Medical Psychology Exam 1

COURSE OVERVIEW; ORIGINS OF MEDICAL/HEALTH PSYCHOLOGY, RELATED NOMENCLATURE, AND APPLICATIONS - 1/21

What’s in a Name?

Medical Psychology

• Often used to describe the specialty of a subset of psychologists with prescribing privileges in select U.S. states

Health Psychology

• Both an applied and basic research field focused on the intersections between psychological/behavioral processes and health and illness

Behavioral Medicine

• Interdisciplinary field concerned with the development and integration of biomedical and behavioral knowledge and techniques relevant to physical health and disease

What does it mean to be “healthy?”

• More than just the absence of disease?

• According to the World Health Organization (WHO) constitution, health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

The Birth of Health Psychology

1973: The American Psychological Association (APA) forms a task force to explore the role of psychology (if any) in medicine.

1978: APA Division 38 (now the Society for Health Psychology) is created.

1982: The inaugural issue of Health Psychology (the Div. 38 journal) is published. Included is a statement of these 4 goals of the field:

• To study scientifically the causes or origins of specific diseases

• To promote health

• To prevent and treat illness

• To promote public health policy and the improvement of the healthcare system

What does a health psychologist do?

• Could be involved in research, teaching, clinical practice, consulting for healthcare providers/systems or some combination therein.

• Work from a bio-psycho-social perspective

• A clinical health psychologist has standard training in clinical psychology and also specialized knowledge and experience in working with people living with chronic physical health problems.

  • Often work in medical settings

  • Behavioral health assessments

  • Individual or group-based interventions to help people manage stress, quit smoking, or change other unhealthy habits

  • Psychotherapy to help people cope with adjusting to chronic illness

THE BIOPSYCHOSOCIAL MODEL - 1/23

Health and Healing Through the Ages

• In ancient times, if a person became ill, this was frequently attributed to weakness in the face of some stronger force. (Trephination - holes in skull) 

• Later came Hippocrates’ humoral theory: health was the perfect balance of 4 bodily fluids. (Black bile, yellow bile, phlegm, and blood) 

• Traditional Chinese medicine was also emerging.

  • Health thought to be the result of internal harmony; the balancing of chi

• In the Middle Ages, illness was thought to be punishment from God.

• The Renaissance brought Descartes’ mind-body dualism. (The idea that the mind and body are two different things and entities) 

The Biomedical Model

• The visualization of individual cells in roughly the 1800s set the stage for Louis Pasteur’s research on the germ theory of disease. (The concept of microorganisms cause infectious diseases by entering a host) 

• Rapid advances in medical knowledge followed, gaining control over diseases plaguing the world since ancient times, such as diphtheria and typhoid.

• The biomedical model - that illness always has a biological cause - was born.

• Consistent with reductionism and mind-body dualism. 

• Health = the absence of disease.

Psychosomatic Medicine

• The biomedical model couldn’t explain every illness.

  • e.g., conversion disorders, identified by Sigmund Freud (Psychological symptoms being converted into physical symptoms - is now referred to as Functional Neurological Disorder or FND - Is found in those people who may be having difficulties expressing psychological symptoms and are expressing them biologically.)

• Unconscious emotional conflicts “converted,” or manifested, in physical form.

• In the 1940s, Franz Alexander took this a step further, establishing a subfield of psychiatry known as psychosomatic medicine. 

• Rheumatoid arthritis and Alexander’s “rheumatoid personality” (Before we knew things about inflammation and could see beyond the surface, he developed a theory of a “neurotic personality” being responsible for disease)

• Also a reductionist model - a single personality factor or other psychological problem triggers disease. 

20th Century Trends Necessitate a New Model

• Increased life expectancy

• Increase in “lifestyle disorders” or “the diseases of ease” (Obesity related diseases that are more prominent as more things like food were more easily mass produced and accessible) 

• Rising health care costs

• Need for a multifactorial model

  • Host factors (e.g, genetic vulnerability)

  • Environmental factors (e.g., exposure to pollution)

  • Behavioral factors (e.g., diet, exercise, smoking)

  • Psychological factors (e.g., optimism)

The Biopsychosocial Model

Biological Mechanisms

• Genetic vulnerabilities

  • BRCA1 and BRCA2 genes (Tumor suppressor genes; BRCA1 - ovarian and breast cancers, BRCA2 - prostate and pancreatic cancers)

  • Alcohol abuse not tied to one specific gene

• Evolution

  • Natural selection and fat storage (Propensity for obesity)

  • Gene-environment interactions - epigenetics

• Life-course perspective

  • Maternal nutrition/smoking status/drug use during pregnancy → impact on child development

HEALTH PROMOTION AND HEALTH BEHAVIOR CHANGE

Psychological Processes

• Personal health practices and behaviors (Blood sugar levels)

• Influenced by beliefs and attitudes

• Stress coping

• Subjective well-being - sense of happiness and satisfaction with life

• Effectiveness of healthcare interventions influenced by patient attitude (Optimism can result in faster recovery time after surgery)

Sociocultural Context

• Birth cohort - influenced by the same historical and social factors

• Gender = socially prescribed role

• Racial, cultural, ethnic identity

• Social support buffers against stress, promotes better health habits, even decreases mortality from all types of cancer

• Socioeconomic status (SES)

• Healthcare system biases

The Hispanic Paradox: Fact or Fiction?

• Low SES typically correlated with poorer health outcomes.

• Despite Latinos in the U.S. often having less access to quality healthcare and lower SES on average, they also appear to have lower rates of heart disease, cancer, and stroke.

• Once a family has been in the U.S. for two generations, this effect washes out. 

Applying the Biopsychosocial Model

Health Behaviors

• Actions people take to improve or maintain their health

  • Exercising regularly

  • Using sunscreen

  • Sleeping 7-8 hours per night

  • Wearing a seatbelt

• Health habits are firmly established and performed automatically

  • Highly resistant to change

  • People have a tendency to relapse

Health Promotion

• “The process of enabling people to increase control over (and to improve) their health” (WHO, 1998)

• A personal and collective effort

• A core function of public health

Health Education Campaigns

• Education and attitude change are often not enough

• Fear appeals

• Message framing

  • Gain-framed

  • Loss-framed

Get Started When They’re Young

• Health promotion efforts focus heavily on children and adolescents

• Socialization is important

• Teachable moments

  • Early childhood pediatrician visits 

  • Middle school - window of vulnerability

  • Pregnancy and the postpartum period

  • New diagnosis of coronary artery disease or diabetes

• Health habits practiced as a teenager or college student may determine future health outcomes

HEALTH BEHAVIOR CHANGE AND PRIMARY PREVENTION

Behavior Change is Challenging

• Age, demographic factors, cultural values, social influence, personal goals, and values, and health-related knowledge all contribute to health behavior. 

• Health locus of control (Wallston et. al., 1978) - “How much you think you have a control of your own health” 

• Access to the healthcare system - ability to get help to make changes and knowing information

• Barriers?

  • Often little immediate incentive for practicing good health habits, especially when young

  • Emotional factors (pleasurable, addictive)

  • Often must be tackled one behavior at a time

  • Related to different factors (e.g., stress, social pressure) for different people

  • Factors maintaining behavior may change over time

The Health Belief Model

• Perceived susceptibility - We have to believe that we are susceptible to a certain illness/disease 

• Perceived severity of the health threat - We have to believe that this illness will pose a threat

• Perceived benefits of and barriers to treatment - Individual’s belief about the positive outcomes or advantages of taking a recommended health action, while barriers are perceived obstacles or costs that might prevent someone from engaging in health behavior

• Cues to action - “Advice from others” or anything that might prompt an individual to take a specific health-related action

Theory of Planned Behavior 

• Strong social component to healthy (and also unhealthy) behaviors

The Transtheoretical Model (TTM) or The Stages of Change Model by Prochaska et al. 

• Precontemplation: No intention to change behavior in the foreseeable future,  not aware, uninformed

• Contemplation: Aware that problem exists, and are thinking about changing behavior but have made no commitment to take action 

• Preparation: Intention to take action to change 

• Action: Have made a modification in their behavior

• Maintenance: Have hit at least 6 months of health behavior modification, prevent relapse

Health Action Process Approach (HAPA)

• Newer model with fewer stages that may be more helpful in designing interventions that accurately predict behavior change 

• Motivational phase (goal-setting)

  • Must perceive a health risk

  • Must believe that taking the action in question will have a favorable outcome

  • Must have self-efficacy - the belief that you can accomplish a specific goal or task 

• Volitional phase (goal pursuit)

The Behavior Change Process

• Identify and define the problem 

• Determine how to measure the behaviors you wish to change 

• Gather baseline data

• Set S.M.A.R.T. goals

• Develop intervention strategies

• Implement strategies and collect data; revise as needed

SMART Goal Setting

Cognitive-Behavioral Approaches to Health Behavior Change

• Self-monitoring - having an idea of starting point 

• Stimulus control - modify factors in the environment so there’s less resistance to make change

• Cognitive restructuring - the altering of thoughts/internal monologue 

• Self-reinforcement - rewarding or punishing to encourage or discourage behaviors

• Behavioral assignments - home practice activities between sessions to attain end goal

• Social and/or assertiveness skills training - the teaching of individuals to effectively interact with others in a confident or respectful manner

• Relaxation training - bulking manners/techniques to help manage stress 

Motivational Interviewing (MI)

• Originally developed for addiction, MI has now been applied to target many health behaviors

• Client-centered, non-judgmental style intended to help a person work through any ambivalence they may have about changing a health behavior

• Open-ended questions and active listening are crucial

• Elicit “change talk” - provide a space for clients to express their reasons both for and against behavior change

Levels of Prevention

• Primary: health-promoting actions taken to prevent a disease or injury from occurring

• Secondary: actions taken to identify and treat an illness early in its course

• Tertiary: actions taken to contain or slow damage once a disease has progressed beyond its early stages

 Life’s Essential 8

As defined by the American Heart Association (AHA), Life’s Essential 8 are eight key measures for improving and maintaining cardiovascular health.

1. Eat a healthy, well-balanced diet

2. Get at least 150 minutes of moderate-intensity physical activity (or 75 minutes of vigorous activity, or a combination) each week. 

3. Don’t smoke, vape, or use other tobacco products

4. Aim for an average of 7-9 hours of sleep each night

5. Reach and maintain a healthy weight (BMI < 25)

6. Get your cholesterol checked

7. Keep fasting blood sugar under 100 mg/dL (or A1c under 5.7% - longitudinal study)

8. Keep blood pressure below 120/80 mmHg

HEALTH-COMPROMISING BEHAVIORS AND THE “DISEASES OF EASE”

Diet - A Controllable Risk?

• Our bodies require 46 nutrients (and water) to remain healthy

• Both a personal and societal responsibility - must pay attention to the entire environment and context shaping our food choices

  • SES disparities

• Sugar vs. fat controversy (Campaign against fat, low-fat foods had carbohydrates added to make these foods palatable but have now found that sugar is related to diseases like obesity, T2 Diabetes, and heart disease) 

• Fast food more than 1x/week → increased risk of obesity

  • More than 2x/week → higher risk of T2D and death from coronary heart disease

• Supersizing and situational eating

• Pleasure-driven

Diet and Disease

• Globally, poor diet is a factor in one in five deaths and in five of the ten leading causes of death

• Excess dietary fat and sugar = major health hazards

• Lower food security (ability to access enough safe, nutritious food at all times) associated with increased probability of 10 chronic illness (HTN - hypertension, CHD - coronary heart disease , hepatitis, stroke, cancer, asthma, T2D, arthritis, COPD - chronic obstructive pulmonary disease, kidney disease)

Stress and Diet

•  High-fat and high-carb foods help turn off stress hormones (e.g., cortisol)

• Stress has a direct and negative effect on diet (More likely to eat more fatty foods, and snack + skip breakfast, eating what is available / on the go)

• Low-status jobs, little control at work, high workloads → less healthy diet

Dietary Interventions

• Most successful when:

  • Intervening with families 

  • Environmental interventions are at the “point of impact”

  • Include education and training in self-monitoring

  • Culturally and linguistically tailored

• Social engineering (Taxing foods)

Physical Activity and Exercise

• Substantial health benefits…

• …and yet, over 2/3 of American adults do not engage in any regular leisure-time physical activity

• Physical activity is more common among:

  • Men

  • Whites compared to African Americans and Hispanics

  • Younger vs. Older Adults

  • Those with higher vs. lower incomes

• Barriers?

• Best predictor of regular exercise is regular exercise

You Snooze… You Win

• Good sleep has many benefits:

  • Clearer thinking and better focus 

  • Increased productivity

  • Helps you manage stress

  • Improves mood

  • Critical for physical health as well:

    • Supports growth and stress hormone functioning

    • Helps regulate appetite and blood pressure

    • Boosts the immune system!

• Quality and quantity are important

• Insomnia is a widespread problem in the U.S. (Trouble falling asleep, trouble staying asleep, still feeling tired)

• Acute stress and changes in routine can get insomnia going

Health-Compromising Habits are Hard to Break

• Habitual and, sometimes, addictive

• “Window of vulnerability” in adolescence

• Tied to peer culture

• Often pleasurable or even thrilling

• Develop gradually

• May be used to cope with the stresses of lower SES

Disordered Eating

• Most common in women ages 15-24, but appears throughout the lifespan

• Pursuit of thinness, like obesity, is a major public health threat

• Binge eating disorder is actually the most common eating disorder in the U.S. and Canada (3x the number of people with AN and BN combined)

HEALTH PSYCHOLOGY IN PRACTICE: MODELS OF CARE 

Substance Use Trends

• CDC recommends 2 drinks or less in a day in men and 1 drink or less in a day in women (Canada equivalent says no drinks)

• Causes more deaths, illnesses, and disabilities than any other preventable health conditions

• Consumption of all illicit drugs (and alcohol and tobacco) sharply declined among high schoolers, according to most recent Monitoring the Future survey (There was a spike during COVID-19 for middle aged women)

• Alcohol consumption → high blood pressure, stroke, cirrhosis, some forms of cancer, brain atrophy, sleep disorders

• Significantly more men are current, binge, and heavy drinkers (Binge drinking is four or more drinks for women, or five or more drinks for men during an occasion) 

• Highest rates among white Americans 

Alcohol Abuse and Health

• Weakens the immune system

• Damages cellular DNA

• Interferes with normal endocrine system development

• Decreases testosterone levels in men

• Menstrual disturbances and miscarriages increase with heavier alcohol consumption in women

• May increase estrogen levels in women → increased risk of Bca (Breast Cancer)

• Promotes formation of fat deposits on heart muscle → CVD (Cardiovascular Disease)

• Increases BP (Blood Pressure) and serum cholesterol

• Contributes to stomach and liver inflammation, GI ulcers

Tobacco / Nicotine Use

• Peaked in the early 1960s in the U.S.

  • Half of all adult men and one-third of adult women smoked!

• Has declined to about 15% of all adults

• Now most prevalent in AI/AN (Native American) population (31.8%) 

• SES predicts smoking rates

• Lowest ever among U.S. youth…but vaping…

• Responsible for one out of every five deaths

• Why do smokers continue smoking?

  • “The most addicting substance” and even people who have quit “harder” substances, nicotine has always been a vice that came along with these substances

The Special Case of Mary Jane

• Is marijuana use a health-compromising behavior?

• Legalization and decriminalization perhaps suggest not

• Some effects are less positive, include anxiety, fear, paranoia, or panic

• Some users do develop a dependency that interferes with daily activities (about 4 million users)

• Use is especially likely in adolescent and young adult men

• Frequent, escalating use in 20-something males from low-income background → changes in neutral circuitry controlling motivation and mood

“Diseases of Ease”

Food Choice

Percent distribution (Fig. 1) and Percentage (Fig. 2) of adults aged 18 and over who met 2018 Physical Activity Guidelines for Americans for aerobic and muscle-strengthening activities: United States, 2020

Mean Occupational Daily Energy Expenditure in Men and Women (1960-2008)

Working from home correlates with increases in sedentary behaviors compared to pre-COVID-19 time period

Who can a health psychologist help?

• Someone utilizing healthcare services!

• Who utilizes health care services? 

  • Perhaps those high in neuroticism? (More attentive to real symptoms) 

  • People who are self-focused vs. focused externally on their environment and activities

  • People who are bored? Socially isolated?

  • People experiencing stress

  • People interpreting their symptoms as catastrophic

    • Influenced by prior experience, expectations, symptom severity, where the symptom is located (Face area issues are more likely to be addressed)

Who else?

• The very young and also older adults

• AFAB individuals 

  • Why? (Seeking out help, pregnancy and childbirth, different specialists for breast cancer or gynecologists, AFAB tend to detect pain earlier, experience temperature changes more rapidly, and smells more quickly or loss)

• More affluent individuals

  • Gap is narrowing, in part, due to the Affordable Care Act (States particularly in the south have rolled back this help during the COVID era) 

  • Medicare “Donut hole” (There is a temporary gap in prescription drug coverage) 

• Those who have been socialized to seek health care services

• What would the Health Belief Model suggest about health care utilization?

The Health Belief Model

• Perceived susceptibility

• Perceived severity of the health threat

• Perceived benefits of and barriers to treatment

• Cues to action 

Who else?

• Physicians estimate that half to two-thirds of their time is taken up by patients whose complaints are psychological or social vs. medical

  • More common for general practitioners

• People seeking secondary gain (term to describe the advantages people gain from maintaining a problem or disorder) 

• People who are malingering (the intentional and deliberate faking or gross exaggeration of physical or psychological symptoms to gain an external benefit) 

• People who have put off care for too long, resulting in needing more intensive treatment when they do finally present for services

  • Need to decide symptom is serious → Decide to seek treatment → Actually get an appointment

What can a health psychologist do?

• A clinical health psychologist has standard training in clinical psychology and also specialized knowledge and experience in working with people living with chronic physical health problems.

  • Often work in medical settings

  • Behavioral health assessments

  • Screening for anxiety, depression, trauma, substance use disorders, etc.

  • Individual or group-based interventions to help people manage stress, quit smoking, or change other unhealthy habits

  • Psychotherapy to help people cope with adjusting to chronic illness

  • Pre- and post surgical assessment and intervention

Where does a clinical health psychologist work?

• Integrated into primary or specialty care clinic (co-located) 

  • May even join the medical visit

• Consultation-liaison psychology in inpatient medical settings

• Academic medical centers

• Private practice

When does a clinical health psychologist see a patient?

• Possible same-day as their medical visit

  • Reduces stigma

• Usually short-term (4-6 visits), problem-focused in primary care

• May be as short as 15 minutes; up to 45 minutes

Why does a clinical health psychologist see a patient?

• Further assessment or treatment of a behavioral health concern

• Help patients move toward behavior change, cope with a new diagnosis, adjust to managing a chronic illness (or to a change in the course of their illness)...

• Make medical provider’s job easier 

OBESITY AND ITS TREATMENT 

What is Obesity?

• Per your textbook, “excessive accumulation of body fat.”

• A complex, chronic disease requiring long-term treatment

• NOT a “motivation problem”

• Body Mass Index (BMI) ≥ 30… but distribution matters (Apple vs. Pear Shaped, Apple is most of your weight around your stomach, while pear-shaped is when most of your weight is around your hips, buttocks, and thighs. Subcutaneous fat is the fat stored beneath the skin, while visceral fat is stored deep within abdominal cavity and more “dangerous”) 

Relationship with Health Outcomes

• It’s complicated

  • Health at Every Size (HAES)

  • After age 65, being underweight is actually more dangerous (bone loss - osteoporosis, fall risk and cushion of additional body fat) 

• Not everyone with obesity will develop every obesity-related condition

• Even a 5-10% weight loss can reduce (or, in some cases, eliminate) the effects of obesity-related conditions

Metabolic Syndrome (MetS) - a cluster of biochemical and physiological “abnormalities” associated with the development of cardiovascular disease and type 2 diabetes

• A set of obesity-related factors that increase risk for coronary artery disease, stroke, inflammation, and diabetes, including 3 or more of the following:

  • Abdominal obesity (Apple-shaped)

  • Hypertension (High blood pressure) 

  • Low HDL - high-density lipoprotein (“good” cholesterol) 

  • High triglycerides

  • High fasting blood glucose

• 35% of all U.S. adults (and 50% of those age 60+) meet criteria for MetS

Obesity Causes/Risk Factors

• Multifactorial - there is lots of things that contribute to disease

• Health Behaviors

  • Energy in/energy out (calories consumed vs calories spent) 

  • Sleep!

• Stress

  • Childhood trauma → Adult obesity 

• Health conditions and medications

• Genetics

  • Linked to about 400 different genes

• Systems and environment

Treating Obesity

• Behavior modification

• Commercial weight loss program (WeighWatchers, Jenny Craig, Nutrisystem, etc.)

• Physician-supervised options

  • May include medications

  • GLP-1 receptor agonists (Ozempic, Wegovy)

  • GIP/GLP-1 (Zepbound, Mounjaro)

  • Bariatric surgery and devices

Psychological Treatment of Obesity

• Dieting alone is not enough!

• Self-monitoring 

• Behavior modification

• Most successful when: 

  • Combined with cognitive strategies to reduce self-defeating thoughts and set more realistic expectations

  • Approached from an interdisciplinary perspective

Internalized Weight Bias

• Weight bias = negative attitudes, beliefs, judgments, stereotypes, and discriminatory acts aimed at people because of their weight

• Overt (openly) or subtle

• Occurs in many settings and forms 

• Lifelong experience of weight stigma and bias

  • Healthcare providers!

  • Bullying and discrimination as children and adults