Mulder, Visser, & Buitelaar, 2002) and breast cancer (Stanton, Kirk, Cameron, & Danoff-Burg, 2000). Even managing the stress of daily life can benefit from emotional- approach coping (Stanton et al., 2000). Coping via emotional approach appears to be especially benefi- cial for women (Stanton et al., 2000). There are several reasons why emotional approach coping may be successful. One is that it may be sooth- ing and beneficially affect stress regulatory systems (Epstein, Sloan, & Marx, 2005). Another possibility is that it leads people to affirm important aspects of their identity, which leads to health benefits (Creswell et al., 2007; Low, Stanton, & Danoff-Burg, 2006). Proactive Coping Much coping is proactive; that is, people anticipate potential stressors and act in advance, either to prevent them or to reduce their im- pact (Aspinwall, 2011; Aspinwall & Taylor, 1997). Proactive coping requires first, the abilities to antici- pate or detect potential stressors; second, coping skills for managing them; and third, self-regulatory skills, which are the ways that people control, direct, and correct their actions as they attempt to counter poten- tial stressful events. Proactive coping has been understudied because, by definition, if stressors are headed off in advance or reduced, they are less likely to occur or be experi- enced as intensely stressful. Clearly though, heading off a stressor is preferable to coping with it when it hits full force, and proactive coping merits additional attention (Aspinwall, 2011). Coping researchers have found that direct action often leads to better adjustment to a stressful event than do coping efforts aimed at avoidance of the issue or denial. © Susan See Photography RF Chapter 7 Coping, Resilience, and Social Support 145 145 In addition to general coping styles, there are a va- riety of specific coping styles that may be adaptive for particular circumstances. For example, the ability to dis- tance oneself from negative experiences can be adaptive for managing stressful events (Kross & Ayduk, 2011). People living in low socioeconomic circumstances who are unable to modify the stressors that affect them may be especially benefitted by framing appraisals of stressors positively (Chen & Miller, 2012; Chen, Miller, Lachman, Gruenewald, & Seeman, 2012). Both de- tached reappraisal and positive reappraisal have benefi- cial effects on regulating emotions during stress (Shiota & Levenson, 2012). The Brief COPE is a measure that allows researchers to assess some of these more specific coping strategies (see Box 7.3). B O X 7.3 The Brief COPE The Brief COPE assesses commonly used coping styles for managing stressful events. People rate how they are coping with a stressful event by answering items on a scale from 0 (“I haven’t been doing this at all”) to 3 (“I’ve been doing this a lot”). Think of a stressful event that you are currently going through (a problem with your family, a roommate difficulty, problems in a course), and see which coping methods you use. 1. Active coping I’ve been concentrating my efforts on doing something about the situation I’m in. I’ve been taking action to try to make the situation better. 2. Planning I’ve been trying to come up with a strategy about what to do. I’ve been thinking hard about what steps to take. 3. Positive reframing I’ve been trying to see it in a different light, to make it seem more positive. I’ve been looking for something good in what is happening. 4. Acceptance I’ve been accepting the reality of the fact that it has happened. I’ve been learning to live with it. 5. Humor I’ve been making jokes about it. I’ve been making fun of the situation. 6. Religion I’ve been trying to find comfort in my religion or spiritual beliefs. I’ve been praying or meditating. 7. Using emotional support I’ve been getting emotional support from others. I’ve been getting comfort and understanding from someone. 8. Using instrumental support I’ve been trying to get advice or help from other people about what to do. I’ve been getting help and advice from other people. 9. Self-distraction I’ve been turning to work or other activities to take my mind off things. I’ve been doing something to think about it less, such as going to movies, watching TV, reading, daydreaming, sleeping, or shopping. 10. Denial I’ve been saying to myself “this isn’t real.” I’ve been refusing to believe that it has happened. 11. Venting I’ve been saying things to let my unpleasant feelings escape. I’ve been expressing my negative feelings. 12. Substance use I’ve been using alcohol or other drugs to make myself feel better. I’ve been using alcohol or other drugs to help me get through it. 13. Behavioral disengagement I’ve been giving up trying to deal with it. I’ve been giving up the attempt to cope. 14. Self-blame I’ve been criticizing myself. I’ve been blaming myself for things that happened. Source: Carver, 1997. 146 Part Three Stress and Coping 146 Examples of the coping strategies used to combat the threat of AIDS appear in Box 7.4. ■ COPING AND EXTERNAL RESOURCES Coping is influenced not only by the internal resources a person brings to a stressor, such as resources and coping style, but also by external resources. These in- clude time, money, education, a decent job, friends, family, standard of living, the presence of positive life events, and the absence of other life stressors. People with greater resources typically cope with stressful events better, because time, money, friends, and other resources simply provide more ways of dealing with a stressful event. In Chapter 6, we saw an example of the moderation of stress by resources. Relative to non- working mothers, working mothers who had adequate child care and whose husbands shared in household tasks benefited psychologically from their work, whereas working mothers without these resources showed higher levels of distress. One of the most potent external resources with respect to health is socioeconomic status (SES). Peo- ple who are high in SES have fewer medical and psy- chiatric disorders of all kinds, and they show lower B O X 7.4Coping with HIV AIDS (acquired immune deficiency syndrome) has killed millions of people worldwide, and thousands more live, sometimes for years, with the knowledge that they have the disease. Here are some of the cop- ing strategies that people with HIV infection have reported using. SOCIAL SUPPORT OR SEEKING INFORMATION A key point in my program is that I have a really good support network of people who are willing to take the time, who will go the extra mile for me. I have spent years cultivating these friendships. DIRECT ACTION My first concern was that, as promiscuous as I have been, I could not accept giving this to anyone. So I have been changing my lifestyle completely, putting everything else on the back burner. STRATEGIES OF DISTRACTION, ESCAPE, OR AVOIDANCE I used to depend on drugs a lot to change my mood. Once in a while, I still find that if I can’t feel better any other way, I will take a puff of grass or have a glass of wine, or I use music. There are certain recordings that can really change my mood drastically. I play it loud and I dance around and try to clear my head. EMOTIONAL REGULATION/VENTILATION Sometimes I will allow myself to have darker feelings, and then I grab myself by the bootstraps and say, okay, that is fine, you are allowed to have these feelings but they are not going to run your life. PERSONAL GROWTH In the beginning, AIDS made me feel like a poisoned dart, like I was a diseased person and I had no self- esteem and no self-confidence. That’s what I have been really working on, is to get the self-confidence and the self-esteem back. I don’t know if I will ever be there, but I feel very close to being there, to feeling like my old self. When something like this happens to you, you can either melt and disappear or you can come out stronger than you did before. It has made me a much stronger person. I literally feel like I can cope with anything. Nothing scares me, nothing. If I was on a 747 and they said we were going down, I would prob- ably reach for a magazine. POSITIVE THINKING AND RESTRUCTURING I have been spending a lot of time lately on having a more positive attitude. I force myself to become aware every time I say something negative during a day, and I go, “Oops,” and I change it and I rephrase it. So I say, “Wonderful,” about 42,000 times a day. Sometimes I don’t mean it, but I am convincing myself that I do. The last chapter has not been written. The fat lady has not sung. I’m still here. Source: Reed, 1989. Chapter 7 Coping, Resilience, and Social Support 147 mortality from all causes of death. So strong is this relationship that, even in animals, higher-status animals are less vulnerable to infection than lower-status animals are (Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997). Figure 7.2 illustrates the relation between social class and mortality (see Adler, Boyce, Chesney, Folkman, & Syme, 1993). ■ COPING OUTCOMES Throughout this discussion, we have referred to suc- cessful coping. What constitutes successful coping? Health psychologists typically assess whether the fol- lowing outcomes have been achieved: ∙ Reducing or eliminating stressors ∙ Tolerating or adjusting to negative events or realities ∙ Maintaining a positive self-image ∙ Maintaining emotional equilibrium ∙ Continuing satisfying relationships with others ∙ Enhancing the prospects of recovery, if one is ill ∙ Keeping physiological, neuroendocrine, and immune reactivity relatively low or restoring these systems to pre-stress levels (Karatsoreos & McEwen, 2011). Another often-used criterion of successful coping is how quickly people can return to their prestress ac- tivities. Many stressors—especially severe ones, such as the death of a spouse, or chronic ones, such as exces- sive noise— interfere with daily life activities. If peo- ple’s coping efforts help them resume usual activities, coping is judged to be successful. Following some stressors, though, life is actually improved; priorities may be reevaluated, and a person may seek to live a better and somewhat different life. ■ COPING INTERVENTIONS Not everyone is able to cope with stress successfully on their own, and so interventions for coping with stress have been developed. Mindfulness Meditation and Acceptance/Commitment Therapy Mindfulness meditation teaches people to strive for a state of mind marked by heightened awareness of the present, focusing on the moment and accepting and acknowledging it without becoming distracted or dis- tressed by stress (Davidson & Kaszniak, 2015). Mind- fulness can improve quality of life, reduce anxiety, and improve coping, and so it has been the basis of FIGURE 7.2 | Mortality Rate Ratios by Socioeconomic Status (Source: Steenland, Hu, & Walker, 2004) 2.5 2.0 1.5 1.0 0.5 0 4 (Highest)321 (Lowest) SES Quartile Men Women M or ta lit y R at e R at io 148 Part Three Stress and Coping when people undergo traumatic events and cannot or do not communicate about them, those events may fes- ter inside them, producing obsessive thoughts for years and even decades. This inhibition of traumatic events involves physiological work, and the more people are forced to inhibit their thoughts, emotions, and behav- iors, the more their physiological activity may increase (Pennebaker, 1997). Consequently, the ability to con- fide in others or to consciously confront one’s feelings may reduce the need to obsess about and inhibit the event, which may, in turn, reduce the physiological ac- tivity associated with the event. These insights have been explored through an intervention called expres- sive writing (Pennebaker & Smyth, 2016). In an early study, J. W. Pennebaker and S. Beall (1986) had 46 undergraduates write either about the most traumatic and stressful event ever in their lives or about trivial topics. Although the people writing about traumas were more upset immediately after they wrote their essays, there was no lasting psychological dis- tress and, most important, they were less likely to visit the student health center during the following 6 months. Subsequent studies have found that when people have talked about or written about traumatic events, psychological and physiological indicators of stress can be reduced (Low, Stanton, Bower, & Gyllenhammer, 2010; Petrie, Booth, Pennebaker, Davison, & Thomas, 1995; Willmott, Harris, Gellaitry, Cooper, & Horne, 2011). Direct effects on health out- comes, such as wound healing, have also been found (Koschwanez, Kerse, Darragh, Jarrett, Booth, & Broadbent, 2013). In part because writing about trauma increases short-term distress, more recent expressive writing in- terventions have encouraged emotional approach cop- ing (Stanton, 2010). These interventions typically improve health without compromising mental health (D’Souza, Lumley, Kraft, & Dooley, 2008; Lu, Zheng, Young, Kagawa-Singer, & Loh, 2012; Petrie, Fonta- nilla, Thomas, Booth, & Pennebaker, 2004), although when meaning in a negative experience is elusive, ex- pressive writing may not help and may impede emo- tional recovery (Sbarra, Boals, Mason, Larson, & Mehl, 2013). There are many reasons why talking or writing about a stressful event or confiding in others is usually useful for coping. Communication allows one to gain information about the event or about effective coping; it may also elicit emotional support from others. There may be beneficial cognitive effects of communicating interventions (Schirda, Nicholas, & Prakash, 2015). Mindfulness-based stress reduction (MBSR) is a systematic training in mindfulness to help people manage their reactions to stress and the negative emo- tions that may result (Dimidjian & Segal, 2015; Ja- cobs et al., 2013). Thus, the goal of mindfulness meditation is to help people approach stressful situa- tions mindfully rather than reacting to them automati- cally (Hölzel et al., 2011). Mindfulness and MBSR can mute biological re- sponses to stress as well (Hughes, Fresco, Myerscough, van Dulmen, Carlson, & Josephson, 2013; Jacobs et al., 2013; Nyklíček, Mommersteeg, Van Beugen, Ramakers, & Van Boxtel, 2013). One study (Roth & Robbins, 2004) explored whether an 8-week MBSR program could improve health in a low-income Latino and Anglo inner-city community. Health and quality of life improved among participants, suggesting that MBSR may have beneficial health effects as well as coping benefits. Neuroscience research has identified one reason why MBSR has these beneficial effects. Mindfulness engages the prefrontal cortical regions of the brain, which regulate affect and downregulate activity in the limbic areas related to anxiety and other negative emotions (Creswell, Way, Eisenberger, & Lieberman, 2007). Similar to MBSR, acceptance and commitment therapy (ACT) is a CBT technique that incorporates acceptance of a problem, mindfulness regarding its occurrence and the conditions that elicit it, and com- mitment to behavior change. Because stress can create thorny problems, sometimes people need to move away from difficult thoughts and feelings and sim- ply accept them while still persisting in desired ac- tions, such as trying to overcome a stressor. The goal of ACT is to try to change the private experi- ence and thereby maintain commitment. ACT does not challenge thoughts directly, but instead teaches people to notice their thoughts in a mindful manner and from a distance so as to be able to respond more flexibly to them (Lillis, Hayes, Bunting, & Masuda, 2009). Acceptance and mindfulness therapies can improve the quality of life while people are coming to grips with the stressors they experience. Expressive Writing Disclosing emotions can have beneficial effects on health. For many years, researchers suspected that Chapter 7 Coping, Resilience, and Social Support 149 What are the benefits? These techniques can reduce heart rate, muscle tension, blood pressure, inflamma- tory activity, lipid levels, anxiety, and tension, among other physical and psychological benefits (Barnes, Davis, Murzynowski, & Treiber, 2004; Lutgendorf, Anderson, Sorosky, Buller, & Lubaroff, 2000; Scheufele, 2000; Speca, Carlson, Goodey, & Angen, 2000). Even 5–10 minutes of deep breathing and pro- gressive muscle relaxation can be beneficial. Yoga may have health benefits. One study found that people who regularly practiced yoga experienced more positive emotions and showed lower inflamma- tory responses to stress than those who were new to the practice. Yoga, then, may ameliorate the burden that stress places on an individual (Kiecolt-Glaser et al., 2010). Joyful music can also be a relaxing stress buster (Miller, Mangano, Beach, Kop, & Vogel, 2010). Coping Skills Training Teaching people effective coping techniques is an- other beneficial intervention individually, in a group setting, or even by telephone (Blumenthal et al., 2014). Most of these interventions draw on principles from CBT (Antoni, Carrico, et al., 2006). Coping ef- fectiveness training typically begins by teaching peo- ple how to appraise stressful events and disaggregate the stressors into specific tasks. The person learns to distinguish those aspects of a stressor that may be changeable from those that are not. Specific coping strategies are then practiced to deal with these specific stressors. Encouraging people to maintain their social support is also an important aspect of coping effec- tiveness training (Folkman et al., 1991). We will dis- cuss several coping effectiveness interventions in the chapters on chronic diseases. Here, we highlight cop- ing effectiveness training for managing the stress of college life. Managing the Stress of College Many peo- ple have difficulty managing stress themselves. Ac- cordingly, health psychologists have developed techniques for stress management. Stress manage- ment programs typically involve three phases. In the first phase, participants learn what stress is and how to identify the stressors in their own lives. In the second phase, they acquire and practice skills for coping with stress. In the final phase, they practice these coping techniques in targeted stressful situations and monitor their effectiveness (Meichenbaum & Jaremko, 1983). about a traumatic event, such as organizing one’s thoughts and being able to find meaning in the experi- ence (Lepore, Ragan, & Jones, 2000). These interven- tions may lead people to change their focus of attention from negative to positive aspects of this situation (Vedhara et al., 2010). Talking or writing about trau- matic or stressful events provides an opportunity for clarifying one’s emotions (Lepore & Smyth, 2002) and for affirming one’s personal values (Creswell, Way, Eisenberger, & Lieberman, 2007; Langens & Schüler, 2007). The benefits of expressive writing have been found not only in the United States but in non-Western cultures as well (Pennebaker & Smyth, 2016). Self-Affirmation Earlier in this chapter we noted how self-related re- sources, such as self-esteem, can help people cope with stress. As noted in Chapter 3, a technique that makes use of this insight is called Self-affirmation. When people positively affirm their values, they feel better about themselves and show lower physiological activity and distress (see Sherman & Cohen, 2006, for a review). Writing about important social relationships appears to be the most impactful self-affirmation task (Shnabel, Purdie-Vaughns, Cook, Garcia, & Cohen, 2013). Self- affirmation can reduce defensiveness about personally- relevant risk information and consequently make people more receptive to reducing their risk (Schüz, Schüz, & Eid, 2013). Consequently, researchers are now using self- affirmation as an intervention to help people cope with stress. In one study (Sherman, Bunyan, Creswell, & Jaremka, 2009), students wrote about an important personal value just before taking a stressful exam. Heart rate and blood pressure responses to the exam were at- tenuated by this self-affirmation. Self-affirmation can also undermine defensive reactions to threats (Harris, Mayle, Mabbott, & Napper, 2007; Van Koningsbrug- gen, Das, & Roskos-Ewoldsen, 2009). Relaxation Training Whereas the techniques we have discussed so far give a person cognitive insights into the nature and control of stress, another set of techniques—relaxation training—affects the physiological experience of stress by reducing arousal. Relaxation therapies include deep breathing, pro- gressive muscle relaxation training, guided imagery, transcendental meditation, yoga, and self hypnosis. 150 Part Three Stress and Coping As an example, college can be an extremely stressful experience for many new students. For some, it is their first time away from home, and they must cope with living in a dormitory surrounded by strang- ers. They may have to share a room with another per- son from a very different background and with very different personal habits. High noise levels, commu- nal bathrooms, institutional food, and rigorous aca- demic schedules may all be trying experiences for new students. Recognizing that these pressures exist, college administrators have increasingly made stress management programs available to their students. A Stress Management Program A program called Combat Stress Now (CSN) makes use of these various phases of education, skill acquisition, and practice. Identifying Stressors In the first phase of the program, participants learn what stress is and how it creates physical wear and tear. In sharing their per- sonal experiences of stress, many students find reas- surance in the fact that other students have experiences similar to their own. They learn that stress is a process of psychological appraisal rather than a factor inher- ent in events themselves. Thus, college life is not in- herently stressful but is a consequence of the individual’s perceptions of it. Monitoring Stress In the self-monitoring phase of the program, students are trained to observe their own behavior closely and to record the circumstances that they find most stressful. In addition, they record their physical, emotional, and behavioral reactions to those stresses as they experience them. Students also record any maladaptive efforts they undertook to cope with these stressful events, including excessive sleep- ing or eating, online activity, and alcohol consumption. Identifying Stress Antecedents Once stu- dents learn to chart their stress responses, they are taught to examine the antecedents of these experi- ences. They learn to focus on what happens just before they experience feelings of stress. For example, one student may feel overwhelmed with academic life only when contemplating having to speak out in class, whereas another student may experience stress pri- marily before exams. By pinpointing exactly those circumstances that initiate feelings of stress, students can more precisely identify their own trouble spots. Avoiding Negative Self-Talk Students are next trained to recognize and eliminate the negative self-talk they go through when they face stressful events. For example, the student who fears speaking out in class may recognize how self-statements contribute to this process: “I hate asking questions,” “I always get tongue- tied,” and “I’ll probably forget what I want to say.” Completing Take-Home Assignments In addition to in-class exercises, students have take- home assignments. They keep a stress diary in which they record what events they find stressful and how they respond to them. As they become pro- ficient in identifying stressful incidents, they are encouraged to record the negative self-statements or irrational thoughts that accompany the stressful experience. There are many stressful aspects of college life, such as speaking in front of large groups. Stress management programs can help students master these experiences. © Rob Melnychuk/Jupiterimages/Brand X/Alamy RF Chapter 7 Coping, Resilience, and Social Support 151 attention of the audience, making some points, and winning over a few converts to their positions). Using Other Cognitive-Behavioral Tech- niques In some stress management programs, contingency contracting and self-reinforcement (see Chapter 3) are encouraged. For example, the student who fears making oral presentations may define a spe- cific goal, such as asking three questions in class in a week, which will be followed by a reward, such as tickets to a concert. Several other techniques are frequently used in stress management interventions. Time management and planning helps people set specific goals, establish priorities, avoid time-wasters, and learn what to ig- nore. Most stress management programs emphasize practicing good health habits and exercise at least 20–30 minutes at least 3 times a week. Assertiveness training is sometimes incorporated into stress man- agement. The person is encouraged to identify the people in their environment who cause them special stress—called stress carriers—and develop tech- niques for confronting them. Because social support is so important to combating stress—a topic to which we next turn—ways of increasing warm social contact are encouraged as well. Overall, stress management training imparts an array of valuable skills for living in a world with many sources of stress. Each person will find the particular techniques that work for him or her. Ulti- mately effectively dealing with stress improves mental and physical health. ■ SOCIAL SUPPORT The most vital of all protective psychosocial resources is social support. Social ties are emotionally satisfy- ing, they mute the effects of stress, and they reduce the likelihood that stress will lead to poor health. What Is Social Support? Social support is defined as information from others that one is loved and cared for, esteemed and valued, and part of a network of communication and mutual obligations. Social support can come from parents, a spouse or partner, other relatives, friends, social and community contacts (such as churches or clubs) (Rietschlin, 1998), or even a devoted pet (McConnell, Brown, Shoda, Stayton, & Martin, 2011). Social support Acquiring Skills The next stage of stress man- agement involves skill acquisition and practice. These skills include cognitive-behavioral management tech- niques, time management skills, and other stress- reducing interventions, such as exercise. Some of these techniques are designed to eliminate the stress- ful event; others are geared toward reducing the expe- rience of stress without necessarily modifying the event itself. Setting New Goals Each student next sets sev- eral specific goals that he or she wants to meet to re- duce the experience of college stress. For one student, the goal may be learning to speak in class without suffering overwhelming anxiety. For another, it may be going to see a particular professor about a problem. Once the goals are set, specific behaviors to meet those goals are identified. In some cases, an appropri- ate response may be leaving the stressful event alto- gether. For example, the student who is having difficulty in a rigorous physics course may need to modify his goal of becoming a physicist. Alterna- tively, students may be encouraged to turn a stressor into a challenge. Thus, the student who fears speaking up in class may come to realize that she must not only master this fearful event but also actually come to en- joy it if she is to realize her long-term goal of becom- ing a professor. Goal setting is important in effective stress man- agement for two reasons. First, it forces the person to distinguish among stressful events to be avoided, tol- erated, or overcome. Second, it forces the person to be specific and concrete about exactly which stressors need to be tackled and what is to be done. Engaging in Positive Self-Talk and Self- Instruction Once students have set realistic goals and identified some target behaviors for reaching their goals, they learn how to engage in self-instruction and positive self-talk. Self-instruction involves reminding oneself of the specific steps that are required to achieve the goal. Positive self-talk involves providing the self with encouragement. For example, the student who is fearful of speaking out in class may learn to begin with simple questions or small points, or bring comments about the reading to class that can be used as a reminder of what point to raise. Once some profi- ciency in public speaking is achieved, students might encourage themselves by highlighting the positive as- pects of the experience (for example, holding the 152 Part Three Stress and Coping support is available (Smith, Ruiz, & Uchino, 2004) or contemplating the sources of support one typically has in life (Broadwell & Light, 1999) can yield bene- ficial effects. Moreover, actually receiving social support from another person can have potential costs. First, one may use up another’s time and attention, which can produce a sense of guilt. Needing to draw on others can also threaten self-esteem, because it suggests a dependence on others (Bolger, Zuckerman, & Kessler, 2000). These potential costs can undermine the distress- reducing benefits of social support. Indeed, research suggests that when one receives help from another but is unaware of it, that help is most likely to benefit the recipient (Bolger & Amarel, 2007). This kind of sup- port is called invisible support. Effects of Social Support on Illness Social support can lower the likelihood of illness, speed recovery from illness or treatment (Krohne & Slangen, 2005), and reduce the risk of mortality due to serious disease (House, Landis, & Umberson, 1988; Rutledge, Matthews, Lui, Stone, & Cauley, 2003). Hundreds of studies of people with both major and minor health disorders show that social support is beneficial for health. Social support also typically benefits health be- haviors as well (Cohen & Lemay, 2007). People with high levels of social support are more adherent to their medical regimens (DiMatteo, 2004), and they are more likely to use health services (Wallston, Alagna, DeVellis, & DeVellis, 1983). However, social support helps people thrive (Feeney & Collins, 2015). People with social support experience less stress when they confront a stressful experience, cope with it more suc- cessfully (Taylor, 2011), and even experience positive life events more positively (Gable, Gosnell, Maisel, & Strachman, 2012). Not having social support in times of need is stressful, and social isolation and loneliness are pow- erful predictors of health and longevity (Cacioppo, Cacioppo, Capitanio, & Cole, 2015). For example, the elderly, the recently widowed, and victims of sudden, severe, uncontrollable life events may need support but have difficulty getting it (Sorkin, Rook, & Lu, 2002). People who have difficulty with social rela- tionships, such as the chronically shy (Naliboff et al., 2004) or those who anticipate rejection by others (Cole, Kemeny, Fahey, Zack, & Naliboff, 2003), are at risk for isolating themselves socially. Just as social support has health benefits, loneliness and social iso- lation have risks for physical, cognitive, and emotional functioning (Shankar, Hamer, McMunn, & Steptoe, 2013). Social support can take any of several forms. Tan- gible assistance involves the provision of material sup- port, such as services, financial assistance, or goods. For example, the gifts of food that often arrive after a death in a family mean that the bereaved family members will not have to cook for themselves and visiting friends and family. Family and friends can provide informational support about stressful events. For example, if an in- dividual is facing an uncomfortable medical proce- dure, a friend who went through the same thing could provide information about the exact steps involved, the potential discomfort experienced, and how long it takes. Supportive friends and family can provide emotional support by reassuring the person that he or she is a valuable individual who is cared for. The warmth and nurturance provided by other people can enable a person under stress to approach the stressful event with greater assurance (Box 7.5). The types of social support just discussed have each been related to health indicators (e.g., Bowen, Uchino, Birmingham, Carlisle, Smith, & Light, 2014). They all involve the actual provision of help and sol- ace by one person to another. But in fact, many of the benefits of social support come from being socially integrated (Barger, 2013) and from the perception that social support is available. Simply believing that Humor has long been thought to be an effective defense against stress. © Cala Images/Glow Images RF 153 can lead to some bad health habits, as when one’s peer group smokes, drinks heavily, or takes drugs (Wills & Vaughan, 1989) or when a lot of social contact is cou- pled with stress; under these circumstances, risk of minor illnesses such as colds or flus may actually in- crease because of contagion through the social net- work (Hamrick, Cohen, & Rodriguez, 2002). Lonely and socially isolated people have poorer health and experience more adverse symptoms on a daily basis (Wolf & Davis, 2014). They also practice poorer health habits, which may contribute to risk for poor health (Shankar, McMunn, Banks, & Steptoe, 2011). Biopsychosocial Pathways The challenge for social support research is to identify the biopsychosocial pathways by which social con- tacts exert beneficial or health-compromising effects. Studies suggest that social support has beneficial ef- fects on the cardiovascular, endocrine, and immune systems (Taylor, 2011). Social support can reduce physiological and neuroendocrine responses to stress. For example, in a study of the common cold, healthy volunteers reported their social ties, such as whether they had a spouse, living parents, friends, or work- mates, and whether they were members of social groups, such as clubs. The volunteers were then given nasal drops containing a virus and were observed for the development of cold symptoms. People who had larger social networks were less likely to develop colds, and those who did have colds had less severe ones (S. Cohen et al., 1997). Psychologists often study the effects of social support using the acute stress paradigm—that is, by taking people into the laboratory, putting them through stressful tasks, and then measuring their biological stress responses. In several studies, researchers have conducted these procedures, having some of the In addition to being an enjoyable aspect of life, social support from family and friends helps keep people healthy and may help them recover faster when they are ill. © Big Cheese Photo/PunchStock RF B O X 7.5Is Social Companionship an Important Part of Your Life? How would you describe your life? Take a few moments to write down a few paragraphs about how your life has progressed so far. What have been the major events of your life? What has been important to you? Now go back to see how often you mention other people in those paragraphs. Two psychologists, Sarah Pressman and Sheldon Cohen (2007), did precisely this. They looked at the autobiographies of 96 psychologists and 220 literary writers and counted how often the authors mentioned social relationships. Pressman and Cohen then related the number of mentions of relationships and emotions to how long the writer lived (Pressman & Cohen, 2011). They found that the number of social words used in these autobiographies predicted a longer life. Why would this be the case? Pressman and Cohen rea- soned that social words used in autobiographies pro- vide an indirect measure of the social relationships with which these people were engaged. As we have seen, good social relationships are associated with longer life. The use of positive-emotion words in these autobiographical accounts also predicted longevity, although only positive emotions conveying activation, such as lively and vigorous, were associated with longevity and not positive statements that were peaceful or calm. So, to the extent that you mentioned important so- cial relationships in your autobiography, it reflects posi- tively on your ability to experience social support and ultimately to enjoy good health and a long life. 154 Part Three Stress and Coping Over time, family members shape each other’s bi- ology including biological responses to stress (Laws, Sayer, Pietromonaco, & Powers, 2015; Saxbe, Margolin, Spies Shapiro, Ramos, Rodriguez, & Iturralde, 2014). Dyadic coping, that is, the effects of each member of a couple on the other’s coping, can be seen both in similar coping styles and in their underlying biology (e.g., Slatcher, Selcuk, & Ong, 2015). Moderation of Stress by Social Support How does social support moderate the effects of stress? Two possibilities have been explored. The direct effects hypothesis maintains that social support is generally beneficial during nonstressful as well as stressful times. The buffering hypothesis maintains that the physical and mental health benefits of social support are chiefly evident during periods of high stress; when there is little stress, social support may offer few such benefits. According to this viewpoint, social support acts as a reserve and resource that blunts the effects of stress when it is at high levels. Evidence suggests both direct and buffering ef- fects of social support (Bowen, Uchino, Birmingham, Carlisle, Smith, & Light, 2014; Cohen, & Hoberman, 1983; Cohen & McKay, 1984). Generally, when re- searchers have looked at social support in terms of the number of people one identifies as friends and the number of organizations one belongs to, direct effects of social support on health are found. When social support is assessed qualitatively, such as by the num- ber of people perceived to be available who will pro- vide help if it is needed, buffering effects of social support have been found (House et al., 1988). Extracting Support The effectiveness of social support depends on how an individual uses a social support network. Some people are better than others at extracting the support they need. Research using twin study methodology has discovered genetic un- derpinnings in the ability either to construe social support as available or to establish supportive net- works (Kessler, Kendler, Heath, Neale, & Eaves, 1992). During periods of high stress, genetic predis- positions to draw on social support networks may be activated, leading to the perception that support will be available to mute stress. Social skills influence the ability to develop social support as well. S. Cohen and colleagues (Cohen, Sher- rod, & Clark, 1986) assessed incoming college freshmen people bring a supportive companion and having oth- ers go through the procedures alone. When a support- ive companion is present, physiological reactivity to the stressful tasks is usually more subdued (Christenfeld, 1997; Smith, Loving, Crockett, & Campbell, 2009). Social support is tied to reduced cortisol responses to stress, which can have beneficial effects on illness (Turner-Cobb, Sephton, Koopman, Blake-Mortimer, & Spiegel, 2000). Social support is also associated with better immune functioning (Herbert & Cohen, 1993), with less accumulation of allostatic load (Brooks, Gruenewald, Karlmangla, Hu, Koretz, & Seeman, 2014), and with less cellular aging (Carroll, Diez Roux, Fitzpatrick, & Seeman, 2013). These bio- psychosocial pathways, then, provide the links be- tween social support and reduced risk of illness. Several studies have also shown that social sup- port modifies the brain’s responses to stress. For ex- ample, in one study (Coan, Schaefer, & Davidson, 2006), married women were exposed to the threat of electric shock while holding their husband’s hand, the hand of an anonymous male experimenter, or no hand at all. Holding one’s husband’s hand led to reduced activation in neural systems related to threat responses: more limited attenuation occurred from just holding an anonymous person’s hand. Of considerable interest, the higher the quality of the woman’s marriage, the more reduction in neural activation there was (Coan, Schaefer, & Davidson, 2006). Even looking at a part- ner’s picture can make a painful experience easier to endure (Master et al., 2009). Animals enjoy the benefi ts of social support just as humans do. For example, female horses who form relationships with unrelated females are more likely to give birth to foals that survive over the long term (Cameron, Setsaas, & Linklater, 2009). © Comstock Images/Alamy RF Chapter 7 Coping, Resilience, and Social Support 155 as to their social competence, social anxiety, and self- disclosure skills to see if these skills influenced whether the students were able to develop and use social support effectively. The students with more social competence, lower social anxiety, and better self-disclosure skills developed more effective social support networks and were more likely to form friendships. What Kinds of Support Are Most Effective? Not all aspects of social support are equally protective against stress. For example, having a confidant (such as a spouse or partner or close friend), particularly on a daily basis, may be the most effective social support (Stetler & Miller, 2008; Umberson, 1987). Marriage, especially a satisfying marriage, is one of the best pro- tectors against stress (Robles, 2014). On average, men’s health benefits substantially from marriage (e.g., Sbarra, 2009), whereas women’s health benefits only slightly from marriage. Leaving a marriage, be- ing unmarried, or being in an unsatisfying marriage all bring health risks, especially for women (Kiecolt- Glaser & Newton, 2001; Liu & Umberson, 2008; Sbarra & Nietert, 2009). Marital strain, fighting, and separation and divorce have powerful negative effects on health (Nealey-Moore, Smith, Uchino, Hawkins, & Olson-Cerney, 2007). Support from family is important as well. Receiv- ing social support from one’s parents in early life and living in a stable and supportive environment as a child have long-term effects on coping abilities and on health (Puig, Englund, Simpson, & Collins, 2013; Repetti et al., 2002). Experiencing the divorce of one’s parents in childhood predicts premature death in mid- dle age (Friedman, Tucker, Schwartz, et al., 1995). Support from one’s community beneficially af- fects health. For example, an investigation in Indonesia found that mothers who were active in the community were more likely to get resources and information about health care for their children, resources that would otherwise not have been accessible (Nobles & Frankenberg, 2009). Thus, one mechanism linking community level support to health may be increased knowledge about resources. Matching Support to the Stressor Different kinds of stressful events create different needs, and social support is most effective when it meets those needs. This is called the matching hypothesis (Cohen & McKay, 1984; Cohen & Wills, 1985). For exam- ple, if a person has someone he or she can talk to about problems but actually needs only to borrow a car, the presence of a confidant is useless. But if a person is upset about how a relationship is going and needs to talk it through with a friend, then the avail- ability of a confidant is a very helpful resource. In short, support that is responsive to a person’s needs is most beneficial (Maisel & Gable, 2009). Support from Whom? Providing effective so- cial support is not always easy for the support net- work. It requires skill. When it is provided by the wrong person, support may be unhelpful or even re- jected, as when a stranger tries to comfort a lost child. Social support may also be ineffective if the type of support provided is not the kind that is needed. Emotional support is most beneficial when it comes from intimate others, whereas information and advice may be more valuable coming from experts. Thus, a person who desires solace from a family member but receives advice instead may find that, rather than be- ing supportive, the family member actually makes the stressful situation worse (Dakof & Taylor, 1990). The benefits of social support are greater when the person from whom one is seeking support is perceived to be responsive to one’s needs (Selcuk & Ong, 2013). Threats to Social Support Stressful events can interfere with obtaining social support. People who are under stress may express distress to others and drive those others away, thus making a bad situation even worse (Alferi, Carver, Antoni, Weiss, & Duran, 2001). Social support can come not only from family and friends but also from a loved pet. Research suggests that dogs are better at providing social support than cats or other animals. © Ingram Publishing/SuperStock RF 156 Sometimes, would-be support providers do not provide the support that is needed and, instead, react in an unsupportive manner that aggravates the negative event (see Box 7.6). Too much or overly intrusive social contact may actually make stress worse. When social support is controlling or directive, it may have some benefits for health behaviors but produce psychological distress (Lewis & Rook, 1999). For example, people who be- long to “dense” social networks (friendship or family groups that spend a lot of time together) can find themselves besieged by advice and interference in times of stress. As comedian George Burns once noted, “Happiness is having a large, loving, caring, B O X 7.6 Can Bad Relationships Affect Your Health? Most people have at least one bad relationship. It might be a sibling with whom you are constantly feud- ing, a sloppy sullen roommate, a demanding partner, or even a parent. Even in usually good relationships, things can go wrong. But do these bad relationships affect health? The answer appears to be yes. In a study by Jessica Chiang and colleagues (2012), college students completed daily diaries each evening for 8 days about their social experiences of that day. They recorded the number of positive social interactions, negative interactions, and competitive experiences they had had that day. For each interac- tion, the students briefly described the experience. A few days later, their levels of inflammation—a marker of stress and a pathway to several diseases—was as- sessed. Students who had experienced primarily posi- tive interactions had normal levels of inflammation. But students who had experienced negative interac- tions, such as conflicts or arguments with others, had higher levels of inflammation. Those who had gone through competitive social interactions had elevated inflammation levels as well, although only certain kinds of competition were tied to inflammation. Competitive leisure-time activities, such as tennis or an online game, did not increase levels of inflammation. However, academic and work- related competitive events and competing for the attention of another person, such as a roman- tic partner or friend, were both associated with heightened inflammation. The more of these nega- tive and competitive events a person experienced, the higher their levels of inflammation. Inflammation in response to a short-term stressor can be adaptive, as it can help heal wounds during competitive struggles. Chronic inflammation, how- ever, is related to hypertension, heart disease, diabetes, depression, and some cancers. So people whose lives have recurring conflict or competition may, over the long term, be at risk for these disorders. Does it matter when in one’s life the negative relationships occur? Research suggests that negative relationships early in life, during childhood, may be especially important for inflammation (Miller & Chen, 2010). When a person grows up in a harsh fam- ily, marked by conflict, neglect, or cold non-nurturant parenting, that person shows a stronger inflammatory response to stress as early as adolescence, suggesting that by adulthood, the risk of chronic illness may al- ready be established. The evidence relating bad relationships to inflam- mation is strong enough to suggest a bit of advice: Avoid bad relationships. They add stress to life and erode good health. Instead, populate your life with supportive and upbeat people. The beneficial effects of social support on mental and physical health are clear. A lot of relationships aren’t all good or all bad, but instead, they make one feel ambivalent. Sometimes the person is there for you and sometimes not. Ambivalent relationships can compromise health (Uchino et al., 2012). © Ingram Publishing RF Chapter 7 Coping, Resilience, and Social Support 157 close-knit family in another city.” When family mem- bers or friends are also affected by the stressful event, they may be less able to provide social support to the person in greatest need (Melamed & Brenner, 1990). Giving Social Support Most research on social support has focused on getting support from others, which has benefits. But giving social support to others has beneficial effects on mental and physical health as well (Li & Ferraro, 2005; Piliavin & Siegl, 2007). For example, one study examined the effects of giving and receiving social support among older married people (Brown, Nesse, Vinokur, & Smith, 2003). People who provided instrumental support to friends, relatives, and neighbors or who provided emotional support to their spouses were less likely to die over the next 5 years. Volunteering, as by working at a soup kitchen or raising funds for others, has health benefits as well (Poulin et al., 2014). Thus, giving support can pro- mote health. Enhancing Social Support Health psychologists view social support as an impor- tant resource in primary prevention. Increasingly, people are living alone for long periods during their lives, either because they have never married, are di- vorced, or have lost a spouse to death (U.S. Census Bureau, 2012). Americans report that they have fewer close friends now than has been true in the past. As of late 2015, Facebook has more than 1.5 bil- lion active users per month, of which one billion log on at least once every day (Facebook, 2015). Clearly, patterns of social support are shifting, but whether they are shifting in ways that continue to provide sup- port remains to be seen. Networking may be an added source of social support for people, but those who use it to express distress may drive others away (Forest & Wood, 2012). Finding ways to increase the effectiveness of ex- isting or potential support from family, friends, and Internet buddies should be a high research priority. (Bookwala, Marshall, & Manning, 2014). A number of interventions have been undertaken to try to reduce loneliness. Some of these focus on improving social skills, whereas others attempt to enhance existing so- cial support. Social support groups (Taylor, 2011) and Internet-based social support interventions (Haem- merli, Znoj, & Berger, 2010) show promise for en- hancing access to socially supportive resources. Some focus on getting people to increase their opportunities for social contact, and others address the maladaptive internal monologues that people sometimes generate about themselves and their social adeptness that can drive other people away. Loneliness is often an emo- tional state, rather than purely a consequence of little social contact (Masi, Chen, Hawkley, & Cacioppo, 2011). Poor quality of sleep and anxiety can lead to depression, negative social cognitions, and further loneliness (Zawadzki, Graham, & Gerin, 2013). Con- sequently, interventions that target social cognitions and encourage people to attend to the positive aspects of the social environment have been most successful in reducing loneliness (Masi et al., 2011). These inter- ventions are covered more fully in Chapter 11. ∙ 158 Part Three Stress and Coping 1. Coping is the process of managing demands that tax or exceed a person’s resources. Coping efforts are guided by internal resources such as optimism, personal control, and self-esteem and external resources such as time, money, the absence of simultaneous life stressors, and social support. 2. Coping styles are predispositions to cope with stress in particular ways. An important distinction is between approach-related coping styles and avoidance-related coping styles. Although avoidance may be successful in the short run, on the whole, approach-related coping styles are more successful. 3. Coping efforts may be directed to solving problems or to regulating emotions. Most stress- ful events evoke both types of coping. 4. Coping efforts are judged to be successful when they reduce physiological indicators of arousal, enable the person to resume desired activities, and free the individual from psychological distress. 5. Coping effectiveness training, which draws on the principles of cognitive-behavioral therapy, teaches effective coping skills. Emotional disclosure and expressive writing about stressful events are also effective coping techniques. 6. Stress management programs exist for those who need help in developing their coping skills. These programs teach people to identify sources of stress in their lives, to develop coping skills to deal with those stressors, and to practice these skills and monitor their effectiveness. 7. Social support involves tangible assistance, information, or emotional comfort that lets people know they are loved and cared for, esteemed and valued, and part of a social network. 8. Social support reduces psychological distress, can improve health habits, and has undeniable benefits on physical health. These benefits are chiefly gained because social support reduces psychological and physiological reactivity to stress. 9. Having a confidant such as a spouse or close friend is especially beneficial, as is support from family early in life. Social support is most effective when it matches one’s needs and is from the person best able to provide it. 10. Increasing the quality and quantity of social sup- port a person receives is an important goal of health psychology interventions. S U M M A R Y K E Y T E R M S approach (confrontative, vigilant) coping style avoidant (minimizing) coping style buffering hypothesis control-enhancing interventions coping coping style direct effects hypothesis emotion-focused coping emotional-approach coping emotional support informational support invisible support matching hypothesis negative affectivity problem-focused coping psychological control self-esteem social support stress carriers stress management stress moderators tangible assistance time management Seeking and Using Health Care Services 4P A R T © Keith Brofsky/Getty Images RF 160 C H A P T E R 8 C H A P T E R O U T L I N E Recognition and Interpretation of Symptoms Recognition of Symptoms Interpretation of Symptoms Cognitive Representations of Illness Lay Referral Network The Internet Who Uses Health Services? Age Gender Social Class and Culture Social Psychological Factors Misusing Health Services Using Health Services for Emotional Disturbances Delay Behavior Using Health Services © Pixtal/AGE Fotostock RF Chapter 8 Using Health Services 161 (Feldman, Cohen, Doyle, Skoner, & Gwaltney, 1999), and they often erroneously believe they have serious dis- eases. As we saw in Chapter 7, neuroticism is a pervasive negative way of viewing the world marked by negative emotions, self-consciousness, and a concern with bodily processes. Neurotic, anxious people may exaggerate their symptoms, or they may simply be more attentive to real symptoms (Howren, Suls, & Martin, 2009; Tomenson et al., 2012). Attentional Differences People who are focused on themselves (their bodies, their emotions, and their reactions in general) are quicker to notice symptoms than are people who are focused externally, on their environment and activities (Pennebaker, 1983). So, people who hold boring jobs, who are so- cially isolated, who keep house for a living, or who live alone report more physical symptoms than do people who have interesting jobs, have active social lives, work outside the home, or live with others. People who experience more distractions and attend less to them- selves experience fewer symptoms than people who have little activity in their lives (Pennebaker, 1983). Situational Factors A boring situation makes people more attentive to symptoms than does an inter- esting situation. For example, people are more likely to notice itching or tickling in their throats and to cough in response during boring parts of movies than during interesting parts (Pennebaker, 1980). A symptom is more likely to be perceived on a day when a person is at home than on a day full of frenzied activity. Intense physical activity takes attention away from symptoms, whereas quiescence increases the likelihood of their recognition. Any situational factor that makes illness or symp- toms especially salient promotes their recognition. For example, a common phenomenon in medical school is medical students’ disease. As they study each illness, many medical students imagine that they have it. Studying the symptoms leads the students to focus on their own fatigue and other internal states; as a consequence, symptoms consistent with the illness under study seem to emerge (Mechanic, 1972). Stress Stress can precipitate or aggravate the expe- rience of symptoms. People who are under stress may believe that they are more vulnerable to illness and so attend more closely to their bodies. Financial strain, disruptions in personal relationships, and other stressors On the surface, the questions of who uses health services and why would seem to be medical issues. The obvious answer is that people use services when they are sick. But this issue can also be psychological: When and how does a person decide that he or she is sick? When are symptoms dismissed as inconsequential? When does a person decide that a symptom requires treatment by a professional, and when do chicken soup, fluids, and bed rest seem to be all that is needed? ■ RECOGNITION AND INTERPRETATION OF SYMPTOMS Although people have some awareness of what is go- ing on in their bodies, that awareness may be limited. This limitation leaves a great deal of room for social and psychological factors to operate in the recogni- tion and interpretation of illness. Recognition of Symptoms I have a tumor in my head the size of a basketball. I can feel it when I blink. —Woody Allen, Hannah and Her Sisters Common observation reveals that some individuals maintain their normal activities in the face of debili- tating symptoms, whereas others take to their beds the moment they detect any minor bodily disturbance. Individual Differences Hypochondriacs, like characters that Woody Allen has played, are con- vinced that normal bodily symptoms are indicators of illness. Although hypochondriacs are only 4–5 per- cent of the population, they make extensive use of medical services, and so understanding the symptom experience is important (Tomenson et al., 2012). The most frequent symptoms experienced by peo- ple who convert their distress into physical symptoms are back pain, joint pain, pain in the extremities, head- ache, abdominal symptoms such as bloating, “allergies” to particular foods, and cardiovascular symptoms such as palpitations (Carmin, Weigartz, Hoff, & Kondos, 2003; Rief, Hessel, & Braehler, 2001). Contrary to ste- reotypes, women are not more likely than men to report these symptoms. But there are pronounced age effects, with older people reporting more symptoms than young people. People who are high in neuroticism recognize their symptoms quickly and report their symptoms quickly 162 Part Four Seeking and Using Health Care Services Prior Experience As the preceding incident at- tests, the interpretation of symptoms is heavily influ- enced by prior experience. Unless a symptom previously indicated a serious disease, people who have experi- ence with a medical condition estimate the prevalence of their symptoms to be greater and often regard the condition as less serious than do people with no history of the condition (Jemmott, Croyle, & Ditto, 1988). Common disorders are generally regarded as less seri- ous than are rare or distinctive risk factors and disorders (Croyle & Ditto, 1990). Expectations Expectations influence the inter- pretation of symptoms. People may ignore symptoms they are not expecting and amplify symptoms they do expect (Leventhal, Nerenz, & Strauss, 1982). When people feel vulnerable to disease, they are more likely to interpret bodily sensations as indicative of illness, and even regard other people in the environment as potential disease carriers (Miller & Maner, 2012). An example is described in Box 8.1. Seriousness of the Symptoms Symptoms that affect highly valued parts of the body are usually interpreted as more serious and as more likely to re- quire attention than are symptoms that affect less valued organs. For example, people are especially anxious when their eyes or face are affected, but less so if the symptom involves part of the trunk. A symp- tom will prompt seeking treatment if it limits mobility or if it affects a highly valued organ, such as chest dis- comfort thought to be indicative of heart disease (Eifert, Hodson, Tracey, Seville, & Gunawardane, 1996). Above all, if a symptom causes pain, it will lead a person to seek treatment more promptly than if it does not cause pain. Cognitive Representations of Illness People hold beliefs, or cognitive representations, about their illnesses that affect their treatment seeking behav- ior. The commonsense model of illness argues that people hold implicit commonsense beliefs about their symptoms and illnesses that result in organized illness representations or schemas (Leventhal, Leventhal, & Breland, 2011; Leventhal, Weinman, Leventhal, & Phillips, 2008). These coherent conceptions of illness are acquired through the media, through personal experience, and from family and friends who have had experience with similar disorders. lead people to believe that they are ill (Ewart, Elder, Laird, Shelby, & Walker, 2014; val Gils, Janssens, & Rosmalen, 2014), perhaps because they experience stress-related physiological changes, such as acceler- ated heartbeat or fatigue, and interpret these changes as symptoms of illness (Cameron, Leventhal, & Leventhal, 1995). Mood and Emotions People who are in a good mood or who have positive expectations rate them- selves as more healthy, report fewer illness-related memories, and report fewer symptoms. Even people who have diagnosed illnesses report fewer or less seri- ous symptoms when they are in a good mood (Gil et al., 2004). People in a bad mood, or with negative expecta- tions, report more symptoms, are more pessimistic that any actions they might take will relieve their symp- toms, and perceive themselves as more vulnerable to fu- ture illness (Leventhal, Hansell, Diefenbach, Leventhal, & Glass, 1996). Positive and negative expectations can be modified, however, which may reduce the symptom experience and effects on mood (Crichton, Dodd, Schmid, Gamble, Cundy, & Petrie, 2014). Interpretation of Symptoms The interpretation of symptoms is also a heavily psy- chological process. Consider the following incident. At a large metropolitan hospital, a man in his late 20s came to the emergency room with the sole symptom of a sore throat. He brought with him six of his relatives: his mother, father, sister, aunt, and two cousins. Because patients usually go to an emergency room with only one other person, and because a sore throat is virtually never seen in the emergency room, the staff were understand- ably curious about the reason for his visit. One particu- larly sensitive medical student reasoned that something more must have caused the man to come to the emer- gency room with his entire family in tow, so he probed cautiously but persistently during the intake interview with the patient. Gradually, it emerged that the young man’s brother had died a year earlier of Hodgkin’s dis- ease, a form of cancer that involves the progressive in- fection and enlargement of the lymph nodes. The brother’s first symptom had been a sore throat, which he and the family had allowed to go untreated. This poignant incident illustrates how important social and psychological factors can be in understand- ing people’s interpretations of their symptoms and their decisions to seek treatment. 163 Most people have at least three models of illness (Leventhal et al., 2008): ∙ Acute illness is believed to be caused by specific viral or bacterial agents and is short in duration, with no long-term consequences. An example is the flu. ∙ Chronic illness is believed to be caused by multi- ple factors, including health habits, and is long in duration, often with severe consequences. An example is heart disease. ∙ Cyclic illness is marked by alternating periods during which there are either no symptoms or many symptoms. An example is herpes. People’s conceptions of illness vary and can greatly influence behavior related to a disease. For example, diabetes may be regarded by one person as an acute condition caused by a diet high in sugar, whereas another person with the same disease may see it as a lifelong condition with potentially cata- strophic consequences. Not surprisingly, these people will treat their disorders differently, maintain different levels of vigilance toward symptoms, and show different patterns of seeking treatment (Petrie & Weinman, 2012). These commonsense models range from being quite sketchy and inaccurate to being extensive, tech- nical, and complete. Their importance stems from the fact that they lend coherence to a person’s comprehen- sion of the illness experience. As such, they can influ- ence people’s preventive health behaviors, their reactions when they experience symptoms or are diag- nosed with illness, their adherence to treatment rec- ommendations, their expectations for their future health (Petrie & Weinman, 2012), and their health outcomes (Kaptein et al., 2010). Commonsense models include basic information about an illness (Leventhal et al., 2008). The identity, or label, for an illness is its name; its causes are the factors that the person believes gave rise to the illness; its consequences are its symptoms, the treatments that result, and their implications for quality of life; time line refers to the length of time the illness is expected to last; and control/cure identifies whether the person believes the illness can be managed or cured through appropriate actions and treatments; and emotional rep- resentations include how people feel about the illness and its possible course and treatment. Coherence refers to how well these beliefs hang together in a cogent representation of the disorder. B O X 8.1Can Expectations Influence Sensations? The Case of Premenstrual Symptoms Many women experience unpleasant physical and psychological symptoms just before the onset of men- struation, including swollen breasts, cramping, irrita- bility, and depression. These symptoms clearly have a physiological basis, but psychological factors may contribute as well (Beal et al., 2014). To test this idea, D. N. Ruble (1972) recruited a number of women to participate in a study. She told them she was using a new scientific technique that would pre- dict their date of menstruation. She then randomly told participants that the technique indicated either that their period was due within the next day or two (premenstrual group) or that their period was not due for 7–10 days (intermenstrual group). In fact, all the women were ap- proximately a week from their periods. The women were then asked to complete a questionnaire indicating the ex- tent to which they were experiencing symptoms typically associated with the premenstrual state. The women who had been led to believe that their period was due within the next day or two reported more psychological and physiological symptoms of premenstruation than did women who were told their periods were not due for 7–10 days. Of course, the results of this study do not mean that premenstrual symptoms have no physical basis. Indeed, the prevalence and seriousness of premen- strual syndrome (PMS) bears testimony to the de- bilitating effect that premenstrual bodily changes can have on physiological functioning and behavior. Rather, the results suggest that women who believe themselves to be premenstrual may be more atten- tive to and reinterpret naturally fluctuating bodily states as consistent with the premenstrual state. These findings also illustrate the significance of psychological factors in the experience of symp- toms more generally. 164 Part Four Seeking and Using Health Care Services two-thirds of Internet users have used the Internet to find health information, and more than half of them say it improved the way they took care of themselves (Dias et al., 2002). Are these trends worrisome? According to a re- cent study of physicians, 96 percent believe that the Internet will affect health care positively, and many physicians turn to the Internet themselves for the most up-to-date information on illnesses, treatments, and the processing of insurance claims. Nonetheless, some of what is on the Internet is not accurate (Kalichman et al., 2006), and people who use the Web to get infor- mation about their illness sometimes get worse (Gupta, 2004, October 24). ■ WHO USES HEALTH SERVICES? Just as illness is not evenly distributed across the pop- ulation, neither is the use of health services. Age The very young and the elderly use health services most frequently (Meara, White, & Cutler, 2004). Young children develop a number of infectious childhood dis- eases as they are acquiring their immunities; there- fore, they frequently require the care of a pediatrician. Both illness frequency and the use of services decline in adolescence and throughout young adulthood. Use of health services increases again in late adulthood, when people begin to develop chronic conditions and diseases of aging (Cherry, Lucas, & Decker, 2010). Gender Women use medical services more than men do (Fuller, Edwards, Sermsri, & Vorakitphokatorn, 1993). Preg- nancy and childbirth account for much of this gender difference in use, but not all. Various explanations have been offered, including the fact that women have better homeostatic mechanisms than men do: They report pain earlier, experience temperature changes more rapidly, and detect new smells faster. Thus, they may also be more sensitive to bodily disruptions, especially minor ones that may elude men (Leventhal, Diefenbach, & Leventhal, 1992). Another possible explanation stems from social norms. Men are expected to project a tough, macho image, which involves being able to ignore pain and not give in to illness, whereas women are not subject to these same pressures (Klonoff & Landrine, 1992). Ambiguity about one’s illness has been tied to poor well-being (Hoth et al., 2013), and so conceptions of ill- ness can be very useful. Those conceptions give people a basis for interpreting new information, influence their treatment-seeking decisions, lead them to alter or fail to adhere to their medication regimens (Coutu, Dupuis, D’Antono, & Rochon-Goyer, 2003), and influence ex- pectations about future health (Leventhal et al., 2008). Sometimes patients’ conceptions of their illnesses match those of their health care providers, but other times they do not. In these latter cases, misunder- standings or misinterpretation of information can result (Brooks, Rowley, Broadbent, & Petrie, 2012). Lay Referral Network Sociologists have written at length about the lay refer- ral network, an informal network of family and friends who offer their own interpretations of symptoms, often well before any medical treatment is sought (Freidson, 1961). The patient may mention the symptoms to a fam- ily member or coworker, who may then respond with personal views of what the symptom is likely to mean (“George had that, and it turned out to be nothing at all”). The friend or relative may offer advice about the advisability of seeking medical treatment (“All he got for going to see the doctor was a big bill”) and recom- mendations for various home remedies (“Lemon and tequila will clear that right up”). In many communities, the lay referral network is the preferred mode of treatment. A powerful lay figure, such as an older woman who has had many children, may act as a lay practitioner; because of her years of experience, she is assumed to have personal wisdom in medical matters (Freidson, 1961; Hayes-Bautista, 1976). Within ethnic communities, the lay referral net- work will sometimes incorporate beliefs about the causes and cures of disease that would be regarded as supernatural or superstitious by traditional medicine. In addition, these lay referral networks often recommend home remedies regarded as more appropriate or more effective than traditional medicine. The Internet The Internet constitutes a lay referral network of its own. Four in every 5 Internet users have searched the Web for health care information (Freudenheim, 2011). The amount of health information on the Internet has mushroomed in recent years, with more than 100,000 health-related websites currently in existence (Center for the Advancement of Health, June 2002). At least Chapter 8 Using Health Services 165 services there are, are often inadequate and understaffed (Kirby & Kaneda, 2005). Consequently, many poor people receive no regular medical care at all and see physicians only in the emergency room. The biggest gap between the rich and the poor is in the use of preventive health services, such as inoculations against disease and screening for treatable disorders, which lays the ground- work for poorer health across the life span. Social Psychological Factors Social psychological factors—including an individu- al’s attitudes toward life and his or her beliefs about symptoms and health services—influence who uses health services. As we saw in Chapter 3, the health be- lief model maintains that whether a person seeks treat- ment for a symptom can be predicted by whether the person perceives a threat to health and whether he or she believes that a particular health measure will be effective in reducing that threat. The health belief model explains people’s use of services quite well. But the model does a better job of explaining the treatment-seeking behavior of people who have money and access to health care services than of people who do not. Life satisfaction is tied to fewer physician visits (Kim, Park, Sun, Smith, & Peterson, 2014). The use of health care services is influenced by socialization—chiefly, by the actions of one’s parents. Just as children and adolescents learn health behaviors from their parents, they also learn when and how to use health care services. To summarize, health services are used by people who have the need, time, money, prior experience, be- liefs that favor the use of services, and access to services. ■ MISUSING HEALTH SERVICES Health services may be abused as well as used. One type of abuse occurs when people seek out health ser- vices for problems that are not medically significant, overloading the medical system. Another type of abuse involves delay, when people should seek health care for a problem but do not. Using Health Services for Emotional Disturbances Physicians estimate that as much as half to two-thirds of their time is taken up by patients whose complaints are psychological rather than medical (Katon et al., 1990). This problem is more common for general Women also use health care services more often because their medical care is more fragmented. Medical care for most men involves a trip to a general practitioner for a physical examination that includes all-preventive care. But women may visit a general practitioner or inter- nist for a general physical, a gynecologist for Pap tests, and a breast cancer specialist or mammography service for breast examinations and mammograms. Thus, women may use services more than men in part because the medical care system is not particularly well struc- tured to meet women’s basic needs. Social Class and Culture The lower social classes use medical services less than do more affluent social classes (Adler & Stewart, 2010), in part because poorer people have less money to spend on health services or little or no insurance (Gindi & Jones, 2014; Gindi, Kirzinger, & Cohen, 2013). How- ever, with Medicare for the elderly, Medicaid for the poor, and other inexpensive health services, the gap be- tween medical service use by the rich and by the poor has narrowed somewhat, and it may narrow even more with the implementation of the Affordable Care Act. In addition to cost, there are not as many high- quality medical services available to the poor, and what Women use medical services more than men, they may be sick more than men, and their routine care requires more visits than men’s. It is sometimes easier for women to use services, and they require services for such gender-related needs as maternity care. © Radius Images/Photolibrary RF 166 Part Four Seeking and Using Health Care Services prolonged hospital stays as well (De Jonge, Latour, & Huyse, 2003; Rubin, Cleare, & Hotopf, 2004). So problematic is the issue of seeking health care treatment for anxiety and depression that a study in the Annals of Internal Medicine suggested that physicians begin all their patient interviews with the direct ques- tions, “Are you currently sad or depressed? Are the things that previously brought you pleasure no longer bringing you pleasure?” Positive answers to questions such as these would suggest that the patient may need treatment for depression as well as, or even instead of, other medical treatments (Means-Christensen, Arnau, Tonidandel, Bramson, & Meagher, 2005; Pignone et al., 2002; Rhee, Holditch-Davis, & Miles, 2005). Another reason that people use health services for psychological complaints is that medical disorders are perceived as more legitimate than psychological ones. For example, a man who is depressed by his job and who stays home to avoid it will find that his behavior is more acceptable to both his employer and his wife if he says he is ill than if he admits he is depressed. Many people still believe that it is shameful to see a mental health specialist or to have mental problems. Illness brings benefits, termed secondary gains, including the ability to rest, to be freed from unpleas- ant tasks, to be cared for by others, and to take time off from work. These reinforcements can interfere with the process of returning to good health. (Some of these factors may have played a role in one famous case of hysterical contagion; see Box 8.2.) Finally, the inappropriate use of health services can represent true malingering. A person who does not want to go to work may know all too well that the only accept- able excuse that will prevent dismissal for absenteeism is illness. Moreover, workers may be required to document their absences in order to collect wages or disability pay- ments and may thus have to keep looking until they find a physician who is willing to “treat” the “disorder.” But errors can be made in the opposite direction as well: People with legitimate medical problems may be falsely assumed to be psychologically disturbed. Physicians are more likely to reach this conclusion about their female patients than their male patients (Redman, Webb, Hennrikus, Gordon, & Sanson- Fisher, 1991), even though objective measures sug- gest equivalent rates of psychological disturbance. Delay Behavior A very different misuse of health services occurs when an individual should seek treatment for a practitioners than for specialists, although no branch of medicine is immune. College health services peri- odically experience this problem during exam time, when symptoms increase in response to stress. These nonmedical complaints often stem from anxi- ety and depression, both of which, unfortunately, are widespread (Howren & Suls, 2011). Patients who come to the emergency room with chest pain or who visit their physicians with cardiac symptoms are especially likely to have complicating anxiety and depressive disorders, with 23 percent estimated to have a psychiatric disorder (Srinivasan & Joseph, 2004). Unfortunately, symptoms such as these can lead physicians to intervene with medical treatments that are inappropriate (Salmon, Humphris, Ring, Davies, & Dowrick, 2007). Why do people seek a physician’s care when their complaints should be addressed by a mental health spe- cialist? Stress and emotional responses to it, such as anxiety, worry, and depression, are accompanied by a number of physical symptoms (Pieper, Brosschot, van der Leeden, & Thayer, 2007). Anxiety can produce diar- rhea, upset stomach, sweaty hands, shortness of breath (sometimes mistaken for asthma symptoms), difficulty in sleeping, poor concentration, and general agitation. Depression can lead to fatigue, difficulty performing everyday activities, listlessness, loss of appetite, and sleep disturbances. People may mistake the symptoms of their mood disorder for a physical health problem and thus seek a physician’s care (Vamos, Mucsi, Keszei, Kopp, & Novak, 2009). Psychologically based com- plaints may not only influence seeking contact initially but may also lead to multiple visits, slow recovery, and Visit the health service of any college or university just before exams begin, and you will see a unit bracing itself for an onslaught. Admissions to health services can double or even triple as papers become due and exams begin. © Purestock/Superstock RF 167 treatment. Delay is composed of several periods, dia- grammed in Figure 8.1: appraisal delay, which is the time it takes an individual to decide that a symptom is serious; illness delay, which is the time between the rec- ognition that a symptom implies an illness and the deci- sion to seek treatment; behavioral delay, which is the time between deciding to seek treatment and actually doing so (Safer, Tharps, Jackson, & Leventhal, 1979); and medical delay (scheduling and treatment), which is the time that elapses between the person’s calling for an appointment and his or her receiving appropriate medi- cal care. Delay in seeking treatment for some symptoms is appropriate. For example, a runny nose or a mild sore throat usually will clear up on its own. However, in other symptom but puts off doing so. A lump, chronic short- ness of breath, blackouts, skin discoloration, radiating chest pain, seizures, and severe stomach pains are se- rious symptoms for which people should seek treat- ment promptly. Unfortunately, a person may live with one or more of these potentially serious symptoms for months without seeking care. This is called delay behavior. For example, a factor contributing to the high rate of death and disability from heart attacks is that patients often delay seeking treatment for its symptoms, instead normalizing them as gastric dis- tress, muscle pain, and other, less severe disorders. Delay is defined as the time between when a person recognizes a symptom and when the person obtains B O X 8.2The June Bug Disease: A Case of Hysterical Contagion One summer, a mysterious epidemic broke out in the dressmaking department of a southern textile plant, affecting 62 workers. The symptoms varied but usually included nausea, numbness, dizziness, and occasionally vomiting. Some of the ill required hospitalization, but most were simply excused from work for several days. Almost all the affected workers reported having been bitten by a gnat or mite immediately before they experienced the symptoms. Several employees who were not afflicted said they had seen their fellow work- ers bitten before they came down with the disease. However, local, state, and federal health officials who were called in to investigate could obtain no reliable description of the suspected insect. Furthermore, care- ful inspection of the textile plant by entomologists and exterminators turned up only a small variety of insects—beetles, gnats, flies, an ant, and a mite—none of which could have caused the reported symptoms. Company physicians and experts from the U.S. Public Health Service Communicable Disease Center began to suspect that the epidemic might be a case of hysterical contagion. They hypothesized that, although some of the afflicted individuals may have been bitten by an insect, anxiety or nervousness was more likely responsible for the onset of the symptoms. On hearing this conclusion, employees insisted that the “disease” was caused by a bite from an insect that was in a ship- ment of material recently received from England. In shifting from a medical to a social explanation, health experts highlighted several points. First, the en- tire incident, from the first to the last reported case, lasted a period of 11 days, and 50 of the 62 cases (80 percent) occurred on 2 consecutive days after the news media had sensationalized earlier incidents. Sec- ond, most of the afflicted individuals worked at the same time and place in the plant. Third, the 58 work- ing at the same time and place were all women; one other woman worked on a different shift, two male victims worked on a different shift, and one man worked in a different department. Moreover, most of these women were married and had children; they were accordingly trying to combine employment and motherhood, often an exhausting arrangement. The epidemic occurred at a busy time in the plant— June being a crucial month in the production of fall fash- ions—and there were strong incentives for employees to put in overtime and to work at a high pace. The plant was relatively new, and personnel and production man- agement were not well organized. Thus, the climate was ripe for high anxiety among the employees. Who, then, got “bitten” by the “June bug,” and why? Workers with the most stress in their lives (mar- ried women with children) who were trying to cope with the further demands of increased productivity and overtime were most vulnerable. Job anxieties, coupled with the physical manifestations of fatigue (such as dizziness), created a set of symptoms that, given appropriate circumstances, could be labeled as illness. The rumor of a suspicious bug and the pres- ence of ill coworkers apparently provided the appro- priate circumstances, legitimizing the illness and leading to the epidemic that resulted. Source: Kerckhoff & Back, 1968. 168 Part Four Seeking and Using Health Care Services are more commonly treated (e.g., a lump for breast can- cer) than atypical symptoms of the same disorder (Meechan, Collins, & Petrie, 2003). Even after a consultation, up to 25 percent of pa- tients delay taking recommended treatments, put off getting tests, or postpone acting on referrals. In some cases, patients have had their curiosity satisfied by the first visit and no longer feel any urgency about their condition. In other cases, patients become truly alarmed by the symptoms and, to avoid thinking about them, take no further action. Delay on the part of the health care practitioner is also a significant factor, accounting for at least 15 per- cent of all delay behavior (Cassileth et al., 1988). In most cases, health care providers delay as a result of honest mistakes. For example, blackouts can indicate any of many disorders ranging from heat prostration or overzealous dieting to diabetes or a brain tumor. A pro- vider may choose to rule out the more common causes of a symptom before proceeding to the more invasive or expensive tests needed to rule out a less probable cause. Thus, when the more serious diagnosis is found to apply, the appearance of unwarranted delay exists. Medical delay is more likely when a patient devi- ates from the profile of the average person with a given disease. ∙ cases, symptoms may be debilitating for weeks or months, and to delay seeking treatment is inappropriate. What Causes Delay? People who delay are very similar to people who do not use services more generally. For example, when money is not available, people may persuade themselves that the symptoms are not serious enough to seek treatment. Delay is more common among people with no regular contact with a physician and among people who are phobic about medical services. The elderly delay less than middle-aged people, especially if they believe the symptoms may be serious (Leventhal, Easterling, Leventhal, & Cameron, 1995). Symptoms predict delay as well. If a symptom is similar to one that previously turned out to be minor, the person will seek treatment less quickly than if the symptom is new. Symptoms that do not hurt or change quickly and that are not incapacitating are less likely to prompt a person to seek medical treatment (Safer et al., 1979). Symptoms that can be easily accommo- dated and do not provoke alarm may be delayed. For example, people have difficulty distinguishing between ordinary moles and melanomas (a potentially fatal skin cancer), and so may delay seeking treatment. Symp- toms that are typical of a disorder, on the other hand, Detects unexplained sign(s) and/or symptom(s) Infers illness Decides to seekmedical attention Acts on decision by making an appointment First receives medical attention Begins treatment for illness Yes Yes Yes Yes Yes Yes No No No NoNo Appraisal delay Illness delay Behavioral delay Scheduling delay Treatment delay Medical delay Total patient delay FIGURE 8.1 | Stages of Delay in Seeking Treatment for Symptoms (Source: Based on B. L. Andersen, J. T. Cacioppo, & D. C. Roberts, Delay in seeking a cancer diagnosis: Delay stages and psychophysiological comparison processes. British Journal of Social Psychology (1995) 34, 33–52. Fig.1, p. 35.) Chapter 8 Using Health Services 169 1. The detection of symptoms, their interpretation, and the use of health services are heavily influenced by psychological processes. 2. Personality and culture, focus of attention, the presence of distracting or involving activities, mood, the salience of illness or symptoms, and individual differences in the tendency to monitor threats influence whether a symptom is noticed. The interpretation of symptoms is influenced by prior experience and expectations about their likelihood and meaning. 3. Commonsense models of illness (which identify the type of disease and its causes, consequences, timeline, controllability/cure, and coherence) influence how people interpret their symptoms and whether they act on them by seeking medical attention. 4. Social factors, such as the lay referral network, can act as a go-between for the patient and the medical care system. 5. Health services are used disproportionately by the very young and very old, by women, and by middle- and upper-class people. The health belief model also influences use of health services. 6. Health services can be abused. A large percentage of patients who seek medical attention are depressed or anxious and not physically ill. Also, people commonly ignore symptoms that are serious, resulting in dangerous delay behavior. S U M M A R Y K E Y T E R M S appraisal delay behavioral delay commonsense model of illness delay behavior illness delay illness representations lay referral network medical delay medical students’ disease secondary gains 170 C H A P T E R 9 The Patient in the Hospital Setting Structure of the Hospital The Impact of Hospitalization on the Patient Interventions to Increase Information in Hospital Settings The Hospitalized Child Preparing Children for Medical Interventions Complementary and Alternative Medicine Philosophical Origins of CAM CAM Treatments Dietary Supplements and Diets Prayer Acupuncture Yoga Hypnosis Meditation Guided Imagery Chiropractic Medicine Osteopathy Massage Who Uses CAM? Complementary and Alternative Medicine: An Overall Evaluation The Placebo Effect History of the Placebo What Is a Placebo? Provider Behavior and Placebo Effects Patient Characteristics and Placebo Effects Patient-Provider Communication and Placebo Effects Situational Determinants of Placebo Effects Social Norms and Placebo Effects The Placebo as a Methodological Tool Patients, Providers, and Treatments C H A P T E R O U T L I N E Health Care Services Patient Consumerism Structure of the Health Care Delivery System Patient Experiences with Managed Care The Nature of Patient-Provider Communication Setting Provider Behaviors That Contribute to Faulty Communication Patients’ Contributions to Faulty Communication Interactive Aspects of the Communication Problem Results of Poor Patient-Provider Communication Nonadherence to Treatment Regimens Good Communication Improving Patient-Provider Communication and Increasing Adherence to Treatment Teaching Providers How to Communicate Rhoda Bear/National Cancer Institute (NCI) Chapter 9 Patients, Providers, and Treatments 171 Patient Consumerism At one time the physician’s authority was accepted with- out question or complaint. Increasingly, though, patients have adopted consumerist attitudes toward their health care. This change is due to several factors. First, patients are often presented with choices, and to make choices, one must be informed. The mere act of choice is empowering. Second, many illnesses, espe- cially chronic ones, require a patient to be actively en- gaged in the treatment regimen. Consequently, the patient’s full cooperation and participation in the devel- opment and enactment of the treatment plan is essential. Patients often have expertise about their illness, espe- cially if it is a recurring or chronic problem. A patient will do better if this expertise is tapped and integrated into the treatment program. All of these factors contrib- ute to patients regarding themselves as consumers of health care rather than passive recipients. Structure of the Health Care Delivery System Until a few decades ago, the majority of Americans received their health care from private physicians, whom they paid directly on a visit-by-visit basis, in what was termed private, fee-for-service care. That picture has changed. More than 85 million Americans now receive their health care through a prepaid financing and delivery system, termed a health maintenance organization (HMO) (Kaiser Family Foundation, January 2015, see Box 9.1). In this arrangement, an employer or employee pays an agreed-on monthly rate, and the employee can then use ■ HEALTH CARE SERVICES “I’ve had this cold for 2 weeks, so finally I went to the Student Health Services to get something for it. I waited more than an hour! And when I finally saw a doctor, he spent a whole 5 minutes with me, told me what I had was viral, not bacterial, and that he couldn’t do anything for it. He sent me home and told me to get a lot of rest, drink fluids, and take over-the-counter medications for the stuffiness and the pain. Why did I even bother?!” (Student account of a trip to the health services) Much of the communication between patients and providers goes very well. Information is exchanged, treatment recommendations are made, and both patient and providers are satisfied. Sometimes, however, things do not go well. Nearly everyone has a horror story about a visit to a physician. Long waits, insensitivity, appar- ently faulty diagnoses, and treatments that have no effect are the themes of these stories. But in the same breath, the storyteller may expound on the virtues of his or her latest physician with an enthusiasm bordering on wor- ship. To what do we attribute this seemingly contradic- tory attitude toward health care practitioners? Health ranks among the values we hold dearest. Good health is a prerequisite to nearly every other ac- tivity, and poor health can interfere with nearly all aspects of life. Moreover, illness is usually uncomfort- able, so people want to be treated quickly and success- fully. Perhaps, then, it is no wonder that physicians and other health care professionals are alternately praised and vilified: Their craft is fundamental to the enjoyment of life. Some of the health care practitio- ners increasingly involved in patient care are described in Table 9.1. TABLE 9.1 | Types of Health Care Providers Nearly half of all office space physicians are in practices that employ nurse practitioners, advanced practice nurses, or physician’s assistants (Park, Cherry, & Decker, 2011). Description Responsibilities Nurse practitioners Affiliated with physicians in private Provide routine medical care; prescribe treatment; practice; see their own patients monitor progress of chronically ill patients; explain disorders and their origins, diagnoses, prognoses, and treatments Advanced-practice nurses Include certified nurse midwives, Some obstetrical care and births; cardiac or cancer clinical nurse specialists, and care; administering anesthesia certified nurse anesthetists Physician’s assistants Educated in 2-year programs in Perform many routine health care tasks, such as medical schools and teaching taking down medical information or explaining hospitals treatment regimens to patients Source: Hing & Uddin, 2011. 172 Part Four Seeking and Using Health Care Services seeking treatment. Table 9.2 describes the differences among types of health care plans. Patient Experiences with Managed Care Although much patient contact with the health care system is positive, there are predictable ways in which communication goes awry, and we focus on those ways here. The changing structure of the health care delivery system can undermine patient-provider com- munication. Prepaid plans operate on a referral basis, so that the provider who first sees the patient deter- mines what is wrong and then recommends specialists to follow up with treatment. Because providers are often paid according to the number of cases they see, referrals are desirable. Therefore, a colleague orien- tation, rather than a client or patient orientation, can develop (Mechanic, 1975). Because the patient no longer pays directly for service, and because the pro- vider’s income is not directly affected by whether the patient is pleased with the service, the provider may not be overly concerned with patient satisfaction. The provider is, however, concerned with what his or her colleagues think, because it is on their recommenda- tions that he or she receives additional cases. In the- ory, such a system can produce high technical quality of care because providers who make errors receive fewer referrals; however, there is less incentive to of- fer emotionally satisfying care. HMOs and other prepaid plans may undermine care in other ways. When providers are pressured to see as many patients as possible, the consequences can be long waits and short visits. These problems are com- pounded if a patient is referred to several specialists. services at no additional (or a greatly reduced) cost. This arrangement is called managed care. In some cases, HMOs have their own staff, from which enroll- ees must seek treatment. In preferred-provider organizations (PPOs), a network of affiliated practitioners have agreed to charge preestablished rates for services, and enrollees in the PPO must choose from these practitioners when When physicians treat patients in a warm, friendly, confident manner, they are judged to be competent as well as nice. © Digital Vision/SuperStock RF TABLE 9.2 | Types of Health Care Plans Name How It Works Health maintenance organization (HMO) Members select a primary-care physician from the HMO’s pool of doctors and pay a small fixed amount for each visit. Typically, any trips to specialists and nonemergency visits to HMO network hospitals must be preapproved. Preferred-provider organization (PPO) A network of doctors offers plan members a discounted rate. They usually don’t need prior authorization to visit an in-network specialist. Point-of-service plan (POS) These are plans, administered by insurance companies or HMOs, that let members go to doctors and hospitals out of the network—for a price. Members usually need a referral to see a network specialist. Traditional indemnity plan Patients select their own doctors and hospitals and pay on a fee-for-service basis. They don’t need a referral to see a specialist. Sources: American Association of Health Plans, 2001; National Committee for Quality Assurance, 2001. Chapter 9 Patients, Providers, and Treatments 173 both nice and competent, whereas a cool, aloof pro- vider may be judged as both unfriendly and incompe- tent (Bogart, 2001). In reality, the technical quality of care and the manner in which care is delivered are un- related. What factors affect quality of communication? Setting In many ways, the medical office is an unlikely set- ting for effective communication. The average visit lasts only 12–15 minutes, and when you are trying to explain your symptoms, the physician will, on aver- age, interrupt you before you get 23 seconds into your comments (Simon, 2003). Moreover, it is difficult to present your complaints effectively when you are in pain or have a fever, or if you are anxious or embar- rassed about your condition. The provider’s role is a difficult one as well. He or she must extract significant information as quickly as possible from the patient. The provider is often on a tight schedule, with other patients backing up in the waiting room. The disorder may have been made more complicated by the patient’s self-treatment, which can mask and distort the symptoms. Further, the patient’s ideas of which symptoms are important may not correspond to the provider’s knowledge, and so important signs may be overlooked. With the pa- tient seeking solace and the provider trying to maxi- mize the efficient use of time, there are clearly potential sources of strain. Patients may feel that they are being shunted from pro- vider to provider with no continuity in their care and no opportunity to build up a personal relationship with any one individual. Precisely because of some patient dissatisfaction, some HMOs have taken steps to reduce long waits, to allow for personal choice, and to make sure a patient sees the same provider at each visit. Changes such as these have resulted in patient-centered care, which involves providing patients with information, involv- ing them in decisions regarding care, and consider- ation of psychosocial issues such as social support needs (Bergeson & Dean, 2006). ■ THE NATURE OF PATIENT- PROVIDER COMMUNICATION As noted, patient-practitioner communication does not always go smoothly. Criticisms of providers usually center on jargon, lack of feedback, and depersonalized care. The quality of communication with a provider is important to patients, but it also affects care. Poor patient-provider communication has been tied to non- adherence to treatment recommendations and the ini- tiation of malpractice litigation, for example. Most of us are insufficiently knowledgeable about medicine and standards of practice to know whether we have been treated well medically. Consequently, we often judge technical quality on how care is delivered. A warm, confident, friendly provider is judged to be FIGURE 9.1 | Percentage of Physicians in Various Forms of Practice (Sources: Bianco & Schine, 1997, March 24; Bureau of Labor Statistics, 2004) 80 60 40 20 0 1984 1994 2002* 2012* Pe rc en t Self-employed Employee *Physicians & surgeons projected 174 Part Four Seeking and Using Health Care Services resumed his conversation with me, and existence was conferred upon me again. (Zimbardo, 1969, p. 298) Nonperson treatment may be employed at partic- ularly stressful moments to keep the patient quiet and to enable the practitioner to concentrate. In that way, it may serve a valuable medical function. But patient depersonalization can also have adverse medical ef- fects. For example, medical staff making hospital rounds often use either highly technical or euphemis- tic terms when discussing cases with their colleagues; these terms may confuse or alarm the nonparticipat- ing but physically present patient, an effect to which the provider may be oblivious. Patient depersonalization also provides emotional protection for the provider. It is difficult for a provider to work in a continual state of awareness that his or her every action influences someone’s state of health and happiness (L. Cohen et al., 2003). Moreover, ev- ery provider has tragedies—as when a patient dies or is left incapacitated by a treatment—but the provider must find a way to continue to practice. Depersonali- zation helps provide such a way. Stereotypes of Patients Negative stereotypes of patients may contribute to poor communication and subsequent treatment. Physicians give less information, are less supportive, and demonstrate less proficient clinical performance with black and Hispanic patients and patients of lower socioeconomic class than is true for more advantaged patients, even in the same health care settings (van Ryn & Fu, 2003) (see Box 9.1) often without realizing it (Schaa, Roter, Biesecker, Cooper, & Erby, 2015). When a person is seen by a physician of the same race or ethnicity, satisfaction with treatment tends to be higher (Laveist & Nuru-Jeter, 2002). Many physicians have negative perceptions of the elderly (Haug & Ory, 1987), and these beliefs can com- promise care. Older patients are less likely than younger patients to be resuscitated in emergency rooms or given active treatment protocols for life-threatening diseases (Haug & Ory, 1987; Morgan, 1985). The negative atti- tudes of physicians seem to be reciprocated in the elderly, in that among people age 65 and over, only 54 percent express high confidence in physicians. Sexism is a problem in medical practice as well. For example, in experimental studies that attributed reported chest pain and stress to either a male or a female patient, medical intervention was perceived to be less important for the female patient (Martin & Lemos, 2002). Provider Behaviors That Contribute to Faulty Communication Inattentiveness Communication between pa- tient and physician can be eroded by certain provider behaviors. One problematic provider behavior is inat- tentiveness—that is, not listening. Typically, patients do not have the opportunity to finish their explanation of concerns before the provider begins the process of diagnosis. Use of Jargon Patients understand relatively few of the complex terms that providers often use. Provid- ers learn a complex vocabulary for understanding ill- nesses and communicating about them to other professionals; they often find it hard to remember that patients do not share this expertise. In some cases, jargon- filled explanations may be used to keep the patient from asking too many questions or from discovering that the provider actually is not certain what the patient’s prob- lem is. The use of jargon may also stem from an in- ability to gauge what the patient will understand. Baby Talk Because practitioners may underesti- mate what their patients will understand about an ill- ness and its treatment, they may resort to baby talk and simplistic explanations. One woman, who is both a can- cer researcher and a cancer patient, reports that when she goes to see her cancer specialist, he talks to her in a very complex, technical manner until the examination starts. Once she is on the examining table, he shifts to very simple sentences and explanations. She is now a patient and no longer a colleague. The truth about what most patients can understand lies somewhere between the extremes of technical jargon and baby talk. Nonperson Treatment Depersonalization of the patient is another problem that impairs the quality of the patient-provider relationship (Kaufman, 1970). One patient—a psychologist—reports: When I was being given emergency treatment for an eye laceration, the resident surgeon abruptly terminated his conversation with me as soon as I lay down on the operating table. Although I had had no sedative, or anesthesia, he acted as if I were no longer conscious, directing all his questions to a friend of mine—questions such as, “What’s his name? What occupation is he in? Is he a real doctor?” etc. As I lay there, these two men were speaking about me as if I were not there at all. The moment I got off the table and was no longer a cut to be stitched, the surgeon 175 understand important details about the illness or treat- ment (Golden & Johnston, 1970). Whereas dissatisfied patients complain about the incomplete or overly tech- nical explanations they receive from providers, dis- satisfied providers complain that even when they give clear, careful explanations to patients, the explanation goes in one ear and out the other. With patients assuming more responsibility for their own care, the issue of health illiteracy has come to the fore. Although millions of young people graduate from high school each year, many of them lack the basic literacy skills needed to adhere to medical prescriptions, comprehend the meaning of their risk factors, or inter- pret the results of tests from physicians. Poorly educated In comparison with male physicians, female phy- sicians generally conduct longer visits, ask more ques- tions, make more positive comments, and show more nonverbal support, such as smiling and nodding (Hall, Irish, Roter, Ehrlich, & Miller, 1994). The matching of gender between patient and practitioner fosters rap- port and disclosure (Levinson, McCollum, & Kutner, 1984; Weisman & Teitelbaum, 1985). However, phy- sicians of both genders prefer male patients (Hall, Epstein, DeCiantis, & McNeil, 1993). Patients who are regarded as seeking treatment largely for depression, anxiety, or other forms of psy- chological disorder also evoke negative reactions from physicians. With these patients, physician atten- tion may be cursory (Epstein et al., 2006). Physicians prefer healthier patients to sicker ones (Hall et al., 1993), and they prefer acutely ill to chronically ill pa- tients; chronic illness poses uncertainties and raises questions about prognosis, which acute diseases do not. Chronic illness can also increase a physician’s distress over having to give bad news (L. Cohen et al., 2003). Patients who are the objects of stereotypes are more likely to become distrustful and dissatisfied with their care. Patients’ Contributions to Faulty Communication Within a few minutes of having discussed their illness with a provider, as many as one-third of patients can- not repeat their diagnosis, and up to one-half do not Patients are often most comfortable interacting with a physician who is similar to themselves. © Henk Badenhorst/Getty Images RF B O X 9.1What Did You Say?: Language Barriers to Effective Communication More than 25.2 million people in the United States have limited English proficiency (Pandya, McHugh, & Batalova, 2011). Consequently, language barriers are a formidable problem in patient-provider communication. Increasingly, language barriers contribute to communica- tion problems (Halim, Yoshikawa, & Amodio, 2013). Consider the experiences of a 12-year-old Latino boy and his mother attempting to communicate what was wrong: “La semana pasada a él le dio mucho mareo y no tenía fiebre ni nada, y la familia por parte de papá todos padecen de diabetes.” (Last week, he had a lot of dizziness, and he didn’t have fever or anything, and his dad’s family all suffer from diabetes.) “Uh hum,” replied the physician. The mother went on. “A mí me da miedo porque él lo que estaba mareado, mareado, mareado y no tenía fiebre ni nada.” (I’m scared because he’s dizzy, dizzy, dizzy, and he didn’t have fever or anything.) Turning to Raul, the physician asked, “OK, so she’s saying you look kind of yellow, is that what she’s saying?” Raul interpreted for his mother: “Es que se me vi amarillo?” (Is it that I looked yellow?) “Estaba como mareado, como pálido” (You were dizzy, like pale), his mother replied. Raul turned back to the doctor. “Like I was like paralyzed, some- thing like that,” he said (Flores, 2006, p. 229). 176 Part Four Seeking and Using Health Care Services tions, patients may feel that their concerns have been ignored. Patients sometimes give providers misleading in- formation about their medical history or their current concerns. Patients may be embarrassed about their health history (such as having had an abortion) or their health practices (such as being a smoker), and so may not report this important information. Interactive Aspects of the Communication Problem Qualities of the interaction between practitioner and pa- tient can perpetuate faulty communication. A major problem is that the patient-provider interaction does not provide the opportunity for feedback to the provider. The provider sees the patient, the patient is diagnosed, treatment is recommended, and the patient leaves. When the patient does not return, any number of things may have happened: The treatment may have cured the disorder; the patient may have gotten worse and de- cided to seek treatment elsewhere; the treatment may have failed, but the disorder may have cleared up any- way; or the patient may have died. Not knowing which of these alternatives has actually occurred, the provider does not know the impact and success rate of the advice given. Obviously, it is to the provider’s psychological advantage to believe that the diagnosis was correct, that the patient followed the advice, and that the patient’s disorder was cured by the recommended treatment. However, the provider may never find out for certain. The provider may also find it hard to know when a satisfactory personal relationship has been estab- lished with a patient. Many patients are relatively cau- tious with providers. If they are dissatisfied, rather than complain about it directly, they may simply change providers. If a patient has stopped coming, the practitioner does not know if the patient has moved out of the area or switched to another practice. When providers do get feedback, it is more likely to be nega- tive than positive: Patients whose treatments have failed are more likely to return than are patients whose treatments are successful (Rachman & Phillips, 1978). Two points are important here. First, learning is fos- tered more by positive than by negative feedback; posi- tive feedback tells one what one is doing right, whereas negative feedback may tell one what to stop doing but not necessarily what to do instead. Because providers get little feedback and more negative than positive feed- back, this situation is not conducive to learning. people, the elderly, and non-English speakers have par- ticular problems adopting the consumer role toward their care (Center for the Advancement of Health, May 2004). As people age, their number of medical problems usually increases, but their abilities to present their com- plaints effectively and follow treatment guidelines declines. About 40 percent of patients over age 50 have difficulty understanding their prescription instructions. Extra time and care may be needed to communicate this vital information to older patients. How Patients Compromise Communication Several patient characteristics contribute to poor com- munication with providers. Neurotic patients often present an exaggerated picture of their symptoms (Ellington & Wiebe, 1999), compromising a physi- cian’s ability to gauge the seriousness of a patient’s condition. When patients are anxious, their learning can be impaired (Graugaard & Finset, 2000). Anxiety makes it difficult to focus attention and process incom- ing information and retain it (Graugaard & Finset, 2000). Negative affectivity more generally compro- mises adherence (Molloy et al., 2012). To the extent that a practitioner can reduce anxiety, anger, and other negative emotions, communication may improve (Ger- hart, Sanchez Varela, Burns, Hobfoll, Fung, 2015; van Osch, Sep, van Vliet, van Dulmen, & Bensing, 2014). Some patients are unable to understand even simple information about their case (Galesic, Garcia- Retamero, & Gigerenzer, 2009; Link, Phelan, Miech, & Westin, 2008). Lack of intelligence or poor cogni- tive functioning impedes the ability to play a con- sumer role (Stilley, Bender, Dunbar-Jacob, Sereika, & Ryan, 2010). Patients for whom the illness is new and who have little prior information about the disorder also have difficulty comprehending their disorders and treatments (DiMatteo & DiNicola, 1982). Patient Attitudes Toward Symptoms Patients respond to different symptoms of their illness than do practitioners (Greer & Halgin, 2006), especially ones that interfere with their activities. But providers are more concerned with the underlying illness, its sever- ity, and treatment. Patients may consequently misun- derstand the provider’s emphasis on factors that they consider to be incidental, they may pay little attention, or they may believe that the provider has made an in- correct diagnosis. Patients typically want to be treated (Bar-Tal, Stasiuk, & Maksymiuk, 2012). If the physi- cian prescribes bed rest and over-the-counter medica- Chapter 9 Patients, Providers, and Treatments 177 McKibbon, & Kanani, 1996). Adherence is highest for treatments for HIV, arthritis, gastrointestinal disorders, and cancer, and poorest among patients with pulmo- nary disease, diabetes, and sleep disorders (DiMatteo et al., 2002). Measuring Adherence Asking patients about their adherence yields artificially high estimates (Kaplan & Simon, 1990; Turk & Meichenbaum, 1991). As a consequence, researchers draw on indirect measures of adherence, such as the number of follow- up or referral appointments kept, but even these mea- sures can be biased. Overall, the research statistics probably underestimate the amount of nonadherence that is actually going on. Good Communication Adherence is highest when the patient receives a clear, jargon-free explanation of the etiology, diagnosis, and treatment recommendations. Adherence is higher if the patient has been asked to repeat the instructions, if the instructions are written down, if unclear recom- mendations are singled out and clarified, and if the instructions are repeated more than once (DiMatteo & DiNicola, 1982). Box 9.2 addresses some ways in which adherence errors may be reduced. Treatment Regimen Qualities of the treatment regimen also influence adherence. Treatment regi- mens that must be followed over a long time, that are complex, that require frequent dosage, and that inter- fere with other desirable activities in a person’s life all show low levels of adherence (Ingersoll & Cohen, 2008; Turk & Meichenbaum, 1991). Keeping first ap- pointments and obtaining medical tests show high ad- herence rates (Alpert, 1964; DiMatteo & DiNicola, 1982). Adherence is high (about 90 percent) when the advice is perceived as “medical” (for example, taking medication) but lower (76 percent) if the advice is vocational (for example, taking time off from work) and lower still (66 percent) if the advice is social or psychological (for example, avoiding stressful social situations) (Turk & Meichenbaum, 1991). People who enjoy the activities in their lives are more motivated to adhere to treatment. Adherence is substantially higher among patients who live in cohe- sive families but lower with patients whose families are in conflict (DiMatteo, 2004). Likewise, people who are depressed show poor adherence to treatment ■ RESULTS OF POOR PATIENT- PROVIDER COMMUNICATION The patient-provider communication problems would be little more than an unfortunate casualty of medical treatment were it not for the toll they take on health. Dissatisfied patients are less likely to comply with treatment recommendations or to use medical services in the future; they are more likely to turn to alternative services that satisfy emotional rather than medical needs; they are less likely to obtain medical checkups; and they are more likely to change doctors and to file formal complaints (Hayes-Bautista, 1976; Ware, Davies-Avery, & Stewart, 1978). Nonadherence to Treatment Regimens Chapters 3, 4, and 5 examined adherence to treatment regimens in the context of health behaviors and noted how difficult it can be to modify or eliminate poor health habits, such as smoking, or to achieve a healthy lifestyle. In this section, we examine adherence to treatment, the role of health institutions, and particu- larly the role of the provider, in promoting adherence. Rates of Nonadherence When patients do not adopt the behaviors and treatments their providers rec- ommend, the result is nonadherence or noncompliance (DiMatteo, 2004). Estimates of nonadherence vary from a low of 15 percent to a staggering high of 93 percent. Averaging across all treatment regimens, nonadherence to treatment recommendations is about 26 percent (DiMatteo, Giordani, Lepper, & Croghan, 2002). But adherence rates vary, depending on the treat- ment recommendations. For short-term antibiotic regimens, one of the most common prescriptions, about one-third of patients fail to comply adequately (see Rapoff & Christophersen, 1982). Between 50 and 60 percent of patients do not keep appointments for modifying preventive health behaviors (DiMatteo & DiNicola, 1982). More than 80 percent of patients who receive behavior-change recommendations from their doctors, such as stopping smoking or following a restrictive diet, fail to follow through. Even heart pa- tients, such as patients in cardiac rehabilitation, who should be motivated to adhere, have an adherence rate of only 66–75 percent (Facts of Life, March 2003). Overall, about 85 percent of patients fail to adhere completely to prescribed medications (O’Connor, 2006). Adherence is typically so poor that the benefits of many medications cannot be experienced (Haynes, 178 over-the-counter preparations to treat symptoms they think were ignored by the physician. Unfortunately, remedies can sometimes interact with prescribed drugs in unpredictable, even dangerous ways. Alternatively, the patient may alter the dosage requirement, reason- ing, for example, that if four pills a day for 10 days will clear up the problem, eight pills a day for 5 days will do it twice as quickly. Creative nonadherence, then, is a widespread and potentially dangerous behavior. Another costly consequence of poor patient- practitioner communication is malpractice suits. Table 9.3 shows some of the reasons why people sue in discretionary malpractice cases. The fallout from the costs of malpractice suits is that some physicians leave medicine altogether. For example, malpractice premi- ums are so high for obstetricians that some have de- cided to move to other specialties where malpractice insurance is lower (Eisenberg & Sieger, 2003, June 9). ■ IMPROVING PATIENT- PROVIDER COMMUNICATION AND INCREASING ADHERENCE TO TREATMENT How can we improve communication so as to increase adherence to treatment? There are simple things that both practitioners and patients can do to improve communication. Teaching Providers How to Communicate Given the motivation, any practitioner can be an effective communicator. Training Providers Many physicians are moti- vated to improve the communication process and to medication (DiMatteo, Lepper, & Croghan, 2000). Disorganized families with no regular routines have poorer adherence (Hall, Dubin, Crossley, Holmqvist, & D’Arcy, 2009; Jokela, Elovainio, Singh-Manoux, & Kivimäki, 2009; Schreier & Chen, 2010). Low IQ is tied to poor adherence, and consequently, low IQ pre- dicts early mortality. Nonadherent patients also cite lack of time, no money, or distracting problems at home, such as insta- bility and conflict, as impediments to adherence. Of- ten people cut back on their prescriptions to save money (Heisler, Wagner, & Piette, 2005). This can lead to creative nonadherence, namely modifying and supplementing a prescribed treatment regimen (Cohen, Kirzinger, Gindi, 2013). For example, a poor patient may change the dosage level of required medication to make the medicine last as long as possi- ble or may keep some medication in reserve in case another family member develops the same disorder. One study of nonadherence among the elderly esti- mated that 73 percent of nonadherence was intentional rather than accidental (Cooper, Love, & Raffoul, 1982). Creative nonadherence can also result from per- sonal theories about a disorder and its treatment (Wroe, 2001). Patients supplement the treatment regimen with TABLE 9.3 | Why Do People Sue? Faulty communication can lead to malpractice litigation. Many suits are due to medical incompetence, but discretionary malpractice suits can be due to faulty communication. Typically, 1. Patients want to find out what happened 2. Patients want an apology from the doctor or hospital 3. Patients want to know that the mistake will not happen again Source: Reitman, 2003, March 24. B O X 9.2 What Are Some Ways to Improve Adherence to Treatment? 1. Make adult literacy a national priority. 2. Require that all prescriptions be typed on a keyboard. 3. Have secure electronic medical records for each person that document his or her complete medication history and that are accessible to both patients and their physicians. 4. Enforce requirements that pharmacists provide clear instructions and counseling along with prescription medication. 5. Develop checklists for both patients and doctors, so they can ask and answer the right questions before a prescription is written. Source: The Center for the Advancement of Health, 2009. 179 address them by name, tell them where they can hang up their clothes, explain the purpose of a procedure while it is going on, say good-bye, and, again, use the patient’s name. Such simple behaviors add a few sec- onds at most to a visit, yet they are seen as warm and supportive (DiMatteo & DiNicola, 1982). Communication training needs to be practiced in the situations in which the skills will be used. Training that uses direct, supervised contact with patients and gives students immediate feedback after a patient in- terview works well for training both medical and nurs- ing students (Leigh & Reiser, 1986). Nonverbal communication can create an atmo- sphere of warmth or coldness. A forward lean and direct eye contact, for example, can reinforce an atmosphere of supportiveness, whereas a backward lean, little eye con- tact, and a postural orientation leaning away from the patient can undercut verbal efforts at warmth by sug- gesting distance or discomfort (DiMatteo, Friedman, & Taranta, 1979; DiMatteo, Hays, & Prince, 1986). Effective nonverbal communication can improve adher- ence to treatment (Guéguen, Meineri, & Charles-Sire, 2010) (see Box 9.3). share in decision making, although they may not know how (Garcia-Retamero, Wicki, Cokely, & Hanson, 2014). Effective communication programs should teach skills that can be learned easily and incorporated in medical routines easily. Many communication failures in medical settings stem from violations of simple rules of courtesy. The practitioners should greet patients, When physicians present concrete advice about lifestyle change, patients are more likely to adhere. © Image Source/Jupiterimages RF B O X 9.3What Can Providers Do to Improve Adherence? 1. Listen to the patient. 2. Ask the patient to repeat what has to be done. 3. Keep the prescription as simple as possible. 4. Give clear instructions on the exact treatment regimen, preferably in writing. 5. Make use of special reminder pill containers and calendars. 6. Call the patient if an appointment is missed. 7. Prescribe a self-care regimen in concert with the patient’s daily schedule. 8. Emphasize at each visit the importance of adherence. 9. Gear the frequency of visits to adherence needs. 10. Acknowledge at each visit the patient’s efforts to adhere. 11. Involve the patient’s spouse or other partner. 12. Whenever possible, provide the patient with instructions and advice at the start of the information to be presented. 13. When providing the patient with instructions and advice, stress how important they are. 14. Use short words and short sentences. 15. Use explicit categorization where possible. (For example, divide information clearly into categories of etiology, treatment, or prognosis.) 16. Repeat things, where feasible. 17. When giving advice, make it as specific, detailed, and concrete as possible. 18. Find out what the patient’s worries are. Do not confine yourself merely to gathering objective medical information. 19. Find out what the patient’s expectations are. If they cannot be met, explain why. 20. Provide information about the diagnosis and the cause of the illness. 21. Adopt a friendly rather than a businesslike attitude. 22. Avoid medical jargon. 23. Spend some time in conversation about nonmedical topics. Source: Based on DiMatteo, 2004. 180 Part Four Seeking and Using Health Care Services practitioners can help patients believe in their treat- ment and become motivated to adhere to it. And fi- nally, patients may need assistance in overcoming any practical barriers to the management of their diseases, which can include such factors as cost or little time (DiMatteo, Haskard-Zolnierek, & Martin, 2012). Fig- ure 9.2 illustrates these processes, as they apply to health behavior. Innovations in technology may make communi- cation more efficient and effective. Smartphone apps, email, and texting can be efficient ways to send mes- sages from patient to physician and vice versa (The Economist, May 2015). Patients can even send pic- tures of rashes or wounds to help with treatment and follow up. ■ THE PATIENT IN THE HOSPITAL SETTING More than 34 million people are admitted yearly to the nearly 6,000 hospitals in this country (American Hos- pital Association, 2016). As recently as 60 or 70 years ago, hospitals were thought of primarily as places where people went to die (Noyes et al., 2000). Now, however, the hospital serves many treatment functions. The average length of a hospital stay has decreased, as Training Patients Interventions to improve patient communication include teaching patients skills for eliciting information from physicians (Greenfield, Kaplan, Ware, Yano, & Frank, 1988). For example, a study by S. C. Thompson and colleagues (Thompson, Nanni, & Schwankovsky, 1990) instructed women to list three questions they wanted to ask their physician during their visit. Compared with a control group, women who listed questions in advance asked more questions during the visit and were less anxious. In a second study, Thompson and her colleagues added a third condition: Some women received a message from their physician encouraging question asking. These women, too, asked more of the questions they wanted to, had greater feelings of personal control, and were more satisfied with the office visit. Thus, listing one’s own questions ahead of time can improve communication during office visits, leading to greater patient satisfaction. Probing for Barriers to Adherence Patients are remarkably good at predicting how compliant they will be with treatment regimens (Kaplan & Simon, 1990). By making use of this knowledge, the provider may discover what the barriers to adherence will be. For example, if the patient has been told to avoid stressful situations but anticipates several high-pressure meetings the following week at work, the patient and provider together might consider how to resolve this dilemma. One option may be to have a coworker take the patient’s place at some of the meetings. Breaking advice down into manageable subgoals that can be monitored by the provider is another way to increase adherence. For example, if patients have been told to alter their diet and lose weight, modest weight- loss goals that can be checked at successive appoint- ments might be established (“Try to exercise 3 times this week for 30 minutes”). In addition, making the medical importance of lifestyle changes clear can im- prove adherence. When lifestyle change programs are “prescribed” for patients by physicians, patients show higher rates of adherence than if they are simply urged to make use of them (Kabat-Zinn & Chapman-Waldrop, 1988). Reasons why the health provider can change patient’s health behaviors are listed in Table 9.4. Overall, the best way to improve adherence is to first, provide patients with information about their treatment, listen to their concerns, encourage their partnership, build trust, and enhance recall. Second, TABLE 9.4 | Why the Health Practitioner Can Be an Effective Agent of Behavior Change • The health practitioner is a highly credible source with knowledge of medical issues. • The health practitioner can make health messages simple and tailor them to the individual needs and vulnerabilities of each patient. • The practitioner can help the patient decide to adhere by highlighting the advantages of treatment and the disadvantages of nonadherence. • The private, face-to-face nature of the interaction provides an effective setting for holding attention, repeating and clarifying instructions, extracting commitments from a patient, and assessing sources of resistance to adherence. • The personal nature of the interaction enables a practitioner to establish referent power by communicating warmth and caring. • The health practitioner can enlist the cooperation of other family members in promoting adherence. • The health practitioner has the patient under at least partial surveillance and can monitor progress during subsequent visits. Chapter 9 Patients, Providers, and Treatments 181 Figure 9.3 illustrates, largely because outpatient visits have increased (American Hospital Association, 2009a); number of deaths in the hospital have declined (Hall, Levant, & DeFrances, 2013). Structure of the Hospital The structure of hospitals depends on the health pro- gram under which care is delivered. For example, some health maintenance organizations (HMOs) and other prepaid health care systems have their own hos- pitals and employ their own physicians. In the case of the private hospital, there are two lines of authority—a medical line, which is based on technical skill and ex- pertise, and an administrative line, which runs the business of the hospital. Cure, Care, and Core The functioning of the hospital typically revolves around three goals—cure, care, and core—which may sometimes conflict with each other. Cure is typically the physician’s responsibil- ity, through performing any treatment action that has the potential to restore patients to good health—that is, to FIGURE 9.3 | Hospital Admissions and Length of Stay, 1946–2010 (Source: American Hospital Association, 2009b) Length of stay (days) Year Admissions (millions) 40 35 30 25 20 15 10 5 0 1946 1955 1960 1965 1970 1975 1980 1983 1986 1990 1995 1998 2001 2004 Admissions (millions) 10 9 8 7 6 5 4 3 2 1 0 Length of stay (days) 2007 2010 Health behavior information Health behavior motivation Health behavior skills Health behavior FIGURE 9.2 | The Information-Motivation-Behavioral Skills Model of Health Behavior The information- motivation-behavioral skills (IMB) model makes it evident that, to practice good health behaviors and adhere to treatment, a person needs the right information, the motivation to adhere, and the skills to perform the behavior. (Sources: Fisher & Fisher, 1992; Fisher, Fisher, Amico, & Harman, 2006; Fisher, Fisher, & Harman, 2003) 182 Part Four Seeking and Using Health Care Services cure them. Patient care, in contrast, is more the orienta- tion of the nursing staff, and it involves the humanitarian side of medicine, that is, to do as much as possible to keep the patient’s emotional and physical state in balance. The administration of the hospital is concerned with maintaining the core of the hospital: ensuring the smooth functioning of the system and the flow of resources, services, and personnel (Mauksch, 1973). These goals are not always compatible. For exam- ple, a clash between the cure and care orientations might occur when deciding whether to administer chemother- apy to an advanced-cancer patient. The cure orientation would maintain that chemotherapy should be initiated even if the chance for survival is slim, whereas the care orientation might argue against the chemotherapy on the grounds that it causes patients great physical and emotional distress. In short, then, the different profes- sional goals in a hospital treatment setting can create conflicting demands. Occupational segregation in the hospital is high: Nurses talk to other nurses, physicians to other physicians, and administrators to other administrators. Physicians have access to some information that nurses may not see, whereas nurses interact with patients daily and know a great deal about their day-to-day progress, yet often their notes on charts may go unread by physi- cians. The U.S. health care system has been likened to a construction team trying to put up a building in which the different construction teams, the electricians, and the plumbers all have different sets of plans, and no one knows what anyone else’s plans look like. An example of the problems associated with lack of communication is provided by nosocomial infec- tion—that is, infection that results from exposure to disease in the hospital setting (Raven, Freeman, & Haley, 1982). In 2011, there were 722,000 people who reported health-care associated infections in American hospitals, resulting in 75,000 deaths (Centers for Disease Control and Prevention, October, 2015). This rate makes hospital infection the number six killer in the United States. Hospital workers often break the seemingly end- less rules designed to control infection, such as the strict guidelines for hand washing, sterilization, and waste disposal. Of all hospital workers, physicians are the most likely to commit such infractions. However, they are rarely corrected by those under them. The preceding discussion has emphasized poten- tial sources of conflict and ambiguity in hospital func- tioning. Burnout, another problem that can result in part from these issues, is described in Box 9.4. How- ever, it is important to remember that hospital function- ing is remarkably effective, given the changing realities to which it must accommodate. Thus, the ambiguities in structure, potential conflicts in goals, and problems of communication occur within a system that generally functions quite well. The Role of Health Psychologists The number of health psychologists who work in hospital settings has more than doubled over the past 10 years, and their roles have expanded. Psychologists partici- pate in the diagnosis of patients and assess patients’ level of functioning, which can help form the basis for therapeutic intervention. Psychologists are also involved in pre- and postsurgery preparation, pain control, interventions to increase medication and treatment compliance, and behavioral programs to teach appropriate self-care following discharge (Enright, Resnick, DeLeon, Sciara, & Tanney, 1990). In addition, they diagnose and treat psychological problems that can complicate patient care, including anxiety and depression. As our country’s medical care system evolves over the next decades, the role of psychologists in the hospital will continue to change. The Impact of Hospitalization on the Patient The patient comes unbidden to a large organization that awes and irritates him, even as it also nurtures and cares. As he strips off his clothing so he strips off, too, his favored costume of social roles, his favored style, his customary identity in the world. He becomes The hospital can be a lonely and frightening place for many patients, leading to feelings of helplessness, anxiety, or depression. © Ingram Publishing RF 183 B O X 9.4Burnout Among Health Care Professionals Burnout is an occupational risk for anyone who works with needy people (Maslach, 2003), including physi- cians, nurses, and other medical personnel who work with sick and dying people (Rutledge et al., 2009). Burn- out is marked by three components: emotional exhaustion, cynicism, and a low sense of efficacy in one’s job. Staff members suffering from burnout show a cynical and seemingly callous attitude toward those whom they serve. Their view of clients is negative, and they often treat clients in detached ways (Maslach, 2003). Burnout has been linked to absenteeism, high job turnover, lengthy breaks during working hours, and even suicide (Schernhammer, 2005). When burned-out workers go home, they are often irritable with their fam- ilies. They are more likely to suffer from insomnia as well as drug and alcohol abuse, and they have a higher rate of psychosomatic disorders. Thus, burnout has sub- stantial costs for both the institution and the person. Burnout has also been tied to elevated stress hormones (Pruessner, Hellhammer, & Kirschbaum, 1999), changes in immune functioning (Lerman et al., 1999), and poor health including coronary heart disease (Toker, Melamed, Berliner, Zeltser, & Shapira, 2012). Why does burnout develop? Burnout develops when a person is required to provide services for highly needy people who may not be helped by those ser- vices: The problems may be just too severe. Moreover, such jobs often require the staff member to be consis- tently empathic, an unrealistic expectation. Caregivers may perceive that they give much more than they get back from their patients, and this imbalance aggravates burnout as well (Van Yperen, Buunk, & Schaufelli, 1992). Too much time spent with clients, little feed- back, little sense of control or autonomy, little percep- tion of success, role conflict, and role ambiguity are job factors that all aggravate burnout (Maslach, 1979). High rates of burnout are found among nurses who work in stressful environments, such as intensive care, emergency rooms, or terminal care (Mallett, Price, Jurs, & Slenker, 1991; Moos & Schaefer, 1987). Many nurses find it difficult to protect themselves from the pain they feel from watching their patients suffer or die. The stress of the work environment, including the hectic pace of the hospital and the hur- ried, anxious behavior of coworkers, also contributes to burnout (Parker & Kulik, 1995). How can burnout be avoided? Group interventions can provide workers with an opportunity to meet infor- mally with others to deal with burnout to obtain emotional support, reduce their feelings of being alone, share feel- ings of emotional pain about death and dying, and vent emotions in a supportive atmosphere. In so doing, they may improve client care (Duxbury, Armstrong, Dren, & Henley, 1984) and control current feelings of burnout, as well as head off future episodes (Rowe, 1999). For example, seeing what other people do to avoid burnout can provide a useful model for one’s own situation. subject to a time schedule and a pattern of activity not of his own making (Wilson, 1963, p. 70). Patients arrive at the hospital anxious about their disorder, anxious and confused over the prospect of hospitalization, and concerned with all the role obliga- tions they must leave behind unfulfilled. The admission is often conducted by a clerk, who asks about schedul- ing, insurance, and money. The patient is then ushered into a strange room, given strange clothes, provided with an unfamiliar roommate, and subjected to tests. © Erproductions Ltd/Blend Images LLC RF 184 Part Four Seeking and Using Health Care Services The patient must entrust him- or herself completely to strangers in an uncertain environment in which all pro- cedures are new. Hospital patients can show problematic psycho- logical symptoms, especially anxiety and depression. Nervousness over tests or surgery can produce insom- nia, nightmares, and an inability to concentrate. Hos- pital care can be fragmented, with as many as 30 different staff passing through a patient’s room each day, conducting tests, taking blood, bringing food, or cleaning up. Often, the staff members have little time to spend with the patient beyond exchanging greet- ings, which can be alienating for the patient. At one time, patients complained bitterly about the lack of communication they had about their disor- ders and their treatments. Because of these con- cerns, hospitals have now tried to ameliorate this problem. Patients are now typically given a road map of what procedures they can expect and what they may experience as a result. ■ INTERVENTIONS TO INCREASE INFORMATION IN HOSPITAL SETTINGS Many hospitals now provide interventions that help prepare patients generally for hospitalization and for the procedures they will undergo. In 1958, psychologist Irving Janis conducted a landmark study that would forever change how pa- tients are prepared for surgery. Janis was asked by a hospital to study its surgery patients to see if some- thing could be done to reduce the stress that many of them experienced both before and after operations. Janis first grouped the patients according to the level of fear they experienced before their operations (high, medium, and low). Then he studied how well they understood and used the information the hospital staff gave them to help them cope with the aftereffects of surgery. Highly fearful patients generally remained fearful and anxious after surgery and showed many negative side effects, such as vomiting, pain, urinary retention, and difficulty with eating (see also Montgomery & Bovbjerg, 2004). Patients who ini- tially had little fear also showed unfavorable reactions after surgery, becoming angry or upset or complain- ing. Of the three groups, the moderately fearful pa- tients coped with postoperative stress most effectively. In interpreting these results, Janis reasoned that highly fearful patients had been too absorbed with their own fears preoperatively to process the preparatory in- formation adequately, and patients with little fear were insufficiently vigilant to understand and process the in- formation effectively. Patients with moderate levels of fear, in contrast, were vigilant enough but not over- whelmed by their fears, so they were able to develop realistic expectations of what their postsurgery reactions would be; when they later encountered these sensations and reactions, they expected them and were ready to deal with them. Subsequent studies have used Janis’s observations to create interventions. For example, in one study (Mahler & Kulik, 1998), patients awaiting coronary artery bypass graft (CABG) were exposed to one of three preparatory videotapes or to no preparation. One videotape conveyed information from a health care ex- pert; the second featured the health care expert but also included clips of interviews with patients who reported on their progress; and the third presented information from a health care expert plus interviews with patients who reported that their recovery consisted of “ups and downs.” Compared to patients who did not receive vid- eotaped preparation, patients who saw one of the videotapes felt significantly better prepared for the re- covery period, reported higher self-efficacy during the recovery period, were more adherent to recommended dietary and exercise changes during their recovery, and were released sooner from the hospital. Research on the role of preparatory information in adjustment to surgery overwhelmingly shows that such preparation has beneficial effects on hospital pa- tients. Patients who have been prepared are typically less emotionally distressed, regain their functioning more quickly, and are often able to leave the hospital sooner. One study (Kulik & Mahler, 1989) even found that the person who becomes your postoperative roommate can influence how you cope with the after- math of surgery (Box 9.5). Preparation for patients is so beneficial that many hospitals show videotapes to patients to prepare them for upcoming procedures. ■ THE HOSPITALIZED CHILD Were you ever hospitalized as a child? If so, think back over the experience. Was it frightening and dis- orienting? Did you feel alone and uncared for? Or was it a more positive experience? Perhaps your parents were able to room in with you, or other children were around to talk to. You may have had either of these experiences because procedures for managing children 185 Patients who are hospitalized for serious illnesses or surgery often experience anxiety. From the earlier dis- cussion of social support (see Chapter 7), we know that emotional support from others can reduce distress when people are undergoing stressful events. Accordingly, James Kulik and Heike Mahler (1987) developed a so- cial support intervention for patients about to undergo cardiac surgery. Some of the patients were assigned a roommate who was also waiting for surgery (preopera- tive condition), whereas others were assigned a room- mate who had already had surgery (postoperative condition). In addition, patients were placed with a roommate undergoing a surgery that was either similar or dissimilar to their own. The researchers found that patients who had a postoperative roommate profited from this contact (see also Kulik, Moore, & Mahler, 1993). Patients with a post-operative roommate were less anxious be- fore surgery, were able to move around after surgery, and were released more quickly from the hospital than were patients who had been paired with a roommate who was also awaiting surgery. Whether the type of surgery was similar or dissimilar made no difference, only whether the roommate’s surgery had already taken place. Why was having a post-operative roommate help- ful for patients awaiting surgery? Possibly roommates were able to provide relevant information about the post-operative period. They may have acted as role models for how to cope post-operatively. Whatever the reason, social contact with a post-operative roommate clearly had a positive impact on the pre- and post- operative adjustment of these surgery patients (Kulik & Mahler, 1993; Kulik et al., 1993). in the hospital have changed dramatically over the past few decades. Hospitalization can be hard on children. It is diffi- cult for a child to be separated from family and home. Some children may not understand why they have been taken away from their families and mistakenly infer that they are being punished for some misdeed. The hospital environment can be lonely and isolating. Physical con- finement in bed or confinement due to casts or traction keeps children from discharging energy through physi- cal activity. Some children may become socially with- drawn, wet their beds, or have extreme emotional reactions ranging from fear to temper tantrums. The dependency that is fostered by bed rest and reliance on staff can also lead to regression. Children, espe- cially those just entering puberty, can be embarrassed or ashamed by having to expose themselves to strang- ers. The child may also be subject to confusing or pain- ful tests and procedures. Preparing Children for Medical Interventions Just as adults are benefited by preparation, so children are as well (Jay, Elliott, Woody, & Siegel, 1991; Manne et al., 1990). In one study (Melamed & Siegel, 1975), children about to undergo surgery were shown either a film of another child being hospitalized and receiving surgery or an unrelated film. Those children exposed to the relevant film showed less pre- and postoperative distress than did children exposed to the irrelevant film. Moreover, parents of the children exposed to the mod- eling film reported fewer problem behaviors after hos- pitalization than did parents of children who saw the control film. Coping skills preparation can be helpful to chil- dren (Cohen, Cohen, Blount, Schaen, & Zaff, 1999). For example, T. R. Zastowny and colleagues (Zastowny, Kirschenbaum, & Meng, 1986) gave children and Recent changes in hospitalization procedures for children have made hospitals less frightening places to be. Increasingly, medical personnel have recognized children’s needs for play and have provided opportunities for play in hospital settings. © 2007 Keith Eng RF B O X 9.5Social Support and Distress from Surgery 186 Part Four Seeking and Using Health Care Services their parents information describing typical hospital- ization and surgery experiences, relaxation training to reduce anxiety, or a coping skills intervention to teach children constructive self-talk. Both the anxiety re- duction and the coping skills interventions reduced children’s fearfulness and parents’ distress. Overall, the children exposed to the coping skills intervention exhibited the fewest maladaptive behaviors during hospitalization, less problem behavior in the week be- fore admission, and fewer problems after discharge. Some preparation can be undertaken by parents. If a parent prepares a child for admission several days before hospitalization—explaining why it is necessary, what it will be like, who will be there, how often the parent will visit, and so on—this preparation may ease the transition. During admission procedures, a parent or another familiar adult can remain with the child un- til the child is settled into the new room and engaged in some activity. The presence of parents during stressful medical procedures is not an unmitigated benefit. Parents do not always help reduce children’s fears, pain, and dis- comfort (Manne et al., 1992). When present during invasive medical procedures, some parents can be- come distressed and exacerbate the child’s own anxi- ety (Wolff et al., 2009). Nonetheless, parental support is important, and most hospitals now provide opportu- nities for extended parental visits, including 24-hour parental visitation rights. Despite some qualifications, the benefits of preparing children for hospitalization are now so widely acknowledged that it is more the rule than the exception. ■ COMPLEMENTARY AND ALTERNATIVE MEDICINE Thus far, our discussion of treatment has focused on traditional treatment venues, including the physician’s office and the hospital. However, nearly two-thirds of adults in the United States use complementary and alternative medicine (CAM) in addition to or instead of traditional medicine (Barnes, Powell-Griner, McFann, & Nahin, 2004; Neiberg et al., 2011). Comple- mentary and alternative medicine is a diverse group of therapies, products, and medical treatments that include prayer, potions, natural herb products, meditation, yoga, massage, homeopathic medicines, and acupuncture, among other treatments. Table 9.5 lists the most com- mon CAM practices. Until the 1990s, CAM was not a thriving business. Now, however, about two-thirds of people in the United States use CAM each year. More than $50 billion a year is spent on CAM therapies, much of which comes out of pocket; that is, it is not reim- bursed by insurance companies. The drugs and treatments of traditional medicine must be evaluated according to federal standards. Medications, for example, are typically evaluated through clinical trials and licensed by the Food and Drug Administration. However, the same is not true of CAM treatments, and so CAM represents a vast and often unevaluated aspect of care. This does not mean that CAM treatments do not work, but only that many have not been formally tested or have been evaluated only in very narrow contexts. For this reason, the Na- tional Center for Complementary and Alternative Med- icine (NCCAM) was created within the National Institutes of Health in 1998. Its mission is to evaluate the usefulness and safety of CAM therapies through rigorous scientific investigation and to discern what roles such therapies might have in improving health and health care (National Center for Complementary and Alternative Medicine, 2012). We begin this sec- tion with an overview of the philosophical origins of complementary and alternative medicine. We then turn to the most common CAM therapies and evaluate them where evidence is available. Philosophical Origins of CAM CAM is rooted in holistic medicine, an approach to treatment that deals with the physical, psychological, and spiritual needs of the person. In many respects, this is a logical extension of the biopsychosocial model introduced in Chapter 1, which also seeks to treat the TABLE 9.5 | Ten Most Common CAM Therapies Among U.S. Adults 1. Prayer—43% 2. Natural products (herbs, vitamins, and minerals)—17.7% 3. Deep breathing—12.7% 4. Meditation—9.4% 5. Chiropractic and Osteopathic—8.6% 6. Massage—8.3% 7. Yoga—6.1% 8. Diet-based therapies—3.6% 9. Progressive relaxation—2.9% 10. Guided imagery—2.2% Source: National Center for Complementary and Integrative Health, 2016. Chapter 9 Patients, Providers, and Treatments 187 whole person. Perhaps the earliest approach to healing was prayer. As we saw in Chapter 1, medicine evolved from religion, in which the healing of the body was believed to result from expelling evil spirits from the body. CAM’s origins lie in ancient African, European, and Middle Eastern religions, and Asian cultures. Traditional Chinese Medicine Traditional Chinese Medicine began more than 2,000 years ago and enjoys wide use throughout Asia. Recently, it has gained adherents in the United States. This approach to healing is based on the idea that a vital force, called qi (pronounced “chee”), flows throughout the body through channels called meridians that connect the parts of the body to each other and to the universe. Qi is considered the vital life force, and so if it is blocked or stagnant, disease can result. Keeping qi in balance, thus, is important both for maintaining good health and for improving health when it has been compromised. Traditional Chinese Medicine also strives to bal- ance two forces, yin and yang. Yin is cold, passive, and slow-energy, whereas yang is hot, active and rapid. Balancing the two is believed to be important for good health and attaining mental and physical harmony. Stress, infectious disorders, and environmental stress- ors can lead to imbalances between these forces, and thus the goal of intervention is to restore the balance. To do so, Traditional Chinese Medicine draws on such techniques as acupuncture, massage, diet, exer- cise, and meditation. It also draws on a variety of herbal preparations, including ginseng, wolfberry, gin- gerroot, dong quai, cinnamon, astragalus, and peony. Dietary intervention, which includes foods that shift the yin-yang balance, is a staple of Traditional Chi- nese Medicine. There has been relatively little formal evaluation of Traditional Chinese Medicine and its treatments, in large part because multiple treatments are often com- bined for individualized treatment based on a person’s particular problem. Without standardized treatments received by a large number of people, formal evalua- tion is difficult. However, there is some formal support for certain aspects of Traditional Chinese Medicine. One theory that is gaining traction, if not yet substantial evidence, is the idea that the activities of Traditional Chinese Medicine, especially its herbal preparations, have anti-inflammatory properties, and thus affect the immune system in a generally beneficial way that may have implications for a broad array of illnesses (Pan, Chiou, Tsai, & Ho, 2011). Whether tra- ditional Chinese medicinal herbs and practices do in- deed have anti-inflammatory actions is as yet unknown, but this is a promising evaluative pathway to pursue. Ayurvedic Medicine A related tradition that de- veloped in India around 2,000 years ago is ayurvedic medicine. Like Traditional Chinese Medicine, the goal is balance among the body, mind, and spirit (Na- tional Center for Complementary and Alternative Medicine, 2009a). Although people are born into a state of balance, events in their lives can disrupt it, compromising health, and so bringing these forces back into balance alleviates illness and maintains good health. As in Traditional Chinese Medicine and holistic medicine more generally, information about lifestyle and behavior is elicited from the patient and family members to identify treatment goals to achieve harmony and balance. Diet, exercise, and massage are important elements of ayurvedic medicine, as are use of herbs, oils, spices, and various minerals, to keep the person in balance. Ayurvedic medicine has been used to treat a variety of disorders, but little formal evalua- tion has been conducted. Homeopathy and Naturopathy Homeopathy is a philosophy developed in Europe in the 1700s, which likewise interprets disease and illness as caused by disturbances in a vital life force. Practitioners of homeopathy typically treat patients using diluted preparations that cause symptoms similar to those from which the patient suffers. When highly diluted, homeopathic remedies are typically safe, although when not sufficiently diluted, they can put patients at risk for illness. For some disorders, such as influenza- like syndromes, homeopathy may alleviate symptoms, but in other cases, the evidence is weak or mixed (Altunç, Pittler, & Ernst, 2007; Linde et al., 1999). At present, with respect to the standards of evidence- based medicine, the success of homeopathic treat- ments is still in question (Bellavite, Marzotto, Chirumbolo, & Conforti, 2011). Other early origins of CAM include naturopathy, a medical system developed in the 1800s, whose cen- tral tenet is that the body can heal itself through diet, exercise, sunlight, and fresh air. In summary, the origins of complementary and al- ternative medicine are at least 2,000 years old and arose from ancient religions and traditional healing practices in China and India, as well as from more 188 Part Four Seeking and Using Health Care Services claim than substance. However, a recent study found that among older men who took a multivitamin daily, cancer rates were reduced by 8 percent (Gaziano et al., 2012). This well-designed study provides some evi- dence that dietary supplements may have health bene- fits for at least some groups of healthy people. Vitamin D supplements may reduce symptoms of depression (Shaffer et al., 2014). However, because sup- plements are perceived to improve health, at least some people use them as insurance against their unhealthy be- haviors. For example, in two studies, people who took placebo dietary supplements were less likely to exercise and more likely to eat unhealthy foods, compared to peo- ple who knew that the drug they had received was a placebo (Chiou, Yang, & Wan, 2011). Thus, at least in some people, dietary supplements may confer an illusory sense of invulnerability that may have hidden costs. Increasingly, people are eating specific foods (and avoiding others) to achieve good health. Foods that affect the microbiome in the gut are among those (Sonnenburg & Sonnenburg, 2015). Beginning in in- fancy with mother’s milk and continuing into old age, how we feed ourselves can influence the microbiotica in the gut, and probiotic supplements are often used to augment these effects. Whether health risks are af- fected is hard to evaluate, in part because each per- son’s microbiome is individual, influenced by genetics, food consumption, and other aspects of the environment (Sonnenburg & Sonnenburg, 2015). Specific diets have also been used in an effort to improve health. These include macrobiotic and vege- tarian diets. Vegetarian diets involve reducing or elim- inating meat and fish and increasing consumption of vegetables, fruits, grains, and plant-based oils. As we saw in Chapter 4, reduced consumption of meat is widely recommended for health. However, vegetari- ans run a risk of obtaining inadequate protein and nu- trients, and so careful attention to the components of vegetarian diets is vital. Macrobiotic diets, which re- strict vegetarian consumption primarily to grains, ce- reals, and vegetables, require even greater attention to nutritional content (American Cancer Society, 2008). Prayer When prayer is included as a CAM therapy, the number of adults in the United States who report using CAM yearly totals two-thirds. Surveys (Gallup Poll, 2009) indicate that the majority of people in the United States believe in God (80 percent), report attending church services at least once a month (55 percent), and say that recent health movements in Europe and the United States. All have as a fundamental principle the idea that the mind, body, spirit, and environment operate to- gether to influence health. Intervention through prayer or meditation, diet, exercise, massage, herbal potions, and specific treatments, such as acupuncture, provide the impetus for the body to return itself to full health. ■ CAM TREATMENTS In this section we review some of the most commonly used CAM therapies, and when possible, evaluate their effects. We begin with the most common CAM therapies, dietary supplements and prayer. We then discuss a central therapy of Traditional Chinese Med- icine, namely acupuncture, following which we con- sider several therapies that have their basis in meditation. These are sometimes called mind-body interventions, and they include yoga, hypnosis, mind- fulness meditation, and guided imagery. Finally, we turn to massage therapy, chiropractic medicine, and osteopathy, which involve the manipulation of soft tis- sue or spine and joints. Dietary Supplements and Diets Dietary supplements contain nutrients in amounts that are as high or higher than levels recommended by the United States Institute of Medicine’s daily recom- mendations. Over one-half of the U.S. population regularly uses dietary supplements, the most common being multivitamins (Gahche et al., 2011). Calcium is taken by nearly 61 percent of women over age 60, and consumption of folic acid and vitamin D supplements has also substantially increased in recent years (Gahche et al., 2011). Although dietary supplements are typically taken by healthy people in the belief that high doses of vitamins can help stave off illness, there is little systematic evidence for this position (Institute of Medicine, 2010; National Institutes of Health, 2006; Nestle & Nesheim, 2013). Moreover, supple- ments that contain iron are associated with increased mortality risk among older women (Mursu, Robien, Harnack, Park, & Jacobs, 2011). Accordingly, some practitioners maintain that dietary supplements should be reserved for people who have symptomatic nutrient deficiency disorders; in these cases, dietary supple- ments have clear health benefits. Overall, the use of dietary supplements is not related to improved health (Rabin, 2012). Many people who take supplements believe that they can stave off chronic disease, but until recently this has been more Chapter 9 Patients, Providers, and Treatments 189 Manheimer, Linde, Lao, Bouter, & Berman, 2007), although how it does so is not fully known. Acupunc- ture may function partly as a counterirritation pain management technique. It is typically accompanied by relaxation, a belief that acupuncture will work, and preparation regarding what sensations the needles will cause and how to tolerate them. All of these factors by themselves can reduce pain. Acupuncture may also be distracting, and it is often accompanied by analgesic drugs that also reduce pain. Some benefits may also be due to placebo effects. Finally, acupuncture may trig- ger the release of endorphins, which reduces the experi- ence of pain. An evaluation of the effectiveness of acupuncture is difficult because of its limited use in the United States. Of 32 reviews of the acupuncture literature, 25 of them failed to demonstrate its effectiveness with respect to many disorders (Ernst, 2009). There may be some ben- efits for certain kinds of pain (Birch, Hesselink, Jonk- man, Hekker, & Bos, 2004), especially short-term pain, but it is not as effective for chronic pain. The broad claims for acupuncture have not yet been upheld scientifically (Ernst, 2009; Ernst, Lee, & Choi, 2011). Moreover, there are some risks of ad- verse effects, such as bleeding or infection (Ernst, Lee, & Choi, 2011). As is true for many other evalua- tions of CAM therapies, studies of acupuncture’s ef- fectiveness are typically limited by small samples, poor controls, and poor design (Ahn et al., 2008). Consequently, using the standards of evidence-based medicine, conclusions regarding the effectiveness of acupuncture for disorders other than management of acute pain are not definitive. Yoga Yoga has been practiced for more than 5,000 years, although it has only recently become popular in the United States. Yoga is a general term that includes breathing techniques, posture, strengthening exercises, and meditation. Originating in spiritual traditions in India, yoga is now practiced by approximately 21 million people in the United States on a regular basis (National Center for Complementary and Inte- grative Health, 2015). The yoga market is a multi- billion dollar industry in the United States, and yoga is now used to treat chronic pain, bronchitis, symp- toms associated with menopause, and a variety of mental and physical ailments related to stress, in- cluding anxiety and depression. Because stress and anxiety contribute to many chronic disorders and religion is important in their personal lives (80 percent). Nearly half the population in the United States uses prayer to deal with health problems (Zimmerman, 2005, March 15). Prayer may have some benefits for coping with illness. For example, in one study, surgery patients with strong religious beliefs experienced fewer com- plications and had shorter hospital stays than those with less strong religious beliefs (Contrada et al., 2004). Spiritual beliefs have been tied to better health practices (Hill, Ellison, Burdette, & Musick, 2007), better health (Krause, Ingersoll-Dayton, Liang, & Su- gisawa, 1999), and longer life (Koenig & Vaillant, 2009; McCullough, Friedman, Enders, & Martin, 2009; Schnall et al., 2010). Religious attendance can protect against high blood pressure (Gillum & Ingram, 2006), complications from surgery (Ai, Wink, Tice, Bolling, & Shearer, 2009), and headache (Wachholtz & Pargament, 2008), among other disorders and symptoms (Berntson, Norman, Hawkley, & Cacioppo, 2008), perhaps because of its promotion of a healthy lifestyle (Musick, House, & Williams, 2004). How- ever, religious beliefs do not appear to retard the pro- gression of cancer or speed recovery from acute illness (Powell, Shahabi, & Thoresen, 2003). Prayer is unusual in that health psychologists have actually evaluated its efficacy with respect to evidence-based medicine standards. On the whole, despite some benefits, many of which may come from the sense of calm or relaxation that religion can pro- vide, prayer itself does not appear to reliably improve health (Masters & Spielmans, 2007; Nicholson, Rose, & Bobak, 2010). The social support that comes from religious attendance, as noted in Chapter 7, can lead to health benefits, but reliable effects of prayer on health have not been found. Acupuncture Acupuncture has been in existence in China for more than 2,000 years. In acupuncture treatment, long, thin needles are inserted into designated areas of the body that theoretically influence the areas in which a patient is experiencing a disorder. Although the main goal of acu- puncture is to cure illness, it may also have an analgesic effect. In China, some patients are able to undergo surgery with only the analgesia of acupuncture. During surgery, these patients are typically conscious, fully alert, and able to converse while the procedures are going on. Acupuncture is often used to control pain (Cherkin et al., 2009; Madsen, Gøtzsche, Hróbjartsson, 2009; 190 Part Four Seeking and Using Health Care Services often achieve an advanced state of relaxation and con- trol of bodily processes. Mindfulness meditation, which was discussed in Chapter 7, teaches people to strive for a state of mind marked by awareness and to focus on the present moment, accepting and acknowledging it without becoming dis- tracted or distressed by stress. Thus, the goal of mindful- ness meditation is to help people approach stressful situations mindfully, rather than reacting to them auto- matically (Bishop, 2002; Hölzel et al., 2011). More empirical investigations have been conducted on mindfulness meditation than on most other CAM therapies. Certain aspects of meditation may be helpful for managing pain (Perlman, Salomons, Davidson, & Lutz, 2010). On the whole, it appears to be successful in controlling stress and anxiety (Chiesa & Serretti, 2009; Grossman, Niemann, Schmidt, & Walach, 2004) and managing HPA reactivity of biological stress responses and blood pressure in response to stress (Jacobs et al., 2013; Nyklíček, Mommersteeg, Van Beugen, Ramakers, & Van Boxtel, 2013). Mindfulness meditation may also be an effective treatment for certain functional disorders such as fibromyalgia (Grossman, Tiefenthaler-Gilmer, Raysz, & Kesper, 2007). Most studies of mindfulness meditation, however, compare those who have been trained in the practice with waitlist controls, that is, peo- ple who are motivated to learn mindfulness but have not yet had the opportunity. True control groups are rare. In one of the few studies to date that has randomly assigned people to mindfulness meditation or to a control group, mindfulness training had some impact on alleviating pain but not on distress (MacCoon et al., 2012). In non- experimental studies, mindfulness-based interventions have been effective in treating depression, anxiety, and other psychiatric disorders (Ivanovski & Malhi, 2007; Keng, Smoski, & Robins, 2011). Still, as is true of most CAM therapies, the quality of the evidence remains in- consistent (Chiesa & Serretti, 2009). Guided Imagery Guided imagery is a meditative procedure that has been used to control discomfort related to illness and treatment, especially cancer. In guided imagery, a pa- tient is instructed to conjure up a picture that he or she holds in mind during a procedure or during the experi- ence of discomfort. Some practitioners of guided im- agery use it primarily to induce relaxation. The patient is encouraged to visualize a peaceful, relatively un- changing scene, to hold it in mind, and to focus on it lower quality of life, a non-pharmacologic therapy that can reduce stress and anxiety has much promise, and yoga is one popular option (Li & Goldsmith, 2012). In studies that have evaluated its effectiveness, most people report lower stress and anxiety, although many studies have small numbers of participants and are not well controlled (Li & Goldsmith, 2012; Lin, Hu, Chang, Lin, & Tsauo, 2011; Smith & Pukall, 2009). Yoga has also been used to treat cancer-related fatigue. In one study of breast cancer survivors, a yoga inter- vention significantly reduced fatigue and improved vigor (Bower et al., 2011). There is, as yet, however, no strong evidence that yoga improves physical health. Hypnosis Hypnosis is one of the oldest CAM techniques. Old medical textbooks and anthropological accounts of healing rituals provide anecdotal evidence of such extreme interventions as surgery conducted with no apparent pain while the patient was under a hypnotic trance. Hypnosis involves a state of relaxation; relaxation alone can help reduce stress and discomfort. Typically, the client is explicitly told that the hypnosis will be successful: Expectations can reduce discomfort via the placebo effect. Hypnosis is itself a distraction, and dis- traction can reduce discomfort. The patient is usually instructed to think about the discomfort differently, and the meaning attached to discomfort influences the experience. And finally, in the case of pain manage- ment, the patient undergoing hypnosis is often given painkillers or other drug treatments. The effects of hypnosis are mixed. The beneficial effects of hypnosis in reducing pain may be due at least in part to the composite effects of relaxation, reinter- pretation, distraction, and drugs. The effects of self- hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation and similar re- laxation therapies (Jensen & Patterson, 2006). The use of hypnosis for other health-related issues has not been formally evaluated. Meditation Meditation refers to a variety of therapies that focus and control attention (National Center for Comple- mentary and Integrative Health, 2016). For example, in transcendental meditation, the person focuses his or her awareness on a single object (such as a flower) or on a word or short phrase called a mantra. Meditators Chapter 9 Patients, Providers, and Treatments 191 believed to both prevent and cure illness. Chiropractic is a popular intervention in the United States, and sev- eral schools of chiropractic education train practitio- ners. About 20 percent of people in the United States will make use of chiropractic services at some point in their lives, primarily for the treatment of pain (Barnes, Powell-Griner, McFann, & Nahin, 2004). Most of the evidence for beneficial effects of chiropractic manage- ment is limited to a few small-scale studies (Pribicevic, Pollard, Bonello, & de Luca, 2010; Stuber & Smith, 2008). Accordingly, more formal evaluation of these techniques for specific disorders is needed. Osteopathy Osteopathy is an alternative medical practice that draws on the body’s ability to heal itself. Using manual and manipulative therapy, the osteopath seeks to facili- tate healing. There is little scientific evidence for the principles of osteopathy, and little empirical evidence that it is effective except for managing lower back pain (New York University Langone Medical Center, 2012). Massage In contrast to chiropracty, massage involves manipula- tion of soft tissue. In Traditional Chinese Medicine, massage (tui na) is used to manipulate the flow of qi. Massage reduces stress and is believed to boost im- mune functioning and flush waste out of the system. Certain forms of exercise such as tai chi, which are methodical and stylized, may induce a meditative state and balance the life force. fully. This process brings on a relaxed state, concen- trates attention, and distracts the patient—all tech- niques that have been shown to reduce discomfort. An example of using guided imagery to control the discomfort of a medical procedure is provided by a patient undergoing radiation therapy: When I was taking the radiation treatment, I imagined I was looking out my window and watching the trees and seeing the leaves go back and forth in the wind. Or, I would think of the ocean and watch the waves come in over and over again, and I would hope, “Maybe this will take it all away.” A different visualization technique may be used by patients trying to take a more aggressive stance toward illness and discomfort. Instead of using imag- ery to calm and soothe themselves, these patients use it to rouse themselves into a confrontive stance by imagining a combative, action-filled scene. The fol- lowing example is from a patient who used aggressive imagery in conjunction with chemotherapy treatment: I imagined that the cancer was this large dragon and the chemotherapy was a cannon, and when I was tak- ing the chemotherapy, I would imagine it blasting the dragon, piece by piece. One chemotherapy patient profited from the use of both types of imagery: It was kind of a game with me, depending on my mood. If I was peaceful and wanted to be peaceful, I would image a beautiful scene, or if I wanted to do battle with the enemy, I would mock up a battle and have my defenses ready. How effective is guided imagery? Early claims that guided imagery can cure diseases such as cancer have no foundation. However, the practice of guided imagery can alleviate stress and induce relaxation. There is some evidence that guided imagery can re- duce pain (Abdoli, Rahzani, Safaie, & Sattari, 2012; Posadzki, Lewandowski, Terry, Ernst, & Stearns, 2012), but on the whole, like other CAM therapies, there are too few rigorous randomized clinical trials that test its effectiveness (Posadzki & Ernst, 2011). Chiropractic Medicine Chiropractic medicine was founded by Daniel Palmer in 1895 and involves performing adjustments on the spine and joints to correct misalignments that are Tai chi is a Chinese martial art and form of stylized, meditative exercise, characterized by methodically slow circular and stretching movements and positions of bodily balance. © Jon Feingersh/Blend Images LLC RF 192 Part Four Seeking and Using Health Care Services formal studies have not been undertaken, and when they have, the samples are often small, the controls poor, and the designs weak. The verdict, accordingly, is out on many of these treatments (The Economist, April 2012), except in particular cases (e.g., specific dietary supplements provide benefits for nutrient deficiencies). It is difficult to evaluate CAM therapies because they are often highly individualized. Thus, formal stan- dards of evidence-based medicine run against the phi- losophy that guides CAM treatment recommendations, namely that each patient’s therapeutic regimen ad- dress that person’s specific problems. One patient’s pain may be treated through one set of CAM thera- pies, whereas another patient’s pain may be treated through a different set of individualized therapies. Because many CAM therapies have not been for- mally evaluated, the conflict posed by these therapies is this: They are now so widely used that they have become a standard part of health care, yet when and why they work is often in question. Moreover, many of these therapies, like traditional interventions, have a placebo component, which means that the mere tak- ing of an action can ameliorate a disorder largely by improving mental and physical adjustment to it. Of course many therapies that are now established as ac- tive treatments were once considered alternative treat- ments. For example, diet change (Chapter 4) and even surgery were once considered alternative medicine, but now are often well integrated into health care. This is because these treatments have been subject to the standards of evidence-based medicine, which is now the standard for making the transition from CAM to medical intervention (Committee on the Use of Complementary and Alternative Medicine, 2005). Some CAM therapies such as massage and some forms of yoga are intrinsically enjoyable, and so ask- ing if they “work” is akin to asking whether reading a book, gardening, or raising tropical fish “works.” They don’t need to work medically to have a beneficial im- pact on well-being. Moreover, if people feel less “stressed out” after having practiced some CAM thera- pies, such as meditation or guided imagery, that may be benefit enough. Overall, though, as patients insist on having more of these alternative therapies included in their treatment, as they pester their physicians and insurance companies to have CAM therapies covered, and as they expend billions of dollars on CAM thera- pies, the pressure to formally evaluate these treatments through more rigorous research mounts. Thus, at present, the importance of CAM derives from the fact that millions of people worldwide use Massage is also used to control stress and pain, and about 5 percent of people in the United States use massage as CAM (Barnes, Powell-Griner, McFann, & Nahin, 2004). Some studies have found massage to be effective for persistent back pain, but the studies are limited by small samples, poor controls, and weak de- signs (Cherkin, Sherman, Deyo, & Shekelle, 2003). Who Uses CAM? Most people who use CAM use only one form. That is, people who take dietary supplements do not neces- sarily also practice yoga or seek treatment from chiro- practors. About 20 percent of adults use two different CAM therapies, but only 5 percent use three or more. Most commonly, those who use more than one CAM therapy combine herbal or dietary supplements with prayer or meditation (Neiberg et al., 2011). Why do people use complementary and alternative medicines? People often turn to CAM if they have disor- ders that are not successfully treated by traditional medi- cine. These include functional disorders that are not well managed by traditional medicine, such as chronic fatigue syndrome; chronic conditions whose existence or treat- ment create side effects, such as cancer; and intractable pain problems, such as back problems or neck pain (Barnes, Powell-Griner, McFann, & Nahin, 2004). De- pression, anxiety, stress, insomnia, severe headaches, and stomach and intestinal disorders also prompt the use of CAM therapies, particularly when these conditions have not been successfully treated through traditional medicine (Frass et al., 2012). Experiencing delays in re- ceiving medical care and high costs of medical care can also lead to use of CAM therapies. Use of CAM thera- pies, particularly chiropractic care, massage, and acu- puncture, increase significantly when access to conventional care has been restricted (Su & Li, 2011). CAM therapies are used more by white people than by minorities, and are especially used by non- Hispanic white middle-aged older women (Frass et al., 2012; Gahche et al., 2011). The typical CAM therapy for this group is a dietary supplement contain- ing calcium. Overall, the use of CAM therapies has grown in the past two decades, especially among non- Hispanic whites (Gahche et al., 2011). Complementary and Alternative Medicine: An Overall Evaluation There is currently insufficient evidence to evaluate the effectiveness of most CAM therapies. In many cases, Chapter 9 Patients, Providers, and Treatments 193 Egyptian mummy (Shapiro, 1960). As late as the 17th and 18th centuries, patients were subjected to blood- letting, freezing, and repeatedly induced vomiting to bring about a cure (Shapiro, 1960). Such accounts make it seem miraculous that any- one survived these early medical treatments. But peo- ple did; moreover, they often seemed to get relief from these peculiar and largely ineffective remedies. Physi- cians have for centuries been objects of great venera- tion and respect, and this was no less true when few remedies were actually effective. To what can one at- tribute the success that these treatments provided? The most likely answer is that these treatments are examples of the placebo effect. What Is a Placebo? A placebo is “any medical procedure that produces an effect in a patient because of its therapeutic intent and not its specific nature, whether chemical or physical” (Liberman, 1962, p. 761). The word comes originally from Latin, meaning “I will please.” Any medical pro- cedure, ranging from drugs to surgery to psychother- apy, can have a placebo effect. Placebo effects extend well beyond the beneficial results of ineffective substances (Stewart-Williams, 2004; Webb, Simmons, & Brandon, 2005). Much of the effectiveness of active treatments that produce real these therapies and spend billions of dollars doing so (The Economist, April 2012). Moreover, more people use self-care and CAM therapies to treat themselves when they are ill than use traditional medicine (Suzuki, 2004), and millions of these people practice integra- tive medicine, that is, the combination of alternative medicine with conventional medicine. Given wide- spread use, the effectiveness and safety of these thera- pies is essential, and so continued evaluation of their effectiveness is critical (Selby & Smith-Osborne, 2013). Moreover, because some use of CAM therapies results from unmet treatment and emotional needs, these factors merit consideration in the treatment pro- cess as well. ■ THE PLACEBO EFFECT Consider the following: ∙ Inhaling a useless drug improved lung function in children with asthma by 33 percent. ∙ People exposed to fake poison ivy develop rashes. ∙ Forty-two percent of balding men who took a placebo maintained or increased their hair growth. ∙ Sham knee surgery reduces pain as much as real surgery (Blakeslee, 1998, October 13). All of these surprising facts are due to one effect— the placebo. History of the Placebo In the early days of medicine, few drugs or treatments gave any real physical benefit. As a consequence, patients were treated with a variety of bizarre, largely ineffective therapies. Egyptian patients were medi- cated with “lizard’s blood, crocodile dung, the teeth of a swine, the hoof of an ass, putrid meat, and fly specks” (Findley, 1953), concoctions that were not only ineffective but dangerous. If the patient did not succumb to the disease, he or she had a good chance of dying from the treatment. Medical treatments of the Middle Ages were somewhat less lethal, but not much more effective. These European patients were treated with ground-up “unicorn’s horn” (actually, ground ivory), bezoor stones (supposedly a “crystallized tear from the eye of a deer bitten by a snake” but actually an animal gallstone or other intestinal piece), theriac (made from ground-up snake and between 37 and 63 other ingredients), and, for healing wounds, powdered This 16th-century woodcut shows the preparation of theriac, a supposed antidote to poison. If theriac was a successful treatment, it was entirely due to the placebo effect. © INTERFOTO/Alamy 194 reveals that when patients report reduced pain after taking a placebo, they also show decreased activity in pain-sensitive regions of the brain (Wager et al., 2004). Evidence like this suggests that placebos may work via some of the same biological pathways as “real” treatments (Lieberman et al., 2004; Petrovic, Kalso, Peterson, & Ingvar, 2002). Box 9.6 describes a case of a successful placebo effect with a cancer patient. What factors determine when placebos are most effective? Provider Behavior and Placebo Effects The effectiveness of a placebo varies depending on how a provider treats the patient and how much the provider seems to believe in the treatment (Kelley et al., 2009). Providers who exude warmth, confidence, and empathy get stronger placebo effects than do more remote and formal providers. Placebo effects are strengthened when the provider radiates competence and provides reassurance to the patient that the condi- tion will improve. Taking time with patients and not rushing them also strengthens placebo effects (Liberman, 1962; Shapiro, 1964). Signs of doubt or skepticism may be communicated subtly, even nonverbally, to a patient, and these signs will reduce the effect. Patient Characteristics and Placebo Effects Some patients show stronger placebo effects than oth- ers. People who have a high need for approval or low self-esteem and who are persuadable in other contexts show stronger placebo effects. Anxious people cures on their own includes a placebo component. For example, in one study (Beecher, 1959), patients com- plaining of pain were injected with either morphine or a placebo. Although morphine was substantially more effective in reducing pain than was the placebo, the placebo was a successful painkiller in 35 percent of the cases. In summarizing placebo effects, A. K. Shapiro (1964) stated: Placebos can be more powerful than, and reverse the action of, potent active drugs. . . . The incidence of placebo reactions approaches 100% in some studies. Placebos can have profound effects on organic illnesses, including incurable malignancies. . . . Place- bos can mimic the effects usually thought to be the exclusive property of active drugs. (p. 74) How does a placebo work? People do not get better only because they think they are going to get better, although expectations play an important role (Geers, Wellman, Fowler, Rasinski, & Helfer, 2011; Webb, Hendricks, & Brandon, 2007). Nor does a pla- cebo work simply because the patient is distracted from the condition (Buhle, Stevens, Friedman, & Wager, 2012). The placebo response is a complex, psychologically mediated chain of events that often has physiological effects. For example, if the placebo reduces a negative mood, then activation of stress systems may be reduced (Aslaksen & Flaten, 2008). Placebos may also work in part by stimulating the re- lease of opioids, the body’s natural painkillers (Levine, Gordon, & Fields, 1978). Research that examines brain activity using fMRI (functional magnetic resonance imaging) technology A dramatic example of the efficacy of the placebo effect is provided by the case history of a cancer patient, Mr. Wright. The patient thought he was being given injections of a controversial drug, Krebiozen, about which his physician was highly enthusiastic. In fact, knowing that Krebiozen was not an effective treatment, the physician gave Mr. Wright daily injections of nothing but fresh water. The effects were astonishing: Tumor masses melted. Chest fluid vanished. He became ambulatory and even went back to flying again. At this time he was certainly the picture of health. The water injections were continued since they worked such wonders. He then remained symptom-free for over 2 months. At this time the fi- nal AMA announcement appeared in the press— “Nationwide Tests Show Krebiozen to Be a Worth- less Drug in Treatment of Cancer.” Within a few days of this report, Mr. Wright was readmitted to the hospital in extremis; his faith was now gone, his last hope vanished, and he succumbed in less than 2 days. Source: Klopfer, 1959, p. 339. B O X 9.6 Cancer and the Placebo Effect Chapter 9 Patients, Providers, and Treatments 195 appears to reduce the drug’s effectiveness and increase side effects, despite no change in the active ingredients (Faasse, Cundy, Gamble, & Petrie, 2013). The nocebo effect refers to the fact that informa- tion about potential adverse effects of a condition or treatment may help produce those adverse effects (Colloca & Miller, 2011). The nocebo effect relies on many of the same mechanisms as placebo effects do. That is, negative expectations can influence mood and symptoms just as positive expectations do (Crichton, Dodd, Schmid, Gamble, Cundy, & Petrie, 2014). For example, one study found that exposing people to information suggesting that wind farm noise can have adverse health effects found an increase in symptoms and negative mood (Crichton et al., 2014). Social Norms and Placebo Effects The placebo effect is facilitated by norms that sur- round treatment regimens—that is, the expected way in which treatment will be enacted. Drug taking is a normative behavior. In the United States, people spend approximately $297 billion each year on pre- scription drugs and an additional $56.9 billion on non-durable medical products such as over-the- counter drugs (Centers for Medicare and Medicaid Services, 2015). About 40 percent of Americans use at least one prescription medication regularly, and 12 percent use three or more (National Center for Health Statistics, 2009) (Figure 9.4). A large number of people are killed or seriously injured each year by overzealous drug taking. Forty- eight percent of people in the United States take at least one prescription drug each month and 11 percent take five or more (Gu, Dillon, & Burt, 2010). There are more than 2.5 million emergency department visits due to adverse side effects or disabilities in the United States each year (Centers for Disease Control and Pre- vention, October 2015), which cost hospitals at least $3 billion in longer hospital stays and other complica- tions (Hansen, Oster, Edelsberg, Woody, & Sullivan, 2011). The more general cost to society of adverse drug reactions is estimated to be $55.7 billion a year (Cen- ters for Disease Control and Prevention, October 2015). However, the drug-taking epidemic continues un- abated. Clearly, there is enormous faith in medications, and the psychological if not the physical benefits can be quite substantial. Thus, placebos are effective in part because people believe that drugs work and because they have a great deal of experience with drug taking. experience stronger placebo effects. This effect seems to result less from personality than from the fact that anxiety produces physical symptoms, including dis- tractibility, racing heart, sweaty palms, nervousness, and difficulty sleeping. When a placebo is adminis- tered, anxiety may be reduced, and this overlay of anxiety-related symptoms may disappear (Sharpe, Smith, & Barbre, 1985). Patient-Provider Communication and Placebo Effects As previously noted, good communication between provider and patient is essential if patients are to fol- low through on their prescribed treatment regimens. This point is no less true for placebo responses. For patients to show a placebo response, they must under- stand what the treatment is supposed to do and what they need to do. One benefit of the placebo is the symbolic value it has for the patient. When patients seek medical treatment, they want an expert to tell them what is wrong and what to do about it. When a disorder is di- agnosed and a treatment regimen is prescribed, how- ever ineffective, the patient has tangible evidence that the provider knows what is wrong and has done some- thing about it (Shapiro, 1964). Situational Determinants of Placebo Effects A setting that has the trappings of medical formality (medications, machines, uniformed personnel) will in- duce stronger placebo effects than will a less formal set- ting. If all the staff radiate as much faith in the treatment as the physician, placebo effects will be heightened. The shape, size, color, taste, and quantity of the placebo also influences its effectiveness: The more a drug seems like medicine, the more effective it will be (Shapiro, 1964). Treatment regimens that seem medi- cal and include precise instructions produce stronger placebo effects than regimens that do not seem very medical. Thus, for example, foul-tasting, peculiar- looking little pills that are taken in precise dosages (“take two” as opposed to “take two or three”) and at prescribed intervals will show stronger placebo effects than will good-tasting, candylike pills with dosage lev- els and intervals that are only roughly indicated (“take one or two anytime you feel discomfort”). Interest- ingly, changing from a branded to a generic drug 196 Part Four Seeking and Using Health Care Services so doing is termed a double-blind experiment. In such a test, a researcher gives one group of patients a drug that is supposed to cure a disease or alleviate symptoms; another group receives a placebo. The procedure is called double-blind because neither the researcher nor the patient knows whether the patient received the drug or the placebo; both are “blind” to the procedure. Once the effectiveness of the treat- ment has been measured, the researcher looks in the coded records to see which treatment each patient received. The difference between the effectiveness of the drug and the effectiveness of the placebo is considered to be a measure of the drug’s effective- ness (America & Milling, 2008). Comparison of a drug against a placebo is essential for accurate mea- surement of a drug’s effect. Drugs may look four or five times more successful than they really are if there is no effort to evaluate them against a placebo (Miller, 1989). ∙ Equally important is the fact that most people have no experience that disconfirms their drug taking. If one is ill, takes a drug, and subsequently gets better, as most of us do most of the time, one does not in real- ity know exactly what caused this result. A drug may be responsible; the disease may have run its course; or one’s mood may have picked up, altering the body’s physiological balance and making it no longer recep- tive to an invader. Probably a combination of factors is at work. Regardless of the actual cause of success, the patient acting as his or her own naïve physician will probably attribute success to whatever drug he or she took, however erroneous that conclusion may be. The Placebo as a Methodological Tool The placebo response is so powerful that no drug can be marketed in the United States unless it has been evaluated against a placebo. The standard method for 2005 $300 2006 2007 2008 2009 Billions of Dollars $50 $100 $150 $200 $250 Y ea r FIGURE 9.4 | Prescription Drug Spending 2005–2009 (Source: Centers for Medicare and Medicaid Services, 2011) Chapter 9 Patients, Providers, and Treatments 197 1. Patients evaluate their health care based more on the quality of the interaction they have with the provider than on the technical quality of care. 2. But many factors can impede effective patient- provider communication. The office setting and the structure of the health care delivery system are often designed for efficient rather than supportive health care. 3. Providers contribute to poor communication by not listening, using jargon-filled explanations, alternating between overly technical explanations and infantilizing baby talk, communicating negative expectations, and depersonalizing the patient. 4. Patients contribute to poor communication by failing to learn details of their disorder and treatment, failing to give providers correct information, and failing to follow through on treatment recommendations. Patient anxiety, lack of education, and lack of experience with the disorder interfere with effective communication as well. 5. Because the provider usually receives little feedback about whether the patient followed instructions or the treatments were successful, it is difficult to identify and correct problems in communication. 6. Poor communication leads to nonadherence to treatment and, potentially, the initiation of malpractice litigation. 7. Adherence to treatment is lower when recommendations do not seem medical, when lifestyle modification is needed, when complex self-care regimens are required, and when patients hold theories about the nature of their illness or treatment that conflict with medical theories. 8. Adherence is increased when patients have decided to adhere, when they feel the provider cares about them, when they understand what to do, and when they have received clear written instructions. 9. Efforts to improve communication include training in communication skills. Patient- centered communication improves adherence. Face-to-face communication with a physician can enhance adherence to treatment because of the personalized relationship that exists. 10. The hospital is a complex organizational system buffeted by changing medical, organizational, and financial climates. Different groups in the hospital have different goals, such as cure, care, or core, which may occasionally conflict. Such problems are exacerbated by communication barriers. 11. Hospitalization can be a frightening and depersonalizing experience for patients. The adverse reactions of children in hospitals have received particular attention. 12. Information and control-enhancing interventions improve adjustment to hospitalization and to stressful medical procedures in both adults and children. 13. Nearly two-thirds of adults in the United States use complementary and alternative medicine (CAM) instead of or in conjunction with traditional medicine. The most common of these are prayer and herbal or vitamin supplements. Other common CAM therapies include meditation, yoga, massage, acupuncture, chiropracty, osteopathy, hypnosis, and guided imagery. 14. People are more likely to turn to CAM therapies if their disorders have not been successfully treated by traditional medicine. Evaluation of CAM therapies has been difficult because they are often individualized, and thus, treatment does not conform to standards required for formal evaluation using standards of evidence-based medicine. 15. Overall, the evidence for CAM therapies suggests success of certain therapies for the management of pain. For other disorders there is as yet insufficient evidence. 16. A placebo is any medical procedure that produces an effect in a patient because of its therapeutic intent and not its actual nature. Virtually every medical treatment shows some degree of placebo effect. 17. Placebo effects are enhanced when the physician shows faith in a treatment, the patient is S U M M A R Y 198 Part Four Seeking and Using Health Care Services 18. Placebos are also a vital methodological tool in evaluating drugs and other treatments. predisposed to believe it will work, these expec- tations are successfully communicated, and the trappings of medical treatment are in place. K E Y T E R M S acupuncture adherence ayurvedic medicine chiropractic medicine colleague orientation complementary and alternative medicine (CAM) creative nonadherence dietary supplements double-blind experiment guided imagery health maintenance organization (HMO) holistic medicine homeopathy hypnosis integrative medicine managed care nonadherence patient-centered care placebo placebo effect preferred-provider organization (PPO) private, fee-for-service care Traditional Chinese Medicine yoga 199 C H A P T E R 10 C H A P T E R O U T L I N E The Elusive Nature of Pain Measuring Pain The Physiology of Pain Neurochemical Bases of Pain and Its Inhibition Clinical Issues in Pain Management Acute and Chronic Pain Pain and Personality Pain Control Techniques Pharmacological Control of Pain Surgical Control of Pain Sensory Control of Pain Biofeedback Relaxation Techniques Distraction Coping Skills Training Cognitive-Behavioral Therapy Pain Management Programs Initial Evaluation Individualized Treatment Components of Programs Involvement of Family Relapse Prevention Evaluation of Programs The Management of Pain and Discomfort © Andersen Ross/Blend Images LLC RF 200 Part Four Seeking and Using Health Care Services 2010; Kalaydjian & Merikangas, 2008). Unfortu- nately, the relationship between pain and the severity of an underlying problem can be weak. For example, a cancerous lump rarely produces pain, at least in its early stages, yet it is of great medical importance. Pain is also medically significant because it can be a source of misunderstanding between a patient and the medical provider. From the patient’s standpoint, pain is the problem. To the provider, pain is a by-product of a disorder. In fact, pain is often considered by practitio- ners to be so unimportant that many medical schools have little systematic coverage of pain in their curricula. This lack of attention to pain is misguided. Although the practitioner focuses attention on symptoms, which, from a medical standpoint, may be more meaningful, the pa- tient may feel that an important problem is not getting sufficient attention. As we saw in Chapter 9, patients may choose not to comply with their physician’s recom- mendations if they think they have been misdiagnosed or if their chief symptoms have been ignored. Pain has psychological as well as medical signifi- cance (Keefe et al., 2002). When patients are asked what they fear most about illness and its treatment, the common response is pain. The dread of not being able to reduce one’s suffering arouses more anxiety than the prospect of surgery, the loss of a limb, or even death. In fact, inadequate relief from pain is the most common reason for patients’ requests for euthanasia or assisted suicide (Cherny, 1996). Moreover, depres- sion, anxiety, guilt, and anger worsen the experience of pain (Berna et al., 2010; Burns et al., 2016; Serbic, Pincus, Fife-Schaw, & Dawson, 2016). Pain has social causes and consequences (Burns et  al., 2016; Eisenberger, 2012a, 2012b). Although social support is usually helpful to people undergoing chronic problems, social support for pain can inadver- tently act as reinforcement of pain behaviors, which then become part of the pain problem. Moreover, physical pain overlaps with social pain (Eisenberger, 2012a, 2012b). That is, social pain, namely the feeling of social rejection or loss, relies on the same pain- related neurocircuitry that physical pain relies on, suggesting that there are meaningful similarities in the way that social and physical pain are experienced. These insights may also help explain why psychologi- cal distress is such a key component of physical pain. No introduction to pain would be complete without a consideration of its prevalence and cost. Chronic pain lasting at least 6 months or longer affects nearly 116 million people in the United States (Jensen & Turk, Pain hurts, and it can be so insistent that it over-whelms other basic needs. But the significance of pain goes beyond the disruption it produces. Although we think of pain as an unusual occurrence, we actually live with minor pains all the time. These pains are critical for survival because they provide low-level feedback about the functioning of our bodily systems. We use this feedback, often unconsciously, as a basis for making minor adjustments, such as shifting our posture, rolling over while asleep, or crossing and un- crossing our legs. Pain also has medical significance. It is the symp- tom most likely to lead a person to seek treatment (see Chapter 8). It can complicate illnesses and ham- per recovery from medical procedures (McGuire et al., 2006). Complaints of pain often accompany men- tal and physical disorders, and this comorbidity fur- ther complicates diagnosis and treatment (Berna et al., Pain is a valuable cue that tissue damage has occurred and activities must be curtailed. © Eyewire/Getty Images RF Chapter 10 The Management of Pain and Discomfort 201 experience, and the degree to which it is felt and how incapacitating it is depend in large part on how it is in- terpreted. Howard Beecher (1959), a physician, was one of the first to recognize this. During World War II, Beecher served in the medical corps, where he ob- served many wartime injuries. In treating soldiers, he noticed a curious fact: Only 25 percent of them re- quested morphine (a widely used painkiller) for what were often severe and very likely painful wounds. When Beecher returned to his Boston civilian prac- tice, he often treated patients who sustained compa- rable injuries from surgery. However, in contrast to the soldiers, 80 percent of the civilians appeared to be in great pain and demanded painkillers. To make sense of this apparent discrepancy, Beecher concluded that the meaning attached to pain substantially deter- mines how it is experienced. For the soldier, an injury meant that he was alive and was likely to be sent home. For the civilian, the injury represented an un- welcome interruption of valued activities. Pain is also heavily influenced by the context in which it is experienced. Sports lore is full of accounts of athletes who injured themselves on the playing field but stayed in the game, apparently oblivious to their pain. One reason is that sympathetic arousal, as occurs in response to vigorous sports, diminishes pain sensitivity (Fillingham & Maixner, 1996; Zillman, de 2014), and costs in disability and lost productivity add up to more than $560 billion annually (Gatchel, McGeary, McGeary, & Lippe, 2014). Nearly two-thirds of people in the United States suffer from back pain at some time in their life, 52 million people suffer from daily arthritis pain, 45 million have chronic headaches, and the majority of patients in intermediate or advanced stages of cancer suffer moderate to severe pain (American Physical Therapy Association, 2012; Centers for Disease Control and Prevention, January 2016; CBS News, 2012; North American Neuromodu- lation Society, 2011). Nearly 25 percent of people who live in nursing homes have chronic pain (Sengupta, Bercovitz, & Harris-Kojetin, 2010). Even children can experience chronic pain (Palermo, Valrie, & Karlson, 2014). The worldwide pain management prescription drug market totaled $46.4 billion in 2011 (Dutton, 2012). In the United States, use of addictive pain killers may contribute to declining life expectancy among poorly- educated whites (Case & Deaton, 2015). The pain busi- ness is big business, reflecting the suffering, both chronic and temporary, that millions of people experience. ■ THE ELUSIVE NATURE OF PAIN Pain is one of the more elusive aspects of illness and its treatment. It is fundamentally a psychological At least $2.6 billion is spent annually in the United States on over-the-counter remedies to reduce the temporary pain of minor disorders. © Erica S. Leeds RF 202 use this information to understand patients’ com- plaints. A throbbing pain, for example, has different implications than does a shooting pain or a constant, dull ache. Researchers have developed pain questionnaires to assess pain (Osman, Breitenstein, Barrios, Gutierrez, & Kopper, 2002) (Figure 10.1). Such measures typically ask about the nature of pain, such as whether it is throb- bing or shooting, as well as its intensity (Dar, Leventhal, & Leventhal, 1993; Fernandez & Turk, 1992). Measures also address the psychosocial components of pain, such as how much fear it causes and how much it has taken over a person’s life (Osman et al., 2000). Measures like these can help practitioners get a full picture of the patient’s pain. A novel effort to assess pain appears in Box 10.2. Methodological tools from neuroscience have yielded insights about pain. Patients with chronic pain disorders show significant loss of gray matter in the brain regions involved in the processing of pain, spe- cifically the prefrontal, cingular, and insular cortex (Valet et al., 2009). These structural markers not only provide objective neural information about changes in the brain due to pain, but may also be useful for Wied, King-Jablonski, & Jenzowsky, 1996). In con- trast, stress and psychological distress aggravate the experience of pain (Strigo, Simmons, Matthews, Craig, & Paulus, 2008). Pain has a substantial cultural component. People from some cultures report pain sooner and react more intensely to it than individuals from other cultures (Lu, Zeltzer, & Tsao, 2013; Palit et al., 2013). An example of these kinds of cultural differences appears in Box 10.1. There are gender differences in the experience of pain as well, with women typically showing greater sensitivity to pain (Burns, Elfant, & Quartana, 2010). Measuring Pain One barrier to the treatment of pain is the difficulty people have in describing it objectively. If you have a lump, you can point to it; if a bone is broken, it can be seen in an X-ray. But pain does not have these objective referents. Verbal Reports One solution to measuring pain is to draw on the large, informal vocabulary that people use for describing pain. Medical practitioners usually B O X 10.1 A Cross-Cultural Perspective on Pain: The Childbirth Experience Although babies are born in every society, the child- birth experience varies dramatically from culture to culture, and so does the experience of pain associated with it. Among Mexican women, for example, the word for labor (dolor) means sorrow or pain, and the expectation of giving birth can produce a great deal of fear. This fear and the anticipation of pain can lead to a more painful experience with more complications than is true for women who do  not bring these fears  and expectations to the  birthing experience (Scrimshaw, Engle, & Zambrana, 1983). In contrast is the culture of Yap in the South Pacific, where childbirth is treated as an everyday occurrence. Women in Yap perform their normal activities until they begin labor, at which time they retire to a childbirth hut to give birth with the aid of perhaps one or two other women. Following the birth, there is a brief period of rest, after which the woman resumes her activities. Problematic labors and complications during pregnancy are reported to be low (Kroeber, 1948). The meaning attached to an experience substantially determines whether it is perceived as painful. For many women, the joy of childbirth can mute the pain associated with the experience. © Digital Vision/Getty Images RF Chapter 10 The Management of Pain and Discomfort 203 from chronic pain, such as distortions in posture or gait, facial and audible expressions of distress, and avoidance of activities (Turk, Wack, & Kerns, 1995). Pain behaviors provide a basis for assessing how pain has disrupted the life of particular patients or groups charting functional pain disorders, such as fibromyal- gia, in which no clear tissue damage is present. Pain Behavior Other assessments of pain have focused on pain behaviors—behaviors that arise FIGURE 10.1 | The McGill Pain Questionnaire (Source: Melzack, R. (1983). Pain Measurement and Assessment. New York: Raven Press) 204 Emotional factors are greatly intertwined with the experience of pain. Negative emotions exacerbate pain, and pain exacerbates negative emotions (Gilliam et al., 2010). As will be seen, these emotions often need to be targeted alongside the management of pain itself. Scientists have distinguished among three kinds of pain perception. The first is mechanical nociception— pain perception—that results from mechanical dam- age to the tissues of the body. The second is thermal damage, or the experience of pain due to temperature exposure. The third is referred to as polymodal noci- ception, a general category referring to pain that trig- gers chemical reactions from tissue damage. Gate Control Theory of Pain Originally, the scientific understanding of pain was developed in the gate-control theory of pain (Melzack & Wall, 1982). Although our knowledge of the physiology of pain has now progressed beyond that early model, it was cen- tral to the progress that has been made in recent de- cades. Many of its insights are reflected in our current knowledge of the physiology of pain. Nociceptors in the peripheral nerves first sense injury and, in response, release chemical messengers, of patients. Because pain behavior is observable and measurable, the focus on pain behaviors has helped define the characteristics of different kinds of pain syndromes. The Physiology of Pain Pain has psychological, behavioral, and sensory com- ponents, and this perspective is useful for making sense of the manifold pathways and receptors involved in the pain experience. Overview The experience of pain is a protective mechanism to bring tissue damage into conscious awareness. At the time of the pain experience, how- ever, it is unlikely to feel very protective. Unlike other bodily sensations, the experience of pain is accompa- nied by motivational and behavioral responses, such as withdrawal, and intense emotional reactions, such as crying or fear, and both verbal and nonverbal commu- nication to others who can ameliorate or enhance the pain experience (Hadjistavropoulos et al., 2011). All of these factors are an integral part of the pain experi- ence and are important to diagnosis and treatment. B O X 10.2 Headache Drawings Reflect Distress and Disability A recent way that psychologists have come to under- stand people’s experiences with pain is through their drawings. In one study, students who experienced persistent headaches were asked to draw a picture of how their headaches affected them. The psycholo- gists (Broadbent, Niederhoffer, Hague, Corter, & Reynolds, 2009) analyzed these drawings for their size, darkness, and content. They found that darker drawings were associated with greater emotional distress and larger drawings were associated with perceptions of worse conse- quences and symptoms, more pain, and greater sad- ness. Drawings, then, offer a novel way to assess people’s experiences of their headaches and appear to reliably reflect illness perceptions and distress (Kirkham, Smith, & Havsteen-Franklin, 2015). These may be a useful way for practicing clinicians to better understand their patients’ experiences of pain. BRAIN Source: Broadbent, Niederhoffer, Hague, Corter, & Reynolds, 2009. Chapter 10 The Management of Pain and Discomfort 205 determined by activity in the A-delta fibers, which project onto areas in the thalamus and the sensory areas of the cerebral cortex (see Figure 10.2). The motivational and affective elements of pain appear to be influenced more strongly by the C-fibers, which project onto different thalamic, hypothalamic, and cortical areas. The experience of pain, then, is deter- mined by the balance of activity in these nerve fibers, which reflects the pattern and intensity of stimulation. Several other regions of the brain are involved in the modulation of pain (Derbyshire, 2014). The periductal gray, a structure in the midbrain, has been tied to pain relief when it is stimulated. Neurons in the periductal gray connect to the reticular formation in the medulla, which makes connections with the neurons in the substantia gelatinosa of the dorsal horn of the spinal cord. Sensations are modulated by the dorsal horn in the spinal column and by downward pathways from the brain that interpret the pain experience. Inflammation that originally occurs in peripheral tissue may be which are conducted to the spinal cord, where they are passed directly to the reticular formation and thal- amus and into the cerebral cortex. These regions of the brain, in turn, identify the site of the injury and send messages back down the spinal cord, which lead to muscle contractions, which can help block the pain, and changes in other bodily functions, such as breathing. Two major types of peripheral nerve fibers are involved in nociception. A-delta fibers are small, my- elinated fibers that transmit sharp pain. They respond especially to mechanical or thermal pain, transmitting sharp, brief pains rapidly. C-fibers are unmyelinated nerve fibers, involved in polymodal pain, that transmit dull, aching pain. (Myelination increases the speed of transmission, so sudden, intense pain is more rapidly conducted to the cerebral cortex than is the slower, dull, aching pain of the C-fibers.) Peripheral nerve fibers enter the spinal column at the dorsal horn. Sensory aspects of pain are heavily The stimulation of nerve endings set off a pain signal. Reflex action 2 1 Pressure, heat, or the release of chemicals from a damaged cell can be sources of this stimulation. Pain signal Damaged cell Nerve ending FIGURE 10.2 | The Experience of Pain The signal from an injured area goes to the spinal cord, where it passes immediately to a motor nerve (1) connected to a muscle, in this case, in the arm. This causes a reflex action that does not involve the brain. But the signal also goes up the spinal cord to the thalamus (2), where the pain is perceived. 206 one could produce such a high level of analgesia that the animal would not feel the pain of abdominal sur- gery, a phenomenon termed stimulation-produced analgesia (SPA). Reynolds’s findings prompted researchers to look for the neurochemical basis of this effect, and in 1972, H. Akil, D. J. Mayer, and J. C. Liebeskind (1972, 1976) uncovered the existence of endogenous opioid peptides. What are endogenous opioid peptides? Opiates, including heroin and morphine, are pain control drugs manufactured from plants. Opioids are opiate-like substances, produced within the body, that constitute a neurochemically based, internal pain regulation sys- tem. Opioids are produced in many parts of the brain and glands of the body, and they project onto specific receptor sites in various parts of the body. Endogenous opioid peptides are important be- cause they are the natural pain suppression system of the body. Clearly, however, this pain suppression sys- tem is not always in operation. Particular factors must trigger its arousal. Stress is one such factor. Acute stress reduces sensitivity to pain, a phenomenon termed stress-induced analgesia (SIA), and research shows that SIA can be accompanied by an increase in brain endogenous opioid peptides (Lewis, Terman, Shavit, Nelson, & Liebeskind, 1984). The release of endogenous opioid peptides may also be one of the mechanisms underlying various techniques of pain control (Bolles & Fanselow, 1982). amplified, as pain-related information is conveyed to the dorsal horn (Ikeda et al., 2006). Pain sensation, intensity, and duration interact to influence the experience of pain, its perceived un- pleasantness, and emotional responses to it through a central network of pathways in the limbic structures and the thalamus, which direct their inputs to the cor- tex. In the cortical regions of the brain, nociceptive input is integrated with contextual information about the painful experience. Processes in the cerebral cor- tex are involved in cognitive judgments about pain, including the evaluation of its meaning, which con- tributes to the strong emotions often experienced dur- ing pain and which can themselves exacerbate pain. The overall experience of pain, then, is a complex out- come of the interaction of these elements of the pain experience (Figure 10.2). An example of just how complex pain and its management can be is provided in Box 10.3. Neurochemical Bases of Pain and Its Inhibition The brain controls the amount of pain an individual experiences by transmitting messages down the spinal cord to block the transmission of pain signals. One landmark study that confirmed this hypothesis was conducted by D. V. Reynolds (1969). He demonstrated that by electrically stimulating a portion of a rat brain, B O X 10.3 Phantom Limb Pain: A Case History Nerve injury of the shoulder is becoming increasingly common because motorcycles are widely accessible and, all too often, their power is greater than the skill of their riders. On hitting an obstruction, the rider is catapulted forward and hits the road at about the speed the bike was traveling. In the most severe of these in- juries, the spinal roots are avulsed—that is, ripped out of the spinal cord—and no repair is possible. C. A., age 25, an Air Force pilot, suffered such an accident. After 8 months, he had completely recovered from the cuts, bruises, and fractures of his accident. There had been no head injury, and he was alert, intel- ligent, and busy as a student shaping a new career for himself. His right arm was completely paralyzed from the shoulder down, and the muscles of his arm were thin. In addition, the limp arm was totally anesthetic so that he had no sensation of any stimuli applied to it. On being questioned, he stated that he could sense very clearly an entire arm, but it had no relationship to his real arm. This “phantom” arm seemed to him to be placed across his chest, while the real, paralyzed arm hung at his side. The phantom never moved and the fingers were tightly clenched in a cramped fist, with the nails digging into the palm. The entire arm felt “as though it was on fire.” Nothing has helped his condi- tion, and he finds that he can control the pain only by absorbing himself in his work. Source: Melzack & Wall, 1982, pp. 21–22. Chapter 10 The Management of Pain and Discomfort 207 chronic virtually forces sufferers to organize their lives around it. Acute Versus Chronic Pain The distinction between acute and chronic pain is important in clini- cal management for several reasons. First, acute and chronic pain present different psychological profiles. Chronic pain often carries an overlay of psychological distress, which complicates diagnosis and treatment. Depression, anxiety, and anger are common and may exacerbate pain and pain-related behaviors (Burns et al., 2008; Bair, Wu, Damush, Sutherland, & Kroenke, 2008). One study found that pain is present in two- thirds of patients who seek care from physicians with primary symptoms of depression (Bair et al., 2004). Thus, pain and depression appear to be especially heavily intertwined. Some chronic pain patients develop maladaptive coping strategies, such as catastrophizing their illness, engaging in wishful thinking, or withdrawing socially, which can complicate treatment and lead to more care seeking (Severeijns, Vlaeyen, van der Hout, & Picavet, 2004). When patients have endured their pain for long periods of time without any apparent relief, it is easy to imagine that the pain will only get worse and be a con- stant part of the rest of their life—beliefs that magnify the distress of chronic pain and feed back into the pain itself (Tennen, Affleck, & Zautra, 2006; Vowles, McCracken, & Eccleston, 2008). When these psycho- logical issues are effectively treated, this fact may in itself reduce chronic pain (Fishbain, Cutler, Rosomoff, & Rosomoff, 1998). A second reason to distinguish between acute and chronic pain is that most pain control techniques work well to control acute pain but are less successful with ■ CLINICAL ISSUES IN PAIN MANAGEMENT Historically, pain has been managed by physicians and other health care workers. Traditional pain man- agement methods include pharmacological, surgical, and sensory techniques. Increasingly, psychologists have become involved in pain management, adding techniques that include a heavily psychological com- ponent. These techniques include relaxation, hypno- sis, acupuncture, biofeedback, distraction, and guided imagery. As these methods have gained prominence, the importance of patients’ self-management, involv- ing responsibility for and commitment to the course of pain treatment, has assumed centrality in pain management. Acute and Chronic Pain There are two main kinds of clinical pain: acute and chronic. Acute pain typically results from a specific injury that produces tissue damage, such as a wound or broken limb. As such, it typically disappears when the tissue damage is repaired. Acute pain is usually short in duration and is defined as pain that goes on for 6 months or less. Although it can produce substan- tial anxiety, anxiety dissipates once painkillers are ad- ministered or the injury begins to heal. Chronic pain typically begins with an acute episode, but unlike acute pain, it does not decrease with treatment and the passage of time. There are several different kinds of chronic pain. Chronic benign pain typically persists for 6 months or longer and is relatively unresponsive to treatment. The pain varies in severity and may involve any of several muscle groups. Chronic low back pain is an example. Recurrent acute pain involves intermittent epi- sodes of pain that are acute in character but chronic inasmuch as the condition recurs for more than 6 months. Migraine headaches, temporomandibular disorder (involving the jaw), and trigeminal neuralgia (involving spasms of the facial muscles) are examples. Chronic progressive pain persists longer than 6 months and increases in severity over time. Typically, it is associated with malignancies or degenerative dis- orders, such as cancer or rheumatoid arthritis. About 116 million Americans suffer from chronic pain at any given time (Jensen & Turk, 2014), with back pain being the most common (Table 10.1). Chronic pain is not necessarily present every moment, but the fact that it is TABLE 10.1 | Common Sources of Chronic Pain • Back pain—70–85 percent of Americans have back trouble at some point in their lives. • Headaches—approximately 45 million Americans have chronic recurrent headaches. • Cancer pain—the majority of advanced cancer patients suffer moderate to severe pain. • Arthritis pain—arthritis affects 40 million Americans. • Neurogenic pain—pain resulting from damage to peripheral nerves or the central nervous system. • Psychogenic pain—pain not due to an identifiable physical cause. Source: National Institute of Neurological Disorders and Stroke, 2007. 208 Part Four Seeking and Using Health Care Services pain? Chronic pain may result from a predisposition to react to a bodily insult with a specific bodily re- sponse, such as tensing one’s jaw or altering one’s posture (Glombiewski, Tersek, & Rief, 2008). This response can be exacerbated by stress or even by efforts to suppress pain (Quartana, Burns, & Lofland, 2007). Chronic pain patients may experience pain especially strongly because of high sensitivity to noxious stimulation, impairment in pain regulatory systems, and an overlay of psychological distress (Sherman et al., 2004). Unlike acute pain, chronic pain usually has been treated through a variety of methods, used both by patients themselves and by physicians. Chronic pain may be exacerbated by inappropriate prior treatments, by misdiagnosis, and/or by inappropriate prescriptions of medications (Kouyanou, Pither, & Wessely, 1997). The Lifestyle of Chronic Pain By the time a pain patient is adequately treated, this complex, dynamic interaction of physiological, psychological, social, and behavioral components is often tightly integrated, making it difficult to modify (Flor et al., 1990). The following case history suggests the disrup- tion and agony that can be experienced by the chronic pain sufferer: A little over a year ago, George Zessi, 54, a New York furrier, suddenly began to have excruciating migraine headaches. The attacks occurred every day and quickly turned Zessi into a pain cripple. “I felt like I was suffering a hangover each morning without even having touched a drop. I was seasick without going near a boat,” he says. Because of the nausea that often accompanies migraines, Zessi lost fifty pounds. At his workshop, Zessi found himself so sensitive that he could not bear the ringing of a telephone. “I was incapacitated. It was difficult to talk to anyone. On weekends, I couldn’t get out of bed,” he says. A neurologist conducted a thorough examination and told Zessi he was suffering from tension. He took several kinds of drugs, but they did not dull his daily headaches. (Clark, 1977, p. 58) As this case history suggests, chronic pain can en- tirely disrupt a person’s life (Karoly, Okun, Enders, & Tennen, 2014). Many chronic pain patients have left their jobs, abandoned their leisure activities, with- drawn from their families and friends, and developed an entire lifestyle around pain. Because their income is often reduced, their standard of living may decline, chronic pain, which requires individualized tech- niques for its management. Third, chronic pain involves the complex interac- tion of physiological, psychological, social, and behav- ioral components, more than is the case with acute pain. For example, chronic pain patients often experience so- cial rewards from the attention they receive from family members, friends, or even employers; these social rewards, or secondary gains, can help maintain pain behaviors (McClelland & McCubbin, 2008). The psychological and social components of pain are important because they are an integral aspect of the pain experience and influence the likelihood of success- ful pain control (Burns, 2000). As such, chronic pain management is complicated and must be thought of not as merely addressing a pain that simply goes on for a long time but as an unfolding complex physiological, psychological, and behavioral experience that evolves over time into a syndrome (Jensen & Turk, 2014). Who Becomes a Chronic Pain Patient? All chronic pain patients were once acute pain patients. What determines who makes the transition to chronic More than 116 million Americans, many of them elderly, suffer from chronic pain. © BananaStock/Alamy RF Chapter 10 The Management of Pain and Discomfort 209 personality—a constellation of personality traits that predispose a person to experience chronic pain. This hypothesis is too simplistic. First, pain itself can produce alterations in personality that are conse- quences, not causes, of the pain experience. Second, individual experiences of pain are too varied and com- plex to be explained by a single personality profile. Nonetheless, certain personality attributes are reliably associated with chronic pain, including neuroticism, introversion, and the use of passive coping strategies (Ramirez- Maestre, Lopez-Martinez, & Zarazaga, 2004). Pre-existing psychological distress, including PTSD, loneliness, depression, and fatigue can also ag- gravate the pain process (Jaremka et al., 2014; Ruiz- Párraga & López-Martínez, 2014). Pain Profiles Developing psychological profiles of different groups of pain patients has proven to be helpful for treatment. To develop profiles, researchers have drawn on personality instruments, such as the Minnesota Multiphasic Personality Inventory (MMPI) (Johansson & Lindberg, 2000). Chronic pain patients typically show elevated scores on three MMPI sub- scales: hypochondriasis, hysteria, and depression. This constellation of traits is commonly referred to as the “neurotic triad.” Depression reflects the feelings of despair or hopelessness that can accompany long-term experi- ence with unsuccessfully treated pain. Depression in- creases perceptions of pain (Dickens, McGowan, & Dale, 2003), and so it can feed back into the total pain experience, increasing the likelihood of pain behaviors such as leaving work (Linton & Buer, 1995). Interven- tions with depressed pain patients must address both depression and pain (Ingram, Atkinson, Slater, Saccuzzo, & Garfin, 1990). People who suppress their anger may also experi- ence pain more strongly than people who manage an- ger more effectively or people who do not experience as much anger (Burns, Quartana, & Bruehl, 2008; Quartana, Bounds, Yoon, Goodin, & Burns, 2010). The relation of anger suppression and pain may be due to a dysfunction in the opioid system that controls pain or to psychological processes involving hypervigi- lance (Bruehl, Burns, Chung, & Quartana, 2008). Chronic pain is also associated with other forms of psychopathology, including anxiety disorders, sub- stance use disorders, and other psychiatric problems (Nash, Williams, Nicholson, & Trask, 2006; Vowles, Zvolensky, Gross, & Sperry, 2004). The reason and they may need public assistance. Economic hard- ship increases the experience of pain as well (Rios & Zautra, 2011).The pain lifestyle becomes oriented around the experience of pain and its treatment. A good night’s sleep is often elusive for months or years at a time; lack of sleep makes pain worse, and pain leads to sleep loss in a vicious cycle (Koffel, Kroneke, Bair, Leverty, Polusny, & Krebs, 2016). Work-related aspirations and personal goals may be set aside be- cause life has become dominated by chronic pain (Karoly & Ruehlman, 1996). The loss of self-esteem that is experienced by these patients can be substantial. Some patients receive compensation for their pain because it resulted from an injury, such as an automo- bile accident. Compensation can actually increase the perceived severity of pain, the amount of disability experienced, the degree to which pain interferes with life activities, and the amount of distress that is reported (Ciccone, Just, & Bandilla, 1999; Groth- Marnat & Fletcher, 2000), because it provides an in- centive for being in pain. The Toll of Pain on Relationships Chronic pain takes a toll on marriage and other family relation- ships. Chronic pain patients may not communicate well with their families, and sexual relationships al- most always deteriorate. Among those chronic pain patients whose spouses remain supportive, such posi- tive attention may inadvertently maintain the pain and disability (Ciccone, Just, & Bandilla, 1999; Turk, Kerns, & Rosenberg, 1992). Chronic Pain Behaviors Chronic pain leads to a variety of pain-related behaviors that can also main- tain the pain experience. For example, sufferers may avoid loud noises and bright lights, reduce physical activity, and shun social contacts. These alterations in lifestyle then become part of the pain problem and may persist and interfere with successful treatment (Philips, 1983). Understanding what pain behaviors an individual engages in and knowing whether they persist after the treatment of pain are important fac- tors in treating the total pain experience. Pain and Personality Because psychological factors are so clearly implicated in the experience of pain, and because pain serves psy- chological functions for some chronic pain sufferers, researchers have examined whether there is a pain-prone 210 Part Four Seeking and Using Health Care Services chronic pain and psychopathology are so frequently associated is not fully known. One possibility is that chronic pain activates latent psychological vulnerabil- ities (Dersh, Polatin, & Gatchel, 2002). ■ PAIN CONTROL TECHNIQUES What is pain control? Pain control can mean that a patient no longer feels anything in an area that once hurt. It can mean that the person feels sensation but not pain. It can mean that he or she feels pain but is no longer concerned about it. Or it can mean that he or she is still hurting but is now able to tolerate it. Some pain control techniques work because they eliminate feeling altogether (for example, spinal block- ing agents), whereas others succeed because they re- duce pain to sensation (such as sensory control techniques), and still others succeed because they en- able patients to tolerate pain more successfully (such as psychological approaches). It will be useful to bear these distinctions in mind as we evaluate the success of specific pain control techniques. Pharmacological Control of Pain The traditional and most common method of control- ling pain is through the administration of drugs. Mor- phine (named after Morpheus, the Greek god of sleep) has been the most popular painkiller for de- cades (Melzack & Wall, 1982). A highly effective painkiller, morphine has the disadvantage of addic- tion, and patients may build up a tolerance to it. Cur- rently, opioid medications are widely prescribed for chronic pain, but their side effects, risks, and even effectiveness raise cautions about their widespread use (Gatchel et al., 2014). Any drug that influences neural transmission is a candidate for pain relief. Some drugs, such as local anesthetics, can affect the transmission of pain im- pulses from the peripheral receptors to the spinal cord. The application of an analgesic to a wound is an ex- ample of this approach. The injection of drugs, such as spinal blocking agents, is another method. Pharmacological relief from pain may also be provided by drugs that act directly on higher brain re- gions. Antidepressants, for example, combat pain not only by reducing anxiety and improving mood but also by affecting the downward pathways from the brain that modulate pain. Sometimes pharmacological treatments make the pain worse rather than better. Patients may consume large quantities of painkillers that are only partially ef- fective and that have undesirable side effects, including inability to concentrate and addiction. Drug-poisoning deaths involving opioid analgesic drugs have been ris- ing steadily over the past 15 years (Chen, Hedegaard, & Warner, 2014). Nerve-blocking agents may be adminis- tered to reduce pain, but these can also produce side effects, including anesthesia, limb paralysis, and loss of bladder control; moreover, even when they are success- ful, the pain will usually return within a short time. The main concern practitioners have about the pharmacological control of pain is addiction, and a subset of pain patients are very vulnerable to addic- tion. On the other hand, even long-term use of pre- scription pain drugs for such conditions as arthritis appears to produce very low rates of addiction. The concern over addiction can lead to under- medication. One estimate is that about 15 percent of patients with cancer-related pain and as many as 80  percent with noncancer chronic pain do not receive sufficient pain medication, leading to a cycle of stress, distress, and disability (Chapman & Gavrin, 1999). Surgical Control of Pain The surgical control of pain also has a long history. Surgical treatment involves cutting or creating lesions in the so-called pain fibers at various points in the body so that pain sensations can no longer be conducted. Some surgical techniques attempt to disrupt the trans- mission of pain from the periphery to the spinal cord; others are designed to interrupt the flow of pain sensa- tions from the spinal cord upward to the brain. Although these surgical techniques are sometimes successful in reducing pain temporarily, the effects About 116 million people in the United States experience chronic pain that requires treatment. © Ariel Skelley/Blend Images RF Chapter 10 The Management of Pain and Discomfort 211 are often short-lived. Therefore, many pain patients who have submitted to operations to reduce pain may gain only short-term benefits, at substantial cost: the risks, possible side effects, and tremendous expense of surgery. It is now believed that the nervous system has substantial regenerative powers and that blocked pain impulses find their way to the brain via different neural pathways. Moreover, surgery can worsen the problem be- cause it damages the nervous system, and this damage can itself be a chief cause of chronic pain. Hence, whereas surgical treatment for pain was once relatively common, researchers and practitioners are increasingly doubtful of its value, even as a treatment of last resort. Sensory Control of Pain One of the oldest known techniques of pain control is counterirritation. Counterirritation involves inhibit- ing pain in one part of the body by stimulating or mildly irritating another area. The next time you hurt yourself, you can demonstrate this technique on your own (and may have done so already) by pinching or scratching an area of your body near the part that hurts. Typically, the counterirritation produced when you do this will suppress the pain to some extent. This common observation has been incorporated into the pain treatment process. An example of a pain control technique that uses this principle is spinal cord stimulation (North et al., 2005). A set of small elec- trodes is placed or implanted near the point at which the nerve fibers from the painful area enter the spinal cord. When the patient experiences pain, he or she ac- tivates a radio signal, which delivers a mild electrical stimulus to that area of the spine, thus inhibiting pain. Sensory control techniques have had some success in reducing the experience of pain. However, their effects are often only short-lived, and they may therefore be appropriate primarily for temporary relief from acute pain or as part of a general regimen for chronic pain. In recent years, pain management experts have turned increasingly to exercise and other ways of increas- ing mobility to help the chronic pain patient. At one time, it was felt that the less activity, the better, so that healing could take place. In recent years, however, exactly the opposite philosophy has held sway, with patients urged to stay active to maintain their functioning. We now turn to psychological techniques for the management of pain. Unlike the pharmacological, surgical, and sensory pain management techniques considered so far, these more psychological tech- niques require active participation and learning on the part of the patient (Jensen & Turk, 2014). Therefore, they are more effective for managing slow-rising pains, which can be anticipated and prepared for than for sudden, intense, or unexpected pains. Biofeedback Biofeedback, a method of achieving control over a bodily process, has been used to treat a variety of health problems, including pain control (see Chapter 6) and hypertension (see Chapter 13). What Is Biofeedback? Biofeedback involves providing biophysiological feedback to a patient about some bodily process of which the patient is usually un- aware. Biofeedback training can be thought of as an operant learning process. First, the target function to be brought under control, such as blood pressure or heart rate, is identified. This function is then tracked by a machine, which provides information to the patient. For example, heart rate might be converted into a tone, so the patient can hear how quickly or slowly his or her heart is beating. The patient then attempts to change the bodily process. Through trial and error and continuous feedback from the machine, the patient learns what thoughts or behaviors will modify the bodily function. Biofeedback has been used to treat a number of chronic pain syndromes, including headaches (Duschek, Schuepbach, Doll, Werner, & Reyes del Paso, 2011), Raynaud’s disease (a disorder in which the small arteries in the extremities constrict, limiting blood flow and producing a cold, numb aching), temporomandibular joint pain (Glaros & Burton, 2004), and pelvic pain (Clemens et al., 2000). How successful is biofeedback in treating pain patients? Despite widely touted claims for its efficacy, there is only modest evidence that it is effective in re- ducing pain (White & Tursky, 1982). Even when bio- feedback is effective, it may be no more so than less expensive, more easily used techniques, such as relax- ation (Blanchard, Andrasik, & Silver, 1980; Bush, Ditto, & Feuerstein, 1985). Relaxation Techniques Relaxation training has been employed with pain pa- tients extensively, either alone or in concert with other pain control techniques. One reason for teaching pain patients relaxation techniques is that it enables them to 212 Part Four Seeking and Using Health Care Services cope more successfully with stress and anxiety, which may ameliorate pain. Relaxation may also affect pain directly. For example, the reduction of muscle tension or the diversion of blood flow induced by relaxation may reduce pains that are tied to these physiological processes. What Is Relaxation? In relaxation, an individual shifts his or her body into a state of low arousal by progressively relaxing different parts of the body. Con- trolled breathing is added, in which breathing shifts from relatively short, shallow breaths to deeper, longer breaths. Anyone who has been trained in prepared childbirth techniques will recognize that these proce- dures are used for pain management during early labor. Meditation, slow breathing, and mindfulness also reduce pain sensitivity and can produce analge- sic effects, possibly through a combination of relax- ation and self-regulatory skills (Grant & Rainville, 2009; Zautra, Fasman, Davis, & Craig, 2010). Spiri- tual meditation tied to religious beliefs can aid in the control of some pains such as migraine head- aches (Wachholtz & Pargament, 2008). Does Relaxation Work? Relaxation is mod- estly successful for controlling some acute pains and may be useful in treating chronic pain when used with other methods of pain control. Some of the beneficial physiological effects of relaxation training may be due to the release of opioids (McGrady et al., 1992; Van Rood, Bogaards, Goulmy, & von Houwelingen, 1993). Distraction People who are involved in intense activities, such as sports or military maneuvers, can be oblivious to pain- ful injuries. These are extreme examples of a com- monly employed pain technique: distraction. By focusing attention on an irrelevant and attention- getting stimulus or by distracting oneself with a high level of activity, one can turn attention away from pain (Dahlquist et al., 2007). How Does Distraction Work? There are two quite different mental strategies for controlling discom- fort. One is to distract oneself by focusing on another activity. For instance, an 11-year-old boy described how he reduced pain by distracting himself while in the den- tist’s chair: When the dentist says, “Open,” I have to say the Pledge of Allegiance to the flag backwards three times before I am even allowed to think about the drill. Once he got all finished before I did (Bandura, 1991). The other kind of mental strategy for controlling stressful events is to focus directly on the events but to reinterpret the experience. The following is a description from an 8-year-old boy who confronted a painful event directly: As soon as I get in the dentist’s chair, I pretend he’s the enemy and I’m a secret agent, and he’s torturing me to get secrets, and if I make one sound, I’m telling him secret information, so I never do. I’m going to be a secret agent when I grow up, so this is good practice (Bandura, 1991). Is Distraction Effective? Distraction is a useful technique of pain control, especially with acute pain (Dahlquist et al., 2007). For example, in one study, 38 dental patients were exposed to one of three condi- tions. One-third of the group heard music during the dental procedure; one-third heard the music coupled with a suggestion that the music might help them reduce stress; and the third group heard no music. Patients in both music groups reported experiencing less discomfort than did patients in the no-treatment group (Anderson, Baron, & Logan, 1991). Biofeedback has been used successfully to treat muscle-tension headaches, migraine headaches, and Raynaud’s disease. However, evidence to date suggests that other, less expensive relaxation techniques may be equally successful. © Owen Franken/Getty Images RF Chapter 10 The Management of Pain and Discomfort 213 Distraction is most effective for coping with low- level pain. Its practical significance for chronic pain management is limited by the fact that such patients cannot distract themselves indefinitely. Moreover, distraction by itself lacks analgesic properties (McCaul, Monson, & Maki, 1992). Thus, while effective, distrac- tion may be most useful when used in conjunction with other pain control techniques. Coping Skills Training Coping skills training helps chronic pain patients man- age pain. For example, one study with burn patients found that brief training in cognitive coping skills, in- cluding distraction and focusing on the sensory aspects of pain instead of its painful qualities, led to reduced reported pain, increased satisfaction with pain control, and better pain coping skills (Haythornthwaite, Lawrence, & Fauerbach, 2001). Active coping skills can reduce pain in patients with a variety of chronic pains (Bishop & Warr, 2003; Mercado, Carroll, Cassidy, & Cote, 2000), and passive coping has been tied to poor pain control (Walker, Smith, Garber, & Claar, 2005). Do Coping Techniques Work? Is any particu- lar coping technique effective for managing pain? The answers depend on how long patients have had their pain. In a study of 30 chronic pain patients and 30 recent-onset pain patients, researchers found that those with recent-onset pain experienced less anxiety and depression and less pain when employing avoid- ant coping strategies rather than attentional strategies. Cognitive Techniques Supportive Educational Techniques Other Techniques Behavioral Techniques CBT Cognitive Restructuring: Direct challenge to alter negative thoughts and/or conviction in maladaptive beliefs, reducing fear of activity Problem Solving: Defining problems, planning responses, trying out problem solutions, evaluation of success, use as needed Relaxation Skills: Deep breathing, mindfulness-meditation, distraction, imagery, progressive muscle relaxation Pacing: Changing activity structure, breaking up activity in smaller chunks throughout day Behavioral Activation: Graded activity, increasing physical activity, increasing enjoyable activity, reduce avoidance Hypnosis: guided by a hypnotherapist to respond to suggestions for change in subjective experience, alteration in perception, sensation, thought, or behavior Biofeedback: awareness of physiology using instruments that provide information on in order to manipulate these functions Relapse Prevention Strategies: Self- monitoring schedules, discussion of triggers for relapse, coping skills and situation matching Psychoeducation: Provision of information about pain, information about etiology and treatment Supportive Psychotherapy: Continued monitoring, encouragement, motivational interviewing Skinner, M., Wilson, H.D., Turk, D.C. “Cognitive-Behaviorial Perspective and Cognitive-Behaviorial Therapy for People With Chronic Pain: Distinctions, Outcomes, and Innovations,” Journal of Cognitive Psychotherapy, 26, 2, 2012. Copyright © 2012 Springer Publishing. Republished with permission; permission conveyed through Copyright Clearance Center, Inc. FIGURE 10.3 | Summary of Cognitive-Behavioral Therapy (CBT) Techniques 214 Part Four Seeking and Using Health Care Services likely to give rise to their pain and to develop alterna- tive ways of coping with the pain, rather than engaging in the pain behaviors they have used in the past, such as withdrawing from social contact. Finally, patients are often trained in therapies that can help them control their emotional responses to pain. Acceptance and commitment therapy, which involves a mindful distancing from the pain experience, as well as therapies for depression or anger implicated in the pain experience, can be helpful (McCracken & Vowles, 2014). Self-determination theory also provides guide- lines for intervening with chronic pain patients by increasing autonomy, feelings of competence, and the experience of support (Uysal & Lu, 2011). Mindful- ness interventions have also shown success for some chronic pain patient groups (Zautra et al., 2008). Do Cognitive-Behavioral Interventions Work? Evaluation of cognitive-behavioral interventions suggests that these techniques can be successful for managing chronic pain (Ehde et al., 2014). Hypnosis (Jensen & Patterson, 2014), acupuncture, and guided imagery are also used by some practitioners and patients to manage pain. These techniques are used more generally to combat the effects and side effects of illness and treatment, and so they were covered in Chapter 9. Their role in pain management requires addi- tional evaluations, but as noted in Chapter 9, acupuncture appears to be successful for treating some kinds of pain. ■ PAIN MANAGEMENT PROGRAMS Only a half century ago, the patient who suffered from chronic pain had few treatment avenues available, except for the possibilities of addiction to morphine or other painkillers and rounds of only temporarily suc- cessful surgeries. Now, however, a coordinated form of treatment has developed to treat chronic pain (Gatchel, McGeary, McGeary, Lippe, 2014). These interventions are termed pain manage- ment programs, and they make available to patients all that is known about pain control. The first pain management program was founded in Seattle at the University of Washington by physician John Bonica in 1960. The earliest pain treatment programs were inpatient, multiweek endeavors designed to decrease use of pain medication and restore daily living skills. Presently, however, most chronic pain management efforts are outpatient programs, because they can be successful and are less costly. Typically, these programs are interdisciplinary efforts, bringing together neurological, cognitive, be- havioral, and psychological expertise concerning pain (Gatchel et al., 2014). As such, they involve the exper- tise of physicians, psychologists or psychiatrists, and physical therapists, with consultation from specialists Because the pain was short term, putting it out of mind worked (Mullen & Suls, 1982). In contrast, for chronic pain patients, attending directly to the pain, rather than avoiding it, was more adaptive (Holmes & Stevenson, 1990). Such studies suggest that pain patients might be trained in different coping strategies, avoidant versus attentive, depending on the expected duration of their pain (Holmes & Stevenson, 1990). Cognitive-Behavioral Therapy Practitioners now typically use cognitive-behavioral therapy to control pain (Ehde, Dillworth, & Turner, 2014). These interventions build on several objectives. First, they encourage patients to reconceptualize the problem from overwhelming to manageable. The pain problem must be perceived to be modifiable for cogni- tive and behavioral methods to have any impact. Ac- ceptance and mindfulness-based treatments have been successful in helping people move outside their pain, fostering objectivity, detachment, and better function- ing (McCracken & Vowles, 2014). Second, clients must be convinced that the skills necessary to control the pain can and will be taught to them, thereby enhancing their expectations that the out- come of this training will be successful (Gil et al., 1996). For example, slow breathing, which is a part of relax- ation therapy, works to manage pain much of the time, but chronic pain patients may require special guidance to get benefits from these techniques (Zautra et al., 2010). Third, clients are encouraged to reconceptualize their own role in the pain management process, from be- ing passive recipients of pain to being active, resourceful, and competent individuals who can aid in the control of pain. These cognitions promote feelings of self-efficacy. Fourth, clients learn how to monitor their thoughts, feelings, and behaviors to break up maladaptive behav- ioral syndromes that accompany chronic pain. As we noted in Chapter 3, patients often inadvertently under- mine behavior change by engaging in discouraging self-talk. Helping pain patients develop more positive monologues increases the likelihood that cognitive- behavioral techniques will be successful. Fifth, patients are taught how and when to employ overt and covert behaviors to make adaptive responses to the pain problem. This skills-training component of the intervention may include relaxation. Sixth, clients are encouraged to attribute their success to their own efforts. By making internal attri- butions for success, patients come to see themselves as efficacious agents of change who are in a better position to monitor subsequent changes in the pain and bring about successful pain modification. Seventh, just as relapse prevention is an important part of health habit change, it is important in pain con- trol as well. Patients may be taught to identify situations Chapter 10 The Management of Pain and Discomfort 215 components tailored to specific pains, such as stretch- ing exercises for back pain patients. Because many pain patients are emotionally dis- tressed, group therapy is often conducted to help them gain control of their emotional responses, especially catastrophic thinking. Catastrophic thinking enhances the pain experience, possibly by its effects on muscle tension and blood pressure reactivity (Shelby et al., 2009; Wolff et al., 2008). Interventions are aimed at the distorted negative perceptions patients hold about their pain. For example, writing interventions have been un- dertaken with pain patients to get them to express their anger and make meaning from the experience; reduc- tions in both distress and pain have been found (Graham, Lobel, Glass, & Lokshina, 2008). Publicly committing to coping well with pain in a group setting can improve psychological adjustment and beneficially affect treat- ment outcomes (Gilliam et al., 2013). Involvement of Family Many pain management programs involve families. On the one hand, chronic pain patients often withdraw from their families, and efforts by the family to be supportive can sometimes inadvertently reinforce pain behaviors. Working with the family to reduce such counterproduc- tive behaviors may be necessary. Helping family mem- bers develop more positive perceptions of each other is also a goal of family therapy, as families can often be frustrated and annoyed by the pain patient’s complaints and inactivity (Williamson, Walters, & Shaffer, 2002). Relapse Prevention Finally, relapse prevention is included so that patients will not backslide once they are discharged from the program. The incidence of relapse following initially successful treatment of persistent pain ranges from about 30 to 60 percent (Turk & Rudy, 1991). Conse- quently, relapse prevention techniques that help patients continue their pain management skills can maintain posttreatment pain reduction (Turk & Rudy, 1991). Evaluation of Programs Pain management programs appear to be successful in helping control chronic pain. Studies that have evalu- ated behavioral interventions in comparison with non- treatment have found reductions in pain, disability, and psychological distress (Center for the Advance- ment of Health, 2000c; Haythornthwaite et al., 2001; Keefe et al., 1992). These interventions can improve social functioning as well (Stevens, Peterson, & Maruta, 1988). However, barriers, including cost and the difficulty of coordinating multiple professionals’ services, are obstacles to implementing these pro- grams (Gatchel et al., 2014). ∙ in neurology, rheumatology, orthopedic surgery, in- ternal medicine, and physical medicine. Initial Evaluation Initially, patients are evaluated with respect to their pain and pain behaviors. This includes a qualitative and quantitative assessment of the pain, including its loca- tion, sensory qualities, severity, and duration, as well as its onset and history. Functional status is then assessed, with patients describing how work and family life have been impaired. Exploring how the patient has coped with the pain in the past helps establish treatment goals for the future. For example, patients who withdraw from social activities in response to their pain may need to increase their involvement in social activities and their family life. Chronic pain patients are often deficient in self-regulatory skills, such as self-control and the ability to cognitively reappraise situations, and so coping skills training may be useful. The willingness to accept pain improves self-regulation and can diminish side effects of pain (Eisenlohr-Moul, Burris, & Evans, 2013). Evaluation of psychological distress, illness behav- ior, and psychosocial impairment is often a part of this phase of pain management, as failure to attend to emo- tional distress can undermine patients’ self- management (Damush, Wu, Bair, Sutherland, & Kroenke, 2008). Treatment for depression can both improve mental health and ameliorate the chronic pain experience (Teh, Zasylavsky, Reynolds, & Cleary, 2010). Individualized Treatment Individualized programs of pain management are next developed. Such programs are typically structured and time limited. They provide concrete aims, rules, and endpoints so that the patient has specific goals to achieve. Typically, these goals include reducing the inten- sity of the pain, increasing physical activity, decreas- ing reliance on medications, improving psychosocial functioning, reducing perception of disability, return- ing to full work status, and reducing the use of health care services (Vendrig, 1999). Components of Programs Pain management programs include several common features. The first is patient education. Often conducted in a group setting, the educational component of the intervention may include discussions of medications; assertiveness or social skills training; ways of dealing with sleep disturbance; depression as a consequence of pain; nonpharmacological measures for pain control, such as relaxation skills and distraction; posture, weight management, and nutrition; and other topics related to the day-to-day management of pain. Most patients are then trained in a variety of measures to reduce pain, such as relaxation training, exercise, and coping skills. The program may include 216 Part Four Seeking and Using Health Care Services 1. Pain is the symptom of primary concern to patients and leads them to seek medical attention. However, pain is often considered of secondary importance to practitioners. 2. Pain is subjective and, consequently, has been difficult to study. It is heavily influenced by the context in which it is experienced. To objectify the experience of pain, pain researchers have developed questionnaires to assess its dimensions and the pain behaviors that often accompany it. 3. According to the gate control theory of pain, A-delta fibers conduct fast, sharp, localized pain; C-fibers conduct slow, aching, burning, and long-lasting pain; higher-order brain processes influence the experience of pain through the central control mechanism. 4. Neurochemical advances in the understanding of pain center around endogenous opioid peptides, which regulate the pain experience. 5. Acute pain is short term and specific to a particular injury or disease, whereas chronic pain does not decrease with treatment and time. Nearly 116 million Americans suffer from chronic pain, which may lead them to disrupt their entire lives in an effort to manage it. 6. Chronic pain is difficult to treat because it has a functional and psychological overlay. Chronic pain patients have elevated scores on the neurotic triad (hyperchondriasis, hysteria, and depression). Anger management is also implicated in pain control. 7. Pharmacologic (for example, morphine), surgical, and sensory stimulation techniques were once the mainstays of pain control, but increasingly, treatments with psychological components, including biofeedback, relaxation, hypnosis, acupuncture, distraction, and guided imagery, have been added to the pain control arsenal. 8. Cognitive-behavioral techniques that help instill a sense of self-efficacy have been used successfully in the treatment of pain. 9. Chronic pain can be treated through coordinated pain management programs oriented toward managing the pain, extinguishing pain behavior, and reestablishing a viable lifestyle. These programs employ a mix of technologies in an effort to develop an individualized treatment program for each patient—a truly biopsychosocial approach to pain. S U M M A R Y K E Y T E R M S acute pain biofeedback chronic benign pain chronic pain chronic progressive pain counterirritation distraction endogenous opioid peptides gate-control theory of pain nociception pain behaviors pain control pain management programs pain-prone personality recurrent acute pain Management of Chronic and Terminal Health Disorders 5P A R T © Realistic Reflections RF 218 C H A P T E R 11 C H A P T E R O U T L I N E Quality of Life What Is Quality of Life? Why Study Quality of Life? Emotional Responses to Chronic Health Disorders Denial Anxiety Depression Personal Issues in Chronic Health Disorders The Physical Self The Achieving Self The Social Self The Private Self Coping with Chronic Health Disorders Coping Strategies and Chronic Health Disorders Patients’ Beliefs About Chronic Health Disorders Comanagement of Chronic Health Disorders Physical Rehabilitation Vocational Issues in Chronic Health Disorders Social Interaction Problems in Chronic Health Disorders Gender and the Impact of Chronic Health Disorders Positive Changes in Response to Chronic Health Disorders When a Child Has a Chronic Health Disorder Psychological Interventions and Chronic Health Disorders Pharmacological Interventions Individual Therapy Relaxation, Stress Management, and Exercise Social Support Interventions Support Groups Management of Chronic Health Disorders © Terry Vine Photography/Blend Images LLC RF Chapter 11 Management of Chronic Health Disorders 219 of the days spent in hospitals, 66  percent of doctor visits, and 55 percent of visits to hospital emergency rooms. Moreover, many adults over age 45 have two or more chronic conditions, which further compli- cates and increases the costs of care (Freid, Bernstein, & Bush, 2012). And as the opening example implies, these conditions are not confined to older adults (see Figure 11.1). More than one-third of young adults age 18–44 have at least one chronic condition (Strong, Mathers, Leeder, & Beaglehole, 2005). Chronic conditions range from moderate ones, such as partial hearing loss, to life-threatening disor- ders, such as cancer, coronary artery disease, and diabe- tes. For example, in the United States, arthritis in its various forms afflicts 53 million people (Centers for Disease Control and Prevention, 2016, April); 20 mil- lion people have had cancer (Centers for Disease Con- trol and Prevention, 2016); diabetes afflicts 29 million people (American Diabetes Association, 2016, April); 33 million people worldwide have sustained a stroke; 0.8 million people suffer from heart attacks each year (American Heart Association, 2015, December); and 80 million people have diagnosed hypertension (Amer- ican Heart Association, 2015, December). Most of us will eventually develop at least one chronic disability or disease, which may ultimately be the cause of our death. During a race at a high school track meet, a young runner stumbled and fell to the ground, caught in the grips of an asthma attack. As her mother franti- cally clawed through her backpack looking for the in- haler, three other girls on the track team offered theirs. As this account implies, asthma rates have sky- rocketed in recent years, particularly among children and adolescents. Nearly 6.3 million children have asthma, and nearly a third of those children require treatment in a hospital emergency room for an asthma attack each year (Centers for Disease Control and Pre- vention, 2016). Scientists are not entirely sure why asthma is on the increase, but the complications that it creates for young adults are evident. Caution, medica- tion, and inhalers become a part of daily life. Psycho- social factors are clearly an important part of this adjustment, helping us answer such questions as “What factors precipitate an asthma attack?” and “What does it mean to have a chronic disease so early in life?” At any given time, 50 percent of the population has a chronic condition, and the medical management of these chronic disorders accounts for three-quarters of the nation’s health spending (Centers for Disease Control and Prevention, 2009c). People with chronic health disorders account for 90 percent of home care visits, 83 percent of prescription drug use, 80 percent FIGURE 11.1 | The Prevalence of Physical Limitations Increases with Age (Source: Holmes, Powell-Griner, Lethbridge-Cejku, & Heyman, 2009) 0 50–59 5.5 2.9 8.1 7.3 9.3 9.6 6.6 26.7 5.9 16.2 4.1 11.5 Pe rc en t 60–69 Age (in years) 70–79 80 and over 10 20 30 40 50 3 or more 2 1 NOTE: The sum of the stacked sections in the bar for each age group represents the total percentage of adults in that age group with one or more physical limitations. 220 Part Five Management of Chronic and Terminal Health Disorders disorders. Quality of life has several components— physical functioning, psychological status, social func- tioning, and disease- or treatment-related symptoms (Kahn & Juster, 2002; Power, Bullinger, Harper, & the World Health Organization Quality of Life Group, 1999). Researchers focus on how much the disease and its treatment interfere with the activities of daily living, such as sleeping, eating, going to work, and engaging in recreational activities. For patients with more ad- vanced diseases, such assessments include whether the patient is able to bathe, dress, use the toilet, be mobile, be continent, and eat without assistance. Essentially, then, quality-of-life assessments gauge the extent to which a patient’s normal life activities have been com- promised by disease and treatment. A broad array of measures is available for evaluating quality of life in both adults (see, for example, Hazuda, Gerety, Lee, Mulrow, & Lichtenstein, 2002; Logsdon, Gibbons, McCurry, & Teri, 2002) and children (Varni, Burwin- kle, Rapoff, Kamps, & Olson, 2004). Why Study Quality of Life? Why should we study quality of life among people with chronic health disorders? There are several reasons. ∙ Documentation of how health disorders affect the activities of daily living can guide interventions designed to improve quality of life. ■ QUALITY OF LIFE “The simple idea that is transforming health care: a focus on quality of life helps medical providers see the big picture and make for healthier, happier patients” (Landro, 2012, p. R1). Until recently, quality of life was not considered an issue of medi- cal importance, except in terms of length of survival and signs of disease. There was virtually no consid- eration of the psychosocial consequences of health disorders and treatments. However, that picture is changing. Medical measures are only weakly related to pa- tients’ or relatives’ assessments of quality of life. In fact, one classic study of a hypertension medication (Jachuck, Brierley, Jachuck, & Willcox, 1982) found that although 100 percent of the physicians re- ported that their patients’ quality of life had improved with the medication, only half the patients agreed and virtually none of the relatives did. Moreover, some health disorders and treatments are perceived by pa- tients to be “fates worse than death” because they threaten valued life activities so completely (Ditto, Druley, Moore, Danks, & Smucker, 1996). What Is Quality of Life? Because of findings like these, quality of life is now given attention in the management of chronic health In the past decade, researchers have begun to consider psychosocial functioning as an important aspect of quality of life among people with chronic health disorders and the disabled. © Stockphoto/Getty Images RF Chapter 11 Management of Chronic Health Disorders 221 the patient’s usual coping efforts fail to resolve these problems, the result can be an exaggeration of symp- toms and their meaning, indiscriminate efforts to cope, an increasingly negative attitude, and worsening health (Drossman et al., 2000; Epker & Gatchel, 2000). The uncertainty and ambiguity inherent in many chronic disorders (e.g., Will it get worse? If so, how quickly?) affects quality-of-life adversely (Hoth et al., 2013). People with chronic health disorders are more likely to suffer from depression, anxiety, and generalized distress (De Graaf & Bijl, 2002; Mittermaier et al., 2004). These psychological changes are important be- cause they compromise quality of life, predict adher- ence to treatment, and increase the risk of dying early (Bruce, Hancock, Arnett, & Lynch, 2010; Christensen, Moran, Wiebe, Ehlers, & Lawton, 2002). Denial Denial is a defense mechanism by which people avoid the implications of a disorder, especially one that may be life-threatening. It is a common early reaction to chronic health disorders (Krantz & Deckel, 1983; Meyerowitz, 1983). Patients may act as if the health disorder is not severe, it will shortly go away, or it will have few long-term implications. Immediately after the diagnosis of the health disorder, denial can serve a protective function by keeping the patient from having to come to terms with problems posed by the health disorder when he or she is least able to do so (Hackett & Cassem, 1973; Lazarus, 1983). ∙ Quality-of-life measures can help pinpoint exactly which problems are likely to emerge for patients with which diseases. ∙ Quality-of-life measures assess the impact of treatments. For example, if a cancer treatment has mediocre survival rates and produces adverse side effects, the treatment may be more harmful than the disease. ∙ Quality-of-life information can be used to compare therapies. For example, if two therapies produce approximately equivalent survival rates but one lowers quality of life substantially, the treatment that keeps quality of life high is preferable. ∙ Quality-of-life information can inform practitioners about care that will maximize long-term health with the highest quality of life possible (Kaplan, 2003) (see Table 11.1). ∙ High quality-of-life can reduce the rate of illness progression (Rauma et al., 2014), symptoms experienced, and need for treatment (Detford, Taylor, Campbell, & Geaves, 2014). ■ EMOTIONAL RESPONSES TO CHRONIC HEALTH DISORDERS Immediately after a chronic health disorder is diag- nosed, a patient can be in a state of crisis marked by physical, social, and psychological disequilibrium. If TABLE 11.1 | Quality of Life Scores for U.S. Population and Several Groups of People with Chronic Health Disorders A look at the typical score for the U.S. population indicates how each of several chronic conditions affects functioning in each area. For example, pain and vitality are most problematic for migraine sufferers, osteoarthritis compromises physical activities related to roles, and diabetes undermines general health. Physical Role- Bodily General Social Role- Mental Functioning Physical Pain Health Vitality Functioning Emotional Health U.S. Population* 92.1 92.2 84.7 81.4 66.5 90.5 92.1 81.0 Clinical depression 81.8 62.8 73.6 63.6 49.0 68.5 47.8 53.8 Migraine 83.2 54.0 51.3 70.1 50.9 71.1 66.5 66.4 Hypertension 89.5 79.0 83.8 72.6 67.2 92.1 79.6 77.3 Osteoarthritis 81.9 66.5 69.7 70.4 57.0 90.1 85.5 76.5 Type II diabetes 86.6 76.8 82.8 66.9 61.4 89.4 80.7 76.6 *U.S. population estimates are for those reporting no chronic conditions. Scores take into account other chronic conditions, age, gender. Source: Based on Ware, 1994. 222 Part Five Management of Chronic and Terminal Health Disorders osteoporosis, and Type II diabetes, and at younger ages. Depression exacerbates the course of several chronic disorders, most notably coronary heart dis- ease. Depression complicates treatment adherence and medical decision making (Hilliard, Eakin, Borelli, Green, & Riekert, 2015). It interferes with patients adopting a comanagerial role, and it can increase use of health services for treatment (Ahmedani, Peterson, Wells, & Williams, 2013). Depression is sometimes a delayed reaction to chronic health disorders, because it takes time for pa- tients to understand the full implications of their condi- tion. For example, a stroke patient comments on his discharge from the hospital: That was a glorious day. I started planning all the things I could do with the incredible amount of free time I was going to have, chores I had put off, museums and galleries to visit, friends I had wanted to meet for lunch. It was not until several days later that I realized I simply couldn’t do them. I didn’t have the mental or physical strength, and I sank into a depression. (Dahlberg, 1977, p. 121) Assessing Depression Depression is so preva- lent among chronically ill patients that experts recom- mend routine screening for depressive symptoms during medical visits (Löwe et al., 2003). Yet assessing de- pression in the chronically ill can be complicated. Many symptoms of depression, such as fatigue, sleep- lessness, and weight loss, can also be symptoms of disease or side effects of a treatment. If depressive symptoms are attributed to illness or treatment, their significance may be less apparent, and, consequently, depression may go untreated (Ziegelstein et al., 2005). Who Gets Depressed? Depression increases with the severity of the health disorder (Cassileth et  al., 1985; Moody et al.,1990) and with pain and disability (Turner & Noh, 1988; Wulsin, Vaillant, & Wells, 1999). These problems are aggravated in peo- ple who are experiencing other negative life events and lack of social support (Bukberg, Penman, & Holland, 1984; Thompson et al., 1989). In recent years, effective cognitive behavioral in- terventions have been developed to deal with the de- pression that so frequently accompanies chronic health disorders (Center for the Advancement of Health, 2000d). Even telephone-administered cogni- tive behavioral therapy can improve depression Over time, however, any benefit of denial gives way to its costs. It can interfere with taking in neces- sary treatment information and compromise health (Mund & Mitte, 2012). Anxiety Following the diagnosis of a chronic health disorder, anxiety is also common. Many patients are over- whelmed by the potential changes in their lives and, in some cases, by the prospect of dying. Anxiety is especially high when people are waiting for test re- sults, receiving diagnoses, awaiting invasive medical procedures, and anticipating or experiencing adverse side effects of treatment (Rabin, Ward, Leventhal, & Schmitz, 2001). Anxiety is a problem not only because it is intrin- sically distressing but also because it interferes with treatment. For example, anxious patients cope more poorly with surgery (Mertens, Roukema, Scholtes, & De Vries, 2010); anxious diabetic patients have poor glucose control (Lustman, 1988); anxiety complicates managing a host of chronic conditions (Favreau, Bacon, Labrecque, & Lovoie, 2014), and is especially prevalent among people with asthma and pulmonary disorders (Katon, Richardson, Lozano, & McCauley, 2004). Symptoms of anxiety may also be mistaken for symptoms of the underlying disease and thus interfere with assessments of the disease and its treatment (Chen, Hermann, Rodgers, Oliver-Welker, & Strunk, 2006). Intervening to treat anxiety is increasingly rec- ommended (Rollman & Huffman, 2013). Depression Depression is a common reaction to chronic health dis- orders. Up to one-third of all medical inpatients with chronic disease report symptoms of depression, and up to one-quarter suffer from severe depression (Moody, McCormick, & Williams, 1990). Depression is especially common among stroke patients, cancer patients, and heart disease patients, as well as among people with more than one chronic disorder (Egede, 2005; see Taylor & Aspinwall, 1990, for a review). At one time, depression was regarded only as an emotional disorder, but its medical significance is in- creasingly recognized. Depression predicts death from all causes (Houle, 2013). People who have intermittent bouts of depression are more likely to get heart dis- ease, atherosclerosis, hypertension, stroke, dementia, B O X 11.1A Future of Fear Mollie Kaplan can remember half a century ago when she was 12 and met her husband, Samuel, at a Halloween party in the Bronx. What she can’t re- member is whether she had breakfast, so sometimes she eats it twice. She doesn’t cook much anymore because if the recipe calls for salt, she can’t remem- ber whether she added it. “It’s so frustrating,” she said. “I can’t read a book anymore, because if I stop and put a bookmark where I leave off, when I pick the book up again, I don’t know what I have read” (Larsen, 1990, pp. E1, E8). Mollie Kaplan has Alzheimer’s disease. Alzheimer’s is the sixth leading cause of death among U.S. adults, accounting for 84,000 deaths in 2013 (Alzheimer’s Association, 2016). Currently, about 5.4 million Americans have the disease, with numbers projected to rise to 13.8 million by 2050 (Alzheimer’s Associa- tion, 2016). Typical symptoms of Alzheimer’s (named after Dr. Alois Alzheimer, who described it in 1906) include gradual progression of memory loss or other cognitive losses (language problems, motor skills), personality change, and eventually loss of function (Mattson, 2004). Increasing frailty may foreshadow the onset of the disorder (Buchman, Boyle, Wilson, Tang, & Bennett, 2007). Personality changes include hostility, withdrawal, inappropriate laughing, agita- tion, and paranoia. The strain of Alzheimer’s disease on both the pa- tient and the caregiver can be great. For the patient, being unable to do simple, routine tasks or remember an activity just completed is frustrating and depressing. For caregivers, the emotional toll is substantial. The family may be left with little alternative but to place the loved one in a nursing home, and the effect on fam- ily finances can be huge. Despite this grim picture, many treatments for Alzheimer’s are in development, and many are currently being tested. As neuroscien- tists learn more about the cellular and molecular changes in the brain that lead to neurodegeneration, progress in prevention and treatment will be made. The Physical Self Body image is the perception and evaluation of one’s physical functioning and appearance. Body image plummets during illness. Not only is the affected part of the body evaluated negatively, the whole body im- age may take on a negative aura. For patients with acute health disorders, changes in body image are short-lived; however, for people with chronic health disorders, negative evaluations may last. These changes in body image are important. First, a poor body image increases risk for depression and anxiety. Second, body image may influence how adherent a person is to the course of treatment and how willing he or she is to adopt a comanagement role. Finally, body image is important because it can be improved through interventions such as exercise (Wenninger, Weiss, Wahn, & Staab, 2003). Perceived health is also an important dimension of physical health. Self-rated health predicts death over and above objective health indicators. It may also promote effective self-care, which requires active engagement (Denford, Taylor, Campbell, & Greaves, 2014). The first line of defense for most people with chronic disorders is self-care, and so promoting the coping resources to make it possible is essential (Hwang, Moser, & Dracup, 2014). (Beckner, Howard, Vella, & Mohr, 2010). Treatment for depression may not only alleviate psychological distress but also reduce symptoms associated with the health disorder (Mohr, Hart, & Goldberg, 2003). ■ PERSONAL ISSUES IN CHRONIC HEALTH DISORDERS To fully understand reactions to chronic health disor- ders requires a consideration of the self, its sources of resilience, and its vulnerabilities. The self is one of the central concepts in psychology. Psychologists refer to the self-concept as a stable set of beliefs about one’s personal qualities and attributes. Self-esteem refers to the evaluation of the self-concept—namely, whether one feels good or bad about one’s personal qualities and attributes. A chronic health disorder can produce severe changes in self-concept and self-esteem (Ferro & Boyle, 2013). Many of these changes will be tempo- rary, but some may be permanent, such as the mental deterioration that is associated with certain diseases (Box 11.1). The self-concept is a composite of self- evaluations regarding many aspects of life, which in- clude body image, achievement, social functioning, and the private self. 223 224 Part Five Management of Chronic and Terminal Health Disorders breakdown in the support system has implications for all aspects of life (Barlow, Liu, & Wrosch, 2015). Per- haps for these reasons, fears about being abandoned by others are among the most common worries of people with chronic health disorders. Consequently, family participation in the health disorder manage- ment process and social activities is generally more widely encouraged. The Private Self The residual core of a patient’s identity—ambitions, goals, and desires for the future—are also affected by chronic health disorders (e.g., Smith, 2013). Ad- justment can be impeded because the patient has an unrealized dream, which is now out of reach, or at least appears to be. For example, the dream of retir- ing to a cabin on a lake in the mountains may not be viable if the management of a chronic condition re- quires living near a major medical center. Encourag- ing the patient to discuss this difficulty may reveal alternative paths to fulfillment and awaken new am- bitions, goals, and plans for the future. ■ COPING WITH CHRONIC HEALTH DISORDERS Although most patients with chronic health disorders experience some distress, most do not seek formal or informal treatment for their symptoms. Instead, they draw on their internal and social resources for solving problems and alleviating psychological distress. How do they cope so well? Coping Strategies and Chronic Health Disorders Few investigations have looked systematically at cop- ing strategies used by people with chronic health disor- ders. In one of the few such studies (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992), cancer patients were asked to identify the aspect of their cancer they found to be the most stressful. Fear and uncertainty about the future were most common (41 percent), followed by limitations in physical abilities, appearance, and life- style (24 percent), and pain management (12 percent). Patients were then asked to indicate the coping strate- gies they had used to deal with these problems. The five most commonly used strategies were social sup- port/direct problem solving (“I talked to someone to The Achieving Self Achievement through vocational and avocational ac- tivities is also an important source of self-esteem and the self-concept. Many people derive their primary life satisfaction from their job or career; others take great pleasure in their hobbies and leisure activities. If chronic health disorders threaten these valued as- pects of the self, the self-concept may be damaged. The converse is also true: When work and hobbies are not threatened or curtailed by health disorders, the patient has these sources of satisfaction from which to derive self-esteem, and they can come to take on new meaning. The Social Self Social resources, such as family and friends, can pro- vide people with chronic health disorders with badly needed information, help, and emotional support. A Chronic health disorders or disability can interfere with some life activities, but a sense of self that is based on broader interests and abilities will sustain self-esteem. © Image Source/PunchStock RF Chapter 11 Management of Chronic Health Disorders 225 health, such as smoking. Thus, developing a realistic sense of one’s health disorder, the restrictions it im- poses, and the regimen that is required is an important process of coping with chronic health disorders. Patients’ Beliefs About Chronic Health Disorders Beliefs About the Nature of the Health Disorder In Chapter 8, we described the com- monsense model of health disorders and the fact that patients develop coherent theories about their health disorder, including its identity, causes, consequences, timeline, and controllability. One of the problems that often arises in adjustment to chronic health disorders is that patients adopt an inappropriate model for their disorder—most notably, an acute model (see Chapter 8). For example, hypertensive patients may believe incor- rectly that, if they feel all right, they no longer need to take medication (Hekler et al., 2008). Thus, it is im- portant for health care providers to probe patients’ be- liefs about their health disorder to check for significant gaps and misunderstandings in their knowledge that may interfere with self-management (Stafford, Jackson, & Berk, 2008). Beliefs About the Cause of the Health Disorder People with chronic health disorders often develop theories about where their health disorder came from (Costanzo, Lutgendorf, Bradley, Rose, & Anderson, 2005). These theories about origins of the health disorder include stress, physical injury, disease- causing bacteria, and God’s will. Of perhaps greater sig- nificance is where patients ultimately place the blame for their health disorder. Do they blame themselves, an- other person, the environment, or a quirk of fate? Self-blame for chronic health disorders is wide- spread. Patients frequently perceive themselves as having brought on their health disorder through their own actions. For example, they may blame their poor health habits, such as smoking or diet. What are the consequences of self-blame? Some researchers have found that self-blame can lead to guilt, self- recrimination, or depression (Bennett, Compas, Beck- jord, & Glinder, 2005; Friedman et al., 2007). But perceiving the cause of one’s health disorder as self- generated may alternatively represent an effort to as- sume control over the disorder. Self-blame may be adaptive under certain conditions but not others (Schulz & Decker, 1985; Taylor et al., 1984a). find out more about the situation”), distancing (“I didn’t let it get to me”), positive focus (“I came out of the experience better than I went in”), cognitive escape/ avoidance (“I wished that the situation would go away”), and behavioral escape/avoidance (efforts to avoid the situation by eating, drinking, or sleeping). These strategies are similar to those employed to deal with other stressful events (see Chapter 7). One notable difference, though, is that people with chronic health disorders use fewer active coping methods, such as problem solving, and confrontative coping, and more passive coping strategies, such as positive focus and escape/avoidant strategies. This difference may reflect the fact that some chronic diseases raise uncontrollable issues that active coping strategies cannot directly address. Which Coping Strategies Work? Do any par- ticular coping strategies facilitate psychological adjust- ment among people with chronic health disorders? As is true for coping with other stressful events, avoidant coping is tied to greater psychological distress and is a risk factor for adverse responses to health disorders (Heim, Valach, & Schaffner, 1997). It may also exac- erbate the disease process itself (Frenzel, McCaul, Glasgow, & Schafer, 1988). Active coping predicts good adjustment. People who cope using positive, confrontative responses to stress; who solicit health-related information about their condition (Christensen, Ehlers, Raichle, Bertolatus, & Lawton, 2000); who have a strong sense of control (Burgess, Morris, & Pettingale, 1988); and who be- lieve that they can personally direct control over a health disorder (Taylor, Helgeson, Reed, & Skokan, 1991) all show better psychological adjustment. Be- cause of the diversity of problems that chronic disor- ders pose, people who are flexible copers may cope better than do people who engage in a predominant cop- ing style (Cheng, Hui, & Lam, 2004). Virtually all chronic health disorders require some degree of self-management. For example, dia- betic patients must control their diet and perhaps take daily injections of insulin. Both stroke and heart patients must make alterations in their daily activities if they have impairments. Patients who do not incorpo- rate chronic health disorders into their self-concept may fail to be effective co-managers. They may not fol- low their treatment regimen. They may not be attuned to signs of recurrent or worsening disease. They may engage in foolhardy behaviors that pose a risk to their 226 B O X 11.2 Chronic Fatigue Syndrome and Other Functional Disorders In recent years, health psychologists have explored the causes and consequences of functional somatic syn- dromes. These syndromes are marked by symptoms, suffering, and disability, but not by any demonstrable tissue abnormality. In short, we don’t know why people have these disorders. Functional somatic syndromes include chronic fatigue syndrome, irritable bowel syn- drome, and fibromyalgia, as well as chemical sensitiv- ity, sick building syndrome, repetitive stress injury, complications from silicone breast implants, Gulf War syndrome, and chronic whiplash. Chronic fatigue syndrome (CFS), one of the most common, involves debilitating fatigue present for at least 6 months. People with CFS show slowed think- ing, reduced attention, and impairments in memory (Majer et al., 2008). For many years, no biological cause for CFS could be found. However, a viral agent and resulting inflammatory activity have now been implicated as potential causes (Lombardi et al., 2009). Chronic fatigue syndrome has also been tied to higher levels of allostatic load, suggesting a likely vulnerability to other chronic disorders (Maloney, Boneva, Nater, & Reeves, 2009). Fibromyalgia is an arthritic syndrome involving widespread pain with tenderness in multiple sites. About 6 million individuals suffer from this disorder. The origins of fibromyalgia are unclear and the symp- toms are varied, but the disorder is associated with sleep disturbance, disability, and high levels of psy- chological distress (Finan, Zautra, & Davis, 2009; Zautra et al., 2005). Functional disorders are extremely difficult to treat inasmuch as their etiology is not well understood. Be- cause of their insidious way of eroding quality of life, the functional syndromes typically cause psychological distress, including depression, and the symptoms of the health disorders are sometimes misdiagnosed as depres- sion (Mittermaier et al., 2004; Skapinakis, Lewis, & Mavreas, 2004). Who develops functional somatic disorders? Functional somatic syndromes are more common in women than men, and people who have a prior history of emotional disorders, especially anxiety and depres- sion (Bornschein, Hausteiner, Konrad, Förstl, & Zilker, 2006; Nater et al., 2009). A history of infec- tions is also implicated (Lacourt, Houtveen, Smeets, Lipovsky, & van Doornen, 2013). People who are low in SES, who are unemployed, and who are members of minority groups have a somewhat elevated likeli- hood of developing chronic fatigue (Taylor, Jason, & Jahn, 2003). Twin studies of chronic fatigue syndrome suggest that there may be genetic underpinnings of these disorders (Buchwald et al., 2001). A history of family disruption, childhood maltreatment and abuse, or childhood trauma may also be implicated (Afari et al., 2014; van Gils, Janssens, & Rosmalen, 2014). The functional syndromes overlap heavily in symptoms (Kanaan, Lepine, & Wessely, 2007). Many of the disorders are marked by abdominal distention, headache, fatigue, and disturbances in the sympathetic and HPA axis stress systems (Reyes del Paso, Garrido, Pulgar, Martín-Vázquez, & Duschek, 2010). Among the common factors implicated in their development are a preexisting viral or bacterial infection and a high number of stressful life events (Fink, Toft, Hansen, Ornbol, & Olesen, 2007). These similarities should not be interpreted to mean that these disorders are psychiatric in origin or that the care of these patients should be shifted exclu- sively to psychology and psychiatry. Instead, this overlap suggests that breakthroughs in understanding the etiology and developing treatments for these dis- orders may be made by pooling knowledge from all these syndromes, rather than by treating them as sepa- rate disorders (Fink et al., 2007). Although each disor- der has distinctive features (Moss-Morris & Spence, 2006), the core symptoms of fatigue, pain, sick-role behavior, and negative affect are all associated with chronic, low-level inflammation, and possibly this sustained immune response is what ties these disor- ders together. How are these disorders treated? Generally, practi- tioners combine pharmacological interventions for such symptoms as sleep deprivation and pain with be- havioral interventions, including exercise and cognitive- behavioral therapy, efforts that appear to achieve some success (Rossy et al., 1999). Coping interventions such as written emotional expression can produce health benefits as well (Broderick, Junghaenel, & Schwartz, 2005). Simultaneous attention to the medi- cal symptoms and the psychosocial distress generated by these disorders is essential for successful treatment. Social support in the family improves functioning as well (Band, Barrowclough, & Wearden, 2014). Chapter 11 Management of Chronic Health Disorders 227 than among whites (Ward & Schiller, 2011). Functional decline in the frail elderly who live alone is a particular problem (Gill, Baker, Gottschalk, Peduzzi, Allore, & Byers, 2002). Physical therapy can amelio- rate these age-related declines and can also help patients recover from treatments designed to alleviate them, such as surgery (Stephens, Druley, & Zautra, 2002). Robots are increasingly being used to help  disabled people maximize their functioning (Broadbent, Stafford, & MacDonald, 2009). Some chronic functional disorders have origins that still baffle scientists; they are described in Box 11.2. Patients may need a pain management program for the alleviation of discomfort. They may require pros- thetic devices, such as an artificial limb after amputa- tion related to diabetes. They may need training in the use of adaptive devices; for example, a patient with multiple sclerosis or a spinal cord injury may need to learn how to use a wheelchair. Certain cancer patients may elect cosmetic surgery, such as breast reconstruc- tion after a mastectomy or the insertion of a synthetic jaw after head and neck surgery. Disorders such as stroke, diabetes, and high blood pressure may compro- mise cognitive functioning, requiring active interven- tion (Zelinski, Crimmins, Reynolds, & Seeman, 1998). Because stress exacerbates so many chronic disorders, stress management programs are increasingly incorpo- rated into the physical treatment regimens as well. The Impact on Sexuality Many chronic health disorders—including heart disease, stroke, and cancer—compromise sexual activity. In many cases, the decline can be traced to psychological factors (such as loss of desire, fears about aggravating the chronic condition, or impotence). The ability to continue physically intimate relations can improve relationship satisfaction among people with chronic health disorders and improve emotional functioning (Perez, Skinner, & Meyerowitz, 2002). Adherence As with all lifestyle intervention, ad- herence to treatment is problematic with people who have chronic health disorders. A first step in increasing adherence is education. Some patients may not realize that lifestyle aspects of their treatment regimen, such as exercise, are important to their recovery and function- ing. High expectations for controlling one’s health and self-efficacy, coupled with knowledge of the treatment regimen, predict adherence to chronic disease regimens (Schneider, Friend, Whitaker, & Wadhwa, 1991). Blaming another person for one’s health disorder is maladaptive (Affleck et al., 1987; Taylor et al., 1984a). For example, some patients believe that their health disorder was brought about by stress caused by family members, ex-spouses, or colleagues at work. Blame of this other person or persons may be tied to unresolved hostility, which can interfere with adjust- ment to the disease. Forgiveness, by contrast, is a healthier response (Worthington, Witvliet, Pietrini, & Miller, 2007). Beliefs About the Controllability of the Health Disorder Patients develop a number of control-related beliefs. They may believe, as do many cancer patients, that they can prevent a recurrence of the disease through good health habits or even sheer force of will. They may believe that by complying with treatments and physicians’ recommendations, they achieve vicarious control over their health disorder. People who have a sense of control or self-efficacy with respect to their health disorders are better adjusted to their circumstances. This relationship has been found for a broad array of health disorders, ranging from asthma in children (Lavoie et al., 2008) to functional disability in old age (Wrosch, Miller, & Schulz, 2009). The experience of control or self-efficacy may even pro- long life (Kaplan, Ries, Prewitt, & Eakin, 1994). ■ COMANAGEMENT OF CHRONIC HEALTH DISORDERS Physical Rehabilitation Physical rehabilitation involves several goals: to learn how to use one’s body as much as possible, to learn how to sense changes in the environment to make the appropriate physical accommodations, to learn new physical management skills, to learn a necessary treat- ment regimen, and to learn how to control energy ex- penditure. Not all chronic health disorders require physical rehabilitation, but some do. Exercise goes a long way in reducing the symptoms of many chronic disorders (van der Ploeg et al., 2008). Physical activity can, in turn, pave the way for more general changes in self-efficacy (Motl & Snook, 2008). Many patients who require physical rehabilitation have problems resulting from prior injuries or partici- pation in athletic activities earlier in life, including knee problems, shoulder injuries, and the like. Most such problems worsen with age. Disabilities are more common among African Americans and Hispanics promptly. Box 11.4 focuses on some health care pro- fessionals who deal with such problems. The Financial Impact of Chronic Health Dis- orders Chronic health disorders can have a sub- stantial financial impact on the patient and the family. Many people are not covered by insurance sufficient to meet their needs. Patients who must cut back on their work or stop working altogether may lose their insur- ance coverage. Thus, many people with chronic health disorders are hit by a double whammy: Income may be reduced, and simultaneously, the benefits that would have helped shoulder the costs of care may be cut back. The United States is the only developed country in which this problem still exists. The ACA (Affordable Care Act) has helped to reduce this problem. Social Interaction Problems in Chronic Health Disorders After diagnosis, some people with chronic health disor- ders have trouble reestablishing normal social relations. Vocational Issues in Chronic Health Disorders Many chronic health disorders create problems for pa- tients’ vocational activities and work status (Grunfeld, Drudge-Coates, Rixon, Eaton, & Cooper, 2013). Some patients need to restrict or change their work activities. Patients with spinal cord injuries who pre- viously held positions that required physical activity will need to acquire skills that will let them work from a seated position. This kind of creative job change is illustrated in Box 11.3. Discrimination Against People with Chronic Health Disorders Some people with chronic health disorders, such as heart patients, cancer pa- tients, and AIDS patients, face job discrimination (Heckman, 2003). Because of these potential prob- lems, job difficulties that the patient may encounter should be assessed early in the recovery process. Job counseling, retraining programs, and advice on how to avoid or combat discrimination can then be initiated B O X 11.3 Epilepsy and the Need for a Job Redesign In infancy, Colin S. developed spinal meningitis, and although he survived, the physician expressed some concern that permanent brain damage might have oc- curred. Colin was a normal student in school until ap- proximately age 11, when he began to have spells of blanking out. At first, his parents interpreted these as a form of acting out, the beginnings of adolescence. However, it became clear that Colin had no recollec- tion of these periods and became angry when ques- tioned about them. His parents took him to a physician for evaluation, and after a lengthy workup, the doctor concluded that Colin was suffering from epilepsy. Shortly thereafter, Colin’s blanking out (known as petit mal seizures) became more severe and fre- quent; soon after that, he began to have grand mal seizures, involving severe and frightening convul- sions. The doctors tried several medications before finding one that controlled the seizures. Indeed, so successful was the medication that Colin eventually was able to obtain a driver’s license, having gone 5  years without a seizure. After he completed high school and college, Colin chose social work as his career and became a caseworker. His livelihood de- pended on his ability to drive because his schedule involved visiting many clients for in-home evalua- tions. Moreover, Colin was married, and he and his wife were supporting two young children. In his early 30s, Colin began to experience sei- zures again. At first, he and his wife tried to pretend that nothing was wrong, but they quickly realized that the epilepsy was no longer under control. Colin’s epilepsy represented a major threat to the family’s income because Colin could no longer do his job as a caseworker. Moreover, his ability to find reemployment was compromised by the revocation of his driver’s license. With considerable anxiety, Colin went to see his employer, the director of the social services unit. After consultation, Colin’s supervisor determined that he had been a valuable worker and they did not want to lose him. They therefore redesigned his position so that he could have a desk job that did not require the use of a car. By having his responsibilities shifted away from the monitoring to the evaluation of cases, and by being given an office instead of a set of addresses to visit, Colin was able to use the skills he had worked so hard to develop. In this case, then, Colin’s employer responded sympathetically and effectively to the compromises that needed to be made in Colin’s job responsibilities. 228 229 B O X 11.4Who Works with People with Chronic Health Disorders? A variety of professionals work with people with chronic health disorders. PHYSICAL THERAPISTS Physical therapists typically receive their training as undergraduates or in a master’s program, which is prep- aration for required licensure. About 209,690 people work as licensed physical therapists in hospitals, nurs- ing homes, rehabilitation centers, and schools for dis- abled children (U.S. Bureau of Labor Statistics, 2016). Physical therapists help people with muscle, nerve, joint, or bone diseases or injuries overcome their dis- abilities. They work primarily with accident victims, disabled children, and older people. Physical therapists administer and interpret tests of muscle strength, motor development, functional capacity, and respiratory and circulatory efficiency. Using these tests, they develop individualized treatment programs, the goals of which are to increase strength, endurance, coordination, and range of motion. Physical therapists also conduct ongo- ing evaluations and modification of these programs in light of treatment goals. In addition, they help patients learn to use adaptive devices and become accustomed to new ways of performing old tasks. OCCUPATIONAL THERAPISTS Occupational therapists work with people who are emotionally and physically disabled to determine skills, abilities, and limitations. In 2015, there were 114,660 occupational therapists (U.S. Bureau of Labor Statis- tics, 2016). They evaluate the existing capacities of patients, help them set goals, and plan a therapy pro- gram with other members of a rehabilitation team to try to build on and expand these skills. They help patients regain physical, mental, or emotional stability; relearn daily routines, such as eating, dressing, writing, or us- ing a telephone; and prepare for employment. They plan and direct educational, vocational, and recreational activities to help patients become more self-sufficient. Patients who are seen by occupational therapists range from children involved in crafts programs to adults who must learn new skills, such as working on a computer or using power tools. In addition, occupa- tional therapists teach creative tasks, such as painting or crafts, which help relax patients, provide a creative outlet, and offer some variety to those who are institu- tionalized. Occupational therapists obtain training through occupational therapy training programs located in universities and colleges around the coun- try, and they must be formally licensed. DIETITIANS Many of the country’s 59,740 dietitians work with people with chronic health disorders (U.S. Bureau of Labor Statistics, 2016). Dietitians are formally li- censed and must complete a 4-year degree program and clinically supervised training to be registered with the American Dietetic Association. Although many dietitians are administrators who apply the principles of nutrition and food management to meal planning for hospitals, universities, schools, and other institutions, others work directly with people with chronic health disorders to help plan and man- age special diets. These clinical dietitians assess the dietetic needs of patients, supervise the service of meals, instruct patients in the requirements and im- portance of their diets, and suggest ways of maintain- ing adherence to diets after discharge. Many dietitians work with diabetics because these patients need to control their calorie intake and types of foods. SOCIAL WORKERS Social workers help patients and their families with social problems that can develop while they are deal- ing with their health disorder and recovery by provid- ing therapy, making referrals to other services, and engaging in general social planning. They may work in hospitals, clinics, community mental health cen- ters, rehabilitation centers, and nursing homes. A medical social worker might help a patient un- derstand the health disorder more fully and deal with emotional responses to health disorders, such as de- pression or anxiety, through therapy. A social worker can also help the patient and family find the re- sources they need to solve their problems, such as household cleaning services or transportation. In 2014, approximately 649,300 individuals were employed as social workers; one-third worked for the local or state government (U.S. Bureau of Labor Sta- tistics, 2015). The minimum qualification for social work is a bachelor’s degree, but for many positions a master’s degree (MSW) is required. More than 500 col- leges nationwide offer accredited undergraduate pro- grams in social work, and more than 200 colleges and universities offer graduate programs (U.S. Bureau of Labor Statistics, 2015). 230 Part Five Management of Chronic and Terminal Health Disorders the chronic illness on other family members. If the patient is married, the health disorder inevitably places increased responsibilities on the spouse. While trying to provide support for the patient, the family’s own social support needs may go unmet. New responsibilities may fall on children and other family members living at home. Consequently, the patient’s family may feel that their lives have gone out of control (Compas, Worsham, Ey, & Howell, 1996). Role strains can emerge as family members find themselves as- suming new tasks and simultaneously realize that their time to pursue recreational and other leisure-time activities has declined (Pakenham & Cox, 2012). Children and ado- lescents who assume more responsibilities than normal for their age group may react by rebelling or acting out. Negative Responses from Others Acquain- tances, friends, and relatives may have problems adjusting to the patient’s altered condition. Many peo- ple hold negative stereotypes about certain groups of people with chronic health disorders, including those with cancer or AIDS (Fife & Wright, 2000). People with disabilities may elicit ambivalence. Friends and acquaintances may give verbal signs of warmth and affection while nonverbally conveying re- jection through their gestures, contacts, and postures. Distant relationships with friends and acquaintances appear to be more adversely affected than close rela- tionships (Dakof & Taylor, 1990). The Impact on the Family People do not de- velop chronic diseases; families do. The family is a social system, and disruption in the life of one family member invariably af fects the lives of others. One of the chief changes brought about by chronic health dis- orders is an increased dependency of the person with Robots, like the one seen here, are increasingly being used to help disabled people maximize their functioning. © Elizabeth Broadbent, The University of Auckland, New Zealand Physical rehabilitation concentrates on enabling people to use their bodies as much as possible, to learn new physical management skills if necessary, and to pursue an integrated treatment regimen. © Don Tremain/Getty Images RF Chapter 11 Management of Chronic Health Disorders 231 Parkinson’s disease, advancing multiple sclerosis, and stroke can be long term and grueling. Family members who provide intense caregiving are at risk for distress, depression, and declining health (Mausbach, Patterson, Rabinowitz, Grant, & Schulz, 2007). Caregivers are often elderly, and, consequently, their own health may be threatened when they become caregivers (Gallagher, Phillips, Drayson, & Carroll, 2009). Many studies attest to the risks that caregiving poses to immune functioning (Li et al., 2007), endocrine functioning (Mausbach et al., 2005), depression (Mintzer et al., 1992), poor quality of sleep (Brummett et al., 2006), cardiovascular diseases (Mausbach et al., 2007; Roepke et al., 2011), risk of infectious disease, and even death (Schulz & Beach, 1999). Caregivers who are experiencing other stressors in their lives or whose caregiving burden is especially great are at particular risk for mental and physical health declines (Brummett et al., 2005; Kim, Knight, & Longmire, 2007). It has been estimated that women lose, on average, more than $324,000 in wages, pensions, and Social Security benefits due to caring for family members; the compa- rable figure for men is approximately $284,000 (Greene, 2011). Caregiving can also strain the relationship between patient and caregiver (Martire, Stephens, Druley, & Wojno, 2002). Patients are not always appreciative of the help they receive and resent the fact that they need help. Their resentment can contribute to the depression often seen in caregivers (Newsom & Schulz, 1998). Caregivers fare better when they have a strong sense of personal mastery and active coping skills (Aschbacher et al., 2005) and good family functioning (Deatrick et al., 2014). Caregivers themselves may be in need of interven- tions (Mausbach et al., 2012). The demands of caregiv- ing may tie them to the home and give them little free time; depression and compromised physical health are common problems (Mausbach et al., 2012). Engaging in pleasant experiences and little activity restriction both promote quality of life and may reduce physical health threats related to caregiving (Chattillion et al., 2013). The Internet can provide support to caregivers. One study (Czaja & Rubert, 2002) reported that caregivers who were able to communicate online with other family members, a therapist, and an online discussion group found the services to be very valuable, suggesting that Internet interventions have promise (DuBenske et al., 2014). Brief daily yoga meditation practice by caregiv- ers may also improve mental health and cognitive Problem behaviors may include regression (such as bed- wetting), difficulties at school, truancy, sexual activity, drug use, and antagonism toward other family members. If family members’ resources are already stretched to the limit, accommodating new tasks is difficult. The wife of one stroke patient suggested some of the burdens such patients can create for their families: In the first few weeks, Clay not only needed meals brought to him, but countless items he wanted to use, to look at, and so forth. He was not aware of how much Jim [the patient’s son] and I developed our leg muscles in fetching and carrying. When he was on the third floor I would say “I am going downstairs. Is there anything you want?” No, he couldn’t think of a thing. When I returned he remembered something, but only one thing at a time. There are advantages to a home with stairs, but not with a stroke victim in the family. (Dahlberg, 1977, p. 124) For people with chronic health disorders, their quality of life depends quite heavily on the quality of life that their spouse experiences (Segrin, Badger, & Harrington, 2012). Consequently, dyadic coping whereby husbands and wives take a “we” approach to maintain their relationship while jointly managing the stress of a chronic disorder helps manage the strain of chronic and life-threatening health disorders (Badr, Carmack, Kashy, Cristofanilli, & Revenson, 2010). Couple-oriented interventions for people with chronic health disorders have generally positive effects on cou- ple functioning and patients’ abilities to manage their symptoms (Martire, Schulz, Helgeson, Small, & Saghafi, 2010). Despite the strains that develop when a family mem- ber has a chronic health disorder, there is no evidence that such strains are catastrophic (Rini et al., 2008). Moreover, some families actually become closer as a consequence of chronic health disorders. The Caregiving Role Care for people with chronic health disorders is notoriously irregular. Few facilities provide the custodial care that may be needed, and so the burden of care often falls on a fam- ily member. Women more commonly become care- givers than men. The typical caregiver is a woman in her 60s caring for an elderly spouse, but caregivers also provide help for their own parents and for dis- abled children. Some caregiving is short term or intermittent, but caregiving for patients with Alzheimer’s disease, 232 Part Five Management of Chronic and Terminal Health Disorders In one study (Collins, Taylor, & Skokan, 1990), more than 90 percent of cancer patients reported at least some beneficial changes in their lives as a result of the cancer, including an increased ability to appre- ciate each day and the inspiration to do things now rather than postponing them. These patients said that they were putting more effort into their relationships and believed they had acquired more awareness of others’ feelings and more empathy and compassion for others. They reported feeling stronger and more self- assured as well. How do people with chronic health disorders so often manage to achieve such a high quality of life? Many people with chronic health disorders perceive that they have some control over what happens to them, hold positive expectations about the future, and have a positive view of themselves. These be- liefs are adaptive for mental and physical health much of the time (Taylor, 1983), but they become especially important when a person faces a chronic health disorder. V. S. Helgeson (2003) examined these beliefs in men and women treated for coronary artery disease with an angioplasty and then followed them over 4 years. These positive beliefs not only predicted positive adjustment to disease but also were associated with a lower likelihood of a repeat cardiac event (see Figure 11.2). When a Child Has a Chronic Health Disorder Chronic health disorders are especially problematic when the person with the chronic illness is a child. First, children may not fully understand their diagnosis and treatment and thus experience confusion as they try to cope (Strube, Smith, Rothbaum, & Sotelo, 1991). Second, because children with chronic health disorders cannot follow their treatment regimen by themselves, the family must participate actively in the treatment process. Such interdependence can lead to tension be- tween parent and child (Manne, Jacobsen, Gorfinkle, Gerstein, & Redd, 1993). Sometimes, children must be exposed to isolating and terrifying procedures to treat their condition (Kellerman, Rigler, & Siegel, 1979). All these factors can create distress for both children and parents (Silver, Bauman, & Ireys, 1995). Children suffering from chronic health disorders can exhibit a variety of behavioral problems, including rebellion and withdrawal (Alati et al., 2005). They may suffer low self-esteem because they believe that the functioning and lower symptoms of depression (Lavretsky et al., 2013). But caregiving can also be a positive time when relationships deepen and the caregiver and recipient be- come closer, deriving meaning in their relationship (Horrell, Stephens, & Breheny, 2015). Gender and the Impact of Chronic Health Disorders Women with chronic health disorders experience more deficits in social support than do men with chronic health disorders. One study found that dis- abled women receive less social support because they are less likely to be married or get married than dis- abled men (Kutner, 1987). Because women with chronic health disorders and/or elderly women may experience reduced quality of life for other reasons as well, such as low income and high levels of disability (Haug & Folmar, 1986), problems in social support may exacerbate these existing differences. Even when women with chronic health disorders are married, they are more likely to be institutional- ized for their health disorder than are husbands. Mar- ried men spend fewer days in nursing homes than do married women (Freedman, 1993). It may be that hus- bands feel less capable of providing care than wives, or, because husbands are older than wives, they may be more disabled than are wives of husbands with chronic health disorders. Positive Changes in Response to Chronic Health Disorders Throughout the chapter, we have focused on problems that chronic health disorders can create. This focus obscures an important point—namely, that human beings are fundamentally resilient (Taylor, 1983; Zautra, 2009). As people strive to overcome the challenges posed by chronic health disorders, they of- ten find that health disorders confer positive as well as negative outcomes (Arpawong, Richeimer, Weinstein, Elghamrawy, & Milam, 2013; Taylor, 1983, 1989). People may experience positive emotions such as joy (Levy, Lee, Bagley, & Lippman, 1988) and optimism (Cordova, Cunningham, Carlson, & Andrykowski, 2001; Scheier, Weintraub, & Carver, 1986). They may perceive that having narrowly escaped death, they should reorder their priorities in a more satisfying way. They may also find more meaning in the daily activities of life (Low, Stanton, & Danoff-Burg, 2006). Chapter 11 Management of Chronic Health Disorders 233 health disorder, and can avoid expressing distress, es- pecially during treatments (DuHamel et al., 2004), the child’s adjustment will be better (Timko, Stovel, Moos, & Miller, 1992). If children are encouraged to engage chronic health disorder is a punishment for bad behav- ior. They may feel cheated because their peers are healthy. Nonadherence to treatment, underachieve- ment in school, and regressive behavior, such as bed- wetting or temper tantrums, are fairly common. Children with chronic health disorders may develop maladaptive coping styles involving repression, which interferes with their understanding of and ability to comanage their disorders (Phipps & Steele, 2002). Like other chronic diseases, childhood chronic dis- eases can be exacerbated by stress. These problems can be further aggravated if families do not have ad- equate styles of communicating with each other and of resolving conflict (Chen, Bloomberg, Fisher, & Strunk, 2003; Manne et al., 1993). Improving Coping Several factors can improve a child’s ability to cope with a chronic health disorder. Parents with realistic attitudes toward the disorder and its treatment can soothe the child emotionally and pro- vide an informed basis for care. If the parents are not depressed, have a sense of mastery over the child’s Improved empathy Greater knowledge about health A second chance A change in personal life priorities Greater appreciation of health and life Improved close relationships Healthy lifestyle change Myocardial infarction patients Breast cancer patients Percent Reporting Positive Effect 0 20 40 60 80 FIGURE 11.2 | Positive Life Changes Experienced by MI Patients and Breast Cancer Patients in Response to Their Health Disorders Most of the benefits reported by heart attack patients involve lifestyle changes, reflecting the fact that heart disease yields to changes in health habits. Cancer patients, in contrast, report changes in their social relationships and meaning attached to life; cancer may not be as directly influenced by health habits as heart disease, but may be amenable to finding purpose or meaning in other life activities. (Source: Petrie, Buick, Weinman, & Booth, 1999) Children’s needs to be informed about their illness and to exert control over illness-related activities and over their lives have prompted interventions to involve children in their own care. © Cathy Yeulet/123RF 234 Part Five Management of Chronic and Terminal Health Disorders Second, collaboration with the patient’s physician and family members is advisable. The physician can inform the psychologist or other counselor of a pa- tient’s current physical condition. Third, therapy with medical patients requires re- spect for patients’ defenses. In traditional psychother- apy, one of the therapist’s goals may be to challenge a patient’s defenses that may interfere with an adequate understanding of his or her problems. However, in the case of patients with chronic health disorders, these defenses may serve a benign function in protecting them from the full realization of the ramifications of their disease. Fourth, the therapist working with a medical pa- tient must have a comprehensive understanding of the patient’s health disorder and its modes of treatment. Health disorders and treatments themselves produce psychological problems (for example, depression due to chemotherapy), and a  therapist who is ignorant of this fact may make incorrect interpretations. Individual therapy is often guided by CBT, target- ing specific problems, such as fatigue, mood-related disorders, functional impairments, or stress. For ex- ample, an eight-week cognitive behavioral therapy intervention directed to reducing fatigue was effective with patients under treatment for multiple sclerosis (Van Kessel et al., 2008). Relaxation therapy was also effective, although CBT was somewhat more so. Even briefer therapies, such as CBT conducted over the telephone, can benefit patients, enhancing a sense of personal control and reducing distress (Cosio, Jin, Siddique, & Mohr, 2011; Shen et al., 2011). Coping skills training can improve functioning for chronic diseases. Such programs can increase knowl- edge about the disease, reduce anxiety, increase pa- tients’ feelings of purpose and meaning in life (Brantley, Mosley, Bruce, McKnight, & Jones, 1990; Johnson, 1982), reduce pain and depression (Lorig, Chastain, Ung, Shoor, & Holman, 1989), improve coping (Lacroix, Martin, Avendano, & Goldstein, 1991), promote adher- ence to treatment (Greenfield, Kaplan, Ware, Yano, & Frank, 1988), and increase confidence in the ability to manage pain and other side effects (Helgeson, Cohen, Schulz, & Yasko, 2001; Parker et al., 1988). In Chapter 7, we discussed the benefits of expres- sive writing for coping with stress. These interventions have been especially beneficial to people with chronic health disorders. A study of metastatic renal cell carci- noma patients, for example, found that those who wrote about their cancer (versus those who wrote about a in self-care as much as possible, and only realistic re- strictions are placed on their lives, adjustment will also be better. Encouraging regular school attendance and reasonable physical activities is particularly beneficial. When families are unable to provide help for their child diagnosed with a chronic health disorder or are overcome by their own distress, interventions may be needed. Providing family therapy and training the family in the treatment regimen can improve family functioning (Bakker, Van der Heijden, Van Son, & Van Loey, 2013). ■ PSYCHOLOGICAL INTERVENTIONS AND CHRONIC HEALTH DISORDERS Most people with chronic health disorders achieve a fairly high quality of life. However, adverse effects of chronic disease and treatments have led health psy- chologists to develop interventions to ameliorate these problems. Because anxiety and depression are inter- mittently high among people with chronic health dis- orders, an evaluation for these problems needs to be a standard part of chronic care. Patients who have a his- tory of depression or other mental illness are at par- ticular risk and so should be evaluated early for potential interventions (Goldberg, 1981; Morris & Raphael, 1987). Pharmacological Interventions Pharmacological treatment may be appropriate for patients suffering from depression associated with chronic health disorders. Antidepressants are com- monly prescribed under such circumstances. Individual Therapy Individual therapy is a common intervention for pa- tients who have psychosocial complications due to chronic health disorders. But there are important dif- ferences between psychotherapy with medical patients and psychotherapy with patients who have primarily psychological disorders. First, therapy with medical patients is more likely to be episodic than continuous. Chronic health disor- ders raise crises and issues intermittently that may re- quire help. For example, recurrence or worsening of a condition may present a crisis that needs to be addressed with a therapist. Chapter 11 Management of Chronic Health Disorders 235 Even health behavior interventions delivered via the telephone directed to improving diet and increas- ing physical activity can be successful (Gorst, Coates, Armitage, 2016). In one study, several patient groups with chronic conditions significantly improved several health behaviors via telephone intervention (Lawler et al., 2010). Relaxation, Stress Management, and Exercise Relaxation training is a widely used intervention with people with chronic health disorders, including asth- matics, cancer patients, and multiple sclerosis patients, among others. Combining relaxation training with stress management and blood pressure monitoring has proven useful in the treatment of hypertension (Agras, Taylor, Kraemer, Southam, & Schneider, 1987). Mindfulness-based stress reduction (MBSR) can improve adjustment to chronic health disorders (Brown & Ryan, 2003). Mindfulness meditation teaches people to be highly aware and focused on the present moment, accepting and acknowledging thoughts and feelings without becoming distracted or distressed by stress. Acceptance and commitment therapy (ACT) has also been used with people with chronic health disorders and helps patients to accept neutral topic) had less sleep disturbance and better sleep quality and duration and fewer problems with activities of daily life (de Moor et al., 2002). With the move toward efficient and targeted ther- apies has come a focus on brief self-management in- terventions directed to debilitating symptoms such as fatigue (Friedberg et al., 2013) or needs, such as exer- cise (Pilutti, Greenlee, Motl, Nickrent, & Petruzzello, 2013). The Internet poses exciting possibilities for provid- ing interventions in a cost-effective manner. Informa- tion about health disorders can be presented in a clear and simple way, and instructions for coping with com- mon health disorder-related problems can be posted on websites for use by patients and their families (Budman, 2000). In one study, breast cancer patients who used the Internet for medical information experi- enced greater social support than those who did not. Moreover, patients spent less than an hour a week on- line at the site, suggesting that psychological benefits may result from a minimal time commitment (Fogel, Albert, Schnabel, Ditkoff, & Neugut, 2002). Other online interventions have been targeted to more gen- eral issues facing people with chronic disorders, such as altering diet in a healthy direction and increasing physical activity (McKay, Seeley, King, Glasgow, & Eakin, 2001). Social support groups can satisfy unmet needs for social support from family and friends and can enable people to share their personal experiences with others like themselves. © Getty Images RF treatment (Martire, Lustig, Schulz, Miller, & Helgeson, 2004), and it can improve course of health disorders (Walker & Chen, 2010). Family members can remind the patient about activities that need to be undertaken and even participate in them, so that ad- herence is more likely. For example, the family may take a daily jog through the neighborhood just before breakfast or dinner. Sometimes family members need guidance in the well-intentioned actions they should avoid because such actions actually make things worse (Dakof & Taylor, 1990; Martin, Davis, Baron, Suls, & Blanchard, 1994). For example, some family members think they should encourage a person who has a chronic health disorder to be relentlessly cheerful, which can have the unintended effect of leaving the patient unable to share distress or concerns with others. At different times during the course of a health disorder, patients may be best served by different kinds of support. Tan- gible aid, such as being driven to and from medical appointments, may be important at some points in time. At other times, however, emotional support may be more important (Dakof & Taylor, 1990; Martin et al., 1994). their health disorder experiences without avoidance or fruitless striving (Lundgren, Dahl, & Hayes, 2008). Exercise also improves quality of life among peo- ple who have chronic health disorders (Sweet, Martin Ginis, Tomasone, & SHAPE-SCI Research Group, 2013). Social Support Interventions Social support is an important resource for people who have chronic health disorders. The benefits of social support have been found for virtually every chronic health disorder in which this resource has been examined, including cancer, spinal cord injury, end-stage renal disease, and cardiovascular disease. Adult day service facilities partially fill this gap, espe- cially for people who need help with some activities of daily living. Older adults, including those with Alzheimer’s, are especially likely to make use of such services (Dwyer, Harris-Kojetin, Valverde, 2014). Family Support Family support is especially important: It enhances the patient’s physical and emotional functioning, it promotes adherence to B O X 11.5 Help on the Internet Janet and Peter Birnheimer were thrilled at the arrival of their newborn but learned almost immediately that he had cystic fibrosis (CF). Shocked at this discovery— they had no idea that they both were carrying the re- cessive gene for CF—they tried to learn as much as they could about the disease. Their hometown physi- cian was able to provide them with some information, but they realized from newspaper articles that there was breaking news as well. Moreover, they wanted help dealing with the coughing, wheezing, and other symptoms so they could provide their youngster with the best possible care. The couple turned to the Internet, where they found a website for parents of children with cystic fi- brosis. Online, they learned much more about the dis- ease, found out where they could get articles providing additional information, chatted with other parents about the best ways to manage the symptoms, and shared the complex and painful feelings they had to manage every day (Baig, 1997, February 17). As this account implies, the Internet is increas- ingly a source of information and social support to people who have chronic health disorders. Websites provide instant access to other people going through the same events. CF is not a common disorder, and so the Birnheimers found that the website was their best source for information about breakthroughs in the  causes and treatments of the disease, as well as the best source for advice from other parents about the psychosocial issues that arose. Websites are only as good as the information they contain, of course, and there is always the risk of misinformation. However, some of the better known websites are scrupulously careful about the informa- tion they post. Among such services currently avail- able is WebMD, devoted to providing consumer and health information on the Internet. Websites have cre- ated opportunities for bringing together people who were once isolated, so that they can solve their prob- lems through shared knowledge. 236 Chapter 11 Management of Chronic Health Disorders 237 mutual concern that arise as a consequence of health disorders. They provide specific information about how others have dealt with the problems and give peo- ple an opportunity to share their emotional responses with others facing the same problems. Social support groups can satisfy unmet needs for social support from family and caregivers, or they may act as an ad- ditional source of support provided by those going through the same event. The Internet now provides manifold opportunities for giving and receiving social support and information online (Box 11.5). ∙ Teaching families about the nature of the chronic health disorder experienced by one family member can be helpful not only to family functioning but to the patient’s course of the health disorder as well (Walker & Chen, 2010). Support Groups Social support groups represent a resource for peo- ple who have chronic health disorders. Some of these groups are initiated by a therapist, and in some cases, they are patient-led. Support groups discuss issues of 238 Part Five Management of Chronic and Terminal Health Disorders 1. At any given time, 50 percent of the population has at least one chronic condition that requires medical management. Quality-of-life measures pinpoint problems associated with diseases and treatments and help in policy decision making regarding the effectiveness and cost-effectiveness of interventions. 2. People with chronic health disorders often experience denial, intermittent anxiety, and depression. But these reactions, especially anxiety and depression, can be underdiagnosed, confused with symptoms of disease or treatment, or presumed to be normal and so not appropriate for intervention. 3. Anxiety is reliably tied to health disorder events, such as awaiting test results or obtaining regular checkups. Depression increases with the severity of disease, pain, and disability. 4. Active coping and flexible coping efforts are more effective than avoidance, passive coping, or use of one predominant coping strategy. 5. Patients develop concepts of their health disorder, its cause, and its controllability that relate to their coping. Perceived personal control over health disorders and/or treatment is associated with good adjustment. 6. The management of chronic health disorders centers around physical problems, especially recovery of functioning and adherence to treatment; vocational retraining, job discrimination, financial hardship, and loss of insurance; gaps and problems in social support; and personal losses, such as the threat that disease poses for long-term goals. 7. Most patients experience some benefits as well as negative effects from chronic health disorders. These positive outcomes may occur because patients compensate for losses in some areas of their lives with value placed on other aspects of life. 8. Interventions with people with chronic health disorders include pharmacological interventions; CBT; brief psychotherapeutic interventions; relaxation, stress management, exercise; social support interventions; family therapy; and support groups. Support groups, including online groups, provide a helpful resource for people with chronic health disorders. S U M M A R Y K E Y T E R M S body image denial depression dietitians occupational therapists physical rehabilitation physical therapists quality of life self-concept social workers support groups 239 C H A P T E R C H A P T E R O U T L I N E Death Across the Life Span Death in Infancy and Childhood Death in Adolescence and Young Adulthood Death in Middle Age Death in Old Age Psychological Issues in Advancing Illness Continued Treatment and Advancing Illness Psychological and Social Issues Related to Dying The Issue of Nontraditional Treatment Are There Stages in Adjustment to Dying? Kübler-Ross’s Five-Stage Theory Evaluation of Kübler-Ross’s Theory Psychological Issues and the Terminally Ill Medical Staff and the Terminally Ill Patient Counseling with the Terminally Ill The Management of Terminal Illness in Children Alternatives to Hospital Care for the Terminally Ill Hospice Care Home Care Problems of Survivors The Survivor Death Education Psychological Issues in Advancing and Terminal Illness 12 © Getty Images/Brand X RF 240 Part Five Management of Chronic and Terminal Health Disorders much less widespread because of substantial advances in public health and preventive medical technologies that were developed in the 20th century. Just since the 1960s, death rates have declined 43 percent (MacDorman & Mathews, 2009). This figure presents a falsely positive picture, how- ever. The United States has substantial racial and ethnic disparities in life expectancy, with the result that we are falling behind in life expectancy faster than any other nation (Kulkarni, Levin-Rector, Ezzati, & Murray, 2011). On average, people in the United States can cur- rently expect to live about 78.8 years (Xu, Kochanek, Murphy, & Arias, 2014). When death does come, it will probably stem from a chronic illness, such as heart disease or cancer, rather than from an acute dis- order, as Tables 12.1 and 12.2 indicate. This fact means that, instead of facing a rapid, unanticipated death, the average American may know what he or she will probably die of for 5, 10, or even more years. Understanding the psychological issues associ- ated with death and dying first requires a rather grim tour of death itself. What is the most likely cause of death for a person of any given age, and what kind of death will it be? Death in Infancy and Childhood Although the United States is one of the most tech- nologically developed countries in the world, our infant mortality rate is still fairly high (5.97 per At the first assembly of freshman year in a subur-ban high school, the principal opened his re- marks by telling the assembled students, “Look around you. Look to your left, look to your right, look in front of you, and look in back of you. Four years from now, one of you will be dead.” Most of the stu- dents were stunned by this remark, but one boy in the back feigned a death rattle and slumped to the floor in a mock display of the principal’s prophecy. He was the one. Two weeks after he got his driver’s license, his car spun out of control at high speed and crashed into a stone wall. The principal, of course, had not peered into the future but had simply drawn on the statistics showing that even adolescents die, especially from accidents. By the time most of us reach age 18, we will have known at least one person who has died, whether it be a high school classmate, a grandparent, or a family friend. Many of these causes of death are preventable. Many children die from accidents in the home. Ado- lescents, as well as children, die in car crashes often related to risky driving, drugs, alcohol, or a combina- tion of factors. Even death in middle and old age is most commonly due to the cumulative effects of bad health habits, such as smoking, poor diet, lack of exer- cise, and obesity. Overall, the risk of dying at any given time has decreased for all age groups, especially at the younger ages, but stubborn causes of prevent- able death, such as obesity, smoking, and alcoholism, remain (Hoyert, 2012). Moreover, overall, gains in longevity have slowed; and one group, namely middle-aged white men and women, have shown an increase (Tavernise, 2015). This increase appears to be due primarily to suicides and drug poisonings (Case & Deaton, 2015). Declines in mental health and the ability to work, and poor liver functioning (often due to alcohol or drug abuse) and increases in pain can prompt self-medication through alcohol and drugs, which over time, can result in death. Poorly educated men and women are more likely to show this pattern. ■ DEATH ACROSS THE LIFE SPAN Comedian Woody Allen is said to have remarked on his 40th birthday, “I shall gain immortality not through my work but by not dying.” A mere 100 years ago, people died primarily from infectious diseases, such as tubercu- losis, influenza, or pneumonia. Now those illnesses are TABLE 12.1 | Deaths: Leading Causes in the United States, 2014 Rank and Cause Number of Deaths 1. Heart disease 614,348 2. Cancer 591,699 3. Chronic respiratory diseases 147,101 4. Accidents (unintentional injuries) 136,053 5. Stroke (cerebrovascular diseases) 133,103 6. Alzheimer’s disease 93,541 7. Diabetes 76,488 8. Influenza/pneumonia 55,227 9. Nephritis* 48,146 10. Intentional self-harm (suicide) 42,773 *Includes nephrotic syndrome and nephrosis. Source: Centers for Disease Control and Prevention, 2016, April. Chapter 12 Psychological Issues in Advancing and Terminal Illness 241 Causes of Death The countries that have a lower infant mortality rate than the United States all have national medical programs that provide free or low-cost maternal care during pregnancy. When in- fants are born prematurely or die at birth, the prob- lems can frequently be traced to poor prenatal care for the mother. We are one of the few developed nations without such a program, although that picture is now changing, due to health care reform. 1,000) (Xu et al., 2014), higher than in most Western European nations. Although these figures represent a substantial decline in infant mortality since 1980 (from 12.6 per 1,000) (Centers for Disease Control and Prevention, 2012, January) (Figure 12.1), African American and Hispanic infants are still more than twice as likely to die during the first year as White infants are (Centers for Disease Control and Prevention, 2012, January). TABLE 12.2 | Leading Causes of Mortality Among Adults, Worldwide, 2013 Mortality, Low-income Countries Mortality, High-income Countries Rank Cause Deaths Rank Cause Deaths 1 Lower respiratory infections 91 1 Ischaemic heart disease 153 2 HIV/AIDS 65 2 Stroke 95 3 Diarrheal diseases 53 3 Trachea, bronchus, lung cancers 49 4 Stroke 52 4 Alzheimer’s and other dementias 42 5 Ischaemic heart disease 39 5 Chronic obstructive pulmonary disease 31 6 Malaria 35 6 Lower respiratory infections 31 7 Preterm birth complications 33 7 Colon and rectum cancers 27 8 Tuberculosis 31 8 Diabetes mellitus 20 9 Birth asphyxia and birth trauma 29 9 Hypertensive heart disease 20 10 Protein energy malnutrition 27 10 Breast cancer 16 Source: World Health Organization, June 2011. Note: Table entries are yearly deaths per 100,000 people. 1900 1960 1980 1995 Year 1999 2001 2003 2005 2007 2009 2011 2013 Life expectancy Infant mortality rate 90 80 70 60 R at e/ A ge 50 40 30 20 10 0 FIGURE 12.1 | Life Expectancy and Infant Mortality in the United States, 1900–2013 (Source: National Vital Statistics Reports, 2016, February). 242 Part Five Management of Chronic and Terminal Health Disorders and other complications. Because of advances in treatment, including chemotherapy and bone marrow transplants, over 80 percent of those treated for cancer survive the disease for 5 years or more (American Cancer Society, 2012a). Unfortunately, these proce- dures, especially bone marrow transplants, can be painful and produce unpleasant side effects. Overall, the mortality rates for most causes of death in infants and children have declined. Children’s Understanding of Death The child’s idea of death appears to develop quite slowly. Up to age 5, most children think of death as a great sleep. Children at this age are often curious about death rather than frightened or saddened by it, partly because they may not understand that death is final and irreversible. Rather, the dead person is thought to be still around, but in an altered state, like Snow White or Sleeping Beauty waiting for the prince (Bluebond- Langner, 1977). Between ages 5 and 9, the idea that death is final develops, although most children do not have a bio- logical understanding of death. For some of these chil- dren, death is personified into a shadowy figure, such as a ghost or the devil. They may, for example, believe that death occurs because a supernatural being comes During the first year of life, the main causes of death are congenital abnormalities and sudden infant death syndrome (SIDS). The causes of SIDS are not entirely known—the infant simply stops breathing— but epidemiologic studies reveal that it is more likely to occur in lower-class urban environments, when the mother smoked during her pregnancy, and when the baby is put to sleep on its stomach or side (Lipsitt, 2003). Mercifully, SIDS appears to be a gentle death for the child, although not for parents: The confusion, self- blame, and suspicion from others who do not under- stand this phenomenon can exact an enormous psychological toll on the parents. After the first year, the main cause of death among children under age 15 is accidents, which account for 40 percent of all deaths in this group. In early child- hood, accidents are most frequently due to accidental poisoning, injuries, or falls in the home. In later years, automobile accidents take over as the chief cause of accidental death (Centers for Disease Control and Pre- vention, 2015, September). Cancer, especially leukemia, is the second lead- ing cause of death in youngsters age 1–15, and its in- cidence is rising. Leukemia is a form of cancer that strikes the bone marrow, producing an excessive num- ber of white blood cells and leading to severe anemia A huge decline in child mortality is now occurring throughout Africa. Broad economic growth and public health policies such as the use of insecticide-treated bed nets to discourage mosquitoes and improvements in diet are among the reasons for this good news. Source: The Economist, May 19, 2012 © commerceandculturestock/Getty Images RF Chapter 12 Psychological Issues in Advancing and Terminal Illness 243 white men (Centers for Disease Control and Preven- tion, 2016, February). Suicide, largely through fire- arms, is the third leading cause of death in this age group, with cancer the fourth. Heart disease and AIDS account for most of the remaining deaths in this age group. Reactions to Young Adult Death Next to the death of a child, the death of a young adult is consid- ered the most tragic. Not surprisingly, when young adults do receive a diagnosis of a terminal illness, such as cancer, they may feel shock, outrage, and an acute sense of injustice. Partly for these reasons, medical staff often find it difficult to work with these patients. They can be angry much of the time and, precisely because they are otherwise in good health, may face a long and drawn-out period of dying. For them, unlike older people, there are fewer biological competitors for death, so they do not quickly suc- cumb to complications, such as pneumonia or kidney failure. to take the person away. The idea that death is univer- sal and inevitable may not develop until age 9 or 10. At this point, the child typically has some understanding of the processes involved in death (such as burial and cremation), knows that the body decomposes, and realizes that the person who has died will not return (Bluebond-Langner, 1977; Kastenbaum, 1977). Death in Adolescence and Young Adulthood When asked their view of death, most young adults envision a trauma or fiery accident. This perception is realistic. Although the death rate in adolescence is low (about 0.95 per 1,000 for youths age 15–19), the major cause of death in this age group is uninten- tional injury, mainly involving automobiles (Centers for Disease Control and Prevention, 2016, April). Homicide is the second leading cause of death overall and the leading cause of death for young black men, approximately 1.3 times more likely for that of young One of the chief causes of death among adolescents and young adults is vehicle accidents. © Sergei Bachlakov/Shutterstock RF 244 Part Five Management of Chronic and Terminal Health Disorders obesity, and hypertension, which can lead to heart attacks and strokes. Death in Old Age Dying is not easy at any time during the life cycle, but it may be easier in old age. The elderly (over age 65) are generally more prepared to face death than are the young. The elderly have seen friends and relatives die and may have thought about their death and have made some ini- tial preparations. Typically, the elderly die of degenerative dis- eases, such as cancer, stroke, or heart failure, or sim- ply from general physical decline that predisposes them to infectious disease or organ failure. The terminal phase of illness is generally shorter for them because there is often more than one biologi- cal competitor for death. Why do some individuals live only into their 60s and others live into their 90s or longer? Health psy- chologists have investigated the factors that predict mortality in the elderly. Obviously, new illnesses and the worsening of preexisting conditions account for many of these differences. But changes in psychoso- cial factors are also important. Poor mental health and reduced satisfaction with life predict decline among the elderly (Myint et al., 2007; Rodin & McAvay, 1992; Zhang, Kahana, Kahana, Hu, & Pozuelo, 2009), whereas a sense of purpose is tied to a longer life (Boyle, Barnes, Buchman, & Bennett, 2009). Close family relationships are protective of health. In part because of such findings, health goals for the elderly now focus less on reducing mortality and more on improving quality of life. In the United States, people age 65 and up are healthier due to lifestyle changes. However, the worldwide picture is quite dif- ferent. People are living longer, about 64 years in third-world countries, but the prevalence of chronic diseases due to smoking, poor diet, sedentary lifestyle, and alcohol abuse means that many older people live poor-quality lives. One curious fact about the elderly is that women typically live longer than men—women to age 81 and men only to age 76 (Centers for Disease Control and Pre- vention, 2016, February). Box 12.1 explores some of the reasons for this difference in mortality rates between men and women. Table 12.3 provides a formula for roughly calculating personal longevity. A more recent website that offers projections about how likely you are to live is www.livingto100.com. Death in Middle Age In middle age, death begins to assume more realistic and, in some cases, fearful proportions, both because it is more common and because people develop chronic health problems that may ultimately kill them. The fear of death may be symbolically acted out as a fear of loss of physical appearance, sexual prowess, or athletic ability. Or it may be focused on one’s work: the realiza- tion that one’s work may be meaningless and that many youthful ambitions will never be realized. The abrupt life changes that are sometimes made in middle age— such as a divorce, remarriage to a much younger per- son, or radical job change—may be viewed partly as an effort to postpone death (Gould, 1972). Premature Death The main cause of premature death in adulthood—that is, death that occurs be- fore the projected age of 79—is sudden death due to heart attack or stroke. When asked, most people re- ply that they would prefer a sudden, painless, and nonmutilating death. Although sudden death has the disadvantage of not allowing people to prepare their exit, in some ways it facilitates a more grace- ful departure, because the dying person does not have to cope with physical deterioration, pain, and loss of mental faculties. Sudden death is, in some ways, kinder to family members as well. The family does not have to go through the emotional torment of witnessing the person’s worsening condition, and finances and other resources are not as severely taxed. A risk is that families may be poorly pre- pared financially to cope with the loss, or family members may be estranged, with reconciliation now impossible. Overall, death rates in the middle-aged group have declined, due in large part to a 60 percent drop in smoking-related lung cancer, although as noted, the death rate in this age group has recently showed a startling uptick (Case & Deaton, 2015). Heart dis- ease and stroke have declined over the past decade (American Heart Association, 2012). Despite the overall increases in life expectancy, whites still live longer than blacks by nearly 2 years (for men) and 1 year (for women) (Centers for Disease Control and Prevention, 2016, April). One factor that accounts for this difference is that socioeconomic status is a strong determinant of age of death: the higher one’s socioeconomic status, the longer one lives. Relative to whites, blacks are also more likely to have diabetes, 245 TABLE 12.3 | How Long Will You Live? Longevity calculators are rough guides for calculating your personal longevity. Although many longevity calculators exist, one of the most popular is Vitality Compass. This calculator asks questions such as: Compared with a year ago, how has your overall health changed? During the past month, how many days have you felt sad or depressed? In the past week, during how many days did you exercise or engage in rigorous physical activity for at least 20 minutes? On average, how many hours a night do you sleep? On average, how many alcoholic drinks do you have in a typical day? During the past week, how many servings of fresh vegetables did you eat? During the past week, how many times did you consume sweets or fast food? How satisfied are you with your work life? How often do you attend religious activities? After these questions are answered, you are provided with four scores: your biological age (your body’s age given your habits), your life expectancy, your healthy life expectancy (years free of cancer, heart disease, and diabetes), and your accrued years (how many years you are gaining or losing as a result of your habits). To get your score, go to http://apps.bluezones.com/vitality. Source: Vitality Compass, http://apps.bluezones.com/vitality. On average, women live nearly 5 years longer than men in the United States, a difference that also exists in most other industrialized countries (The World Factbook, 2009). Only in underdeveloped countries, in which childbirth technology is poorly developed, or in countries where women are denied access to health care, do men live longer. Why? Women seem to be biologically more fit than men. Although more male than female fetuses are conceived, more males are stillborn or miscarried than are females, and male babies are more likely to die than females. In fact, the male death rate is higher at all ages, so that there are more females than males left alive by the time young people reach their 20s. Exactly what biological mechanisms make females more fit are still unknown. Some factors may be genetic; others may be hormonal. For example, wom- en’s buffered X chromosome may protect them against certain disorders to which men are more vulnerable. Another reason why men die earlier than women is that men engage in more risky behaviors (Williams, 2003). Chief among these is smoking, which accounts for as much as 40 percent of the mortality difference between men and women. Men are exposed to more occupational hazards and hold more hazardous jobs, such as construction work, police work, or firefight- ing. Men’s alcohol consumption is greater than wom- en’s, exposing them to liver damage and alcohol-related accidents, and they consume more drugs than do women. Men are more likely to participate in hazard- ous sports and to use firearms recreationally. Men’s greater access to firearms, in turn, makes them more likely to use guns to commit suicide—a method that is more effective than the methods typically favored by women (such as poison). Men also use automobiles and motorcycles more than women, contributing to their high death rate from accidents. Men’s tendencies to cope with stress through fight (aggression) or flight (social withdrawal or withdrawal through drugs and alcohol) may thus also account for their shorter life span; women are more likely to tend and befriend in- stead (Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000). Men engage in less preventive healthcare, and this is more true of men with strong masculinity be- liefs (Springer and Mouzon, 2011). Macho men, then, live shorter lives. Social support may be more protective for women than for men. On the one hand, being married benefits men more than women (Kiecolt-Glaser & Newton, 2001). However, women have more close friends and participate in more group activities, such as church or women’s groups, that may offer support. Social sup- port keeps stress systems at low levels and so may prevent some of the wear and tear that men, especially unattached men, sustain. All of these factors seem to play a role in women’s advantage in longevity. B O X 12.1Why Do Women Live Longer Than Men? 246 Part Five Management of Chronic and Terminal Health Disorders back to dying people the means for achieving a digni- fied death at a time of one’s choosing. Receptivity to such ideas as suicide and assisted suicide for the terminally ill has increased in the American population. In a 1975 Gallup Poll, only 41  percent of respondents believed that someone in great pain with no hope of improvement had the moral right to commit suicide, whereas, as of 2013, about two-thirds of adults did; however, that is fewer than the 71% who supported euthanasia in 2007 (Reyes, 2013). Many European countries, as well as Australia and Canada, have much higher levels of support for assisted dying, with several approaching 90% (The Economist, October 20, 2012). Although some experts found that these preferences may change when people realize that they are facing death (Sharman, Garry, Jacobson, Lof- tus, & Ditto, 2008), declines in functioning appear to lead to reduced interest in life-sustaining treat- ments (Ditto et al., 2003) (see Box 12.2). Moral and Legal Issues Increasingly, societies must struggle with the issue of euthanasia, that is, end- ing the life of a person who is suffering from a painful terminal illness. Euthanasia comes from the Greek word meaning “good death” (Pfeifer & Brigham, 1996). Terminally ill patients most commonly request euthanasia or assisted suicide when they are experi- encing extreme distress and suffering, often due to inadequate relief from pain. In 1994, Oregon became the first state to pass a law permitting physician-assisted dying. To exercise this option, the patient must be mentally competent and have a terminal illness with less than 6 months to live. He or she must also be informed about alterna- tives, such as pain control and hospice care. He or she must make the request at least 3 times, and the case must be reviewed by a second physician for accuracy and to ensure that family members are not pressuring the patient to die (The Economist, October, 2012). Typically, if these conditions are met, the physician provides a lethal dose of medication or sleeping pills that the patient can then ingest to end his or her life. Statistics show a steady increase in the number of peo- ple taking advantage of the law, with 71 Oregonians choosing assisted suicide in 2011. Many other patients obtain the drugs but do not use them (Oregon Depart- ment of Human Services, 2011). Although a 1997 Su- preme Court ruling did not find physician-assisted dying to be a constitutional right, the Court nonethe- less left legislation to individual states, and so the ■ PSYCHOLOGICAL ISSUES IN ADVANCING ILLNESS Although many people die suddenly, many people who are terminally ill know that they are going to die for some time before their death. As a conse- quence, a variety of medical and psychological is- sues arise for the patient. Continued Treatment and Advancing Illness Advancing and terminal illness frequently bring the need for continued treatments with debilitating and unpleasant side effects. For example, radiation ther- apy and chemotherapy for cancer may produce dis- comfort, nausea and vomiting, chronic diarrhea, hair loss, skin discoloration, fatigue, and loss of energy. The patient with advancing diabetes may require am- putation of extremities, such as fingers or toes. The patient with advancing cancer may require removal of an organ to which the illness has now spread, such as a lung or part of the liver. The patient with degenera- tive kidney disease may be given a transplant, in the hope that it will forestall further deterioration. There may, consequently, come a time when the question of whether to continue treatments becomes an issue. In some cases, refusal of treatment may indi- cate depression and feelings of hopelessness, but in many cases, the patient’s decision may be supported by thoughtful choice. Is There a Right to Die? In recent years, the right to die has assumed importance due to several legislative and social trends. In 1990, Congress passed the Patient Self-Determination Act, requiring that Medicare and Medicaid health care facilities have written policies and procedures concerning pa- tients’ wishes for life- prolonging therapy. These poli- cies include the provision of a Do Not Resuscitate (DNR) order, which patients may choose to sign or not, in order to provide explicit guidance regarding their preferences for medical response to cardiopul- monary arrest. An important social trend affecting terminal care is the right-to-die movement, which maintains that dying should become more a matter of personal choice and personal control. Derek Humphry’s book Final Exit virtually leaped off bookstore shelves when it ap- peared in 1991. A manual of how to commit suicide or assist in suicide for the dying, it was perceived to give 247 on their charts. Thus, at present, the living will and related tools are not completely successful in allowing patients to express their wishes and ensure that they are met. Box 12.3 presents a case of assisted suicide. The complex moral, legal, and ethical issues sur- rounding death are relatively new to our society, prompted in large part by substantial advances in health care technologies. These issues will assume increasing importance in the coming decades with the aging of the population. Psychological and Social Issues Related to Dying Advancing and terminal illness raises a number of im- portant psychological and social issues. Changes in the Patient’s Self-Concept Ad- vancing illness can threaten the self-concept. As the disease progresses, patients are increasingly less able to present themselves effectively. It may be- come difficult for them to maintain control of bio- logical and social functioning. They may be incontinent (unable to control urination or bowel movements); they may drool, have distorted facial expressions, or shake uncontrollably. None of this is attractive either to the patient or to others. These patients may also be in intermittent pain, may suffer from uncontrollable retching or vomiting, and may experience a shocking deterioration in ap- pearance due to weight loss, the stress of treatments, or the sheer drain of illness. Even more threatening to 1997 Oregon Death with Dignity Act became official, with the first physician-assisted death occurring in 1998 (Sears & Stanton, 2001). Currently, 5 other states also have physician assisted dying procedures legally in place (Lovett & Pérez-Peña, 2015). More passive measures to terminate life have also received attention. A number of states have now en- acted laws enabling people with terminal diseases to write a living will, or provide advance directives, re- questing that extraordinary life-sustaining procedures not be used if they are unable to make this decision on their own. Advance directives provide instructions and legal protection for the physician, so that life- prolonging interventions, such as use of respirators, will not be indefinitely undertaken in a vain effort to keep the patient alive. This kind of document also helps to ensure that the patient’s preferences, rather than a surrogate’s (such as a relative), are respected (Ditto & Hawkins, 2005; Fagerlin, Ditto, Danks, Houts, & Smucker, 2001). Overall, 88 percent of hos- pice care patients, 65 percent of nursing-home resi- dents, but only 28 percent of home healthcare patients have filed at least one advanced directive with their physicians, usually a do not resuscitate order or a living will (Jones, Moss, & Harris-Kojetin, 2011). Unfortunately, research suggests that many physi- cians ignore the wishes of their dying patients and needlessly prolong pain and suffering. One study (Seneff, Wagner, Wagner, Zimmerman, & Knaus, 1995) found that although one-third of the patients had asked not to be revived with cardiopulmonary re- suscitation, half the time this request was not indicated (This is an example of the kind of letter that might be given by a patient to his or her physician.) Dear Dr. _________________. I wish to maintain the last weeks of my life with dig- nity and to die an appropriate death. To that end, I ask: ∙ That my health care choices (or those of the person designated to choose for me) be respected. ∙ That if palliative care is warranted, you will recommend a plan or facility. ∙ That I may be allowed to die with dignity and that extraordinary life-saving measures will not be taken. ∙ That my “do not resuscitate” request will be honored. I appreciate the opportunity to communicate my wishes with respect to the end of my life and your willingness to honor my requests so as to minimize the burden on me and my family. Sincerely, Signature Date B O X 12.2A Letter to My Physician 248 In recent years, grassroots movements expressing the rights to die and to physician-assisted suicide have gained strength in the United States. © AP Photo/Richard Sheinwald some patients is mental regression and the inability to concentrate. Cognitive decline accelerates in the years prior to death (Wilson, Beck, Bienias, & Bennett, 2007). Losses in cognitive function may also be due May Harvey, age 60, was dying slowly and painfully of gastric cancer. She no longer had the energy to see friends and needed help for every daily activity, in- cluding basic hygiene. She decided to take her own life and asked her physician to help her. He refused, explaining that the law was very clear about not as- sisting a suicide. She turned to her husband who had been a medic overseas, but he also refused. He would lose his license to practice nursing and could go to prison. So May decided she would have to do it herself. She began hoarding her sleeping pills and com- plained of insomnia, so her physician would in- crease the dosage. One day, May decided she had accumulated enough pills, and so she swallowed them all with water, expecting to slip into sleep and away from life. Instead, within the hour she threw them all up. Frantic, she gathered them up, dried what re- mained off, and put them away for another try. Soon she had accumulated a few more pills. She picked a day when she was feeling better and swallowed them all again. The same thing happened. This time her husband realized what she was trying to do. He in- formed her physician who reduced her sleep medica- tion. It did not matter because May was now too weak to try it a third time. A few days later, May’s daughter came in to help, and May told her what she had tried to do. “I don’t see why they can’t help me. When they put the dog to sleep, it was so easy and painless. Why can’t they do the same for me?” May lived a few more weeks until finally she got the death she sought. B O X 12.3 Ready to Die: The Question of Assisted Suicide either to the progressive nature of disease or to the tranquilizing and disorienting effects of painkillers and other medications. Issues of Social Interaction These issues spill over into social interactions. Although terminally ill patients often want and need social contact, they may be afraid that their obvious mental and physical dete- rioration will upset visitors. Thus, patients may begin a process of social withdrawal, whereby they gradually restrict visits to only a few family members. Family and friends can help make this withdrawal less ex- treme: They can prepare visitors in advance for the patient’s state so that the visitor’s reaction can be con- trolled; they can also screen out some visitors who cannot keep their emotions in check. Some disengagement from the social world is normal and may represent the grieving process through which the final loss of family and friends is anticipated. This period of anticipatory grieving may compromise communication because it is hard for the patient to express affection for others while simulta- neously preparing to leave them. Communication Issues As long as a patient’s prognosis is favorable, communication is usually open; however, as the prognosis worsens and treatment Chapter 12 Psychological Issues in Advancing and Terminal Illness 249 medical care. Many such patients fall victim to dubi- ous remedies offered outside the formal health care system. Frantic family members, friends who are try- ing to be helpful, and patients themselves may scour fringe publications for seemingly effective remedies or cures; they may invest thousands of dollars in their generally unsuccessful search. What prompts people to take these often un- comfortable, inconvenient, costly, and worthless measures? Some patients are so frantic at the pros- pect of death that they will use up both their own savings and those of the family in the hope of a mir- acle cure. In other cases, turning to nontraditional medicine may be a symptom of a deteriorating relationship with the health care system and the desire for more humanistic care. This is not to sug- gest that a solid patient-practitioner relationship can prevent every patient from turning to quackery. However, when the patient is well informed and feels cared for by others, he or she is less likely to look for alternative remedies. ■ ARE THERE STAGES IN ADJUSTMENT TO DYING? Do people pass through a predictable series of stages of dying? Kübler-Ross’s Five-Stage Theory Elisabeth Kübler-Ross, a pioneer in the study of death and dying, suggested that people pass through five stages as they adjust to the prospect of death: denial, anger, bargaining, depression, and acceptance. Al- though research shows that people who are dying do not necessarily pass through each of these stages in the exact order, all of these reactions are commonly experienced. Denial Denial is thought to be a person’s initial re- action on learning of the diagnosis of terminal illness. Denial is a defense mechanism by which people avoid the implications of an illness. They may act as if the illness were not severe, it will shortly go away, and it will have few long-term implications. In extreme cases, the patient may even deny that he or she has the illness, despite having been given clear information about the diagnosis (Ditto, Munro, et al., 2003). Denial, then, is the subconscious blocking out of the full realization of the reality and implications of the disorder. becomes more drastic, communication may break down. Medical staff may become evasive when questioned about the patient’s status. Family members may be cheerfully optimistic with the patient, but confused and frightened when they try to elicit information from med- ical staff. Each person involved may believe that others do not want to talk about the death. Death itself is still a taboo topic in our society. The issue is generally avoided in polite conversation; little research is conducted on death; and even when death strikes within a family, the survivors often try to bear their grief alone. The right thing to do, many people feel, is not to bring it up. The Issue of Nontraditional Treatment As both health and communication deteriorate, some terminally ill patients turn away from traditional Many terminally ill patients who find themselves repeated objects of intervention become worn out and eventually refuse additional treatment. © Photodisc/Getty Images RF 250 Part Five Management of Chronic and Terminal Health Disorders anger in favor of a different strategy: trading good be- havior for good health. Bargaining may take the form of a pact with God, in which the patient agrees to engage in good works or at least to abandon selfish ways in exchange for better health or more time. A sudden rush of charitable activity or uncharacteristically pleasant behavior may be a sign that the patient is trying to strike such a bargain. Depression Depression, the fourth stage in Kübler-Ross’s model, may be viewed as coming to terms with lack of control. The patient acknowledges that little can now be done to stay the course of illness. This realization may be coincident with a worsening of symptoms, tangible evidence that the illness is not go- ing to be cured. At this stage, patients may feel nause- ated, breathless, and tired. They may find it hard to eat, to control elimination, to focus attention, and to escape pain or discomfort. Kübler-Ross refers to the stage of depression as a time for “anticipatory grief,” when patients mourn the prospect of their own deaths. This grieving process may occur in two stages, as the patient first comes to terms with the loss of past valued activities and friends and then begins to anticipate the future loss of activities and relationships. Depression, though far from pleas- ant, can be functional in that patients begin to prepare for the future. Depression can nonetheless require treat- ment, so that symptoms of depression can be distin- guished from symptoms of physical deterioration. Acceptance The final stage in Kübler-Ross’s the- ory is acceptance. At this point, the patient may be too weak to be angry and too accustomed to the idea of dying to be depressed. Instead, a tired, peaceful, though not necessarily pleasant calm may descend. Some pa- tients use this time to make preparations, deciding how to divide up their remaining possessions and say- ing goodbye to old friends and family members. Evaluation of Kübler-Ross’s Theory How good an account of the process of dying is Kübler-Ross’s stage theory? As a description of the reactions of dying patients, her work was invaluable. She has chronicled nearly the full array of reactions to death, as those who work with the dying will be quick to acknowledge. Her work is also of inestimable value in pointing out the counseling needs of the dying. Finally, along with other researchers, she broke Denial early on in adjustment to life-threatening illness is both normal and useful because it can protect the patient from the full realization of impending death (Lazarus, 1983). Usually it lasts only a few days. When it lasts longer, it may require psychological intervention. Anger A second reaction to the prospect of dying is anger. The angry patient is asking, “Why me? Consid- ering all the other people who could have gotten the illness, all the people who had the same symptoms but got a favorable diagnosis, and all the people who are older, dumber, more bad-tempered, less useful, or just plain evil, why should I be the one who is dying?” Kübler-Ross quotes one of her dying patients: I suppose most anybody in my position would look at somebody else and say, “Well, why couldn’t it have been him?” and this has crossed my mind several times. An old man whom I have known ever since I was a little kid came down the street. He was eighty- two years old, and he is of no earthly use as far as we mortals can tell. He’s rheumatic, he’s a cripple, he’s dirty, just not the type of person you would like to be. And the thought hit me strongly, now why couldn’t it have been old George instead of me? (quoted in Kübler-Ross, 1969, p. 50) The angry patient may show resentment toward anyone who is healthy, such as hospital staff, family members, or friends. Angry patients who cannot ex- press their anger directly by being irritable may do so indirectly by becoming embittered. Bitter patients show resentment through death jokes, cracks about their deteriorating appearance and capacities, or pointed remarks about all the exciting things that they will not be able to do because those events will happen after their death. Anger is one of the harder responses for family and friends to deal with. They may feel they are being blamed by the patient for being well. The family may need to work together with a therapist to understand that the patient is not really angry with them but at fate; they need to see that this anger will be directed at anyone who is nearby, especially people with whom the patient feels no obligation to be polite and well behaved. Unfortunately, family members often fall into this category. Bargaining Bargaining is the third stage of Kübler- Ross’s formulation. At this point, the patient abandons Chapter 12 Psychological Issues in Advancing and Terminal Illness 251 Medical Staff and the Terminally Ill Patient Unfortunately, death in the institutional environment can be depersonalized and fragmented. Wards may be understaffed, with the staff unable to provide the kind of emotional support a patient needs. Hospital regula- tions may restrict the number of visitors or the length of time that they can stay, thereby reducing the avail- ability of support from family and friends. Pain is one of the chief symptoms in terminal illness, and in the busy hospital setting, the ability of patients to get the amount of pain medication they need may be compro- mised. Moreover, as we saw in Chapter 10, prejudices against drug treatments for pain still exist, and so ter- minal patients run the risk of being undermedicated for their pain (Turk & Feldman, 1992a, 1992b). Death in an institution can be a long, lonely, mechanized, painful, and dehumanizing experience. The Significance of Hospital Staff to the Patient Physical dependence on hospital staff is great because the patient may need help for even the smallest activity, such as turning over in bed. Patients through the silence and taboos surrounding death, making it an object of both scientific study and sensi- tive concern. Nonetheless, it bears mention, again, that patients do not typically go through five stages in a predetermined order, but rather may experience these stages in a various intermittent order. Kübler-Ross’s stage theory also does not fully acknowledge the importance of anxiety, which, next to depression, is one of the most common re- sponses. What patients fear most is not being able to control pain; they may welcome or even seek death to avoid it (Hinton, 1967). Other symptoms, such as difficulty breathing or uncontrollable vom- iting, likewise produce anxiety, which may exacer- bate the patient’s already deteriorating physical and mental condition. ■ PSYCHOLOGICAL ISSUES AND THE TERMINALLY ILL Approximately one-third Americans who die each year die in hospitals (Centers for Disease Con- trol and Prevention, 2015, November). Medical staff can be very significant to a dying patient because they see the patient on a regular basis, provide realistic information, and are privy to the patient’s last personal thoughts and wishes. © Flying Clours Ltd./Getty Images RF 252 Part Five Management of Chronic and Terminal Health Disorders ∙ Anticipatory grief—Both the patient and his or her family members should be aided in working through their anticipatory sense of loss and depression. ∙ Timely and appropriate death—The patient should be allowed to die when and how he or she wants to, as much as possible. The patient should be allowed to achieve death with dignity. These guidelines, established many years ago, still pro- vide the goals and means for terminal care. Unfortu- nately, a “good death” is still not available to all. A survey of the survivors of 1,500 people who had died revealed that dying patients often had not received enough medication to ease their pain and had not expe- rienced enough emotional support. Lack of open com- munication and lack of respect from medical staff are two other common complaints (Teno, Fisher, Hamel, Coppola, & Dawson, 2002). Counseling with the Terminally Ill Many dying patients need the chance to talk a coun- selor. Therapy is typically short-term and the nature and timing of the visits typically depend on the desires and energy level of the patient. Moreover, in working with the dying, patients typically set the agenda. Therapy with the dying is different from typical psychotherapy in several respects. First, for obvious reasons, it is likely to be short term. The format of therapy with the dying also varies from that of tradi- tional psychotherapy. The nature and timing of visits must depend on the inclination and energy level of the patient, rather than on a fixed schedule of appoint- ments. The agenda should be set at least partly by the patient. And if an issue arises that the patient clearly does not wish to discuss, this wish should be respected. Terminally ill patients may also need help in resolv- ing unfinished business. Uncompleted activities may prey on the mind, and preparations may need to be made for survivors, especially dependent children. Through careful counseling, a therapist may help the patient come to terms with the need for these arrange- ments, as well as with the need to recognize that some things will remain undone. Some thanatologists—that is, those who study death and dying—have suggested that behavioral and cognitive-behavioral therapies can be constructively employed with dying patients (Sobel, 1981). For ex- ample, progressive muscle relaxation can ameliorate are entirely dependent on medical staff for amelioration of their pain. And staff may be the only people to see a dying patient on a regular basis if he or she has no friends or family who visit regularly. Moreover, staff may be the only people who know the patient’s actual physical state; hence, they are the patient’s only source of realistic information. The pa- tient may welcome communication with staff because he or she can be fully candid with them. Finally, staff are important because they are privy to one of the pa- tient’s most personal and private acts, the act of dying. Risks of Terminal Care for Staff Terminal care is hard on hospital staff. It is the least interesting physical care because it is often palliative care—that is, care designed to make the patient feel comfortable— rather than curative care—that is, care designed to cure the patient’s disease. Terminal care involves a lot of unpleasant custodial work, such as feeding, chang- ing, and bathing the patient, and sometimes symptoms go undertreated. The staff may burn out from watching patient after patient die, despite their best efforts. Staff may be tempted to withdraw into a crisply efficient manner rather than a warm and supportive one so as to minimize their personal pain. Physicians, in particular, want to reserve their time for patients who can most profit from it and, consequently, may spend little time with a terminally ill patient. Unfortu- nately, terminally ill patients may interpret such be- havior as abandonment and take it very hard. Accordingly, a continued role for the physician in the patient’s terminal care in the form of brief but fre- quent visits is desirable. Achieving an Appropriate Death Psychia- trist Avery Weisman (1972, 1977), a distinguished clinician who worked with dying patients for many years, outlined a useful set of goals for medical staff in their work with the dying: ∙ Informed consent—Patients should be told the nature of their condition and treatment and, to some extent, be involved in their own treatment. ∙ Safe conduct—The physician and other staff should act as helpful guides for the patient through this new and frightening stage of life. ∙ Significant survival—The physician and other medical staff should help the patient use his or her remaining time as well as possible. Chapter 12 Psychological Issues in Advancing and Terminal Illness 253 Counseling with a terminally ill child may be required and typically follows some of the same guidelines as is true with dying adults, but therapists can take cues about what to discuss from the child, talking only about those issues the child is ready to discuss. Parents, too, may need counseling to help them cope with the impending death. They may blame themselves for the child’s illness or feel that there is more they could have done. The needs of other children may be passed over in the process of dealing with the dying child’s situation. A counselor working with the family can help restore balance. Parents of dying children experience an enormous stress burden to the degree that they sometimes have the symptoms of post-traumatic stress disorder. The emotional distress of parents with dying children may require supportive mental health services and meet- ings with the physician to help the patients make sense of and derive meaning from the child’s terminal ill- ness, especially during the first few months after the child’s diagnosis (Dunn et al., 2012) and death (Meert et al., 2015). ■ ALTERNATIVES TO HOSPITAL CARE FOR THE TERMINALLY ILL Hospital care for the terminally ill is palliative, emotion- ally wrenching, and demanding of personalized atten- tion in ways that often go beyond the resources of the hospital. Consequently, hospice care in one’s own home or in a hospice facility is increasingly an option for dying people. Hospice Care The idea behind hospice care is the acceptance of death, emphasizing the relief of suffering rather than the cure of illness. Hospice care is designed to provide palliative care and emotional support to dying patients and their family members. About 1.65 million people received services from hospices in 2014, making hos- pice care a significant contributor to the delivery of services to advancing in terminally ill patients (National Hospice and Palliative Care Organization, 2015, September). In medieval Europe, a hospice was a place that provided care and comfort for travelers. In keeping with this original goal, hospice care is both a philoso- phy concerning a way of dying and a system of care for the terminally ill. Typically, painful or invasive discomfort and instill a renewed sense of control. Pos- itive self-talk, such as focusing on one’s life achieve- ments, can undermine the depression that often accompanies dying. Family therapy can also be an ap- propriate way to deal with issues raised by terminal illness, to help the family and patient recognize and plan for the future. The Management of Terminal Illness in Children Working with terminally ill children is perhaps the most stressful of all terminal care. As a result, family members, friends, and even medical staff may be re- luctant to talk openly with a dying child about his or her sit