What are research topics in Health & Medical Psychology?

In the area of Health and Medical Psychology much research is done in the fields of health promotion and prevention, stress (for example, how stress works in relation to work or chronic diseases), psychological factors in somatic conditions (like chronic fatigue, chronic pain and itches), placebo/nocebo, expectancy learning, conditioning and interventions on health behaviour (for example, e-health).

Health and Medical Psychology is a relatively novel area in the field of psychology. It often requires knowledge of more than psychology alone to better understand the complex problems, therefore health/medical psychologists often work very tightly with doctors. Interaction with medical care professionals to consult and receive advise both ways is extremely important.

What is stress?

We all know what stress is, yet it is hard to define. Stress depends on the threat value and the resources an individual has to cope with a stressful situation. Stress is associated with development and the maintenance of a variety of illnesses, like heart diseases and strokes. The more stressed you are, the more likely you are to get a chronic disease. If you are able to destress, you are more likely to be free of any symptoms. Besides, stress is not necessarily bad, as many people think. Stress can be very functional, for example when you have to fight or flight. According to the Yerkes-Dodson law there is an empirical relationship between arousal and performance. The law says that performance increases with physiological or mental arousal, but only up to a certain point. Too much arousal can cause impaired performance because of strong anxiety.

Stress can be unhealthy when we chronically active stress systems which were developed for acute fight-flight situations. Stress is good, but it must not be chronic. Acute cataclysmic events may have long term consequences. Those reporting both a high amount of stress and the perception that stress affects their health are at a greater risk of premature mortality. Being convinced that ‘stress is bad for you’ was prospectively associated with somatic symptoms during a stressful period.

Stress response has a biological cost. The duration of the physiological response is important. Repeated or prolonged stress can cause an overload of physiological system due to ‘wear and tear’. There is an excessive energy consumption during high stress, therefore reinstatement to normal body functions can fail and the system will wear out. An allostatic load occurs when body systems achieve a kind of balance, but everything is working too hard and we then slowly begin to break down. When there’s a balance between stress and adaption, it is called allostasis.

How does the physiological stress response work?

There are two important stress systems, because we need fast and slow systems to respond to stimuli/stress.

The sympathetic nervous system (SNS) is the faster system. Transmission goes through neurotransmitters, therefore the SNS is the faster system. It works for immediate action and it produces hormones like catecholamines and (nor)adrenalines. Acute physiological responses to stress are considered adaptive. When catecholamines and glucodorticoids are produces, energy sources increase and are redistributed to the skeletal muscles and brain

In the hypothalamic pituitary adrenal system (HPA) transmission goes through hormones, therefore the HPA system is a slower system. It works for longer-term arousal and has tight links with the immune system. The sympathetic stimulation/fight-flight response and parasympathetic stimulation (relaxation) are part of this system.

If acute physiological stress system responses are repeatedly activated, tissue damage and diseases can occur. Besides, prolonged stress responses are associated with increased morbidity and mortality. There is most evidence for a link between stress exposure and cardiovascular diseases and pain. A stressful life may lead to a higher chance of getting heart attacks.

Cortisol is the key regulator in declined neurocognitive integrity. Positive effects of cortisol are that it is essential in regulating the immune response and it causes increases availability of energy and inhibition of inflammation. The negative effects of cortisol are decreased energy (by exerting negative feedback effects on the HPA axis), a reduced ability to adapt to stress and brain damage and cognitive declines. With a lot of stress, there is a reduction of the numbers of dendrites in the hippocampus, amygdala, medial prefrontal and orbitofrontal cortex which leads to fewer connections. These areas control the cortisol production (off-button), therefore if there are fewer connections, the cortisol production will be less controlled, which cause the feedback loop to not work properly anymore.

Genetic variation linked to HPA axis functions moderates the effects of early life stress on threat-related amygdala function and may confer risk for anxiety symptoms.

Stress affects cognitive performances, particularly memory and attention.

There has also been found a direct link between stress and the immune system. This is what they call psychoneuroimmunology. Subjective stressors may lead to the development of inflammatory markers. According to science we can boost the immune system. This has been done in a research project in which people were given four individual 1-hour sessions of stress management with a trained therapist over two consecutive weeks, including relaxation techniques, psycho-education, breathing and visualisation exercises. After training, those people were encouraged to stick to a relapse prevention checklist during a 9 week follow-up period.

Some evidence has been found of direct effect on illness development, but there are also findings of differences in stress responses in healthy vs. ill subjects.

The general adaption syndrome consists of three stages. The first stage is the alarm stage, in which an initial response and increased arousal occurs. The second stage is the resistance stage, in which the person tries to adapt to the stressor or uses bodily defences. In the final, third stage of exhaustion a depletion of bodily resources occurs, which causes diseases of adaption. Some criticism is that the physiological response can differ depending on the type of stressor.

There are different kinds of events that may lead to stress, like acute-time limiting stressors, traumatic events or (major) life events, but repeated or chronic (intermittent) stress can be caused by daily hassles and work-related stress as well. According to the life events theory, the more severe life events you have, the more likely you are to develop chronic diseases. Life events can also be positive things, like marriage or having a baby. Predisposition of psychopathology (e.g. depression, PTSD) after cardiac surgery mainly depends on trait anxiety, life events, genetic variation of the HPA axis, gender and age.

Cognitive appraisal theories

According to the transactional model of stress, stress is as subjective experience. Cognitive appraisal is central as to whether an event is considered stressful. Primary appraisal are the perceived demands of an individual and it is a personal meaning of an event, consideration of quality and nature of the event. These demands are harm loss, threats and challenges. They are closely related to emotions, sadness, threat, anxiety/fear, challenge and confidence. They are dependent on motivational relevance, motivational congruence and ego involvement. Secondary appraisals are one’s resources. It’s one’s beliefs of capacity to reduce the stressor, consideration of resources (internal and external) and coping potential. They involve assessments of internal/external accountability, problem-focusing coping potential, emotion-focused coping potential and future expectancy concerning situational change. Stress occurs when there is a mismatch between perceived demands and resources.

Interpretation (appraisal) of the event is critical in how stress affects health/illness. Individual differences in personality, cognition and social resources are thus important in explaining whether an event is experienced as stressful or not.

Why does one develop an illness when exposed to stress and someone else doesn’t?

Individual differences in important positive and negative moderators that determine the influence stress has. According to the stage model of stress and disease every individual may deal differently with stressful life events and other stressful stimuli. An overview of this model is shown on slide 48.

The stress coping model says the degree to which a chronic illness is considered a source of psychological stress depends on individual personal resources, social resources and life goals. Individual adaption processes to stressors are describes by stress coping models. Personal and interpersonal influenced on appraisals and stress responses are coping styles, personality, cognitions, emotions and social support.

Coping styles are interdependent and can occur together as seemingly oppositional strategies to create the overall coping response. They can change dynamically according to the context.

• Problem focused: to reduce demands of stressor or increase personal resources (e.g. confronting the source of stress)
• Emotion focused: managing the emotional response (e.g. by venting anger)
• Approach oriented: e.g. attending to source of stress
• Avoidance: e.g. distraction

Personality can be described in terms of OCEAN (Openness, Conscientiousness, Extraversion, Agreeableness, Neuroticism) and in terms of Type A (hostility and anger, are predictors of illness), Type C (passive, repressing negative emotions, perhaps associated with an elevated cancer risk) and Type D (negative affectivity, social inhibition, links with cardiac events, distressed). Negative affectivity is to experience negative mood, feel distressed and feel critical about oneself. It is the tendency to experience negative affect, view the self and the world in generally negative terms. It is related to neuroticism.

Cognitions related to stress are for example thinking you are not stressed, meanwhile you actually are unconsciously. Some cognitions may lead to chronic major stress and long-lasting activation of the physiological stress response. Perseverative cognitions are passive, repetitive and self-focused thinking about negative emotional states and implications/consequences of these states are worry (anticipation of future events) and rumination (dwelling on past events). A perceived locus of control is appraisal of the control of the outcome and can be either internal or external. With an internal locus of control you see the causes of outcome X as your own doing, meanwhile with an external locus of control you see the causes of outcome X by other things. Self-efficacy are beliefs about one’s own capabilities of achieving the desired outcome.

Emotional disclosure is a possible moderator of coping and can give long-term benefits of reduced stress. However, venting negative emotions is sometimes associated with poorer prognosis. Stress-related illnesses can be related to worse health outcomes via appraisals and coping actions, unhealthy behaviour, direct physiological pathways or feeling less able to seek social support.

Social support is a resource and will affect appraisal and coping. Perceived social support is more predictive of outcome than the actual support. Social support is particularly effective when illness results in physical dependence. Lack of social support is related to a strongly increased risk of mortality of heart disease, cancer and strokes. Direct effects of social support are greater self-esteem, confidence, self-efficacy, a positive outlook on life, reduce blood pressure reactivity and reduced cortisol levels. Indirect effects (explained by the buffering hypothesis) are influencing cognitive appraisal and coping responses (e.g. acting on proactive coping by anticipating potential stressors and acting in advance either to prevent them or to mute their impact). Giving and receiving social support helps in becoming resilient to stress. Oxytocin affects social bonding processes and stress regulation dependent on aspects of context and interindividual factors. Women report a higher level of stress than men. Women may be more susceptible to interpersonal stress, meanwhile males may be more susceptible to stress related to achievement related tasks.

Certain event features increase appraisal of stressfulness, like unexpected, ambiguous, unpredictable, undesirable and life changing events. The duration of the adaption to stressors also influence the appraisal of stressfulness.

Negative moderators of stress are neuroticism, negative affectivity, social inhibition, hostility and anger and perseverative cognitions. Positive moderators to reduce stress are social support, optimism, self-efficacy, perceived locus of