Stress and Gender Gender related differences in a changing society

1
Stress and GenderGender related differences in
a changing society

• Maria S Kopp MD, PhD, Árpád Skrabski, PhD, Csilla
  Csoboth, MD, PhD.
• Gender Medicine Working Group,
• Institute of Behavioural sciences, Budapest,
  Hungary
• www.behsci.sote.hu
• Gender-Specific Medicine Conference
• February 23-26,2006, Berlin

2
Gender differences

• Although men and women share the same
  socio-economic circumstances, there are
  significant gender differences in worsening
  mortality rates in Hungary
• Socioeconomic differences are more closely
  connected with male premature mortality rates
• What is the explanation for the increased
  vulnerability of middle aged men during this
  period of rapid economic change?

3
Aggregate mortality according to low versus high
education(Mackenbach et al, 1999)
4
Mortality rates of middle aged (45-64) men and
women in Hungary (2001)
5
Special experimental model

• The paradoxical features of gender related
  premature mortality and morbidity rates in
  Central-Eastern-European countries might be
  regarded as
• a special experimental model to understand better
  the human consequences of chronic stress and
• gender differences in this respect

6
What can explain the opposite changes in gender
differences in life expectancy?

• In the 1970s no differences in Austrian and
  Hungarian life expectancy
• Life expectancy in Hungary today
• Male 68.2, female 76.5 years-8.3 years
  differences in Hungary, 2.3 years lost
• In neighbouring Austria
• Male 75.9- they live 7.7 years longer,
• Female 81.7- they live 5.2 years longer
• 5.8 years differences in Austria

7
Growing polarization of the socio-economic
situation between 1960 and 2002

• Until 1960, practically no income inequality,
  there were no mortality differences between
  socio-economic strata and there were smaller
  gender differences
• Since that time increasing disparities in
  socio-economic conditions have been accompanied
  by a widening socio-economic gradient in
  mortality, but much more among men.

8
Mortality rate in 1000 men in corresponding age
groups in the Hungarian population (Demographic
Yearbook, 2004)
9
Possible explanations

• This deterioration cannot be ascribed to
  defficiencies in health care,because
• during these years there was a significant
  decrease in infant and old age mortality and
  improvements in other dimensions of health care.
• Between 1960 and 1989 there was a constant
  increase in the gross domestic product in
  Hungary. Worsening material situation cannot be
  the explanation
• Genetic causes- sudden changes, not probable,
  possible changes in genetic expression

10
General adaptation Theory of János Selye

• The three phases of stress
• alarm reaction,
• resistance phase and,
• the third, physiologically most harmful phase,
  exhaustion, chronic stress
• What type of chronic stress level is higher among
  men than among women in Hungary?

11
Gender differences

• There are no fundamental gender differences in
  physiological adaptation processes
• Although male and female hormones influence it in
  both respect
• Estrogenes decrease the stress reactivity
• According to animal studies, males appear to be
  more vulnerable to long-lasting stress-induced
  hippocampal damage than females (Uno et al, J.
  Neurosci,9,1705-1711,1989), the decline of
  circulating testosterone levels resulting from
  uncontrollable stress seems to play an additional
  role.
• Perinatal processes might result in
  dysregulation- post-natal depression

12
Early life chronic stress

• Phases of disruption of mother-infant or peer
  bonding
• 1. "protest" behaviour (acute and resistance
  phases of stress).
• 2.despair locomotor inactivity and a
  disinterst in motivationally salient external
  stimuli.
• 3."detachment""hardwired" in the brain of many
  social mammals and results in high stress
  vulnerability

13
Attachment theory (Bowlby, Imre Hermann)

• Physiological, psychological and developmental
  importance of the early childhood affective
  mother-child bond and the negative consequences
  of the disruption of this relationship.
• According to follow up studies, insecure
  attachment predicts later emotional instability
  and health deterioration. Maltreatment at an
  early age can have enduring negative effects on a
  childs brain development and function, and on
  his or her vulnerability to stress.

14
Special gender roles, crucial effect of maternal
care

• Maternal neglect behaviour results in attachment
  disturbances
• Animal experiments influence of caring and
  non-caring mothers on development of offsprings
• Naturally occuring variations in maternal care
  alter the expression of genes that regulate
  behavioral and endocrine responses to stress, as
  well as hippocampal synaptic development
  related to oxytocin receptor gene expression
  (M.J.Meaney Ann Rev Neurosci2001, 24,1161-1192)
• Intergenerational transmission- importance of
  maternal care- in low socioeconomic groups more
  maternal neglect

15
Learned helplessness as result of chronic stress

• A condition of loss of control created by
  subjecting animals or humans to an unavoidable,
  emotionally negative life situation (such as
  unavoidable shocks, relative deprivation, role
  conflict, etc). Being unable to avoid or escape
  (flight or fight) an aversive situation for a
  long period of time produces a feeling of
  helplessness that generalises to subsequent
  situations.

16
Brain consequences of learned helplessness

• The hippocampus is primarily affected by the
  long-lasting elevations of circulating
  corticosteroids resulting from uncontrollable
  stress. Severe stress for a prolonged period
  causes damage in hippocampal pyramidal neurons,
  especially in the CA 3 and CA4 region and
  reductions in the length and arborization of
  their dendrites.

17
Main biological pathways of chronic stress

• - Dysregulation of the hypothalamus-hypophysis-adr
  enocortical (HPA) axis and the sympathetic-adrenal
  -medullary system (SAM) resulting in elevations
  in serum catecholamin and cortisol levels.
• Sympathoadrenal hyperactivity contributes to the
  development of CVD through effects of
  catecholamines upon the heart, blood vessels and
  platelets.
• Sympathoadrenal activation modifies the function
  of circulating platelets

18
Human learned helplessness

• expectancy that responses and outcomes are
  uncontrollable and might result in only
  emotionally negative consequences.
• refers to the motivational, cognitive and
  emotional components of the interpretation of the
  environmental stimuli
• Central importance values, self-ideal,
  expectations, attitudes
• Gender differences in this respect.

19
Gender differences?

• Differences in environmental, cultural and gender
  role requirements
• Masculine versus feminine societies ( Geert
  Hofstede, 2001Cultures consequences ) Hungary is
  extremely masculine society- different gender
  roles
• Socioeconomic status seems to be more important
  for men,
• Family affairs for women
• Differences according to education level

20
Effect of sex nonconformity

• Girls who are more masculine according to
  attitude scores
• and boys who are more feminine tend to do
  better in intellectual giftednes measured by
  National Merit test score
• This nonconforming seems to be more important
  among girls
• Bem Sex-Role Inventory (BSRI) masculine,
  feminine adjective checklists (Lippa,R, 1998, in
  Males, Females and Behavior, edsEllis L, Ebertz,
  L,Praeger, pp.177-194.)

21
Gender differences

• Anxiety and depression is significantly higher
  among women according to most of the studies
• In Hungary male depression rate is relatively
  higher, similar to female depression rates
• Anxiety rates are twofold of male anxiety rates
• Alcohol and drog abuse, smoking is much more
  prevalent among men
• Depression seems to influence cardiovascular risk
  more among men than among women according to
  follow up studies. (Pennix et al, 2001,
  Arch.Gen.Psych,58,221-227)
• Despite similar free cortisol responses of men
  and women (studied in the luteal phase) to
  psychosocial stress, gender may exert
  differential effects on the immune system by
  modulating glucocorticoid sensitivity of
  proinflammatory cytokine production.(Rohleider et
  al,2001,Psychosom Med 63,966-972)

22
Objectives of our behavioral medicine studies in
Hungary

• To reveal those social, mental and behavioural
  factors in their inter-relatedness with
  biological processes that lead to health
  deterioration in the Hungarian middle-aged
  population,
• Analyse gender related differences in this
  respect,
• introduce effective preventive strategies that
  are based on research findings

23
National representative surveys in the Hungarian
population

• The samples represent the Hungarian population
  above age 16 according to gender, age and county
• Hungarostudy 1983 more than 6000 persons
• Hungarostudy 1988 20.902 persons
• Hungarostudy 1995 12.463 persons

24
Latest surveys Hungarostudy 2002 and follow up
in progress

• 12,643 persons were interviewed in their homes,
  they represented the population above age 18
  according to age and sex and counties
• The refusal rate was 17,7 for the full sample,
  although there were significant differences,
  depending on settlements
• About 6.500 persons agreed to participate in a
  follow up study- now in progress

25
Socio-economic factors

• Education,
• Income,
• Subjective socioeconomic status (Nancy Adler)
• Acces to car
• Employment

• Marital status
• Housing environment
• Family environment
• Childhood experiences
• Self-rated socioeconomic changes

26
Hungarostudy indicators, mental health

• Shortened Beck Depression Score
• Hospital Anxiety Score
• WHO Wellbeing Questionnaire
• Self-efficacy score

• Vital exhaustion score
• Hostility Score
• Type D Personality Questionnaire
• Hopelessness Score

27
Further mental health indicators

• Ways of coping questionnaire
• Purposes in Life
• Meaning (R.Rahe)
• Anomie score
• TCI shortened cooperativeness and sensation
  seeking
• Dysfunctional attitude score
• Life events

• Social support questionnaire
• (Caldwell)
• Marital stress questionnaire
• Social capital measures trust, civic
  associations
• Chicago collective efficacy
• Stress and coping

28
Work stress variables

• Control at work
• Social support at work
• Working hours per week days
• and weekend days
• Income as job related reward
• Job security
• Unemployment

29
Health behaviour, lifestyle and other confounding
factors

• Religious involvement
• Suicidal behaviour
• Womens health- factors related to pregnancy and
  birth
• ethnical factors

• Smoking
• Alcohol (AUDIT)
• Drug consumption
• Physical activity
• Body weight and height- BMI
• Sleep complaints

30
Depression severity categories in 1988, 1995 and
2002 in the Hungarian adult population (above 18)
31
Clinical depression (BDI 18-), men Hungarostudy
2002
32
Clinical depression (BDI 18-),
female Hungarostudy 2002
33
Mean Beck depression score according to age among
Hungarian men and women (Hungarostudy 2002)
34
Significance of chronic stress-depressive
symptomatology

• Based on the data of our national representative
  surveys, we found that the worse socioeconomic
  situation is linked to higher morbidity and
  mortality rates in Hungary as well,
• however, higher morbidity rates are connected to
  relatively poor socioeconomic situations mainly
  through the mediation of depressive symptoms,
• in broader sense through chronic stress

35
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36
Low income, depression and morbidity

• In 1988 depression mediated between low income
  and self-rated morbidity among men,
• while among women low income was not
  significantly connected neither to depression,
  nor with self reported morbidity.
• In 1995 low income became directly connected to
  morbidity both in men and women,
• but the mediating effect of depression between
  low income and morbidity remained more important
  among men than among women.

37
Why are men more susceptible to relative income
inequality?

• 1.Income inequality is much higher among men.
• 2. Men are more susceptible to loss of status
  than women. Animal experiments have shown males
  to be more sensitive than females to loss of
  dominance position, that is loss of position in
  hierarchy. In animal studies social rank is the
  best predictor of quality of life and health
  among males.

38
Depression and chronic stress

• A self-destructive circle develops from the
  enduring relatively disadvantageous socioeconomic
  situation and depressive symptoms,
• This circle resulting in chronic stress, might
  play a significant role in the increase of
  morbidity and mortality rates in the lower
  socioeconomic groups of the population.
• Kopp MS, Réthelyi J (2004) Where psychology meets
  physiologychronic stress and premature
  mortality- the Central-Eastern-European health
  paradox, Brain Research Bulletin ,62,351-367.

39
Ecological level analysesdeterminants of
mid-aged mortality differences based onnational
representative survey data and national
statistical mortality data

• for 150 Hungarian subregions

40
Mortality rates of middle aged men and depression
scores in 2002
41
Ecological studies on determinants of chronic
stress in the Hungarian population

• Socio-economic status (education and income),
  social capital and collective efficacy
  (neigborhood cohesion) explained a considerable
  part of the sub-regional variance in middle aged
  mortality rates,
• Competitive attitude was a significant predictor
  of mortality only among men, while religious
  involvement was a significant protective factor
  only among women.
• Skrabski Á, Kopp MS, Kawachi I (2004) Social
  capital and collective efficacy in
  Hungarycross-sectional associations with middle
  aged female and male mortality rates, J
  Epidemiology and Community Health ,30, 65-70.

42
Interaction between male and female health

• It is an interesting finding that the most
  important social capital variables of the
  opposite sex seem to influence the mortality for
  the other sex
• Civic support perceived by men is a protective
  factor for women, while the amount of reciprocity
  perceived by women seems to be a significant
  predictor of male health.
• Skrabski ,Á, Kopp MS, Kawachi I.(2003) Social
  capital in a changing societycross sectional
  associations with middle aged female and male
  mortality rates, J Epidemiology and Community
  Health 57, 2, 114-119.

43
Which are the protective factors for women?

• Relative economic deprivation, rival attitude and
  social distrust are all less important risk
  factors for women
• The socio-economic differences are less important
  regarding the middle aged female mortality
  differences.
• Neighborhood cohesion, religious involvement and
  reciprocity were not so much influenced by sudden
  socio-economic changes, therefore the protective
  network of women remained relatively unchanged.

44
Gender paradox of subjective social status

• Female subjective social status influenced highly
  significantly the male mid-aged mortality
• r (female SSS and male mid-aged mortality)
  -.597 p.000
• That is, the subjective evaluation of the
  relative social deprivation by women might be an
  important risk factor for men as well
• Kopp MS, Skrabski Á, Kawachi I, Adler NE (2005)
  Low socioeconomic staus of the opposite gender is
  a risk factor for middle aged mortality, J.
  Epidemiology and Community Health 59,675-678.

45
Correlations of male and female social status and
male mid aged mortality
Korrelációs együtthatók, középkoró férfiak
halálozása
46
Significant correlations of total mid-aged CV
mortality rates among men (n150)

• Education -.599
  
• Income -.512
• Unemployment .465
• Social support from friends -.372
• Subjective social status .353
• Depression .352
• Weekend work hours
  .344
• Anomie .340

• Non stop alcohol .288
• Morning alcohol .266
• Hostility .257
• Control at work -.255
• Self-blame because of alcohol .250
• Job security -.220
• Social support at work -.197
• Smoking (cigarettes pro day)
  .188

47
Significant correlations of total mid-aged CV
mortality rates among women

• Education -.527
  
• Income -.402
• Unemployment .378
• Social support from friends -.345
• Depression .331
• Non stop alcohol .313
• Job security -.304
• Subjective social status .303

• Anomie .287
• Hostility .229
• Control at work -.275
• Weekend work hours
  .225
• Morning alcohol .224
• Social support at work -.179
• Smoking (cigarettes pro day)
  .151

48
Work stress variables in relation to total
mid-aged CV mortality rates

• Total male mid-aged CV mortality
• Explained
  variance
• - weekend work hours 11.2
• - social support at work 14.7
• Total female mid-aged CV mortality
• - job security 8.7
• - weekend work hours 10.9

49
Work stress variables in relation to mid-aged
ischemic heart disease mortality rates

• Male mid-aged IHD mortality
• Explained
  variance
• - social support at work 3.9
• - weekend work hours 7.6
• Female mid-aged IHD mortality
• - control at work 10.6

50
Work stress variables in relation to mid-aged
cerebrovascular mortality rates

• Male mid-aged cerebrovascular mortality
• Explained
  variance
• - weekend work hours 11.7
• - control at work 14.4
• Female mid-aged cerebrovascular mortality
• - job security 4.8
• - week day work hours 7.2

51
Gender differences

• Low control at work and low social support at
  work were strongly associated with premature
  cardiovascular mortality rates in both sexes
• although considerable gender differences
• Weekend workload was most closely connected with
  male
• Job insecurity with female CV mortality

52
Other psychosocial risk factors

• Low social support from friends
• Depression
• Anomie
• Hostility were significantly connected with
  premature CV mortality differences,
• These factors explained 18.4 of male a
• And 15.1 of female total CV mortality
  differences
• Significantly connected with work stress variables

53
Socio-economic and behavioural factors

• Low personal income, low education and non-stop
  drinking explained 31.6 of male premature CV
  mortality differences,
• Low education and non stop drinking explained
  25.3 of female CV mortality differences,
• Low education and income were strongly associated
  with work stress, i.e. low control at work,
  weekend workload, low job security, low social
  support at work and depression

54
Conclusion mediating role of work stress and
psycosocial factors

• The worse socioeconomic situation is linked to
  higher CV mortality rates in Hungary as well,
• however, higher CV mortality rates are connected
  to relatively poor socioeconomic situations
  mainly through the mediation of work related and
  psychosocial risk factors,
• These factors create chronic stress situations,
  which can be measured by depressive
  symptomatology, especially in the low
  socio-economic strata and in the deprived
  regions.
• Kopp MS, Skrabski Á, Szántó Zs, Siegrist J
  (accepted for publication) Psychosocial
  determinants of premature cardiovascular
  mortality differences within Hungary, J. Epid.
  Community Health

55
Marital stress and cardiovascular vulnerability
Piroska Balog, Maria S Kopp Institute of
Behavioral Sciences Semmelweis University
56
Methods I.

• Hungarostudy 2002
• 12680 persons national representative study
• middle aged (lt65 years), actively working,
  married or cohabiting men (2206) and women
  (1820)
• 343 men and 300 women treated with
  hypertension
• 49 men and 106 women treated with depression
• Control healthy men (731) and women (434)
• 242 men and 280 women with high marital stress

57
Methods II.

• Marital stress Shortened Marital Stress Scale (5
  questions related to the quality of marital
  relationship).
• Depression Shortened Beck Depression Inventory
  (9 questions)

• Has been treated with hypertension?
• Has been treated with depression?

• Age, socio-economic status
• Body Mass Index
• Smoking
• Alcohol
• Lack of physical activity

58
ResultsMarital stress and depressive symptoms
(BDI).
Healthy men and women
Men and women treated with hypertension
Men and women treated with depression
59
Marital stress as a risk factor for hypertension
men
Age
OR1.08 (95 CI 1.06-1.10)
Hypertension
OR1.74 (95 CI 1,09-2,79)

Marital stress
OR1.16 (95 CI 1.12-1.21)
OR1.01 (95 CI 1.00-1.02)
Body Mass Index
NS
Socio-economic status, alcohol, sedentary
lifestyle
Smoking
60
Marital stress as a risk for seeking help for
depression (treatment for depression)
Women
Age
OR1.02 (95 CI 1.00-1.05)
OR2,78 (95 CI 1,58-4,88)
Treatment for depression

Marital stress
OR1.14 (95 CI 1.07-1.20)
NS
Body Mass Index
Socio-economic status, alcohol, smoking,
sedentary lifestyle
61
Depression as a risk for hypertension
men
Age
OR1.08 (95 CI 1.06-1.10)
Hypertension
OR1.17 (95 CI 1.12-1.22)
Body Mass Index

OR1.01 (95 CI 1.00-1.02)
Smoking
OR1.07 (95 CI 1.05-1.10)
NS
NS
Depression (BDI)
Socio-economic status, alcohol, sedentary
lifestyle,
Marital stress
62
Summary

• High marital stress
• Is related to increase of depressive symptoms
  both in men and women
• In men it is a risk factor for hypertension,
  independently from traditional risk factors
  through depressive symptoms
• In women it is an independent risk factor for
  treatment for depression
• In men with hypertension depression remained
  unrecognized (and untreated!)

63
Mental health promotion consequences

• Cognitive behavioural methods of early correction
  of vulnerability in high risk groups are in the
  focus of our preventive programmes
• School and working place related lifeskills
  programmes seems to strenghten the coping
  abilities of high risk groups
• There is a need for differentiated preventive and
  health promotion programmes for male and female
  subgroups of the population

64
References

• Kopp MS, Réthelyi J (2004) Where psychology meets
  physiologychronic stress and premature
  mortality- the Central-Eastern-European health
  paradox, Brain Research Bulletin ,62,351-367.
• Kopp MS, Skrabski Á, Réthelyi J, Kawachi I, Adler
  N (2004) Self Rated Health, Subjective Social
  Status and Middle- Aged Mortality in a Changing
  Society, Behavioral Medicine,30, 65-70.
• Kopp MS (interview) (2000) Stress The invisible
  Hand in Eastern Europe s Death Rates, Science,
  288, 9.June 2000, 1732-1733.
• Kopp MS, Skrabski Á, Szedmák S (2000)
  Psychosocial risk factors, inequality and
  self-rated morbidity in a changing society,
  Social Sciences and Medicine 51, 1350-1361.
• Kopp MS, Skrabski Á, Kawachi I, Adler NE (2005)
  Low socioeconomic staus of the opposite gender is
  a risk factor for middle aged mortality, J.
  Epidemiology and Community Health, 59,675-678.
• Kopp MS, Skrabski Á, Szántó Zs, Siegrist J
  (accepted for publication) Psychosocial
  determinants of premature cardiovascular
  mortality differences within Hungary, J. Epid.
  Community Health
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• Skrabski ,Á, Kopp MS, Kawachi I.(2003) Social
  capital in a changing societycross sectional
  associations with middle aged female and male
  mortality rates, J Epidemiology and Community
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