Health Psychology Research

Joshua Fogel, PhD

Disclosures

March 16, 2004

Editorial Collaboration

Medscape &

Introduction

Health psychology is an area of psychology where there is an emphasis on understanding the biological, behavioral, and social factors that influence health and illness. This conceptualization is referred to as the biopsychosocial model. As described by Division 38 (Health Psychology) of the American Psychological Association, "Health psychologists are on the leading edge of research focusing on the biopsychosocial model in areas such as HIV, oncology, psychosomatic illness, compliance with medical regimens, health promotion, and the effect of psychological, social, and cultural factors on numerous specific disease processes (eg, diabetes, cancer, hypertension and coronary artery disease, chronic pain, and sleep disorders)."[1]

A symposium coordinated by Frank J. Keefe, PhD, of Duke University Medical Center, titled, "New Directions in Health Psychology Research" was presented at the American Psychological Association's 111th Annual Convention.[2] He introduced the symposium by stating that all the presenters were those who had received awards for their outstanding research in health psychology and are leaders in their respective areas of study.

Changing Diagnostic Thresholds and Increased Disease Levels

Robert M. Kaplan, PhD, of the University of California-San Diego, spoke about changing health diagnostic thresholds and their impact on healthcare in the United States.[3] He discussed the concept of a "disease reservoir" hypothesis where the presence of disease is quite common, especially in older adults. If one looks for disease, one will find it. However, he stated that much of this disease is "pseudo-disease," and if clinical attention is not focused upon it, there will be no harmful effects from this disease. True disease affects an individual's life expectancy and/or quality of life, while "pseudo-disease" is where an individual may be classified with a disease, but the presence of this disease does not affect the individual's life expectancy and/or quality of life.

He offered a number of examples to demonstrate the new technological advances that detect and classify those with disease. For example, in 1982, only hepatic lesions of 20 millimeters were able to be detected. Today with the use of spiral CT scans, hepatic lesions of 2 millimeters can be detected. Also, current technological assessment techniques can point out that more than 65% of individuals above the age of 65 years have evidence of small strokes in the brain.

Dr. Kaplan stated that overall, there are changed definitions of disease that now lead to greater prevalence of disease. Over the past few years, there has been an increase in diabetes prevalence by 14%. This does not mean that we are having a diabetes epidemic but rather modified definitions can result in greater prevalence. Another example that he cited was the body mass index (BMI) threshold that changed from the old threshold of 27 to the current one of 25. He gave an example of a colleague who is 5 feet 9 inches tall, weighs 179 pounds, and has a BMI of 26.7. According to the old BMI definition, he was not overweight. Today, according to the new BMI definitions, he is overweight. However, both he and his colleague do not believe this to be so.

Dr. Kaplan cited some data from his research with the National Health and Examination Survey (NHANES) database. His analyses showed that these disease definition changes over the past few years affect 38% of those aged 50 years and older. The estimated costs to treat individuals with these newly diagnosed diseases is about US $25 billion. He stated that the potential health benefits from this extra emphasis are quite minimal. If one views life expectancy as a marker of benefit, he believes that this cost and effort will result in changing the life expectancy by just a few hours.

He concluded by pointing out that all the changing diagnostic thresholds mean is that "we are all sick." At this point in time, with all these new disease classifications, 75% of adults in the United States qualify for a chronic disease diagnosis.

He stated that health psychologists could play a role in this new healthcare area. As individuals are increasingly told that they are ill, they will demand treatment. Health psychologists can help people cope with and interpret these newly diagnosed diseases. Also, health psychologists can help with medical decision making by helping patients process the risks and benefits of treatment vs no treatment for their disease diagnoses.

Coping With Breast Cancer

Annette L. Stanton, PhD, of the University of California-Los Angeles, discussed her extensive research on the coping processes experienced by those with breast cancer.[4] She discussed how some individuals cope by finding benefit in this adverse circumstance. Some individuals look for the positive aspects in their life while experiencing stressors and look for good things that can be learned from that experience. They try to "grow" as a result of the stressful experience. In a sample of 92 women after treatment for breast cancer, 83% found benefits from their experience of breast cancer, and 46% found they related better to others after their experience with breast cancer.[5]

Dr. Stanton discussed the typical concerns experienced by women with breast cancer in the first year after treatment. Fifty-one percent had concerns in the emotional domain, with the fear of recurrence being the main concern. Twenty-six percent had physical domain concerns, with weight gain being the main concern.[6]

Dr. Stanton also emphasized the harmful impact of avoidance coping. In a sample of 117 breast biopsy patients, avoidance of illness concerns predicted distress at biopsy, diagnosis, and postsurgery.[7] In a study of 70 women with breast cancer prior to surgery, avoidance of illness concerns predicted increased fear of cancer recurrence one year later.[6] Also, in another sample of 92 women with breast cancer after treatment completion, avoidance of illness concerns predicted increased distress and decreased vigor 3 months later.[8]

Dr. Stanton discussed helpful coping techniques she has found in her research for women with breast cancer. Those who expressed emotions about their cancer had better outcomes than those who did not.[8] She and her colleagues recently published the results of a randomized, controlled trial in which 60 early stage breast cancer patients were randomly assigned to write over 4 sessions about either: (1) their deepest thoughts and feelings regarding breast cancer; (2) positive thoughts and feelings regarding their experience with breast cancer; or (3) facts about their experience with breast cancer.[9] After 3 months, those in the first 2 groups who wrote about their emotions had fewer medical appointments for cancer-related illness than those in the control group who wrote about breast cancer facts.

Harmful Impact of Irrational Health Appraisals

Alan J. Christensen, PhD, of the University of Iowa, discussed the harmful impact of irrational health appraisals.[10] He and his colleagues showed, in a series of studies, that distorted or negative health appraisals (eg, catastrophizing) predict disability in chronic pain conditions, above and beyond what is expected due to the illness or health condition. In a study of 50 postmyocardial infarction patients assessed before and after a 12-week cardiac rehabilitation program, even after controlling for cardiovascular disease severity, those who had a greater number of cognitive distortions had greater levels of impairment.[11]

Dr. Christensen gave an example of these harmful appraisals. The individual with a myocardial infarction attends a baseball game with his family. They are all enjoying the game through the first 8 innings. In the ninth inning, the individual with the myocardial infarction has chest pains and then thinks, "What an awful way to spend the afternoon." Thoughts like these are often consistent throughout many aspects of daily life and can cause these harmful effects.

Dr. Christensen and his colleagues also developed an Irrational Health Belief Scale. They found that higher irrational health belief scores were associated with worse diabetic control and self-reported adherence.[12] Dr. Christensen stated that health psychologists can help individuals identify their faulty health-related appraisals/beliefs and help these individuals appraise illness and disease in a more rational way. This will lead to better psychological and medical outcomes for these individuals.

Cognitive Deficits Due to Hypertension

Shari R. Waldstein, PhD, of the University of Maryland -- Baltimore, discussed the role of hypertension in cognitive function.[13] In the United States, approximately 25% of adults have hypertension, and this affects more than 50% of individuals over 60 years old. A large number of studies show that having hypertension predicts poor performance among many areas of cognitive function, including abstract reasoning, attention, and concentration.[14]

In her research, she observed that among men not taking any medication for their hypertension, they had better scores on a number of memory tests than men without hypertension. She also observed that certain subgroups are more vulnerable to the harmful effects of hypertension. Those who are either younger or with lower levels of education or hyperinsulinemic and have hypertension are most likely to have these harmful effects on their cognitive function. She also suggested that there may be a genetic component to these harmful cognitive effects, as those with hypertension who were the children of those with hypertension had greater rates of cognitive impairment than those not having parents with hypertension.

She stated that in clinical settings, many do not think of those with hypertension as having cognitive deficits or impairment. The role of the health psychologist is to assess for these possible cognitive issues. If present, the health psychologist should communicate these results to the patient's healthcare providers, caregivers, and if medically/psychologically appropriate, to the patient too.

Conclusion

Health psychology research covers a broad variety of areas and has implications for a variety of settings and diseases. These presenters were selected for their expertise and their award-winning research by the Health Psychology division of the American Psychological Association to share their results in this symposium. Their research discusses disease definition, illness appraisal thoughts, coping with breast cancer, and cognitive effects of having hypertension. Their research areas have implications for health psychologists in a variety of settings.

References
  1. American Psychological Association -- Health Psychology Division 38. What a health psychologist does and how to become one. Available at:
    http://www.health-psych.org/whatis.html. Accessed August 20, 2003.

  2. Keefe FJ. Symposium: new directions in health psychology research. Program and abstracts of the American Psychological Association 111th Annual Meeting; August 7-10, 2003; Toronto, Ontario, Canada. Abstract 1231.

  3. Kaplan RM. Effects of changing diagnostic thresholds on health and health-care costs. Program and abstracts of the American Psychological Association 111th Annual Meeting; August 7-10, 2003; Toronto, Ontario, Canada. Abstract 1231.

  4. Stanton AL. Research directions in understanding adjustment to cancer. Program and abstracts of the American Psychological Association 111th Annual Meeting; August 7-10, 2003; Toronto, Ontario, Canada. Abstract 1231.

  5. Sears SR, Stanton AL, Danoff-Burg S. The Yellow Brick Road and the Emerald City: benefit-finding, positive reappraisal coping, and posttraumatic growth in women with early-stage breast cancer. Health Psychol. 2003; In press.

  6. Stanton AL, Danoff-Burg S, Huggins ME. The first year after breast cancer diagnosis: hope and coping strategies as predictors of adjustment. Psychooncology. 2002;11:93-102. Abstract

  7. Stanton AL, Snider P. Coping with a breast cancer diagnosis: a prospective study. Health Psychol. 1993;12:16-23. Abstract

  8. Stanton AL, Danoff-Burg S, Cameron CL, et al. Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. J Consult Clin Psychol. 2000;68:875-882. Abstract

  9. Stanton AL, Danoff-Burg S, Sworowski LA, et al. Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients. J Clin Oncol. 2002;20:4160-4168. Abstract

  10. Christensen AJ. Irrational health appraisals: an alternative view of cognition and health. Program and abstracts of the American Psychological Association 111th Annual Meeting; August 7-10, 2003; Toronto, Ontario, Canada. Abstract 1231.

  11. Christensen AJ, Edwards DL, Moran PJ, et al. Cognitive distortion and functional impairment in patients undergoing cardiac rehabilitation. Cognit Ther Res. 1999;23:159-168.

  12. Christensen AJ, Moran PJ, Wiebe JS. Assessment of irrational health beliefs: relation to health practices and medical regimen adherence. Health Psychol. 1999;18:169-176. Abstract

  13. Waldstein SR. Relation of hypertension to cognitive function. Program and abstracts of the American Psychological Association 111th Annual Meeting; August 7-10, 2003; Toronto, Ontario, Canada. Abstract 1231.

  14. Waldstein SR. The relation of hypertension to cognitive function. Curr Dir Psychol Sci. 2003;12:9-12.

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