Medical psychology: Where psychology meets physiology

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Medical psychologyWhere psychology meets
physiology?

• Psychosocial factors influencing health
• September 5, 2006
• Professor Maria Kopp,MD, PhD
• Institute of Behavioural Sciences
• www.behsci.sote.hu

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CentralEastern European legacy

• In the twentieth century, Hungarian born
  scientists, such as
• Sándor Ferenczi,
• Franz Alexander,
• Hans Selye,
• Michael Bálint,
• significantly contributed to laying the
  foundations of psycho-social attitude in medicine

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What is stress and how does it influence disease?

• Stress theory Hans Selye- General adaptation
  syndrome
• In widest sense in the process of
  interrelationship between person and his/her
  environment those situations which need new
  behavioural responses
• Harmful or protective?

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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!
• Kopp MS, Réthelyi J Where psychology meets
  physiology chronic stress, morbidity and
  mortality,Brain Research Bulletin, 2004,
  62,351-367

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Evolutionary model of stress

• Stress responses act as triggers for the adaptive
  modification of the structure and the function of
  the brain.
• Stress responses serve to adjust in the physical,
  emotional and personality development in a
  self-optimising manner,
• in accordance with the ever-changing requirements
  of the external world.

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Modern stress concept central importance of lack
of perceived control

• Elements of stress
• 1. An aversive stimulus event-
• life events- stressors
• change in routine
• situations of monotony
• 2. A specific physiological and psychological
  response- stress responses-
• discrepancy between psycological and
  physiological responses

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Person and environment

• 3.Special type of transaction between the person
  and the environment
• feelings of threat, harm or loss
• For example low socio-economic status for men or
  women, consequently
• mortality differences in middle aged population

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Aggregate mortality according to low versus high
education(Mackenbach et al, 1999)
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Status syndrome

• M. Marmot Status syndrome, Times Books,2004
  British civic servants
• In 1992-96 10 years difference between
• the highest educational group- 78 years life
  expectancy and
• the lowest - 68 years life expectancy 1.5-times
  higher myocardial infarct mortality after
  controling for smoking and alcohol consumption

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Morbidity and mortality crisis in the
transforming societies

• The morbidity and mortality crisis of the
  transforming Central and Eastern European
  countries is an extraordinary natural experiment
  to understand better the importance of
  psychosocial factors in health,
• Because the existing explanatory models are not
  able to explain these rapid changes in the health
  status of these populations.

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Characteristics of the Central-Eastern-European
(CEE) health paradox

• In the 60-ies the mortality rates were better for
  example in Hungary than in some Western-European
  countries
• In the last decades while mortality rates
  declined in Western Europe, in CEE countries this
  tendency reversed, especially among middle-aged
  men
• Paradoxical features
• The health status worsened during economic
  development
• Why are middle aged men most vulnerable?
• Why is the life expectancy relatively better
  after 65 years of age?

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Characteristics of health crisis in Hungary

• Since the late 1980s, the mortality rates among
  45-64 year old men in Hungary has risen to higher
  levels than they were in the 1930s,
• Large gender difference in mortality rates.
• Large regional differences in the 20 Hungarian
  counties and in the 150 subregions

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Mortality rate in 1000 men in corresponding age
groups in the Hungarian population (Demographic
Yearbook, 2004)
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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.
• Since that time increasing disparities in
  socio-economic conditions have been accompanied
  by a widening socio-economic gradient in
  mortality, especially among men.

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Trends in the other CEE countries

• Similar trends in Poland and in Czech Republic,
  but the improvement had started much earlier and
  it was more considerable,
• Dramatic health crisis in Russia, Ukraine and in
  the Baltic countries
• Common features health crisis among middle aged
  men

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Life expectancy of men in 1965 and 1992
Marmot M The social pattern of heath and
disease In.Health and Social Organization, Edited
by D Blane, E Brunner, R Wilkinson
Michael
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Life expectancy of women in 1965 and 1992
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Mortality rates of middle aged (45-64) Hungarian
men and women in 2001
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Special experimental model

• The paradoxical features of premature mortality
  and morbidity in Central-Eastern-European
  countries might be regarded as
• a special experimental model to understand the
  health consequences of sudden societal changes
• that is those processes where psychology meets
  physiology, which is the central question of
  health psychology

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What can explain the opposite changes in
East-West 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,
• Life expectancy in neighbouring Austria
• Male 75.9- they live 7.7 years longer,
• Female 81.7- they live 5.2 years longer

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Gender differences

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

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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

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Paradox of old age mortality

• Above 65 years the male life expectancy is
  similar to the Western patterns
• What could be the explanation?
• The influence of medical care is most important
  for the ageing population and around birth
• In middle aged population the psychological
  factors would be fundamental in successful coping

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National representative surveys in the Hungarian
population

• The samples represent the Hungarian population
  above age 18 according to gender, age and county
• Hungarostudy 1983 more than 6000 persons
• Hungarostudy 1988 20.902 persons
• Hungarostudy 1995 12.463 persons

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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 150 subregions
• 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

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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

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Hungarostudy indicators, health psychology

• Shortened Beck Depression Score
• WHO Wellbeing Questionnaire (Bech,1996)
• Hostility score (Cook-Medley, 1954)
• Self-efficacy score (Schwarzer, 1992)

• Vital exhaustion score (Appels, 1988)
• Type D Personality Questionnaire(Dennolet, 2000)
• Hospital Anxiety Score
• Hopelessness Score (Beck, 2000)

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Further psychological indicators

• Ways of coping (Folkman, Lazarus, 1980)
• Purposes in Life(Crumbaugh, Maholick,1964)
• Anomie score
• TCI shortened cooperativeness and sensation
  seeking
• Dysfunctional attitudes
• (Weissman,1979)

• Social support (Caldwell,1987)
• Marital stress questionnaire
• Stress and coping (Rahe,2002)
• Meaning in life (Rahe,2002)
• Life events

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Social capital measures

• Social capital defined as the assets and
  resources available to individuals through civic
  participation appears to be a potential
  determinant of population health status
• Social trust
• Reciprocity
• Participation in civic organizations
• Low anomie
• Low competitiveness- rivalry
• Chicago collective efficacy (Neighbourhood
  cohesion)
• Religious involvement

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Work stress variables

• Job security
• Control at work
• Social support at work
• Working hours per week days and weekend
• Troubles with work as life event
• Income as job related reward
• Satisfaction with work situation
• Satisfaction with boss
• Unemployment

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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

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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

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Depressive symptomatology (BDI) severity
categories in the Hungarian population
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(No Transcript)
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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.

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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.

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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.

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Ecological level analysespositive psychology
determinants of mid-aged mortality
differencesbased onnational representative
survey data and national statistical mortality
data

• For 20 counties and 150 subregions

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Mortality rates of middle aged men and depression
scores in 2002
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What is behind depression?

• Depressive symptomatology is the best measure of
  chronic stress,
• What is behind?

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Determinants of middle aged mortality in the
150 Hungarian subregions

• Socio-economic status (education and income),
  social capital (social distrust) 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.

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Amos structural model for male mortality
(CFI0.99,CMIN/Df3.02)

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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.

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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.

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Differences in cognitive appraisal of the given
situations

• Gender differences- values, i.e lower education,
  income, unemployment
• For example
• The risk of male cardiovascular mortality (OR)
  associated with low education was 4.0233
  (CI3.7789-4.2835, p.000)
• The risk of female cardiovascular mortality (OR)
  associated with low education was 1.6074
  (CI1.4720- 1.6074, p.000)

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Gender paradox of subjective social status

• Female subjective social status influenced highly
  significantly the male mid-aged mortality
• r for female SSS and male mid-aged mortality
  was -.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.

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Correlations of male and female social status and
male mid aged mortality
Korrelációs együtthatók, középkoró férfiak
halálozása
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Extremes of appraisal

• Extraverts- high risk activities
• Anxiety- ! Subjective experience
• of loss of control in an emotionally negative
  situation
• Normal anxiety? Evolution- avoidance behaviour

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Pathological anxiety

• if certain situations unrealistically produce
  enduring alarm reaction
• and the feeling of lack of control
• Examples
• agoraphobia
• special anxieties (simple phobias)
• panic disorder

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Cognitive restructuring- basis of cognitive
behavioural therapies

• Coping
• emotional ways of coping
• problem solving ways of coping
• support seeking
• Social support- protective, medical importance
• - Hostility, Cynicism- risk factor

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The importance of ways of coping and social
support

• Both the behavioural patterns and the cognitive
  feedback are characteristic of the person's
  conflict solving ability, the so-called coping
  strategy.
• It is obvious from the model that the
  non-adaptive conflict solving strategies play an
  important role in resulting chronic stress
  situation and causing and maintaining physical
  symptoms and illnesses of psychological origin
• The importance of social support.

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The importance of positive psychology

• Learned resourcefulness (Mihály
  CsikszentmihályiFlow)
• The experience of the controllability of stress
  situations
• The ability to deal successfully with stressors
  strengthens the self-esteem, self-efficacy and
  the problem solving, coping skills of the person.
  

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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.
• Skrabski,Á.Kopp MS, Rózsa S, Réthelyi J, Rahe RH
  (2005)Life meaning an important correlate of
  health int he Hungarian population, International
  Journal of Behavioral Medicine, 12,2, 78-85.
• 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,M., Skrabski, Á., Szántó, Zs., Siegrist,
  J. Psychosocial determinants of premature
  cardiovascular mortality differences within
  Hungary, J ournal of Epidemiology Community
  Health (in press)