The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist [1 ed.] 9781452261720, 9780761926146

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^HEALTH PSYCHOLOGY HANDBOOK

T o my earliest teachers, R o z and Gertrude, and to my family, Michelle, Fred, Hazel, Alan, Lucy, and Penny. L . M . C. T o the cornerstones o f my life. T h a n k you J o d i , Paul, Diane, and Stephanie. D. Ε. M . T o R o b i n and Erin. T h a n k you for sharing me with my w o r k and sharing your life with me. F . L . C.

^ HEALTH PSYCHOLOGY HANDBOOK Practical Issues for the Behavioral Medicine Specialist Editors

Lee M.Cohen Texas T e c h University

Dennis E. McChargue University of Illinois, C h i c a g o

Frank L.Collins, Jr. Oklahonna S t a t e University

/®\ SAGE Publications l^W

I International Educational and Professional T h o u s a n d O a k s • L o n d o n • N e w Delhi

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Copyright © 2 0 0 3 by Sage Publications, Inc. All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. For

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The health psychology handbook : practical issues for the behavioral medicine specialist / editors, Lee M. Cohen, Dennis E . McChargue, Frank L . Collins, Jr. p. cm. Includes bibliographical references and index. I S B N 0-7619-2614-3 (cloth) 1. Clinical health psychology—Handbooks, manuals, etc. I. Cohen, Lee M. II. McChargue, Dennis Ε . III. Collins, Frank L . , Jr. R726.7.H43357 2003 6 1 3 . 0 1 '9—dc21 2003007165 03

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Acquiring Editor: Editorial Assistant: Production Editor: Typesetter: Copy Editor: Indexer: Cover Designer:

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Jim Brace-Thompson Karen Ehrmann Sanford Robinson C & M Digitals (P) Ltd. D. J . Peck David Luljak Michelle Lee

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Contents

Foreword

ix

CYNTHIA D . BELAR

Part I. Practical Issues for the Behavioral Medicine Specialist Introduction to Part I 1.

1

Health Psychology Practice in Medical Settings RICHARD J . SEIME, MATTHEW M .

2.

C L A R K , AND STEPHEN P .

3

WHITESIDE

Psychological Assessment Screening in Medical Settings MICHAEL D .

3.

1

FRANZEN

Working With a Multidisciplinary Staff

28

H E L E N R . W I N E F I E L D AND A N N A C H U R - H A N S E N

4.

Motivational Enhancement Interventions and Health Behaviors 42 THAD R .

5.

LEFFINGWELL

Brief Psychotherapies and Group Treatments in General Health Care Settings 55 D E B O R A H J . W I E B E , L I N D S E Y B L O O R , AND T I M O T H Y W .

Part II. Behaviors That Compromise Overall Health Status Introduction to Part II 6.

75

Alcohol Problems: Causes, Definitions, and Treatments 79 J O E L E R B L I C H AND M I T C H EARLEYWINE

SMITH

75

17

7.

The Etiology and Treatment of Nicotine Dependence: A Biopsychosocial Perspective LEE M .

C O H E N , DENNIS E . M C C H A R G U E ,

CORTEZ-GARLAND,

8.

MONICA

E R I C H . P R E N S K Y , AND SADIE E M E R Y

Obesity and Body Image Disturbance M Y L E S S . F A I T H AND J . K E V I N

9.

101

125

THOMPSON

Physical Inactivity as a Risk Factor for Chronic Disease 146 KRISTA A . BARBOUR, T I M O T H Y T . AND PATRICIA M .

HOULE,

DUBBERT

10. Stress and Health

169

FRANK L . COLLINS, J R . , KRISTEN H .

SOROCCO,

KIMBERLY R . HAALA, BRIAN I. M I L L E R , AND W I L L I A M R .

LOVALLO

11. Management of Inappropriate Medication-Seeking Behavior S U Z Y B I R D G U L L I V E R , BARBARA A . AND A L E X A N D E R

187

WOLFSDORF,

MICHAS

12. Adherence to Medical Recommendations N I C O L E E . B E R L A N T AND SHERI D .

208

PRUITT

Part III. Behavioral Aspects of Medical Problems 225 Introduction to Part III

225

13. Diagnostic and Treatment Considerations in Chronic Pain JENNIFER L . B O O T H B Y , MELISSA C .

229

KUHAJDA,

AND B E V E R L Y E . T H O R N

14. Hypertension

252

M U S T A F A A L ' A B S I AND R I C H A R D G . H O F F M A N

15. Coronary Heart Disease: Behavioral Cardiology in Clinical Practice

279

S T E V E N M . S C H W A R T Z AND M A R K W . K E T T E R E R

16. Behavioral Management of Type 2 Diabetes AHNA L . H O F F , JANELLE L .

WAGNER,

L A R R Y L . M U L L I N S , AND J O H N M .

CHANEY

303

17. Psycho-Oncology

325

SHULAMITH K R E I T L E R

18. Sexual Dysfunctions: Etiology and Treatment

359

SHEILA G A R O S

19. Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome A N D R E W C . B L A L O C K AND P E T E R E .

CAMPOS

20. Irritable Bowel Syndrome JEFFREY M .

397

LACKNER

2 1 . Insomnia and the Sleep Disorders V A L E R I E A . W O L F E AND SHERI D .

Part IV.

383

PRUITT

Special Issues

Introduction to Part IV

425

441

441

22. Ethical Issues for Clinicians in Behavioral Medicine Settings 443 N I C O L E J . SIEGFRIED AND C H E B O N A . P O R T E R

23. Ethnocultural Issues in Behavioral Medicine

456

H E C T O R F . M Y E R S AND W E I - C H I N H W A N G

24. Women's Health Issues CSILLA T .

469

CSOBOTH

25. Issues With Geriatric Populations B A R R Y A . EDELSTEIN, ANDREA K . A D A M P . SPIRA, AND L E S L E Y P .

485

SHREVE-NEIGER,

KOVEN

26. Public Health Approaches: Finding the Interface With Health Psychology J A L I E A . T U C K E R , JOSHUA C . K L A P O W , AND C A T H Y A .

502 SIMPSON

27. Practical Research in a Medical Setting Is G o o d Medicine 514 KATHLEEN M . PALM, JACK L . M .

MUTNICK,

D A V I D O . A N T O N U C C I O , AND ELIZABETH V .

GIFFORD

28. Evaluating Outcomes in Health Care Settings J O A Q U I N B O R R E G O , J R . , AND W I L L I A M C . F O L L E T T E

525

Author Index

537

Subject Index

567

About the Editors

579

About the Contributors

581

Foreword

W

riting a foreword for The Health

Psychology

Handbook

has stimulated

me to look both backward and forward. Although research and practice in health and behavior has a long history, the year 2 0 0 3 marks the 2 5 t h

anniversary o f the formalization o f health psychology in the United States. It was in 1 9 7 8 that a number o f us obtained sufficient support to establish the Division o f

Health Psychology within the American Psychological Association. During that same year, we met in C h i c a g o to establish the Society o f Behavioral Medicine with the purpose o f bringing together scientists and practitioners from multiple disciplines to advance knowledge o f behavior and health. Shortly thereafter, the Institute o f Medicine ( 1 9 8 2 ) published Health Biobehavioral

Sciences,

and Behavior:

Frontiers

of Research

in the

a landmark study that promoted a surge o f federal funding

for health and behavior research. Research programs expanded, journals grew, and education and training flourished. Recently, within 2 0 years o f that initial report, the Institute o f Medicine ( 2 0 0 1 ) published Health Biological,

Behavioral,

and Societal

Influences.

and Behavior:

The Interplay

of

This report is also a landmark; it

not only updates research on health and behavior but also identifies effective applications o f behavioral interventions and promotes their implementation in our health care delivery system. Although there is much m o r e to do, there is little doubt that health psychology has n o w become mainstream. W h a t has often been missing from the literature in health psychology are those works that provide the kinds o f nuts-and-bolts information that facilitates the translation o f psychological science to practice. In 1 9 8 5 , while writing the first primer for practitioners in clinical health psychology (Belar & Deardorff, 1 9 9 5 , is a revised edition), my postdoctoral fellows and I focused on what I had been teaching at the University o f Florida and Kaiser Permanente Health Care Program about working in tertiary care settings. There was a dearth o f practical advice available at that time. W h e n I began my career during the early 1 9 7 0 s , I had had excellent role models in training (e.g., Doyle Gentry, J o e M a t a r a z z o ) , but there were few written resources; we learned by watching and doing. As I was reading the chapters for this current h a n d b o o k , I found myself wishing that it had been a resource available to me then; there was nothing o f the kind. E D I T O R S ' N O T E : These views are those of the author and not those of the American Psychological Association.

ix

χ

T H E HEALTH PSYCHOLOGY H A N D B O O K W h a t this h a n d b o o k does is facilitate the progression o f the learner from the classroom to the clinical setting by focusing on the translation o f science to practice using practical examples. It does so by reviewing literature on behaviors that compromise overall health status (e.g., smoking, nonadherence) and behavioral aspects o f selected medical problems (e.g., cancer, pain, coronary heart disease). T h e nature o f the health problems is described, related psychological concepts are defined, measurement issues are addressed, and relevant treatments are detailed. There are analyses o f evidence-based clinical assessments and interventions that identify what is k n o w n as well as current gaps in knowledge. However, in addition, experienced authors discuss the application o f those interventions in the real world, noting pitfalls and providing the kind o f practical advice never found in scholarly journals. F o r each problem, a case study is presented that facilitates understanding of the implementation process; the reader can learn what an experienced clinician has actually " s a i d " to a patient and the rationale behind decisions made regarding treatment. It is sure to be an invaluable resource to scientist-practitioners during the education and training process as well as to those continuing their professional development—which includes all o f us. In addition to addressing specific health problems, this h a n d b o o k contains a wealth o f information related to professional issues such as working with a multidisciplinary staff, conducting research in a medical setting, and evaluating clinical outcomes. T h e chapter on public health approaches contextualizes clinical health psychology in our health system, highlighting that it involves more than those services provided in medical settings and by traditional health care providers. T h e public health emphasis represents a major thrust in health care policy that is likely to receive increasing support during the 2 1 s t century given the importance o f population-based approaches to health, the increased awareness o f behavioral components in chronic disease, and the need for attention to issues o f diversity in our health care system. I have always believed that our students should surpass us in knowledge and skills related to our areas o f teaching, research, and practice. Looking backward, it is apparent that those beginning their careers today are at a much different starting point than when we entered the field. This is good. Looking forward, I continue to see great opportunities for the development o f health psychology, which these students have an opportunity to maximize given this different starting point. I f I have an opportunity to write a foreword to a revised Health

Psychology

Handbook

2 0 years from n o w , I anticipate that it will contain many chapters on issues such as technology, prevention, genetic counseling, and health informatics. For example, there are numerous technologies that have been developed during recent years for which we do not have long-term follow-up data to inform our clinical w o r k (e.g., assisted reproductive technologies). Other developments have presented challenges in coping and care for which we are still designing and testing appropriate behavioral interventions (e.g., genetic testing for diabetes, breast cancer) or assessing the impact o f medical interventions (e.g., prophylactic mastectomy). In other cases, interventions that look promising n o w will have been sufficiently tested through widespread randomized controlled studies (e.g., telehealth delivery o f behavioral interventions). Given the explosion in knowledge and information delivery systems,

Foreword there will also be increased focus on h o w to access and evaluate information as well as h o w to facilitate clinical decision making. But in the meantime, with this current handbook, we have a great resource to facilitate what is ready for translation from research to practice now. O u r patients c a n benefit from these services now, and we need a well-trained health care workforce to meet these needs. — C y n t h i a D . Belar, P h . D . , A.B.P.P.

REFERENCES Belar, C. D., & Deardorff, W. W. (1995). Clinical health psychology in medical settings: A practitioner's guidebook. Washington, DC: American Psychological Association. Institute of Medicine. (1982). Health and behavior: Frontiers of research in the biobehavioral sciences. Washington, DC: National Academy Press. behavioral, Institute of Medicine. (2001). Health and behavior: The interplay of biological, and societal influences. Washington, DC: National Academy Press.

\

xi

Parti PRACTICAL ISSUES FOR THE BEHAVIORAL MEDICINE SPECIALIST Introduction

T

to Part I

he first five chapters o f this h a n d b o o k provide an overview and frame o f reference for the clinical health psychologist. T h e s e chapters attempt to build on the broad and general training c o m m o n to all professional psychology

training programs and provide an overview o f some o f the unique skills critical for becoming a behavioral medicine specialist. In Chapter 1, Seime, Clark, and Whiteside provide the reader with a broad overview o f the unique roles played by psychologists working in medical settings. R o l e

identification is critical because many o f the experiences o f psychologists in medical settings are in stark contrast t o experiences in traditional psychology clinics. T h e authors emphasize the unique contributions in the areas o f assessment, treatment, and research that psychology brings to medical settings as well as the unique experiences that c o m e from working in a system dominated by the medical model. In Chapter 2 , Franzen builds on the framework presented in Chapter 1 by providing detailed examples o f the similarities and unique aspects o f psychological assessment in medical settings as c o m p a r e d with traditional psychology clinics. Attention is given t o cognitive, intellectual, and psychiatric screenings, pointing out the unique role o f psychology in medical settings. T h e chapter concludes with

2

PRACTICAL ISSUES specific recommendations for assessment and training needed to w o r k as a clinical health psychologist in a medical setting. In Chapter 3 , Winefield and Chur-Hansen provide a detailed discussion o f the challenges and rewards o f working in a multidisciplinary setting. This is perhaps the aspect o f clinical health psychology that most differentiates it from other professional psychology settings. Medical settings are by their nature multidisciplinary, and psychologists are often not trained to function in this professional arena. T h e authors provide both a historical perspective and detailed information about the specific skills that will facilitate integration into medical settings. In Chapter 4 , Leffingwell describes the importance o f motivational enhancement interventions for use in medical settings. T h e chapter reviews the historical basis o f these procedures and provides a great deal o f detail for h o w these interventions can and should be used for helping clients to change health-related behaviors. T h e author provides specific examples o f dialogue between the therapist and the client to illustrate the conceptual and practical aspects o f these interventions. Finally, in Chapter 5 , Wiebe, Bloor, and Smith present a review o f other brief interventions and group methods used in the practice o f clinical health psychology. T h e chapter illustrates how these interventions fit within a biopsychosocial model, with an emphasis on the unique goals for intervention with health-related problems. T h e authors provide reviews o f the use of psychoeducational, cognitive-behavioral, and interpersonal approaches for reducing the risk of disease, improving disease outcomes, and improving quality o f life. As with the other chapters in this section, a major focus is the unique training necessary to serve as a clinical health psychologist.

1

CHAPTER

Health Psychology Practice in Medical Settings RICHARD J . SEIME, MATTHEW M . CLARK, AND STEPHEN P. WHITESIDE

T

here has been tremendous

growth

and they experience different challenges to

in the number o f psychologists with

their health. Previously, many died from infec-

a primary interest in practicing in

tious

diseases

such

as

tuberculosis

and

medical settings. In this chapter, we c a n n o t

influenza. T h e death rate from life-threatening

provide an exhaustive review o f the literature

infectious diseases declined during the mid-

but instead present a perspective that will

2 0 t h century due to advances in preventive

help put the subsequent chapters into a pro-

measures and medical care. While the AIDS

fessional context. T h e goal o f this chapter is

epidemic has created complex and important

to briefly review the roles o f clinical health

new challenges, most Americans will experi-

psychologists, address some issues o f practice

ence health problems related to cardiovascular

in a medical setting, and focus on specific strate-

disease, cancer, cerebrovascular disease, unin-

gies and recommendations on " h o w t o " func-

tentional injuries, and chronic

tion as a clinical health psychologist in an

pulmonary disease (Kaplan, Sallis, & Patterson,

obstructive

academic health science center. T h e authors

1 9 9 3 ) . Americans are becoming more obese,

o f this chapter represent different levels o f

are being less physically active, and are con-

training and background; therefore, they pro-

suming more dietary fat (Kottke et al., 2 0 0 0 ) .

vide the perspectives o f a psychologist in

It has been estimated that lifestyle behaviors

training (Stephen Whiteside), a health psycho-

account for more than 5 0 % of the mortality

logy researcher/clinician/educator ( M a t t h e w

from these diseases (McGinness &

Clark),

1 9 9 3 ) . Smoking, physical activity level, and

and

a

senior

clinician/educator/

Foege,

administrator (Richard Seime).

nutrition all are lifestyle factors, but so are

BACKGROUND

clinical health psychology has an opportunity

mood, social support, and personality. Thus, to contribute to the health and wellness of our The health issues facing Americans have changed

population. T w o case examples may help to

greatly over the past century. People live longer,

highlight these issues.

4

PRACTICAL ISSUES Case 1: Mr. Smith is a 55-year-old business executive who recently completed his annual physical. His father died at 58 years of age from a myocardial infarction, or heart attack, and Mr. Smith worries frequently about his health. However, he is 40 pounds overweight, has not been a consistent exerciser since college, smokes one pack of cigarettes per day, and has three alcoholic drinks after work to "unwind." He is on antihypertensive and lipid-lowering medications. His physician is recommending numerous lifestyle changes, and Mr. Smith was referred to you, a clinical health psychologist, for consultation.

UNIQUE CONTRIBUTIONS OF PSYCHOLOGISTS Increasingly over the past 2 5 years, the field of medicine has been recognizing the benefits o f the biopsychosocial model. This philosophy adds an understanding and

incorporation

of psychosocial variables to the traditional biomedical approach (Engel, 1 9 7 7 ) . As experts in measuring and altering behavior, psychologists have a unique set of skills to combine with the practice o f our medical colleagues in an effort to apply the biopsychosocial model

Case 2: Ms. Jones is a 65-year-old, recently widowed female who has coronary artery disease and had coronary artery bypass surgery. Her cardiologist referred her to a 12-week cardiac rehabilitation program, but Ms. Jones does not attend on a regular basis. When present, she appears lethargic, does not follow instructions, and reports that she is frequently feeling alone and isolated. Her cardiologist wants your assistance in evaluating her mood and providing assistance in her care.

to patient care. In an environment consisting of multiple health and mental health professions, psychology's most important contributions are its study o f complex behavior and its commitment to critical evaluation of treatment

strategies and outcomes (cf.

Schofield, 1 9 6 9 ) . As a subspecialty o f psychology, clinical health psychology applies assessment

and

learning theories to a unified view o f physical and psychological health. Through this integration, health psychology can evaluate and

These cases highlight different aspects o f

treat many areas that frequently have not been

clinical health psychology. T h e first case may

addressed by the more traditional practices

benefit from cognitive-behavioral therapy for

of clinical psychology and psychiatry. For

lifestyle changes. R e c o r d keeping, stimulus

instance, Belar and Deardorff ( 1 9 9 5 ) identi-

control, enhancing social support, stress man-

fied three areas o f consultation that clinical

goal-setting

health psychologists address more directly

strategies could be beneficial. T h e second

than do other mental health practitioners:

agement

techniques,

and/or

case portrays h o w psychiatric comorbidity

(a) treatment

may affect adherence to recommendations

self-regulation or learning theory to medical

involving psychophysiological

for health behavior changes. Depression in car-

problems, (b) predictions o f response to medi-

diac patients, for example, increases the risk o f

cal-surgical treatments, and (c) reduction o f

reoccurrence (Frasure-Smith, Lesperance, &

health risk behaviors. T h e distinct ability of

Talajic, 1 9 9 5 ) and lowers medication adher-

clinical health psychology to address these

ence (Carney, Freedland, Eisen, Rich, &c Jaffe,

types o f questions stems from

1 9 9 5 ) . Thus, assessment and treatment of

with other mental health fields in four general

differences

comorbid depression would be important for

areas: training, assessment, treatment,

the second case example.

research.

and

Health Psychology

Training

in Medical

Settings

Assessment

Professional training influences the manner

The foundation o f clinical health psychology

in which health care professionals think about

is in standardized assessment, a practice that

clinical issues and influences the tools with

continues to be a hallmark o f the discipline.

which they evaluate and subsequently treat

Consultations often incorporate psychomet-

patients. T h e training of clinical health psycho-

ric assessment, which may be one o f clinical

logists is complementary to the medical train-

health psychology's most unique contribu-

ing o f physicians due to its focus on the

tions to patient care (Belar &

Deardorff,

empirical investigation o f cognition, behavior,

1 9 9 5 ) . Use o f standardized measures, such as

emotions, and

self-report questionnaires, reduces the chance

Specifically,

interpersonal

relationships. in

o f interviewer bias in assessment and adds an

research, program evaluation, and measure-

psychologists are trained

objective piece o f information that can be

ment o f behavior, areas in which psychiatrists

used to standardize the assessment and mon-

and other mental health practitioners are not

itor the success o f the treatment interven-

as thoroughly trained (Belar &c Deardorff,

tions. N o other mental health field has this

1 9 9 5 ) . T h e focus on health behavior change

foundation and expertise in psychometrics.

and prevention in training for the clinical

Another strength o f the discipline is the

health psychology subspecialty equips practi-

type o f information collected by clinical health

tioners with a perspective that has advantages

psychologists. Some disciplines focus primar-

over both traditional clinical psychology and

ily on deriving a diagnostic label; in contrast,

psychiatry training models. Namely, the former

clinical

two disciplines are often viewed as being overly

conduct a functional analysis. A functional

focused on psychopathology (Belar & Deardorff,

analysis o f the symptoms incorporates the

1 9 9 5 ) , thereby limiting services primarily to

antecedents and consequences o f each symp-

individuals with diagnosable mental disorders.

tom or behavior. T h e singular use o f psychi-

This focus on psychopathology

excludes

atric diagnoses has a number o f pitfalls and

patients without psychiatric disorders who,

liabilities. First, D S M - I V diagnoses (American

nonetheless, are exhibiting maladaptive cogni-

Psychiatric Association, 1 9 9 4 ) are not etiology

health

psychologists

frequently

tive or behavioral patterns that affect their

based but rather descriptive in nature. Thus,

health status and quality o f life. Training in

psychiatric diagnoses

clinical health psychology, in contrast, incor-

address or describe the factors that may have

porates the study o f behaviors that promote

precipitated and/or maintained

good physical and emotional health, such as

symptoms and therefore do not provide suffi-

smoking

cessation, weight

do

not

adequately a

patient's

management,

cient information to determine which treat-

development o f adaptive coping mechanisms,

ment interventions are likely to be successful

and adjustment to chronic illness, in addition

for a given patient (Beutler, Wakefield, &

to traditional mental health training. Health

Williams, 1 9 9 4 ) . Second, diagnostic labels,

psychologists are thereby able to assess these

such as hypochondriasis and borderline per-

areas and intervene to promote healthy behav-

sonality disorder, can have pejorative or moral

iors with or without a D S M - I V

(Diagnostic

connotations that lead to negative effects (Van

Disorders,

Egeren & Striepe, 1 9 9 8 ) . For example, these

fourth edition) diagnosis (American Psychiatric

diagnoses can influence health care profession-

Association, 1 9 9 4 ) .

als to inaccurately attribute patients' physical

and

Statistical

Manual

of Mental

5

6

PRACTICAL ISSUES complaints to symptoms of psychopathology

only by the patient but also by caregivers, both

(Belar &

Geisser, 1 9 9 5 ) or can increase

familial and professional. This approach stands

patients' fear that their symptoms will not be

in stark contrast to a purely biological explana-

taken seriously (Van Egeren & Striepe, 1 9 9 8 ) .

tion that locates pathology primarily within the

Finally, diagnostic labeling can to mind-body

dichotomous

contribute

thinking.

For

patient. T h e contribution o f clinical health psychology lies in emphasizing the role that learn-

example, although the D S M - I V diagnosis o f

ing and reinforcement play in

maladaptive

"psychological factors affecting a medical

behaviors while also acknowledging biologically

condition" is an improvement over the previ-

based personality and psychopathology factors.

ous nomenclature o f "psychogenic pain," this new diagnosis still maintains a unidirectional causal link rather than acknowledging

the

interaction between patients' physical symp-

Treatment As in assessment, one o f the strengths of

toms and their behavior and emotional func-

psychologists in a medical center is that they

tioning (Van Egeren & Striepe, 1 9 9 8 ) .

can add a unique set o f skills and options to

A functional analysis has the strengths o f objectively quantifying

the frequency

and

the treatment plan. Although many physicians request that complicated psychophar-

intensity o f a target symptom and locating

macological management

where within the environmental context it

their psychiatric colleagues, an

occurs. This approach

that

physician will frequently employ a first-line

behavioral symptoms interact with emotional,

antidepressant or anxiolytic before requesting

acknowledges

be managed

by

attending

processes

a psychiatry consult. However, many physi-

within the patient. T h e patient is seen as not

cians understandably lack the training exper-

cognitive,

social,

and

physical

merely acting on his or her environment but

tise or comfort level to address many o f the

rather as responding and reacting to behaviors

issues routinely treated by psychologists such

from health professionals and the demands o f

as application o f motivational interviewing to

being in the hospital. Moreover, the patient's

health behavior change (Bellg, 1 9 9 8 ) . Thus,

care

consultation to a clinical health psychologist

factors, so a thorough "assessment requires

can add a novel treatment approach to a

awareness o f life circumstances and an appre-

complex and challenging medical patient.

environment

extends

beyond

health

ciation o f expectancies placed on patients by

M a n y o f the strengths of the treatments

themselves and others" (Rozensky, Sweet, &

offered by clinical health psychologists emerge

Tovian, 1 9 9 7 , p. 6 3 ) . Completing a functional

directly from their training and assessment. For

analysis to understand the environment in

example, because clinical health psychologists

which a target behavior occurs, including the

have expanded from a narrow focus on psy-

precipitating stimuli and reinforcing conse-

chopathology, they can offer treatment options

quences, logically suggests a treatment plan to

for patients w h o are not described by D S M - Γ ν

alter the expression of the symptom. Ultimately,

diagnoses (American Psychiatric Association,

providing information that clearly leads t o a

1 9 9 4 ) . Clinical health psychologists can work

treatment is the goal o f any clinical health

with psychologically well-functioning individ-

psychology consultation.

uals w h o are faced with challenging health

M o r e so than any other discipline, psycho-

problems. This is an important quality because

logy has developed a body o f knowledge

it is not necessary to suffer from psychopatho-

regarding behavioral assessment (through inter-

logy to have difficulties in the hospital setting,

view and direct observation) that can be applied

in coping with illness, or in adhering to medi-

to understanding maladaptive behaviors not

cal recommendations. T o illustrate, adherence

Health Psychology

in Medical

Settings

7

rates in pediatric populations can be as low as

health psychologists can systematically study the

5%,

effectiveness o f a particular treatment within a

and thus many patients will benefit strategies

single patient or can compare separate treat-

(Dickey, Mattar, & Chudzik, 1 9 7 5 ) . Clearly, a

ments within an individual patient. This could

singular focus on psychopathology, defined in

be accomplished by obtaining

part as a deviation from "normal" functioning,

behavioral observations o f target symptoms

from

assistance with

adherence

structured

would not address a problem that occurs in

before and after interventions from health

the majority o f individuals faced with a given

care providers. Psychologists can also apply

medical situation. As a result o f this expanded

their research training to the evaluation o f

focus, clinical health psychology interventions

new treatment protocols. T o date,

with nonpsychiatric patients have facilitated

numerous other accomplishments, psychology

among

health-promoting behavior changes and can

has demonstrated the effectiveness o f psycho-

have direct effects on biological factors that

logical interventions in reducing hospitaliza-

influence the onset and progression of disease

tion rates in asthmatic and diabetic children

(Bellg, 1 9 9 8 ) .

(Christie-Seely &

An additional strength o f the interventions

Crouch,

1 9 8 7 ) and

in

managing chronic pain (Hardin, 1 9 9 8 ) .

enlisted by clinical health psychologists is that they are theory driven, with an understanding of the mechanism o f action. This is particu-

Summary

larly true for interventions based on learning

Clearly, because of the nature of their train-

and behavioral principles. T h e opportunities

ing, clinical health psychologists have a multi-

for clinical health psychologists to apply these

tude of unique skills and techniques that can

skills in medical centers are numerous, includ-

be applied to the assessment and treatment of

ing stimulus control strategies to help patients

patients in medical centers. T h e contribution

with cardiovascular disease manage

of a psychological consultation is being able to

environments, treatment

their

o f adjustment

to

assess the biopsychosocial factors that affect a

medical illness, behavior problems and adher-

patient and then provide a cogent explanation

ence in chronic health problems, cognitive

to the patient for why he or she is experiencing

distortions exacerbating symptoms o f anxiety

difficulties. This empirically based explanation

in patients with medical disease, and family

focuses on the patient as an individual with a

problems exacerbating and resulting

history of experiences interpreted through the

from

health problems faced by the patient (cf.

patient's

Camic & Knight, 1 9 9 8 ) .

processing and logically suggests potential

specific cognitive and

emotional

interventions. However, communicating and applying these skills effectively in the medical

Research T h e fourth general area o f unique contri-

center, an environment that can feel alien to the inexperienced psychologist, can be challenging.

butions by clinical health psychology to medical center consultation is the application o f research to patient care. Training in research design, implementation, and interpretation is emphasized in doctoral training in psychology to a greater degree than in medical training. These research skills can be applied at the individual patient level or at the treatment team level (Malec, 1 9 9 1 ) . For example, clinical

IMPORTANT ISSUES IN MEDICAL SETTINGS THAT AFFECT PSYCHOLOGICAL PRACTICE The Medical Model Clinical health psychologists have clinical and research training and

skills that

are

8

PRACTICAL ISSUES transportable

training

unique skills that psychologists bring to the

arena to the medical setting (cf. Belar, 1 9 8 0 ) .

from

the doctoral

medical setting. It has been our experience

However, psychologists frequently confront a

that these colleagues appreciate the clinical

setting that is steeped in the medical model.

health psychologist who is able to help both

T h e medical model is the cornerstone o f

the patient and the physician to understand

clinical practice in health science centers. T h e

problematic emotions and behavior and to

medical model assumes that a practitioner

intervene effectively.

will diagnose a problem, identify etiological factors, and ultimately correct the underlying issues that result in the overt dysfunction or problem. This is often seen initially by psychologists and psychologists in training who are unfamiliar with practice in a medical set-

Concerns

Related

to the Medical Diagnosis

Model

by Exclusion.

It is essential that

clinical health psychologists avoid making a

ting as antithetical to behavioral or psycho-

diagnosis by exclusion. Often patients

logical formulation. As Shows ( 1 9 7 6 ) pointed

referred when there are no positive physical

are

out, doctoral students often emerge from their

findings but there is dysfunction, and referring

doctoral training with negative attitudes about

colleagues may erroneously conclude that this

the medical model. Mistakenly, psychologists'

equates with the assumption that "there must

initial reaction to the medical model is that

be something psychologically wrong." In such a

physicians may be trying to find a disease

circumstance, we as psychologists must still

where none exists. In fact, historically some o f

identify positive findings to conclude

the tension between psychologists and psychi-

psychological or behavioral factors can account

that

atrists in the medical setting is around the

for a problem. Here is where our skills in func-

medicalization or pathologizing o f behavioral

tional analysis, use o f data gathering,

issues or emotional distress. At its worst, the

psychometric assessment all can play a role in

medical model can "portray the patient as sick

determining what might account for dysfunc-

and dependent and the professional as imperi-

tion in the absence o f physical findings. It is

and

alistic and heroic" (Belar &c Deardorff, 1 9 9 5 ,

important to have a working knowledge o f

p. 3 0 ) . So, psychologists must come to terms

the pathophysiology, behavioral, and psycho-

with the medical model.

logical issues c o m m o n with medical disorders medical

that we are called on to evaluate as a consul-

model, but it is a "fact o f life" in medical

tant. Keep in mind also that some diseases,

Psychologists often malign the

settings. Therefore, it is important to address

such as multiple sclerosis, have elusive or

one's attitude about the medical model so that

equivocal findings. In most cases, it is far too

one can effectively communicate, collaborate,

simpleminded to dismiss as psychological or

and intervene in the medical setting. It may be

functional a patient's presenting problems if

helpful to reframe this model as representing

no definitive physical signs or findings are

an empirical approach to diagnosis and treat-

obtained. In cases such as this, it behooves us

ment. A c o m m o n value held by both clinical

to recognize that we play an important role in

health psychologists and our medical colleagues

ensuring that the patient continues to feel that

is an emphasis on empiricism. Likewise, it is

we will encourage an ongoing consultation

important to get to k n o w colleagues and to

with the referring physician as we also work

ascertain their attitudes toward psychology

to help the patient get well. Somatizing patients

and psychologists. W i t h the increased repre-

in particular can represent a real challenge,

sentation of psychologists in medical settings,

but even patients with somatization disorders

medical colleagues have become aware o f the

have legitimate needs for ongoing medical

Health Psychology

in Medical Settings

|

evaluation and care. W h a t we have to offer

training. F r o m the time a physician graduates

these difficult patients is a different model for

from medical school, he or she is expected to

addressing their dysfunction

that looks at

be caring for patients, making decisions, being

behavioral, social, and psychological factors

on the "front line," and quickly diagnosing

as they interact with biological factors to

and treating medical issues. However, physi-

account for their difficulties and dysfunction.

cians frequently have limited confidence in their ability to counsel patients or deal with

This is the

psychological and behavioral issues due to a

converse in a sense o f diagnosis by exclusion.

lack o f training. Thus, it is important to real-

In this pitfall, a physician may have recently

ize that physicians often feel quite inadequate

diagnosed a physical or biological problem

in addressing the behavioral and emotional

Ignoring

Psychological

Factors.

after having not been able to do so for some

factors that are present in so many o f the

time. Perhaps a patient has been suffering

patients they evaluate and treat (e.g., Kroenke &

from distress or depression, engaging in mal-

Mangelsdorff, 1 9 8 9 ; Philbrick, Connelly, &

adaptive behaviors, or reinforced for sick role

Wofford, 1 9 9 6 ) .

behavior. N o w the patient has received a med-

T h e psychology trainee who is new to the

ical diagnosis, and this new "organic" finding

medical setting, or the psychologist who has

is seen as accounting for all o f his or her diffi-

little experience in the medical setting, can

culties and symptoms. This error in thinking

find the medical environment quite intimi-

can lead to poor patient management in some

dating. Besides often feeling as though his or

cases. For example, assume that an individual

her medical knowledge is lacking, the psycho-

has been having severe anxiety and panic

logist can be intimidated by the pace, the

attacks that have led to agoraphobic behav-

presumed

iors. A recent physical now reveals abnor-

psychological formulations and interventions,

mally high thyroid hormone levels. Does the

and the expectation o f "answers." T o manage

fact that this individual may be more prone to

these feelings and

anxiety as a result n o w account for the behav-

remember that although physicians have had

expectation o f certainty

assumed

about

expectations,

ioral dysfunction? T h e basic principle is sim-

a different " t r a c k " in their training compared

ply that in the process o f serial diagnosis of

with other health professionals, this does not

problems, it is not necessarily the case that a

in any way invalidate the unique knowledge,

particular physical finding accounts for all o f

clinical assessment, and intervention skills

the subsequent or preceding problems. F r o m a

that clinical health psychologists bring to the

biopsychosocial perspective, many factors are

health care arena. In terms o f training, Belar

at work simultaneously. W h a t we are best at

and Deardorff ( 1 9 9 5 ) stated that didactic

doing as psychologists is assessing what is

experiences alone are not sufficient for the

happening

practice o f health psychology. T h e y empha-

in the dimensions o f behavior,

cognition, and emotion as well as in the social

sized the importance o f appropriate

milieu of the patient that provides some avenue

models, supervisors, and mentors. This is

role

for understanding the current dysfunction and

consistent with our experience in

how to ameliorate the dysfunction.

trained and supervised practicum students,

having

predoctoral interns, and postdoctoral fellows.

Medical Background Versus Psychology Background

T h o s e trainees and psychologists w h o have had mentors working in medical settings, who have had physician collaborators and

There are obvious differences between psy-

mentors, and who have had the opportunity

chologists and physicians in the nature o f their

to train side by side with physician trainees

9

10

PRACTICAL ISSUES have an appreciation for physician knowledge

informal aspects of how best to be effective in

without being intimidated.

a consultative role. T h e informal aspects o f effectiveness include the quality o f the collaborative relations with other disciplines (Sweet

Working Within the Organizational and Political Structure of a Medical Setting

&c Rozensky, 1 9 9 1 ) and the psychologist's personal style. For example, Belar and Deardorff ( 1 9 9 5 ) suggested that the most effective clinical

T h e clinical health psychologist with a solid

health psychologists in a hospital setting are

training background in assessment, interven-

those who are "active, open, direct, assertive,

tion, and professional skills enters a challeng-

and energetic" (p. 3 3 ) and w h o have a higher

ing environment in the medical setting. It is an

tolerance for frustration. W e would add that

environment governed

the most effective psychologists are those who

by formalized

rules

(e.g., hospital bylaws, staff privileging) and

have the background, knowledge,

informal "rules," many o f which are not

clinical

familiar to psychology graduate

training,

and

interest,

interpersonal

skills

students.

needed to deal with both complex patient care

Therefore, we emphasize the importance of

issues and a complex, multilayered health care

receiving training in a medical setting from

delivery environment.

mentors who are familiar with the medical

At a minimum, the clinical health psycho-

setting. It has been our experience that physi-

logist who intends to work effectively in a

cians and other allied health professionals are

medical setting needs to understand the formal

welcoming

pitfalls

governance aspects o f psychological practice

abound. Belar and Deardorff ( 1 9 9 5 ) discussed

in a medical setting. This topic is addressed

the implicit and

hierarchy

only briefly here, and the reader is referred to

that affects a psychologist's role function in a

expanded yet succinct coverage of these issues by

medical setting. Psychologists, especially those

others (e.g., Belar & Deardorff, 1 9 9 5 ; Rozensky

o f psychologists—but explicit power

w h o are new to the field or who are still in

et al., 1 9 9 7 ) . T h e medical staff/hospital bylaws,

training, need to be especially sensitive to the

rules, and regulations govern how psycho-

role of the referring physician—the provider

logists are formally recognized in the hospital

who is in charge o f ordering consultations

setting. W h a t a psychologist is able to do pro-

and who ultimately is responsible for the

fessionally in a hospital or medical center is

patient in a hospital setting. A clinical health

governed by staff privileges (i.e., what a psy-

psychologist is invited to see a patient by the

chologist is permitted to do once granted a for-

physician w h o orders a consultation. Although

mal status with

it is important to have excellent relationships

psychologist participates in formally determin-

the hospital). Whether a

with an entire treatment team, ultimately it is

ing rules and in setting standards for practice in

the attending physicians who have the final

the hospital organization is determined by the

say as to w h o sees their patients and what is

category of staff membership (e.g., active staff,

offered to the patients. This process can be

consulting staff, courtesy staff, allied heath

confusing to the clinical health psychology

staff).

trainee or psychologist more familiar with

active staff) permits a formal voice in medical

outpatient practice, where several consultants

staff/hospital staff affairs.

Only voting staff membership

(i.e.,

may be working with the same patient. In our

A clinical health psychologist also needs to

experience, a psychologist needs to consider

be well aware o f the administrative structure

both the formal aspects (i.e., rules and regula-

of psychology in the medical setting where he

tion governing practice) o f h o w to function as

or she works. T h e psychologist needs to know

a psychologist in a consultative role and the

the organized "unit," whether it be a section

Health Psychology

in Medical Settings

\

or division within other clinical departments

psychologist serves the dual role of a consultant

or an independent department o f psychology.

and a liaison psychologist (e.g., being involved

An organized psychology unit facilitates the

with a program, regularly interacting about

individual

psychologist's professional role

psychological and behavioral adjustment of

function in the medical setting. Frank ( 1 9 9 7 )

patients,

and Seime ( 1 9 9 8 ) reviewed some of the issues

patients). As the clinical health psychologist

associated with the organizational structures

gets involved in a liaison role, he or she begins

within health science settings. Connecting

to move away from a more traditional mental

consulting

with

staff,

treating

with the administrative structure for psycho-

health practice and toward a clinical health

logy is required in most institutions. T h e medi-

psychology practice. Liaison roles provide a

cal setting provides such an enticing wealth

rich opportunity for both research and clinical

of professional opportunities that novice psy-

collaboration. T h e physician or other health

chologists can make serious mistakes, without

care professional is not directly

intending to do so, that may jeopardize their

patients "to the psychologist," but the psy-

future practice. Thus, as Rozensky ( 1 9 9 1 )

chologist becomes a regular part o f the

pointed out, it is important to both under-

program's evaluation and service delivery. A

referring

stand and master a specific hospital's "politi-

liaison role also provides an excellent oppor-

cal milieu." Fortunately, we are n o w at a stage

tunity for the psychologist to intervene with

in the development o f clinical health psychol-

the treatment team, to educate, and to affect

ogy throughout many medical settings and

program development.

academic health science centers where seasoned

Typically, consulting roles involve fee-

clinicians/mentors are readily available to

for-service. T h e psychologist interviews the

assist the junior psychologist in how to be

patient and assesses for behavioral, cognitive,

effective in medical settings.

social, and/or mental health difficulties. There may be difficulties in billing for these services, particularly for patients who do not have a

Consulting and Liaison Opportunities

mental health diagnosis under the D S M - I V criteria. However, as of January 2 0 0 2 , there are

The role o f a consultant in a medical setting

now "current procedural codes" (American

can take many forms, and serving as such is

Medical Association, 2 0 0 1 ) that include health

the most c o m m o n role for clinical health psy-

and

chologists. Typically, a consultation involves

codes for patients whose primary diagnosis is

an evaluation whereby the patient is provided

physical. This is a major breakthrough to per-

with a formulation and treatment recommen-

mit appropriate reimbursement for the delivery

dations. Often, the patient is referred

for

of psychological services to the patient with

further services that may require additional

significant physical problems requiring psycho-

medical consultation, mental health services,

logical intervention but without a D S M - I V

and/or other health care services (e.g., occupa-

mental health diagnosis.

tional or physical therapy, nutritional counsel-

behavior assessment and

intervention

Liaison roles for psychologists are satisfying,

ing). This consultation model fits well with a

but practical fiscal issues can limit the psychol-

traditional outpatient practice. There also has

ogist's time in such activities. It is important to

been a recent surge o f interest in psychologists

negotiate with a program to compensate for the

affiliating with primary care clinics or depart-

psychologist's time that does not involve direct

ments of family practice where ongoing con-

billable services. In our experience, it is not

sultation is provided to both patients and

uncommon for programs to greet the involve-

health care professionals. In this capacity, the

ment o f a clinical health psychologist in the

11

12

PRACTICAL ISSUES liaison role but to not be able to pay for the

toward assisting the psychologist in becoming

intensive time involved in such efforts. In aca-

board certified in clinical health psychology.

demic health science settings, one strategy is for

The American Board o f Professional Psycho-

psychologists to pair the ongoing liaison role

logy has recognized clinical health psychology

with a research endeavor funded by a grant that

as a specialty since 1 9 9 0 (Belar &

serves to both purchase time and fulfill research

1995).

interests and goals.

Jeffrey,

As we advance in our careers, we all will need to constantly further our knowledge and develop new skills. For a practicing psycholo-

Training Background and Skills

gist, whether early or late in his or her career, that

there are suggested principles that can guide

graduate students now have a multitude of

self-directed learning to remain competent

Belar and colleagues ( 2 0 0 1 ) noted

opportunities to obtain appropriate prepara-

and to develop new areas o f competency as a

tory

graduate

psychologist providing services to medical-

students, predoctoral interns, or postdoctoral

surgical patients. Belar and colleagues ( 2 0 0 1 )

supervised

experiences

as

fellows. Graduate school training serves as the

developed a template for self-assessment for

foundation by providing training in the biolog-

the practicing clinical health psychologist.

ical, cognitive, affective, social, and psycholog-

T h e template is presented in T a b l e 1.1.

ical bases of behavior. Such training could be integrated with graduate training, but it has been our experience that this training more typically is obtained during the predoctoral internship year or as a postdoctoral fellow.

Translating Psychology Practice and Skills Into a Medical Setting As noted previously, graduate

education

Although postdoctoral fellowship programs

may provide doctoral students with training

have existed for a number of years, only

that will facilitate their functioning as clinical

recently has there been an emphasis on having

health psychologists. These educational experi-

organized, structured, and accredited post-

ences include course work and clinical training

doctoral fellowship training. Recently the

in epidemiology, health psychology, psy-

Committee on Accreditation of the American

chological testing, behavior therapy, family

Psychological Association (ΑΡΑ) has recognized

therapy, geriatrics, and psychopharmacology.

specialty postdoctoral fellowship programs in

Unfortunately, it has been our experience that

clinical health psychology. There are a few

some needed skills are not taught and that

postdoctoral programs that have received ΑΡΑ

some psychology practices do not translate

accreditation, with others soon to be added.

well into medical centers.

Training at the predoctoral internship level in an ΑΡΑ-accredited program within a medical

There are many skills that are crit-

Pitfalls.

setting will ensure supervised experience in the

ical for the successful practice of clinical health

medical environment. T h e opportunity

psychology but that are overlooked during

to

practice under supervision, to consult regularly

graduate

with other health professionals, and to evalu-

to health settings (e.g., managing on-call

ate and treat medically referred patients is an

schedules, learning I C D - 1 0

invaluable training experience. T h e opportu-

Classification

nity to then obtain further depth and breadth

codes), whereas other skills are general prac-

training. Some skills are

of

Diseases,

unique

[International 10th

edition]

of experience and expertise is provided by

tice skills often overlooked in graduate educa-

postdoctoral fellowship training. Postdoctoral

tion (e.g., billing procedures, documentation

fellowship training will also go a long way

requirements and modalities). M a n y clinical

Health Psychology Table 1.1

in Medical

Settings

Template for Self-Assessment of Readiness for Delivery of Services to Patient With Medical-Surgical Problems

1. Do I have the knowledge of the biological bases of health and disease as related to this problem? How is this related to the biological bases of behavior? 2. Do I have knowledge of the cognitive-affective bases of health and disease as related to this problem? How is this related to the cognitive-affective bases of behavior? 3. Do I have the knowledge of the social bases of health and disease as related to this problem? How is this related to the social bases of behavior? 4. Do I have the knowledge of the developmental and individual bases of health and disease as related to this problem? How is this related to the developmental and individual bases of behavior? 5. Do I have the knowledge of the interactions among biological, affective, cognitive, social, and developmental components (e.g., psychophysiological aspects)? Do I understand the relationships between this problem and the patient and his or her environment (including family, health care system, and sociocultural environment)? 6. Do I have the knowledge and skills in the empirically supported clinical assessment methods for patients with this problem and how assessment might be affected by information in areas described by Questions 1 to 5? 7. Do I have knowledge of, and skill in implementing, the empirically supported interventions relevant to patients with this problem? Do I have knowledge of how the proposed psychological interventions affect physiological processes and vice versa? 8. Do I have knowledge of the roles and functions of other health care professionals relevant to this patient's problem? Do I have skills to communicate and collaborate with them? 9. Do I understand the sociopolitical features of the health care delivery system that can affect this problem? 10. Do I understand health policy issues relevant to this problem? 11. Am I aware of distinctive ethical issues related to practice with this problem? 12. Am I aware of the distinctive legal issues related to practice with this problem? 13. Am I aware of special professional issues associated with practice with this problem? S O U R C E : Copyright © 2001 by the American Psychological Association. Adapted with permission.

health psychology trainees are not initially

language easily understood by a number of

prepared for the unique challenges posed by

different health care professionals. In a mental

medical centers. It is not uncommon

for

health care setting, psychologists are provid-

trainees to be asked to make a diagnosis after

ing most (if not all) o f the treatment, whereas

conducting a brief bedside consultation (e.g.,

in a health care setting, psychologists are only

1 5 minutes) with a client in a medical setting,

part o f the treatment team where psychologi-

whereas mental health clinics would

cal interventions must be coordinated with

fre-

quently set aside at least 1 full hour for an

medical treatments. This transition is not

initial intake interview. Likewise, trainees are

always easy for individuals who have little or

often taught to write extensive evaluation

no experience with interdisciplinary teams.

reports primarily intended for other psycho-

In spite o f the challenges and pitfalls, it has

logists, whereas clinical health psychology

been our experience that the transition to a

reports are expected to be brief and to use

medical center is a rewarding yet challenging

14

PRACTICAL ISSUES experience that can be facilitated

through

that may differ from those of other professions.

adequate preparation. A template for effec-

It has been our experience that direct clear

tive practice is described in the next section.

communication can prevent many dilemmas and will be well received by one's medical colleagues. For example, the importance o f

Strategies for Effective Practice

limiting and preventing dual relationships can

First, the psychologist should select an area

be explained in a manner that is well received.

of high interest. T h e patient population needs to

In addition, discussions about how psycho-

be one for which the provider has a "passion."

logical test data and reports are different from

Much time, energy, and devotion will be needed

lab work, and thus have different needs for

to develop expertise, so being passionate about

confidentiality, have been well received by

one's work

our medical institutions.

is important.

T h e psychologist

should also pursue additional training through

Trainees can be wonderful bridge builders.

seminars, workshops, readings, and supervised

Having psychology trainees mentored,

clinical experience as suggested in the self-assess-

cated, or supervised by physicians has built

ment template presented in Table 1.1. Once the

many bonds for us. Similarly, mentoring, edu-

psychologist has the expertise, forming

an

cating, or supervising medical students, resi-

alliance with physicians will ensure continuity

dents, and fellows builds relationships with

of medical care and will facilitate referrals.

potential future colleagues and builds relation-

Completing comprehensive evaluations

with

ships with the medical training faculty. Our

clear recommendations will enhance satisfaction

predoctoral interns and postdoctoral fellows

from referring physicians. Ongoing communica-

have established numerous collaborative clini-

tion with health care providers is essential for

cal and research projects with our medical

edu-

patient care and will promote future referrals

staff. Collaborative research not only improves

(Jowsey, Taylor, Schneekloth, & Clark, 2 0 0 1 ) .

the quality and

Maintaining contact with applied psychologists

research but also fosters collaborative clinical

and other mental health providers will enhance

projects. Struggling through a grant applica-

the psychologist's effectiveness with his or her

tion, preparation

medical colleagues. For example, " N o , I'm not

chart review can be a wonderful team-building

able to assist your patient with couples counsel-

experience (Bock et al., 1 9 9 7 ) .

comprehensiveness

o f the

for a presentation,

or a

ing, but I can offer an excellent referral" is a more useful response than "Sorry, I don't provide couples counseling." W e do not expect physicians to treat all problems, but we do expect them to refer as needed.

T H E F U T U R E IS B R I G H T Although psychologists have been an integral

Finally, developing research projects focus-

part of medical settings for a long time, the

ing on program evaluation will assist in solid-

past quarter century has been a time of rapid

ifying a clinical practice and will allow for

growth.

documentation of effectiveness o f services. As

emerged as a result o f the new and exciting

Many

professional

societies have

noted earlier, one o f the distinctive skills that

opportunities for psychologists in medical set-

psychology brings to the medical setting is

tings. These organizations include the Society

psychologists' extensive training in research.

of Behavioral Medicine and the Association

Psychologists are in the unique position o f

for

continuing to contribute to scholarly endeav-

Education. In addition, divisions o f ΑΡΑ, such

ors as part of their professional practice.

the Behavioral Sciences and

Medical

as Division 3 8 (Health Psychology), Division

ethical

4 0 (Clinical Neuropsychology), Division 5 4

guidelines and standards o f practice to follow

(Society o f Pediatric Psychology), and Division

Psychologists have

professional

Health Psychology 12

in Medical Settings

\

(Society of Clinical Psychology), have

available online, and literature searches are

grown and developed around the interests o f

readily accessible through resources such as

those working in medical settings. There are a

PsycINFO, M E D L I N E , and E B M (Evidence-

host of ΑΡΑ-accredited internships in medical

Based

settings and a growing number of postdoc-

Systematic Reviews. Information relevant to

toral fellowship programs focusing on clinical

psychological practice n o w is at our fingertips.

Medicine)-Cochrane

Database

of

that

Psychologists will continue to play a signifi-

have clinically relevant research specifically

cant role in medical settings through the deliv-

health psychology. Likewise, journals

related to medical settings have emerged (e.g.,

ery o f clinical services, teaching, research, and

Annals

Health

health service administration. Perhaps the next

Medicine,

frontier will be the involvement of clinical

Medical

health psychologists in the genomic revolution

of

Behavioral

Medicine,

Psychology,

Journal

of Behavioral

Journal

Clinical

Psychology

of

in

T h e growth o f information techno-

as advances in the understanding and use of

logy offers incredible opportunities for psy-

genetic data affect how diseases are treated,

chologists to be informed and to practice in an

prevented,

evidence-based fashion. Journal articles are

Guttmacher, &c Collins, 2 0 0 2 ) .

Settings).

and

understood

(Patenaude,

REFERENCES American Medical Association. (2001). Physicians' current procedural terminology 2002. Chicago: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Belar, C. D. (1980). Training the clinical psychology student in behavioral medicine. Professional Psychology, 11, 6 2 0 - 6 2 7 . Belar, C. D., Brown, R. Α., Hersch, L. E., Hornyak, L. M., Rozensky, R. LL, Sheridan, E. P., Brown, R. T., & Reed, G. E. (2001). Self-assessment in clinical Professional health psychology: A model for ethical expansion of practice. Psychology: Research and Practice, 32, 1 3 5 - 1 4 1 . Belar, C. D., & Deardorff, W. W. (1995). Clinical health psychology in medical guidebook (rev. ed.). Washington, DC: American settings: A practitioner's Psychological Association. Belar, C. D., Se Geisser, M . (1995). Roles of the clinical health psychologist in the management of chronic illness. In P. Nicassio &C T. Smith (Eds.), Managing perspective (pp. 3 3 - 5 8 ) . Washington, DC: chronic illness: A biopsychological American Psychological Association. Belar, C. D., &c Jeffrey, T. (1995). Board certification in health psychology. Journal of Clinical Psychology in Medical Settings, 2, 1 2 9 - 1 3 2 . Bellg, A. J . (1998). Clinical cardiac psychology. In P. M . Camic & S. J . Knight (Eds.), Clinical handbook of health psychology: A practical guide to effective interventions (pp. 5 3 - 9 8 ) . Seattle, WA: Hogrefe & Huber. Beutler, L., Wakefield, P., &c Williams, R. (1994). Use of psychological tests/instrupsychological ments for treatment planning. In M . Maruish (Ed.), The use of tests for treatment planning and outcome assessment (pp. 5 5 - 7 4 ) . Hillsdale, NJ: Lawrence Erlbaum. Bock, B., Albrecht, Α., Traficante, R., Clark, M., Pinto, B., Tilkemeier, P., & Marcus, B. (1997). Predictors of exercise adherence following participation in a cardiac rehabilitation program. International Journal of Behavioral Medicine, 4(1), 6 0 - 7 5 . Camic, P. M., & Knight, S. J . (Eds.). (1998). Clinical handbook of health psychology: A practical guide to effective interventions. Seattle, WA: Hogrefe & Huber.

15

PRACTICAL ISSUES Carney, R., Freedland, K., Eisen, S., Rich, M., &c Jaffe, A. (1995). Major depression and medication adherence in elderly patients with coronary artery disease. Health Psychology, 14, 8 8 - 9 0 . Christie-Seely, J . , &C Crouch, M . (1987). The history of the family in medicine. In M. Crouch & L. Roberts (Eds.), The family in medical practice (pp. 1-29). Berlin: Springer-Verlag. Dickey, F., Mattar, M., &C Chudzik, G. (1975). Pharmacist counseling increases drug regimen compliance. Hospitals, 49, 8 5 - 8 6 . Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 1 2 9 - 1 3 6 . Frank, R. G. (1997). Marketing psychology at academic health science centers. Journal of Clinical Psychology in Medical Settings, 4, 4 1 - 5 0 . Frasure-Smith, N., Lesperance, F., &c Talajic, M. (1995). The impact of negative emotions on prognosis following myocardial infarction: Is it more than depression? Health Psychology, 14, 3 8 8 - 3 9 8 . Hardin, Κ. N. (1998). Chronic pain management. In P. M . Camic & S. J . Knight (Eds.), Clinical handbook of health psychology: A practical guide to effective interventions (pp. 1 2 3 - 1 6 5 ) . Seattle, WA: Hogrefe & Huber. Jowsey, S., Taylor, M., Schneekloth, T., & Clark, M . (2001). Psychosocial challenge in transplantation. Journal of Psychiatric Practice, 7, 4 0 4 ^ 1 1 4 . Kaplan, R., Sallis, J . , Jr., & Patterson, T. (1993). Health and human behavior. New York: McGraw-Hill. Kottke, T., Brekke, M., Brekke, L., Dale, L., Brandel, C , DeBoer, S., Hayes, S., Hoffman, R., Menzel, P., Nguyen, T., & Thomas, R. (2000). The CardioVision 2020 baseline community report card. Mayo Clinic Proceedings, 75, 1 1 5 3 - 1 1 5 9 . Kroenke, K., & Mangelsdorff, A. D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome. American Journal of Medicine, 86, 262-266. Malec, J . (1991). Research in the medical setting: Implementing the scientist-practitioner model. In J . Sweet, R. Rozensky, &c S. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 2 6 9 - 2 8 4 ) . New York: Plenum. McGinness, J . , &C Foege, W. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270, 2 2 0 7 - 2 2 1 2 . Patenaude, A. F., Guttmacher, A. E., & Collins, F. S. (2002). Genetic testing and psychology: New roles, new responsibilities. American Psychologist, 57, 2 7 1 - 2 8 2 . Philbrick, J . T., Connelly, J . E., & Wofford, A. B. (1996). The prevalence of mental disorders in rural office practice. Journal of General Internal Medicine, 11, 9 - 1 5 . Rozensky, R. H. (1991). Psychologists, politics, and hospitals. In J . Sweet, R. Rozensky, &c S. M. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 5 9 - 7 9 ) . New York: Plenum. Rozensky, R. H., Sweet, J . J . , & Tovian, S. M . (1997). Psychological assessment in medical settings. New York: Plenum. Schofield, W. (1969). The role of psychology in the delivery of health services. American Psychologist, 24, 5 6 5 - 5 8 4 . Seime, R. J . (1998). The section of psychology: Psychology in an academic health sciences center's department of behavioral medicine and psychiatry. Journal of Clinical Psychology in Medical Settings, 5, 2 1 5 - 2 3 2 . Shows, W. D. (1976). Problem of training interns in medical schools: A case of trying to change the leopard's spots. Professional Psychology, 7, 3 9 3 - 3 9 5 . Sweet, J . J . , & Rozensky, R. H. (1991). Professional relations. In M. Hersen, A. Kazdin, & A. Bellack (Eds.), The clinical psychology handbook (2nd ed.). Elmsford, N Y : Pergamon. Van Egeren, L., & Striepe, M . I. (1998). Assessment approaches in health psychology: Issues and practical considerations. In P. M. Camic & S. J . Knight (Eds.), Clinical handbook of health psychology: A practical guide to effective interventions (pp. 1 6 - 5 0 ) . Seattle, WA: Hogrefe & Huber.

CHAPTER

2

Psychological Assessment Screening in Medical Settings MICHAEL D . FRANZEN

T

in

psychological/psychiatric diagnosis. Because

specialty medical settings has been

psychological interventions in medical settings

c o m m o n since the late 1 9 6 0 s

and

focus more on enhancing the provision of

1 9 7 0 s . During that era, there was increasing

medical care than on in-depth psychotherapy,

he presence o f a psychologist

attention paid to the use o f psychological

assessment must be tailored to the needs o f the

principles to understand or enhance the treat-

setting. T h e psychologist might be called on to

ment of cancer patients, cardiac patients, and

develop a plan to help manage chronic pain

chronic pain patients. Recently, more atten-

from a psychological perspective or to help

tion has been given t o the potential role o f

manage anxiety related to upcoming surgery.

psychologists in general medical or family

In all o f these cases, the assessment is aimed at

practice and pediatric clinics. These health

elucidating psychological and

care providers, namely pediatricians, primary

factors that could be useful in the provision o f

practice physicians (sometime k n o w n as pri-

adequate medical care. In addition to formu-

environmental

m a r y care physicians [PCPs]), and family prac-

lating interventions, the psychologist might be

tice doctors, are the frontline care providers,

called on to assess the patient for the presence

even in those situations where it might be

o f psychological o r cognitive factors

that

necessary to involve specialists. F o r example,

would negatively affect the provision of medi-

most o f the antidepressant prescriptions in

cal care. These interfering factors may include

the United States are written

cognitive impairment, psychological distress,

by general

practitioners. In addition, even if a diagnosis requires specialized care, the first person to

or substance abuse behaviors. Screening assessment is one type o f psycho-

c o m e into c o n t a c t with the patient is most

logical assessment frequently

likely to be the person's P C P .

medical setting. T h e purpose o f screening is to

used in

the

Psychological interventions begin with a

identify important areas that may require more

psychological assessment. Psychological assess-

detailed assessment and evaluation. Therefore,

ment has various forms, from behavioral func-

the screening target is partially a function of the

tional analysis to personality assessment and

setting, the base rate of potential problem areas,

18

PRACTICAL ISSUES and the population being seen. For example, the

than is general assessment. This is true both

base rate of active psychosis in a family practice

for the administration o f procedures and for

is fairly low, and it would make little sense to

the interpretations

and

recommendations

screen for symptoms o f schizophrenia on a

made on the basis o f the assessment results.

regular basis. Alternatively, there is a fairly

In

high comorbidity between depression

and

appointment may be made for the following

certain medical conditions, and it would be

week and the typed report may be ready a

eminently sensible to screen for depression in an

week after that. In screening, whether for an

endocrinology outpatient clinic.

general

psychological assessment,

an

inpatient setting or an outpatient setting, the person must be screened in the same appointment as the identification of the problem is

PSYCHOLOGY IN THE CLINIC VERSUS PSYCHOLOGY IN THE MEDICAL SETTING

raised and the interpretation must frequently be provided to the referral source outside the consultation room. A second feature that distinguishes screening from general assessment

T h e practice o f psychology in a medical

is the length o f the procedures and the sensi-

setting has characteristics that differentiate it

tivity and completeness with which the target

from the general practice o f psychology. For

constructs are evaluated.

example, the issue o f assessment in a medical

T h e three areas o f most concern in general

setting is complicated by the other variables

medical settings are the possibilities o f neu-

in addition to environmental influences that

rologically based cognitive impairment, o f

may impinge on the patient's behavior. In

psychological or psychiatric disorders, and o f

behavioral assessment, it is assumed

that

substance abuse. Even if a specific psychiatric

the medical and physiological factors have

diagnosis is n o t appropriate, it may be help-

been ruled out. In personality or traditional

ful to screen for the presence o f anxiety or

psychological assessment, it is assumed that

depression, either o f which can significantly

the medical factors are already

affect medical outcome. T h e t w o reasons for

accounted

for. In neuropsychological assessment, it is

screening for these variables are that their

assumed that environmental variables have

presence can negatively affect the medical

been minimized. In screening and evaluating

treatment and that their presence may indi-

the medical patient in a behavioral frame-

cate the need for referral for further evalua-

work, none o f these assumptions

tion or specialized treatment.

can be

reasonably made. In fact, a more accurate assumption would be that all o f these variables are playing a role in the current clinical presentation. Therefore, it would be important for the behavioral medicine clinician to

PSYCHOMETRIC CONSIDERATIONS IN SCREENING

consider medical, cognitive, and psychological

Even though psychological screening might

features. Screening assessment seeks to iden-

not necessarily entail the full range o f psycho-

tify the possibility of an issue such as cognitive

metric complexity that comprehensive or diag-

impairment. Psychological assessment seeks to

nostic assessment might, it is still important to

identify the construct at issue and provide an

pay attention to the relevant psychometric con-

estimate o f the precise level o f that construct.

siderations. T h e several issues of validity and

There are some features o f screening that

accuracy that need to be addressed in assess-

general psychological

ment are simplified somewhat in screening.

assessment. First and most obvious, screening

T h e most relevant aspect of the psychometric

is conducted in a more restricted time frame

properties of the screening instrument is related

distinguish

it from

Psychological

Assessment

Screening

to its accuracy in identifying the presence

symptoms have been noticed or brought to the

of a pathological state and its utility in the

attention of the patient. Other content informa-

decision-making process leading to a referral

tion includes the time course of the symptoms

for comprehensive assessment. T h e construct

and whether there are any consistent changes

underlying the instrument, whether it be mem-

in the level of symptoms. A second important

ory or attention, is less important in screening

source of information comes from the clinical

than whether a score above a certain level is

observations made by the clinician. T h e clinician

indicative o f some form of cognitive problem

can note the quality o f the verbalizations of the

with an organic basis.

patient. Is the articulation understandable? Is

In choosing a screening instrument and in

the diction accurate? Is there any word-finding

setting a cutoff score, it is important to ask

difficulty, paraphasic

error, or paucity o f

what the likelihood is that a certain score would

speech? Are the station and gait normal? What

be associated with a correct decision to pursue

is the appearance of the person? Is the grooming

further evaluation. Similarly, it is important to

and hygiene adequate (inadequate hygiene may

ask what the likelihood is that a certain score

reflect either depression or cognitive impair-

would be associated with a correct decision to

ment)? These factors were addressed in greater

not pursue further evaluation. The first ques-

depth in Berg, Franzen, and Wedding (1994).

tion is an issue of sensitivity. T h e second ques-

In addition to using the observations to

tion is an issue o f specificity. Sensitivity is the

generate hypotheses regarding which areas to

extent to which the assessment

consider for screening purposes, the clinician

instrument

identifies the presence of the target construct.

can

Specificity is the extent to which positive assess-

purpose as well. Any changes in usual functions

ment findings do not occur in the absence o f the

can be a "red flag" that cognitive screening

use the historical information for that

target construct. Positive predictive power is the

might be useful. A history of recent minor auto-

accuracy with which a positive score predicts

mobile accidents might be an indication to

the target. Negative predictive power is the

screen for attention or for visual-spatial skills.

accuracy with which a negative score predicts

The clinician may want to also screen for any

the absence o f the construct. In screening, it

alcohol or substance abuse. If the patient has

may be more important in some cases that an

had to change jobs or was forced into early

instrument be sensitive even when it might not

retirement, cognitive screening may be in order.

be specific. For example, in high-risk situations

A history of multiple sex partners or o f high-

where the incorrect decision to not pursue

risk sexual behavior may also indicate the need

further evaluation could result in missing the

for screening. Occupational history also gives

presence o f a growing brain tumor, the fact that

useful information. If the patient worked in

many cases of no tumor are found with high

an industrial setting with exposure to solvents,

scores (poor specificity) is less important than

heavy metals, or insecticides, cognitive screen-

the fact that cases of tumor are found with high

ing may be indicated.

scores (good sensitivity). COGNITIVE SCREENING THE USE OF T H E INTERVIEW Cognitive screening is not as simple as it The most potent weapon in the armamentarium

may seem. Although discussion o f screening

of the clinician is the interview and history.

frequently involves only a single instrument,

There are two sources o f clinical information

there is no adequate single instrument for

derived from the interview. The first is the

screening all populations in all settings. There

content information such as whether certain

is a range o f decisions that need to be made in

19

PRACTICAL ISSUES the choice o f an appropriate instrument, and

the context of screening because a positive result

because o f the nature o f screening itself, inter-

would be followed by more extensive evaluation

pretations and conclusions are limited. O n e

in which the nature and extent of the impair-

of the first decisions is also one o f the most

ment could be delineated more extensively.

difficult ones to make. T h e clinician needs to

T o guide the psychologist in the screening

decide just which aspects o f cognition are

procedure, there is little available in terms

suspected o f being impaired. Although there

of training at the graduate level where the

is usually considerable correlation

emphasis is on either specialized assessment

different

cognitive skills, this

among

correlation

methods

(e.g., neuropsychological,

marital,

tends to be disrupted under conditions o f

career) or traditional intellectual and person-

impairment. It is quite possible for conversa-

ality methods. T h e psychologist who wishes to

tional speech to be intact while short-term

learn h o w to screen needs to seek out super-

memory is severely impaired and vice versa.

vised experience in a medical setting such as

Choosing a screening instrument that is sensi-

might be available at the internship level and

tive to memory skills when the person is

through continuing education

suspected o f having a cerebral vascular acci-

In addition, there is some published material.

dent with expressive language

impairment

will not be a useful endeavor. Broad-based

screening

requires

Two

excellent b o o k resources are A

Neuropsychology: that

a

range of impairments be considered. There are

opportunities.

Pocket

(Snyder & Nussbaum, 1 9 9 8 ) and for Brain Impairment

Clinical Handbook Screening

(Berg et al., 1 9 9 4 ) .

a few instruments that are sensitive to a broad range of types of impairment. Their sensitivity is derived from the fact that several cognitive skills are required for adequate performance. An example is the Digit Symbol subtest of the

Screening for Dementia Dementia

is

broadly

defined

as

any

Wechsler Adult Intelligence Scale-ΙΠ (WAIS-

acquired cognitive impairment sufficient to dis-

ni). T h e Digit Symbol test requires eye-hand

rupt occupational, social, or adaptive function-

coordination, visual scanning, symbolic transla-

ing. There can be many causes and different

tion, and motor speed as well as learning skill.

manifestations. However, the most frequent

Impairment in any one o f these areas may result

cognitive difficulty evidenced by

in poor performance on the Digit Symbol test.

patients is memory impairment. Therefore, a

dementia

Other examples of such instruments include

brief memory screening procedure can be

Part Β o f the Trail Making test and

the

helpful in uncovering dementia. T h e Digit

Category test of the Halstead-Reitan Neuro-

Span procedure is relatively useless in this

psychological Battery. These instruments tend

situation and has limited utility in screening in

to be sensitive to psychiatric disturbance and

general. T h e maximum span forward in the

also have significant age-related effects. Inter-

digit procedure

pretation o f the results of such an instrument

acquired impairment until either the late stages

is problematic because poor performance can

of a progressive condition or the severe range

is relatively impervious

to

be the result o f any number o f impairments.

of an injury. Suggested procedures for memory

However, this seeming drawback is also the

screening include the Hopkins Verbal Learning

instrument's strength because when the area of

Test (Brandt, 1 9 9 1 ) , the Rey Auditory Verbal

impairment is unknown, it is useful to have a

Learning Test (Schmidt, 2 0 0 0 ) ,

single instrument that can detect impairment

Visual Spatial M e m o r y Test (Benedict, 1 9 9 7 ) ,

in any one of the suspected areas. T h e lack o f

and

specificity is not a tremendous shortcoming in

(Sivan, 1 9 9 2 ) .

the

Benton

Visual

the

Retention

Brief Test

Psychological

Folstein Mini Mental State Exam (MMSE)

Assessment

Screening

\

disorders. These authors concluded that the M M S E was less useful and less reliable when the total scores dip below 1 0 to 1 2 points.

T h e Folstein Mini M e n t a l State E x a m (MMSE)

(Folstein, Folstein, &

This is an important consideration in the

McHugh,

overall use o f the M M S E , but it might not be

1 9 7 5 ) is perhaps the most widely used (and

a substantial problem in a general medical

some say the most widely abused) instrument

setting where cognitive impairment is likely to

for the quick assessment o f cognitive status.

be more subtle and total scores o f 1 0 to 1 2

T h e M M S E is nearly ubiquitous among physi-

may be infrequent. Bidzan and Bidzan ( 2 0 0 2 )

cians, especially those working in neurological

reported on a 5-year follow-up study involv-

or psychiatric settings. T h e M M S E screens

ing 2 0 4 individuals over the age o f 5 5 years.

for different cognitive functions, frequently

Eventually,

using only one item for each construct (e.g.,

diagnosed with Alzheimer's dementia. T h e

1 9 o f these individuals

were

one item taps visual-spatial construction by

Folstein M M S E , the Cognitive subscale o f

asking the individual to copy a drawing o f two

the Alzheimer's Dementia Assessment Scale,

overlapping pentagons). T h e M M S E is heavily

the Instrumental Activity o f Daily Living

weighted toward orientation questions, with

Scale, and the Physical Maintenance Scale

1 0 of a possible 3 0 points being directed at

were found to contribute to predicting even-

orientation to time, place, and date.

tual dementia, although a comparison among

T h e M M S E has been criticized for produc-

the instruments was not conclusive. There

ing too many false negatives, but part o f the

have been reported demographic effects on

problem may exist in the use o f suboptimal

total scores o f the M M S E , making it obvious

cut points. T h e degree o f accuracy depends

that good normative information is necessary.

on the eventual diagnosis o f the individual

Jones and colleagues ( 2 0 0 2 ) presented norma-

(Harper, C h a c k o , Kotik-Harper, & Kirby,

tive data

regarding

the

performance

of

1 9 9 2 ) , something that is not usually k n o w n

community-dwelling

at the time o f the screening. T h e M M S E , the

data are very helpful in interpreting the scores

Mattis Dementia

o f older persons.

Neurobehavioral

R a t i n g Scale, and Cognitive Status

the

elderly persons. Such

Exam

were found to be roughly equivalent in discriminating patients

with

Alzheimer's or

vascular dementia from healthy elderly when

Clock Drawing Test

optimal cut points were used rather than the

T h e C l o c k Drawing Test (Freedman et al.,

cut points suggested in the literature. Because

1 9 9 4 ) is, as its name suggests, a test in which

the M M S E takes less time to administer, it

individuals are asked to draw a clock face

has an advantage over the other t w o tests. T o

with the hands set to " 1 0 after 1 1 . " After

increase the clinical utility o f the M M S E , it

the clock is drawn from c o m m a n d , a line-

would be helpful to use more extensive norms

drawing model is provided

as well as norms that are sensitive to the dif-

task. Adunsky, Flessig, Levenkrohn, Arad,

ferences associated with age and education.

and N o y ( 2 0 0 2 ) reported that the

Grigoletto ( 1 9 9 9 ) presented norms on 9 0 8

Drawing Test is roughly equivalent to the

for the same Clock

healthy Italian elderly persons. M o r e data like

M M S E in identifying impairment. However,

this are needed.

the greater variety o f items in the M M S E may

Barbarotto, Cerri, Acerbi, Molinari, and

provide for a broad-based evaluation. T h e

Capatani ( 2 0 0 0 ) reported data from a study

Clock Drawing Test has its greatest utility

of 2 7 patients with a variety o f cognitive

with the elderly.

21

22

PRACTICAL ISSUES related to medical care. Screening assessment

Other Cognitive Screening Tests T h e r e are several additional screening tests available for the psychologist. Some were designed specifically for screening, whereas others are part o f larger test procedures or shortened from the original versions. T h e Trail M a k i n g test (especially Part B) of the Halstead-Reitan Neuropsychological Battery is very sensitive to any cognitive impairment. It is easy to administer and takes less than 1 0 minutes to complete. T h e disadvantages are that it is not very specific and that psychiatric conditions such as depression can affect it. T h e Digit Symbol subtest o f the Wechsler Adult Intelligence Scale-Revised is the most sensitive o f all the Wechsler subtests. T h e corresponding research on the WAIS-III has not yet been conducted, but the modification introduced

by the WAISTII will probably

make it more specific as well as more sensitive. Somewhat longer alternatives Neurobehavioral

Cognitive

include

Status

the

Exam

(Northern California Neurobehavioral Group, 1 9 8 8 ) . This test includes subtests o f attention, memory, construction, language skills, and practical problem solving, but the meaning of the various subtest profiles is unclear, and it is best to stick with the total score as an indicator o f cognitive impairment.

is insufficient to answer these questions. H o w ever, screening for intellectual capacity may guide the clinician in deciding whether to refer the person for a m o r e complete evaluation. Although short forms of the Wechsler Adult Intelligence Scale are available (Kulas & Axelrod, 2 0 0 2 ) , and there is even a short form available from the publisher (Axelrod, 2 0 0 2 ) , it appears that a seven-subtest short form is as abbreviated as one can go and still expect reasonable reliability (Axelrod, Ryan, & W a r d , 2 0 0 1 ) . Other options include the use of short tests and procedures that have been shown to correlate acceptably (but not optimally) with

longer, m o r e

comprehensive

intellectual exams such as the WAIS-III and the Stanford-Binet-IV. These short tests include the Slosson Intelligence Test, the Beta-Ill, and the Test o f Nonverbal Intelligence-2. T h e Slosson Intelligence Test is a short test based on the Stanford-Binet. Although short and easy to administer, it may have significant limitations in estimating I Q in the lower ranges (Kunen, Overall, & Salles, 1 9 9 6 ) . T h e Beta-Ill (Kellogg & M o r t o n , 2 0 0 1 ) is a set o f five nonverbal procedures that can be administered in less than 1 5 minutes and give a reasonably culture-fair estimate o f intelligence. T h e Test o f Nonverbal Intelligence-2 (Brown, Sherbenou, & Johnsen, 1 9 9 0 ) also provides a reasonable estimate o f culture-fair intelligence

INTELLECTUAL SCREENING

by assessing visual abstraction skills. It does not have as many different types o f tasks as

T h e utility of intelligence quotient (IQ) scores

the Beta-Ill, and it is somewhat shorter in

is largely related to academic planning and

administration time.

the suitability o f the person for certain services available from the state. In certain cases, a physician may question the intelligence level

PSYCHIATRIC SCREENING

of a patient where the documentation o f mental retardation may make the patient eligible

Affective problems are typically brought to the

for government-reimbursed support services.

attention of primary care providers (PCPs)

In other instances, there may be questions

first. This is not sufficient unless the PCPs

about the capacity of the person to follow a

can accurately recognize emotional disorders.

complicated medical regimen or about the

Wittchen

competency o f the person to make decisions

that in a study o f more than 2 0 , 0 0 0 patients,

and

colleagues ( 2 0 0 2 )

reported

Psychological

Assessment

Screening

\

PCPs were able to reasonably well identify

T h e Beck Anxiety Inventory (Beck &c Steer,

the presence o f serious psychiatric disorders

1 9 9 0 ) has 2 1 items that are endorsed on a

but were not as accurate in determining the

scale from 1 to 3. It correlates well with other

actual diagnoses. T h e role o f psychologists

instruments to measure anxiety and is fairly

here is to act as a resource to w h o m PCPs c a n

accurate in identifying D S M - I I I

turn when emotional disorder is suspected to

and Statistical

provide correct diagnoses and

third edition) (American Psychiatric Associ-

recommend

appropriate treatments.

Manual

(Diagnostic

of Mental

Disorders,

ation, 1 9 8 8 ) anxiety diagnoses. T h e Beck

Derogatis and Dellapietra ( 1 9 9 4 ) discussed

Scale for Suicide Ideation (Beck &

Steer,

screening for psychiatric disorders but did so

1 9 9 1 ) has 1 9 items that can be helpful in

largely from a perspective o f the outpatient

quickly o b t a i n i n g

psychiatric clinic. They reviewed a variety o f

the possibility o f suicide-related thoughts but

screening instruments, including the Symptom

that is not particularly accurate in predicting

Checklist-90 Revised, the brief Psychiatric

actual suicide attempts.

Rating Scale, the Center for Epidemiological

information

An even shorter assessment

regarding

instrument

Studies-Depression Scale (CES-D), the Self-

is the Center for Epidemiological Studies-

Rating Depression Scale, and the Hamilton

Depression Scale, with only 1 0 items. T h e

Anxiety and Depression scales.

C E S - D has been used in multiple settings, including Puerto R i c a n primary care patients (Robison, Gruman, Gaztambide, 8c Blank,

The Beck Scales

2 0 0 2 ) . It has generally been found to have

T h e B e c k Depression

Inventory ( B D I )

adequate sensitivity and specificity.

(Beck & Steer, 1 9 8 7 ) is one o f the most widely

Often, the decision to screen is made after

used self-report instruments for the assessment

some suspicion regarding a general probability

o f depression. Although its authors recom-

that a disorder might be present. For example,

mend the B D I as an instrument suitable for

in cases where individuals complain of cardiac

evaluating the level o f depression as well as

symptoms and describe histories of going to

sensitive to changes in level, the B D I has

emergency rooms because o f fear that myo-

great utility as a screening instrument. It is

cardial infarcts were occurring, the clinicians

brief,

are

might suspect a panic disorder, and screening

endorsed at one o f four levels. There is an

efforts would be directed at this construct

even shorter form that consists o f 1 3 items.

using an instrument such as the Autonomic

T h e r e is considerable agreement

between

Nervous System Questionnaire, a self-report

these two instruments (Reynolds &c Gould,

instrument that contains only five items but

1 9 8 1 ) , and the short form might be prefer-

has been found to have good sensitivity but

able when there are time constraints.

low specificity (Stein et al., 1 9 9 9 ) .

consisting

of

21

items

that

Beck and his associates developed other self-report instruments that have utility in a screening setting. T h e Beck

Hopelessness

Scale (Beck & Steer, 1 9 8 8 ) taps the feelings

PSYCHOLOGICAL ADAPTATION TO ILLNESS

o f negative expectations about the future and global cognitions o f despair. Although it has

Yet another feature o f psychological screening

been found to be helpful in identifying suici-

is particular to the medical setting. T h e con-

dal risk in clinical populations, at least one

struct of interest here can be broadly defined as

study has questioned the utility o f the instru-

psychological reaction to the medical condi-

ment in a m o r e general setting (Steed, 2 0 0 1 ) .

tion. For example, individuals may vary in

23

PRACTICAL ISSUES the degree to which they develop maladaptive

•

behaviors in response to the medical condition. T h e Illness Behaviour Questionnaire is an

•

Have you ever felt guilty about your alcohol use? Did you ever need a drink as an eye opener?

example o f an instrument that can evaluate these responses, defined as the inappropriate

As simple as this assessment method is, it

experience of the state o f health (Pilowsky,

is also fairly effective at identifying people

1 9 9 4 ) . Unfortunately, attempts to shorten the

w h o are likely to have been abusing alcohol

test (cf. Chaturvedi, Bhandari, Beena, &c R a o ,

(Bradley, Boyd-Wickizer, Powell, & Burman,

1 9 9 6 ) have not been successful (Bond & Clark,

1 9 9 8 ; Ewing, Bradley, &

2 0 0 2 ) . Another example o f an

Nadeau, Guyon, & Bourgault, 1 9 9 8 ) . It has

instrument

Burman, 1 9 9 8 ;

that is somewhat shorter is the Health Anxiety

all the prerequisites o f a screening procedure;

Questionnaire (Lucock &c Morley,

it is short, simple, and easy to use and score.

1996).

T h e Illness Behaviour Questionnaire has

In addition, it is n o t generally intrusive and

also been used in patients with chronic pain

is acceptable to patients. It also possesses the

(Pilowsky & Katsikitis, 1 9 9 4 ) . But there are

shortcoming c o m m o n to screening proce-

also instruments

dures, namely fairly high false positives.

that

are

more

directly

focused on pain behaviors and cognitions,

Other procedures for screening for sub-

including the Pain Anxiety Symptoms Scale,

stance abuse behaviors include the Maryland

the Fear Avoidance Beliefs Questionnaire, and

Addiction Questionnaire (O'Donnell, DeSoto,

the Fear o f Pain Questionnaire ( M c C r a c k e n ,

& DeSoto, 1 9 9 7 ) and the Michigan Alcoholism

Gross, Aikens, & Carnike, 1 9 9 6 ) .

Screening Test (MAST) (Seltzer, 1 9 7 1 ) .

SCREENING FOR SUBSTANCE ABUSE BEHAVIORS Individuals w h o abuse alcohol and/or other substances are overrepresented in psychiatric settings and in general medical settings. A large number o f health problems can arise from alcohol abuse, including disorders o f the pancreas, stomach, liver, and intestines as well as hypertension. Obviously, a psychologist working in a medical setting will be exposed to alcoholism continuously. There is a need to screen for substance abuse behaviors on a regular basis. O n e o f the simplest measures that is useful in screening for alcohol abuse is k n o w n as

"CAGE" (cut,

the

annoy, guilty, eye) ques-

tions. These questions are as follows: • •

Have you ever tried to cut down on your alcohol consumption? Does it make you annoyed when people discuss your alcohol use?

REPORT WRITING Report writing for psychological consultation in a medical setting follows the same format of the consult notes written by medical practitioners. These reports are brief, concise, and pointed toward answering the referral question. Unfortunately, sometimes the referral question is not well articulated or thought out. In those instances, it would be helpful t o have a brief conversation with the referral source to clarify the information needed. This conversation can serve to elucidate the current concerns as well as to educate the referral source as to future consultation requests. Psychologists sometimes have a tendency to "show and tell" all that went into an assessment. This is good and well when the recipient o f the report is the patient's psychotherapist or when the psychologist's assessment skills are being assessed, but in a medical setting it is the bottom line that is most important. T h a t is not to say that fine points or subtlety should be ignored. However,

Psychological

Assessment

Screening

the concise report is the report that gets read

to be quick, and the psychologist is often

and used.

called on to think on his or her feet. T h e psychologist clinician should

have

familiarity with a range o f medical disorders

Specialized Training and Skills Needed

and k n o w their basic pathophysiology, etiology, and treatment. F o r example, it would be

T h e psychologist w h o desires to w o r k in a

important for the psychologist to k n o w that

medical setting should first receive supervised

hypertension can be associated with mildly

clinical training in that setting. Any good

impaired attention and memory and

clinical psychology graduate training

pro-

some antihypertensive medications can cause

gram will provide training in psychological

side effects that mimic depression. In partic-

that

assessment, but much o f graduate training in

ular, the psychologist should be familiar with

assessment is conducted in an environment

the types o f patients and disorders seen in

very different from the typical medical set-

that clinic. Cultural sensitivity is a must. I f

ting. Graduate psychology training in assess-

the psychologist is not totally familiar with

ment typically takes place in the university

the particulars o f that clinic, he or she should

clinic, where entire days might be

spent

seek out learning experiences. T h e physician

psychological tests. Reports

is a good resource for medical information

are written over the course o f several weeks

regarding the disorders, and the nursing and

and are lengthy treatises.

support staff are good sources o f information

administering

In contrast, psychological assessment and

regarding the patients and their subculture.

screening in a general health care setting takes place at the bedside in a hospital or in an examining r o o m in the outpatient clinic o f the medical service. T h e psychologist is not on his or her home turf and must be prepared to

OPTIMAL CHARACTERISTICS OF A SCREENING PROCEDURE

conduct the assessment with whatever mate-

It would be useful to briefly reiterate the

rials have been brought to the appointment.

characteristics o f a good screening test. It

T h e report may include a dictated note that

should be accurate. It should be sensitive to

can be up to one page long, but an initial note

the construct under consideration. It should

should be on the chart or given to the referral

possess at least m o d e r a t e

agent immediately on finishing the adminis-

should have moderate

specificity. It

positive predictive

tration o f assessment instruments. For these

power and high negative predictive power. It

reasons, traditional

could be administered by paraprofessional

graduate

training

in

assessment is necessary but insufficient. There

staff or self-administered, thereby meeting

must also be training in the context o f a gen-

the final characteristic o f using a minimal

eral health care setting. Interpretation needs

a m o u n t o f professional time.

REFERENCES Adunsky, Α., Flessig, Y., Levenkrohn, S., Arad, M., & Noy, S. (2002). A comparative study of Mini-Mental test, Clock Drawing, and Cognitive FIM in evaluating functional outcome of elderly hip fracture patients. Clinical Rehabilitation, 16, 414-419.

PRACTICAL ISSUES American Psychiatric Association. (1988). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Axelrod, Β. N. (2002). Validity of the Wechsler Abbreviated Scale of Intelligence and other very short forms of estimating intellectual functioning. Assessment, 9, 1 7 - 2 3 . Axelrod, Β. N., Ryan, J . J . , & Ward, C. L. (2001). Evaluation of seven-subtest short forms of the Wechsler Adult Intelligence Scale-Ill in a referred sample. Archives of Clinical Neuropsychology, 16, 1-8. Barbarotto, R., Cerri, M., Acerbi, Α., Molinari, S., & Capatani, E. (2000). Is the SIB or BNP better than MMSE in discriminating the cognitive performance of severely impaired elderly patients? Archives of Clinical Neuropsychology, 15, 2 1 - 2 9 . Depression Beck, A. T., & Steer, R. A. (1987). Manual for the Revised Beck Inventory. San Antonio, T X : Psychological Corporation. Beck, A. T., & Steer, R. A. (1988). Manual for the Beck Hopelessness Scale. San Antonio, T X : Psychological Corporation. Beck, A. T., & Steer, R. A. (1990). Beck Scale Anxiety Inventory manual. San Antonio, T X : Psychological Corporation. Beck, A. T., & Steer, R. A. (1991). Beck Scale for Suicidal Ideation: Manual. San Antonio, T X : Psychological Corporation. Benedict, R. H. B . (1997). Brief Visuospatial Memory Test-Revised. Odessa, FL: Psychological Assessment Resources. Berg, R. Α., Franzen, M . D., & Wedding, D. (1994). Screening for brain impairment. New York: Springer. Bidzan, L., Si Bidzan, M . (2002). The predictive values of MMSE, ADAS-cog, IADL, and PSMS as instruments for the diagnosis of pre-clinical phase of dementia of Alzheimer's type. Archives of Psychiatry and Psychotherapy, 4, 2 7 - 3 3 . Bond, M . J . , & Clark, M. S. (2002). A comparison of alternative indices of abnormal illness behavior derived from the Illness Behaviour Questionnaire. Psychology, Health, and Medicine, 7, 2 0 3 - 2 1 3 . Bradley, Κ. Α., Boyd-Wickizer, J . , Powell, S. H., & Burman, M . L. (1998). Alcohol screening questionnaires in women: A critical review. Journal of the American Medical Association, 280, 1 6 6 - 1 7 1 . Brandt, J . (1991). The Hopkins Verbal Learning Test: Development of new memory test with six alternate forms. The Clinical Neuropsychologist, 5, 1 2 5 - 1 4 2 . Brown, L., Sherbenou, R. J . , & Johnsen, S. K. (1990). Test of Nonverbal lntelligence-2nd edition. Austin, T X : Pro-Ed. Chaturvedi, S. K., Bhandari, S., Beena, M . B . , & Rao, S. (1996). Screening for abnormal illness behaviour. Psychopathology, 29, 3 2 5 - 3 3 0 . Derogatis, L. R., & Dellapietra, L. (1994). Psychological tests in screening for psychiatric disorder. In M. E. Maruish (Ed.), The use of psychological testing in screening for psychiatric disorder (pp. 2 2 - 5 4 ) . Hillsdale, NJ: Lawrence Erlbaum. Ewing, J . Α., Bradley, Κ. Α., & Burman, M. L. (1998). Screening for alcoholism using CAGE. Journal of the American Medical Association, 280, 1904. Folstein, M . E., Folstein, S. E., & McHugh, P. R. (1975). "Mini Mental State": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 1 8 9 - 1 9 8 . Freedman, M., Leach, L., Kaplan, E., Winocur, G., Shulman, K., Sc Delis, D. (1994). Clock drawing: A neuropsychological analysis. New York: Oxford University Press. Grigoletto, F. (1999). Norms for the Mini-Mental State Examination in a healthy population. Neurology, 53, 3 1 5 - 3 2 0 . Harper, R. G., Chacko, R. C , Kotik-Harper, D., & Kirby, Η. B . (1992). Comparison of two cognitive screening measures for efficacy in differentiating dementia from depression in a geriatric inpatient population. Journal of Neuropsychiatry and Clinical Neurosciences, 4, 1 7 9 - 1 8 4 .

Psychological

Assessment

Jones, T. G., Schinka, J . Α., Vanderploeg, R. D., Small, B. J . , Graves, A. B . , & Mortimer, J . A. (2002). 3MS normative information for the elderly. Archives of Clinical Neuropsychology, 17, 1 7 1 - 1 7 7 . Kellogg, C. E., & Morton, N. W. (2001). Beta III manual. San Antonio, T X : Psychological Corporation. Kulas, J . F., & Axelrod, Β. N. (2002). Comparison of seven-subtest and Satz-Mogel short forms of the WAIS-III. journal of Clinical Psychology, 58, 7 7 3 - 7 8 2 . Kunen, S., Overall, S., & Salles, C. (1996). Concurrent validity study of the Slosson Intelligence-Revised in mental retardation testing. Mental Retardation, 34, 380-386. Lucock, M . P., & Morley, S. (1996). The Health Anxiety Questionnaire. British Journal of Health Psychology, 1, 1 3 7 - 1 5 0 . McCracken, L. M., Gross, R. T., Aikens, J . , & Carnike, C. L. M., Jr. (1996). The assessment of fear and anxiety in persons with chronic pain: A comparison of instruments. Behaviour Research and Therapy, 34, 9 2 7 - 9 3 3 . Nadeau, L., Guyon, L., & Bourgault, C. (1998). Heavy drinkers in the general population: Comparison of two measures. Addiction Research, 6, 1 6 5 - 1 8 7 . Northern California Neurobehavioral Group. (1988). Manual for the Neurobehavioral Cognitive Status Examination. Fairfax, CA: Author. Addictions O'Donnell, W. E., DeSoto, C. B . , & DeSoto, J . L. (1997). Maryland Questionnaire. Los Angeles: Western Psychological Services. Pilowsky, I. (1994). Abnormal illness behaviour: A 25th anniversary review. Australian and New Zealand Journal of Psychiatry, 28, 5 6 6 - 5 7 3 . Pilowsky, L, & Katsikitis, M. (1994). A classification of illness behaviour in pain clinic patients. Pain, 57, 9 1 - 9 4 . Reynolds, W. M., & Gould, J . W. (1981). A psychometric investigation of the standard and short forms of the Beck Depression Inventory. Journal of Consulting and Clinical Psychology, 49, 3 0 6 - 3 0 7 . Robison, J . , Gruman, C , Gaztambide, S., & Blank, K. (2002). Screening for depression in middle-aged and older Puerto Rican primary care patients. Journal of Gerontology: Biological Sciences and Medical Science, 57, M 3 0 8 - M 3 1 4 . Schmidt, M . (2000). The Rey Auditory Verbal Learning Test manual. Odessa, FL: Psychological Asssessment Resources. Seltzer, M . L. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, \Y7-Y16. Sivan, A. B. (1992). The Benton Visual Retention Test-Revised (5th ed.). New York: Psychological Corporation. Snyder, P. J . , & Nussbaum, P. D. (1998). Clinical neuropsychology: A pocket handbook. Washington, DC: American Psychological Association. Steed, L. (2001). Further validity and reliability evidence for Beck Hopelessness Scale. Educational and Psychological Measurement, 61, 3 0 3 - 3 1 6 . Stein, M. B., Roy-Byrne, P. P., McQuaid, J . R., Laffaye, C , Russo, J . , McCahill, M. E., Katon, W., Craske, M., Bystritsky, Α., & Sherbourne, C. D. (1999). Development of a brief diagnostic screen for panic disorder in primary care. Psychosomatic Medicine, 61, 3 5 9 - 3 6 4 . Wittchen, H-U., Kessler, R. C , Beesdo, K., Krouse, P., Hoefler, M., & Hoyer, J . (2002). Generalized anxiety and depression in primary care: Prevalence, recognition, and management. Journal of Clinical Psychiatry, 63, 2 4 - 3 4 .

Screening

3

cHAPTER

Working With a Multidisciplinary Staff HELEN R . WINEFIELD AND ANNA CHUR-HANSEN

T

here are unique problems for clinical

promote interprofessional agendas (Jones &c

multidisci-

Salmon, 2 0 0 1 ) , but this is not the case in

plinary settings compared with those

Australia, even though public sector mental

health psychologists in

faced by psychologists working in more tradi-

health services are most often provided

tional settings such as mental health clinics and

multidisciplinary teams, including

private practice. These include

professional

logists (Australian Department

by

psycho-

of

Health

isolation and the difficulties o f communication

and Aged Care, 2 0 0 0 ; Herrman,

with other professionals trained with different

W a r n o c k , & Professional Liaison Committee

vocabularies and conceptual

[Australia] Project T e a m , 2 0 0 2 ) .

frameworks,

Trauer,

status conflicts, and the risks o f role ambiguity

It is somewhat ironic that many of the inter-

among the treatment team members as well

pretations and analyses o f teamwork, decision

as public confusion over roles affecting the

making, and

expectations o f patients/clients. J o n e s and

based on models from social and cognitive

Salmon ( 2 0 0 1 ) consider "multidisciplinary" as

psychology, yet psychology as a profession is

two or more professional groups with parallel

often not represented. In terms of a scientist-

interprofessional

relations are

but independent goals, whereas "interprofes-

practitioner model, it appears that the science

sional" is the preferred term for situations

of psychology is used in an interdisciplinary

where

back-

way more often than are the practitioner

grounds work together to achieve collabora-

aspects of the discipline. Because o f this dearth

professionals

from

different

tion. In this chapter, however, these two terms

of specific information, this chapter generalizes

are not strictly separated.

principles from studies involving a range of

A

number

o f authors

have

identified

health care professions. T h e traditional sociological wisdom

education at undergraduate and postgraduate levels as the linchpin for successful inter-

that

professions are self-interested groups divided

professional practice. T h e United States, the

by

United Kingdom, and Scandinavia all have in

nomies was rejected by Hudson ( 2 0 0 2 ) as

different

identities, statuses, and

auto-

place a formalized system o f policies that

pessimistic and problematic. H e argued that

Working members o f one profession may have more in

including

common with members o f a different profes-

capabilities.

With a Multidisciplinary

quality o f life and

Staff

functional

sion than with members o f their own profession and that the promotion o f professional values of trust and service to users can form the

HISTORICAL ISSUES

basis of interprofessional partnership. H e further proposed that socialization to an immedi-

T h e various health disciplines likely to be

ate work group can override professional or

working together with psychologists in health

hierarchical differences among staff, that pro-

care settings include physicians, psychiatrists,

fessionals and bureaucracies can join forces

and other medical specialists; nurses; social

in a collective effort to achieve their goals, and

workers; occupational therapists; physiothera-

that effective interprofessional working can

pists; and other allied health professionals such

lead to more effective service delivery and user

as podiatrists,

outcomes. Hudson's vision is an enticing one,

logists, and nutritionists. T h e collaboration

audiologists, speech

patho-

but to consider strategies to move toward his

between psychologists and medical practition-

ideal, we first need to consider the benefits

ers is reported more fully in the psychological

and obstacles of multidisciplinary health care.

literature than is the collaboration between

Advantages that have been identified include

psychologists and other health care profession-

continuity o f care for the patient, a wider range

als. Whatever the reason for that, the sparse

of skills and talents, greater choice for the

literature about nurse-psychologist collabora-

patients in choosing a practitioner from the

tion or social worker-psychologist collabora-

preferred

back-

tion deserves augmentation through careful

ground or sexual orientation (Balon, 1 9 9 9 ) , a

research investigations. T h e collaboration

gender,

cultural/language

more holistic approach to management, and

among the other disciplinary groups, excluding

(for the coworkers) more emotional

and

psychology, must be left for books about inte-

professional support as well as a more satis-

grated care o f those sorts (e.g., medicine with

fying work environment and ethic (Cook,

nursing,

Gerrish, &c Clarke, 2 0 0 1 ) .

Other allied health professions may have a less

social work with

physiotherapy).

W e need to specify relevant outcomes to

ambiguous relationship with medicine than

assess the success o f multidisciplinary staff

does psychology because they are more clearly

teams as opposed to other sorts o f staff

identified as providers o f auxiliary services. In

teams. T h e following seem the most impor-

contrast, psychology defines itself as a science

tant: (a) j o b satisfaction and

as well as a health care profession.

consequent

physical and psychological well-being for the

M u c h o f what follows focuses primarily

clinical health psychologists and the other

on effective collaboration between psycho-

health professionals w h o w o r k together as

logists and medical professionals, whether

well as better staff morale, retention, and

specialists (principally psychiatrists) or those

productivity (Barnes, Carpenter, &c Bailey,

providing primary care. But several authors

2000);

cost-effectiveness o f

have drawn attention to the need for psy-

service delivery such as better use o f the skills

chologists to learn to collaborate with other

(b) improved

and knowledge o f professionals with diverse

nonmedical health professions, pointing out,

backgrounds, higher quality w o r k

perfor-

for example, the key role of nurses, especially

mance, and fewer mistakes and errors in

in hospital care. It is clear that psychologists

diagnosis and

may need to develop effective models for

treatment;

and

(c) greater

satisfaction with services for the clients as

working with mental health-trained

well as improved mental and physical health,

also in primary care. There are many more

nurses

29

PRACTICAL ISSUES nurses than psychologists and will be for the

•

foreseeable future, and nurses seem likely t o have important functions to provide basic •

supportive community care. Consultation-liaison psychiatry is based on the psychosomatic idea o f health and disease arising from

an interaction o f biological,

psychological, and social factors. Lipowski ( 1 9 6 7 ) defined consultation-liaison psychiatry as the subspecialty of psychiatry concerned

• •

with clinical service, teaching, and research in nonpsychiatric health care settings. T h e paral-

•

lel development in psychology has been that o f the subspecialty o f clinical health psychology (Belar & Deardorff, 1 9 9 5 ) . As explained by

•

A concern that psychologists might not have sufficient expertise to deal with serious mental health problems Differences in training between psychiatrists and psychologists, in particular the biological bent of the former against the behavioral bent of the latter (Goldsmith, Paris, & Riba, 1999) A lack of knowledge about each other's roles and capabilities (Neal &c Calarco, 1999) Dilution of psychologists' responsibility for patients The potential for personality clashes, compounded by professional differences The complexity of coordinating and arranging teamwork (Cook et al., 2001)

Home, The clinical psychologist is an expert in the application of clinical assessment and treatment skills to change an individual's maladaptive behavior, thoughts, and emotions. Health psychology provides an expanding knowledge base regarding psychological factors in health and illness within a biological and sociological context. The clinical health psychologist draws on expertise from both clinical and health psychology to work as a practitioner in a medical/health care setting. (Strain & Home, 2 0 0 1 , p. I l l ) H o m e then outlined the key issues particularly well managed by psychologists, including (a) clinician-patient communication, tors in adherence to treatment,

(b) fac-

(c) dealing

with medical anxieties and phobias in patients and clinicians, and (d) preparing patients for invasive and surgical procedures (Strain & Home, 2001). Disadvantages o f interprofessional practice between psychologists and psychiatrists have been identified, including factors such as the following: • •

Perceptions by some members of the medical profession that shared care is unethical An unwillingness by some psychiatrists and psychologists to let go of ideological prejudices

In a report on the roles and relationships of psychiatrists and other service providers, Herrman and colleagues ( 2 0 0 2 ) identified five main obstacles to effective teamwork: (a) ambiguity or conflict over roles, with a common assumption in practice and in the literature that the psychiatrist or medical professional is the team leader who allocates roles and duties, with the other professionals viewed as "physician extenders"

(Schuster, Kern, Kane, 8 t

Nettleman, 1 9 9 4 ) ; (b) conflict and confusion over leadership, whereby the psychiatrist usually assumes leadership on the basis of superior knowledge and training; (c) differing understandings of responsibility and accountability, with psychiatrists sometimes hesitating to work in teams because they are concerned that they may be held responsible for other professionals' errors (which in fact is not the case); (d) interprofessional misperceptions related to differences in skills and training, values, culture, socialization, and cognitive style; and (e) differing rewards among professions, with power, status, and income all playing a role. Gilbert and colleagues ( 2 0 0 0 ) noted that these differences in rewards across professions may also become confounded

with gender

disparities

across professions. Nicholas and Wright ( 2 0 0 1 ) , in discussing collaborative w o r k

by psychologists

and

Working

With a Multidisciplinary

Staff

\

psychiatrists in pain clinics, commented that

undergo the necessary extra training, thereby

mostly the question o f w h o provides which

bolstering the argument for more public access

service should be decided on the grounds o f

to psychologists.

who can do it best, not a priori on the grounds

Other historical (and some continuing)

of discipline. However, as they noted, the

influences include the reimbursement sched-

biomedical background o f psychiatrists makes

ules via government and other third-party

them better able to use psychotropic medica-

payers, insurers, and managed care organiza-

tions and to assess how these may interact

tions. In Australia, the universal public health

with other medical aspects o f the patient's

insurance does not include payment for psy-

condition, whereas psychologists are usually

chologist services; it includes payment only

better able to use cognitive and behavioral

for medically qualified practitioners (includ-

interventions for individuals and groups and

ing, o f course, psychiatrists). Accordingly, pri-

have more expertise in the development and

vate practitioner psychologists are very limited

use o f psychometric measures. This situation

in what proportion o f the population can

is not static. Recently, some U.S. psychologists

afford their services. A recent governmental

have gained

psy-

policy innovation, the Better Outcomes for

chotropic drugs despite intense resistance to

Mental Health initiative, implies more exten-

this innovation by psychiatrists—and some

sive possible roles for psychologists in two

psychologists (Goode, 2 0 0 2 ) .

ways, although their involvement is not stated

the right to prescribe

the

explicitly. O n e is that primary care physicians,

expectations o f each profession regarding its

or general practitioners, will need training in

roles in patient care, and in different amounts

mental health care to qualify for

of emphasis on the scientific evidence base and

rebates for the longer consultations that this

There are historical influences on

higher

how to evaluate the scientific literature and

form o f treatment requires. T h e other is that

whether one is expected to contribute to it.

general practitioners may gain discretionary

Each profession probably has a different view

government

funding

to pay for specialist

of where it stands on various "skills pyramid"

mental health care for their patients, and if

conceptualizations. T h e Australian Psycholo-

they hire psychologists to provide this care,

gical Society ( 2 0 0 0 ) , for example, developed a

they will overcome the financial burden for

model o f the levels o f expertise in mental

patients that seeing a psychologist currently

health care that has specialized clinical psy-

imposes.

chologists at the top level, dealing

with

In

Britain, all clinical psychologists are

complex cases, innovations to treatment, and

employed by the publicly funded

evaluations o f effectiveness. At the bottom

Health Service and work alongside doctors

level are generic counselors w h o , after being

and other health professionals, again at the

trained by psychologists, offer first-line help to

discretion of the general practitioners who

National

those in need and can recognize the need to

direct the spending o f government funds for

refer upward as appropriate. T h e middle level

health care. T h e fact that psychologists are

of skill is characterized by the delivery o f inter-

salaried rather than private practitioners, o f

ventions (after some training) such as assertive

course, increases their accessibility to

therapy, couples therapy,

public enormously.

and

manualized

the

cognitive-behavioral therapy. T h e middle level

In the United States, the managed care

might be where medical practitioners with

movement has created much consternation for

appropriate

best fit,

mental health workers w h o were not accus-

although in normal circumstances many o f

extra training would

tomed to concepts o f accountability and cost-

them will not have the time or interest to

effectiveness (Todd, 1 9 9 4 ) . However, its focus

31

32

PRACTICAL ISSUES problem-focused

health care team to monitor their own practice

treatments sits well with the usual mode o f

and its outcomes in a scientific way, to keep

psychological intervention in medical settings.

useful records of the process and results o f

Conversely, psychologists' familiarity

on brief, evidence-based,

with

care, to design controlled studies of innovative

empirically supported treatments is entirely

treatments, and to communicate with others

compatible with medicine's current emphasis

through the professional literature. O n e recent

on evidence-based practice.

step in this direction has been the acknowledgment that the effort to be scientific about practice need not be abandoned if the "gold

SPECIALIZED SKILLS NEEDED FOR MULTIDISCIPLINARY WORK IN HEALTH SETTINGS

standard" multisite randomized control trial is impractical to undertake. Psychology has a history o f deriving valid and reliable conclusions from the small-sample research study

Although medical patients are likely to show

(Morgan

high rates o f anxiety, depression, and other

Chamberlain, 2 0 0 1 ) . T h i s methodological

&

Morgan,

2 0 0 1 ; Radley

&

affective and cognitive pathologies, psycholo-

expertise is newly valued, particularly when

gists and other clinicians working in medical

managed care demands m a x i m u m account-

settings need a thorough understanding o f

ability and the identification and use o f the

normal psychosocial development, stress and

most cost-effective treatment plan.

coping, and behavioral health issues. In our

Another contribution that psychologists may

society that retains dualistic mind-body con-

be able to offer their professional colleagues is

cepts, the effort to bridge health and mental

their understanding of systemic factors in the

health may always be challenging. As Belar,

workplace that may facilitate or impede effec-

Paoletti, and Jordan ( 2 0 0 1 ) pointed out, psy-

tive delivery of care. Specifically, jobs in health

chologists and psychiatrists in medical settings

care are often high in the demands they make

act as bridges between their core disciplines

on workers (e.g., workload, responsibility, com-

and the rest o f health care, being mainstream

plexity). Therefore, organizational

in neither. They have to accept a consultative

such as the demand-control-support

role, and they also need to become comfort-

(Johnson & Hall, 1 9 8 8 ) predict that the levels

theories model

able in working with patients w h o are sick,

of control and autonomy that workers have,

disabled, disfigured, injured, or even dying.

and the supportiveness of coworkers and super-

This is despite the possibility that a desire to

visors, will have a major impact on worker

avoid contact with illness and death might

satisfaction, retention, and even quality of work

have been a motivating factor for some health

performance (Dollard, Winefield, Winefield, &

professionals to be drawn to psychology or

De Yonge, 2 0 0 0 ; Judge, Thoresen, Bono, &

psychiatry.

Patton, 2 0 0 1 ; Winefield, 2 0 0 3 ) . Although risk

Beyond patient care, there are large areas o f

management in health care is a huge

and

interprofessional collaboration where the spe-

specialized field that must take account of the

cific training o f the psychology graduate may

multiple pathways through which mistakes and

enhance the professional effectiveness and j o b

adverse events may occur, psychologists' educa-

satisfaction o f health coworkers. T h e scientist-

tional background may uniquely fit them to see

practitioner model equips psychologists to

the management and job design issues behind

understand empirical evidence and interpret

these and other work stressors and to suggest

the literature critically; this skill is not empha-

sustainable remedies (Barach 8c Small, 2 0 0 0 ;

sized in the training o f many other health pro-

Griffiths, Randall, Santos, &c C o x , 2 0 0 3 ; Jones

fessionals. T h e model may assist members o f a

etal., 1 9 8 8 ) .

Working

Skills Needed for Hospital Settings

With a Multidisciplinary

Staff

\

mind and to facilitate the resolution o f these conflicts. Mutual respect and understanding

M i l g r o m , Burrows, and Schwartz ( 2 0 0 1 )

among team members is vital for the team to

provided a checklist for new psychologists

function effectively. Dual relationships increase

adapting to w o r k in medical settings. Items

the risk o f exploiting the power differences

include being brief and clear in communica-

between therapists and patients, confidentiality

tion, respecting the organizational

can raise difficulties, and all practitioners have

culture

and unwritten rules o f conduct, becoming

a responsibility to continually update their

familiar with medical procedures and drugs

own professional learning. T e a m approaches

as well as their side effects, being prepared

increase the possibility that responsibility for

to admit ignorance and ask for advice, and

patient care may become diffused (Belar et al.,

adopting a long-term approach to educate

2 0 0 1 ) , so it becomes very important to main-

colleagues over time. F o r example, it will be

tain alertness to follow-up and to appropriate

necessary to attend and participate in team

documentation of cases.

meetings,

however

time-consuming

this

At the m o r e preventive health

promo-

seems, in the interest o f increasing familiarity

tional level, M i c h i e ( 1 9 9 8 ) wrote about con-

and confidence among team members.

sultancy or targeted research undertaken at

Nicholas and Wright ( 2 0 0 1 ) described the

the request of another health professional.

gradual replacement o f "multidisciplinary"

T h e examples she cited c a m e from requests

health care teams (headed by physicians) with

from

"interdisciplinary" teams (led by individuals

occupational health officers, medical educa-

who

tors, and primary health care visitors and

can

coordinate

the

collaboratively

surgeons, physiotherapists,

nurses,

agreed-on treatment plan and manage the

nurses. She commented on the empathy and

team dynamics). These are bound to be tense

tact, in addition to the communication skills

occasionally as people with different concep-

and research design expertise, needed by con-

tual frameworks try to deal effectively with

sultant

highly distressed and complex patients. It is

that psychologists in this role act collectively

psychologists. She also

advocated

essential, according to Nicholas and Wright,

and strive to avoid "the trap o f the individu-

that team members agree on the treatment

alism that has sometimes been associated

model they are using and that mechanisms

with psychologists" (p. 1 6 7 ) . M e m b e r s o f

exist for them to cope with disagreements and

the College o f Health Psychologists o f the

continue supporting each other. Milgrom and colleagues ( 2 0 0 1 ) noted that

Australian trained

Psychological Society are also

in public health psychology

and

nurses often have a unique role to observe

health promotion. Very few physicians, with

patients, their responses to treatment, and their

the possible exception o f epidemiologists

family interactions on a daily basis, making

and public health specialists (who rarely w o r k

nurses key members

multidisciplinary

directly with patients in delivery o f care set-

teams. Doctors may seem pressed for time but

tings), have this perspective, and neither do

should not be excluded from consideration of

nurses or other allied health professionals.

of

the psychosocial aspects o f patient care. Such teams have a complex and largely unspoken hierarchy o f status roles and expectations that are bound to cause some conflict. Psycho-

Skills Needed for Primary Health Care

logists and psychiatrists, with their training in

All o f this is relevant to psychologists

interpersonal relations, should be in a good

working in multidisciplinary primary care

position to keep the systemic perspective in

settings, although these settings have their

PRACTICAL ISSUES o w n special characteristics as well and in fact

to increase the well-being and decrease the

represent one o f the most exciting new direc-

health care use o f a group o f patients generally

tions for applied health psychology at the

regarded as problematic and frustrating in

current time. W i t h the unresolved difficulties

primary care, namely those individuals with

o f providing mental health care through a

undiagnosable physical symptoms and high

separate system that is often parallel but infe-

rates o f consultation, sometimes referred to as

rior in resources to the "physical" health sys-

somatizers. M a n y of these patients are likely

tem, countries such as Britain and Australia

to be suffering from anxiety or depression (cf.

are actively exploring the value t o consumers

M c L e o d , Budd, & McClelland, 1 9 9 7 ) .

of making treatment for psychological diffi-

Bray and Rogers ( 1 9 9 7 ) provided some

culties and dysfunctions available where the

valuable examples o f the differences in profes-

public is—in primary health care.

sional culture and practices between clinical

In Australia, 8 2 % o f the population is

psychology (focused on understanding and

likely to visit a primary health care physician

questioning) and primary health care (focused

(general practitioner) each year. Although

on fixing problems). T h e number of patients

about one o f five adults will experience a

seen per day, speed o f access to

psychological problem sufficient to interfere

sources, and expectations about the confiden-

significantly

tiality o f patient records all vary greatly, as do

with

daily life and

(Andrews, Hall, Teesson, &

function

Henderson,

reimbursement opportunities.

referral

Practical tips

1 9 9 9 ) , only a minority o f those receive any

about h o w a doctor can manage referrals to a

mental health treatment, and when they do

therapist center on demonstrating the collabo-

it is unlikely to be from a mental health

rative nature o f the care, making it clear that

specialist. However, general practitioners are

the therapist will provide specialist help while

p o o r at both detecting and treating high-

the doctor continues to provide other medical

prevalence psychological disorders such as

care, with a shared first consultation in the

anxiety, depression, and substance abuse.

doctor's office for resistant patients. Physical

Untreated anxiety disorders are associated

proximity o f the providers and regular settings

with substantial health care costs, including

for contact seem crucial to the maintenance o f

unnecessary ambulance trips, hospital emer-

the collaboration between practitioners, just

gency department

presentations, diagnostic

as physical sharing o f training experiences is

such as E C G s (electrocardio-

crucial to their initial entry into the collabora-

grams), and frequent use o f primary health

tion. Openness to the emotional impact o f the

procedures

services. Greenberg and colleagues ( 1 9 9 9 ) esti-

work (especially in difficult cases) and the

mated the annual cost o f anxiety disorders,

chance to discuss such issues within the team

adjusted for demographic factors and comor-

may help the professionals to prevent burnout

bid psychiatric conditions, to be U.S. $ 1 , 5 4 2

and secondary trauma. Being able to give each

per sufferer in 1 9 9 0 , with 5 4 % o f the total

other feedback and support creates a cohesive

costs being for nonpsychiatric medical care.

team that is greater than the sum of its parts

T h e human and social costs o f anxiety disor-

(McDaniel & Campbell, 1 9 9 7 ) .

ders

(Mendlowicz &

Stulp deGroot, Price, and Leslie ( 1 9 9 8 )

Stein, 2 0 0 0 ) . Psychological interventions have

are also substantial

reported their experiences in developing a col-

been demonstrated to be successful treatments

laborative primary health care service for

for a range o f conditions, including anxiety

more than 1 0 , 0 0 0 patients using primary care

and depression (Chambless & Hollon, 1 9 9 8 ;

physicians (PCPs) and mental health clinicians

Chambless & Ollendick, 2 0 0 1 ) . In addition,

( M H C s ) . T h e y carefully documented

psychological interventions have been shown

process and were able to derive the following

this

Working

With a Multidisciplinary

Staff

\

conclusions about h o w to make the project

discipline must experience shared

successful. First, the M H C s had to learn to

Here they learn about each other's knowledge

training.

listen and ask questions in a way that helped

bases, conceptual frameworks, and expecta-

the PCPs to sort things out for themselves

tions of both patients and how the health

rather than to give them answers to their ques-

system operates. T h e frequently

tions. Second, c o l l a b o r a t i o n involves the

stereotypes that physical and psychological

negative

whole system—including office staff, family

health professionals have o f each other need to

members, case managers, and so on—and not

be discussed and set in the context o f the dif-

just the PCPs and M H C s . Third, frequent and

ferent professional cultures and working styles.

timely c o m m u n i c a t i o n is essential in

the

In the United States, interprofessional col-

various forms o f face-to-face hallway conver-

laboration is facilitated by the Interdisciplinary

sations, written chart notes, voice messages,

Professional Education Collaborative, a body

e-mails, and responses to pages. Fourth, roles

that stresses the need to incorporate interpro-

should stay flexible and include attention to

fessional expectations and skills into education

the mental health needs o f the staff. Fifth, col-

(Gelmon, White, Carlson, & Norman, 2 0 0 0 ) .

laboration can work best when the process is

The collaborative has identified some o f the

informal. Sixth, not everyone engages in the

obstacles to achieving integration of profes-

collaborative process at the same rate.

sions at the training level. Historically, there has been reluctance by staff from the different health science disciplines to interact with one another in teaching as well as in the pro-

TRAINING TO WORK IN MULTIDISCIPLINARY HEALTH CARE SETTINGS

fessional sense (Gilbert et al., 2 0 0 0 ) . Although psychologists are often employed within medical schools, their role within the teaching o f

In what follows, it is assumed that the specif-

medicine and medical students tends to be in

ically health psychology content o f the health

the role of scientists rather than practitioners.

psychologist's training and education

Psychology students do not, as a rule, train

has

been thoroughly mastered. It must contain,

next to medical students in the clinical compo-

as we have seen, a comprehensive review o f

nents of their courses as fellow apprentices.

the knowledge base in psychology as applied

A further difficulty is the method o f teach-

to health and illness, measurement, research

ing that is commonly employed at universities.

design, and an understanding o f health ser-

Didactic teaching through lectures, where

vice delivery systems. Hopefully but less pre-

students sit passively in the classroom, will

dictably, the other health professionals with

not result in better collaboration between pro-

w h o m the psychologist will end up working

fessionals (Gelmon et al., 2 0 0 0 ) . Hilton and

conjointly will also have received at least

Morris ( 2 0 0 1 ) argued that the ideal learning

basic training in the principles o f human

environment for developing skills for collabo-

behavior and h o w to study it scientifically

rative practice is the clinical setting, where

(cf. Winefield, 1 9 9 8 ) . This section focuses

learning is experiential and in context. They

specifically on methods to facilitate effective

stressed that in addition to students being

collaborative w o r k shared by health profes-

on placements, successful

sionals with multidisciplinary backgrounds.

requires collaboration between clinicians and

implementation

McDaniel and Campbell ( 1 9 9 7 ) described

academics, with the former sharing their prac-

in detail the training experiences that facilitate

tice philosophies and the latter promoting

collaborative care by psychologists and physi-

appropriate teaching and learning principles.

cians. First and foremost, members o f each

Because most clinicians are trained not as

PRACTICAL ISSUES educators but rather as supervisors, academics

institutional

reward

structures

for

faculty

have an essential support role. T h e responsi-

engaged in curriculum improvement,

bility o f students is also stressed; during clini-

tions o f inflexibility and fear o f the innovative,

tradi-

cal placements, more senior students should

and a resistance t o community-based

be responsible for the coordination o f an

project learning. Few interprofessional courses

aspect o f patient care within the team. Some

have been incorporated into curricula, with

educators have attempted to use simulated

time, expense, funding,

placements (Fallsberg 8c H a m m a r , 2 0 0 0 ) or

coordination

2-day workshops (Gilbert et al., 2 0 0 0 ) instead

mentation (Gilbert et al., 2 0 0 0 ) .

of real clinical placements using an existing

cooperation,

difficulties hampering

Multidisciplinary w o r k

and

and

imple-

is highly politi-

authentic team due to the number o f difficul-

cized and complex, so students o f professions

ties involved in arranging such placements.

where teamwork will be required need "pol-

T o date, we have no empirical studies to pro-

icy acumen" (Jones 8c Salmon, 2 0 0 1 , p. 6 7 ) ,

vide us with information about the relative

which should be included as part o f their

merits and weaknesses o f particular teaching

education. Psychologists, like all health care

approaches.

However, Hilton

and

Morris

professionals, need an understanding o f the

(2001)

convinced

encouraging

social, political, and economic frameworks

are

that

students to collaborate with other profession-

around which policies that affect their w o r k

als in a real setting with experiential learning

are structured, and curricula need to address

is educationally beneficial in terms o f out-

this. Such knowledge will encourage proac-

come. Such student experiences are likely to

tive responses to social policy so as to benefit

result in graduates who are able to function as

both the individual practitioner and the wider

team members, with more positive attitudes,

professional body. Without such knowledge,

abilities in collaborative problem solving, and

there may be a tendency to focus on profes-

better professional development.

sion-centered arguments and perceptions that

In situations where didactic lectures are

are antithetical t o interprofessionalism.

the most appropriate, students from across

M c D a n i e l , Hargrove, Belar, Schroeder, and

different disciplines could be taught together,

Freeman (in press) prepared a detailed cur-

where the same base knowledge is required.

riculum for the education o f psychologists to

Problem-based learning curricula in medicine

practice and research in primary health care

work on the premise that there are no depart-

settings. For example, in the

mental

issues" module, they suggested the following

or discipline boundaries

(Harden,

Davis, 8c Crosby, 1 9 9 7 ) . Therefore, the prob-

student exercises that

lem-based philosophy lends itself easily to

some o f the necessary skills:

neatly

"professional demonstrate

the incorporation o f interprofessional collaboration in training. Rather than groups o f eight medical students, groups composed o f students across a range o f health professions would be possible. This ambitious suggestion would require a major shift in university structures. Indeed, the Interdisciplinary Professional Education Collaborative (Gilbert et al., 2 0 0 0 ) suggested

that

higher

education

institu-

tions offer many barriers to implementation of change that would foster interprofessionalism. It listed as major challenges a lack o f

1. Construct a strategy for seeking reimbursement in your community for psychoeducational groups and collaborative sessions (i.e., sessions for which there is more than one clinician present). 2. Write a justification to an insurance company for a child to be treated by a psychologist for attention deficit hyperactivity disorder. 3. Write a one-page advocacy statement for inclusion of psychological services in

Working primary care for submission to your state legislature. out

Staff

\

teamwork and interprofessionalism, but there is a lack o f hard evidence to demonstrate the effectiveness

This training needs to be carried

With a Multidisciplinary

o f interprofessional

training

across the board and there is a need for quan-

jointly by members o f the disciplines con-

titative, large-scale, longitudinal

cerned w h o model a respectful partnership,

studies (Jones & Salmon, 2 0 0 1 ) . Hammick,

evaluation

Barr, Freeth, Koppel, and Reeves ( 2 0 0 2 ) have

shared care, and shared inquiry. Students need to learn which sorts of prob-

conducted a substantial systematic review of

lems need which kind o f professional exper-

evaluations o f interprofessional

tise. In their article on teaching health care

seeking evidence linking professional educa-

education

professionals to collaborate, M c D a n i e l and

tion to a change in either professional practice

Campbell ( 1 9 9 7 ) urged primary care doctors

or patient care, but their work has not yet been

to use counseling skills for simple and mild

published. In educating students about inter-

problems and to use collaboration with a ther-

professionalism, the users o f services are also

apist for more complex problems such as non-

stakeholders, so their views must be solicited

adherence, somatization, significant anxiety

and taken into account in any evaluation.

or depression, and coping with terminal ill-

A major methodological consideration o f

ness. In addition, these authors distinguished

any evaluation o f interprofessional training

"red flag" problems that demand collabora-

or practice is that studies conducted in one

tion and referral, including psychosis, physical

location might not necessarily be meaning-

or sexual abuse, previous treatment failure,

fully compared cross-culturally because cul-

and nonresponse to three or four counseling

tural factors can affect the strategies used.

sessions with the primary care physician.

F o r example, Skjorshammer ( 2 0 0 1 ) , in his

In the literature about training health pro-

study on interprofessional negotiations in a

fessionals to enhance their capacity for later

Norwegian hospital, suggested that the high

multidisciplinary work, it is noteworthy that

incidence o f avoidance to allay conflict may

although authors are quite often able to report

reflect a cultural n o r m o f evasion rather than

on long experiences with large numbers of

a generalizable finding. J o n e s and Salmon

students and practitioners, there are very few

( 2 0 0 1 ) also pointed out that different issues

reports of controlled studies. Yet especially to

are pertinent, depending on the setting, even

psychologists with their awareness of method-

within the same culture. T h e results o f

ological issues in discovering new knowledge,

research into interprofessional training and

it is a concern that the powerful nonspecific

practice will be difficult to generalize across

effects o f having enthusiastic, highly commit-

different situations and teams due to the con-

ted faculty offering innovative programs with

siderable variations encountered in educa-

determination to seek student feedback could

tional institutions and team composition as

engender a corresponding student enthusiasm

well as to cross-cultural differences.

for the training method that was independent

T h e r e are

even greater

difficulties o f

of other outcomes. It is only by random allo-

demonstrating better quality o f health care

cation of students to treatment and control

work in multidisciplinary settings compared

groups (including placebo control groups) that

with the other models such as that of parallel

the highest standards of scientific evidence

work by different professions. T h e problems

could be attained. Such standards are probably

hinge mostly on the unsolved task o f measur-

unreachable in most educational settings.

ing quality o f health care work. Beyond

There is a body o f interesting qualitative literature

emerging

into

the

efficacy

of

patient satisfaction, other measures might be the

j o b satisfaction

o f the

health

care

37

PRACTICAL ISSUES providers and the numbers o f patients cured

stereotyping, and jealousy. Nonetheless, there

or returned to work or normal activities. But to

seems to be agreement among experienced

demonstrate the cost-effectiveness in economic

practitioners that these negatives can be over-

terms that are meaningful to accountants and

come by mutual respect and a focus on the

shareholders is more challenging. Certainly,

c o m m o n goal o f improved patient well-being.

one requirement would be a way in which to

This chapter suggested that psychologists' par-

capture the entire health system utilization costs

ticular

for patients treated with the two models of

teams, beyond their specific expertise in

professional care (multidisciplinary and parallel).

understanding patient behaviors, can lie in

contributions

to

multidisciplinary

reducing conflict within mixed groups, translating scientific evidence for colleagues, and

SUMMARY

monitoring the stressfulness o f the

work

environment. This chapter has reviewed some o f the poten-

To

gain acceptance in multidisciplinary

tial hazards and advantages for clinical health

hospital and primary care settings, psycholo-

psychologists o f working with colleagues who

gists need to learn about these settings' pre-

have multidisciplinary backgrounds. T h i s

vailing cultures and acquire the skills needed

challenge is not unique to medical settings,

to negotiate them effectively. There is now a

but in these highly responsible and complex

growing literature about how to do this,

workplaces and in caring for very vulnerable

although it is a descriptive literature rather

patients, the need to develop

high-quality

than an experimental one. A fundamental rec-

work

unarguable.

ommendation about shared training opportu-

Further careful research is still required to

nities to teach such skills has often proved to

practices is acute and

establish the details of the most effective mod-

be too difficult to test in practice. There are

els for health care shared among providers

likely to be many opportunities for psycholo-

from diverse professions, but this chapter

gists to add to the current scientific literature

focused on how psychologists may extract the

and to use this chapter's findings construc-

maximum benefit from this arrangement for

tively to improve the contribution o f psychol-

their clients, their coworkers, and themselves. The history o f interprofessional relationships in health care has included suspicion,

ogist practitioners within

multidisciplinary

health care teams as well as to enhance the functioning o f such teams.

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Working

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Barach, P., & Small, S. D. (2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal, 320, 7 5 9 - 7 6 3 . Barnes, D., Carpenter, J . , & Bailey, D. (2000). Partnerships with service users in interprofessional education for community mental health: A case study. Journal of Interprofessional Care, 14, 1 8 9 - 2 0 0 . Belar, C. D., & Deardorff, W. W. (1995). Clinical health psychology in medical settings: A practitioner's guidebook (rev. ed.). Washington, DC: American Psychological Association. Belar, C. D., Paoletti, N., & Jordan, C. (2001). Assessment and intervention in a medical environment. In J . Milgrom & G. D. Burrows (Eds.), Psychology and psychiatry: Integrating medical practice (pp. 6 5 - 9 2 ) . Chichester, UK: Wiley. Bray, J . H., &C Rogers, J . C. (1997). The Linkages Project: Training behavioral health professionals for collaborative practice with primary care physicians. Families, Systems, and Health, IS, 5 5 - 6 3 . Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7 - 1 8 . Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716. Cook, G., Gerrish, K., & Clarke, C. (2001). Decision-making in teams: Issues arising from two U.K. evaluations. Journal of Interprofessional Care, 15, 1 4 1 - 1 5 1 . Dollard, M., Winefield, H. R., Winefield, A. H., & De Yonge, J . (2000). Psychosocial job strain and productivity in human service workers: A test of the demand-control-support model. Journal of Occupational and Organizational Psychology, 73, 5 0 1 - 5 1 0 . Fallsberg, M. B., & Hammar, M. (2000). Strategies and focus at an integrated, interprofessional training ward. Journal of Interprofessional Care, 14, 3 3 7 - 3 5 0 . Gelmon, S. B., White, A. W., Carlson, L., & Norman, L. (2000). Making organizational change to achieve improvement and interprofessional learning: Perspectives from health profession educators. Journal of Interprofessional Care, 14, 1 3 1 - 1 4 6 . Gilbert, J . H. V., Camp, R. D., Cole, C. D., Bruce, C , Fielding, D. W., & Stanton, S. J . (2000). Preparing students for interprofessional teamwork in health care. Journal of Interprofessional Care, 14, 2 2 3 - 2 3 5 . Goldsmith, R. J . , Paris, M., & Riba, M . B. (1999). Negative aspects of collaborative treatment. In M. B. Riba & R. Balon (Eds.), Psychopharmacology and psychotherapy: A collaborative approach (pp. 3 3 - 6 3 ) . Washington, DC: American Psychiatric Press. Goode, E. (2002, March 26). Psychologists get prescription pads and furor erupts. The New York Times. Greenberg, P. E., Sisitsky, T., Kessler, R. C , Finkelstein, S. N., Berndt, E. R., Davidson, J . R., Ballenger, J . C , & Fyer, A. J . (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 4 2 7 - 4 3 5 . Griffiths, Α., Randall, R., Santos, Α., &c Cox, T. (2003). Senior nurses: Interventions to reduce work stress. In M. F. Dollard, A. H. Winefield, & H. R. Winefield (Eds.), Occupational stress in the human services professions (pp. 1 6 5 - 1 8 5 ) . London: Taylor & Francis. Hammick, M., Barr, H., Freeth, D., Koppel, I., & Reeves, S. (2002). Systematic reviews of evaluations of interprofessional education: Results and work in progress. Journal of Interprofessional Care, 16, 8 0 - 8 4 . Harden, R. M., Davis, M. H., & Crosby, J . R. (1997). The new Dundee medical curriculum: A whole that is greater than the sum of the parts. Medical Education, 31, 2 6 4 - 2 7 1 .

Staff

PRACTICAL ISSUES Herrman, H., Trauer, T., Warnock, J . , &c Professional Liaison Committee (Australia) Project Team. (2002). The roles and relationships of psychiatrists and other service providers in mental health services. Australian and New Zealand Journal of Psychiatry, 36, 7 5 - 8 0 . Hilton, R., & Morris, J . (2001). Student placements: Is there evidence supporting team skill development in clinical practice settings? Journal of Interprofessional Care, IS, 1 7 1 - 1 8 3 . Hudson, B . (2002). Interprofessionality in health and social care: The Achilles' heel of partnership? Journal of Interprofessional Care, 16, 7 - 1 7 . Johnson, J . V., & Hall, Ε. M. (1988). Job strain, workplace social support, and cardiovascular disease: A cross-sectional study of a random sample of Swedish working population. American Journal of Public Health, 78, 1 3 3 6 - 1 3 4 2 . Jones, J . W., Barge, B . N., Steffy, B . D., Fay, L. M., Kunz, L. K., & Wuebker, L. J . (1988). Stress and medical malpractice: Organizational risk assessment and intervention. Journal of Applied Psychology, 73, 7 2 7 - 7 3 5 . Jones, M., & Salmon, D. (2001). The practitioner as policy analyst: A study of student reflections of an interprofessional course in higher education. Journal of Interprofessional Care, 15, 67-77. Judge, T. Α., Thoresen, C. J . , Bono, J . E., & Patton, G. K. (2001). The job satisfaction-job performance relationship: A qualitative and quantitative review. Psychological Bulletin, 127, 3 7 6 - 4 0 7 . Lipowski, Z. J . (1967). Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosomatic Medicine, 29, 1 5 3 - 1 7 1 . McDaniel, S. H., &c Campbell, T. L. (1997). Training health professionals to collaborate. Families, Systems, and Health, 15, 3 5 3 - 3 5 9 . McDaniel, S. H , Hargrove, D. S., Belar, C. D., Schroeder, C , & Freeman, E. L. (in press). Recommendations for education and training in primary care psychology. In R. Frank, S. McDaniel, J . Bray, & M . Heldring (Eds.), Primary care psychology. Washington, DC: American Psychological Association. McLeod, C. C , Budd, Μ . Α., St McClelland, D. C. (1997). Treatment of somatization in primary care. General Hospital Psychiatry, 19, 2 5 1 - 2 5 8 . Mendlowicz, M . V., St Stein, M . B . (2000). Quality of life in individuals with anxiety disorders. American Journal of Psychiatry, 157, 6 6 9 - 6 8 2 . Michie, S. (1998). Consultancy. In A. S. Bellack & M. Hersen (Eds.), Comprehensive clinical psychology, Vol. 8: Health psychology (pp.153-169). Oxford, UK: Pergamon. Milgrom, J . , Burrows, G., St Schwartz, S. (2001). The future of psychology and psychiatry in the medical centre. In J . Milgrom St G. D. Burrows (Eds.), Psychology and psychiatry: Integrating medical practice (pp. 2 9 7 - 3 3 2 ) . Chichester, UK: Wiley. Morgan, D. L., St Morgan, R. K. (2001). Single-participant research design. American Psychologist, 56, 1 1 9 - 1 2 7 . Neal, D. L., & Calarco, M. M. (1999). Mental health providers: Role definitions and collaborative practice issues. In M. B. Riba 8t R. Balon (Eds.), Psychopharmacology and psychotherapy: A collaborative approach (pp. 6 5 - 1 0 9 ) . Washington, DC: American Psychiatric Press. Nicholas, M . K., St Wright, M . (2001). Management of acute and chronic pain. In J . Milgrom St G. D. Burrows (Eds.), Psychology and psychiatry: Integrating medical practice (pp. 1 2 7 - 1 5 4 ) . Chichester, UK: Wiley. Radley, Α., Se Chamberlain, Κ. (2001). Health psychology and the study of the case: From method to analytic concern. Social Science and Medicine, 53, 3 2 1 - 3 3 2 . Schuster, J . M., Kern, Ε. E., Kane, V., & Nettleman, L. (1994). Changing roles of mental health clinicians in multidisciplinary teams. Hospital and Community Psychiatry, 45, 1 1 8 7 - 1 1 8 9 .

Working

With a

Multidisciplinary

SkJ0rshammer, M . (2001). Cooperation and conflict in a hospital: Interprofessional differences in perception and management of conflicts. Journal of Interprofessional Care, 15, 7 - 1 8 . Strain, J . J . , & Home, D. J . deL. (2001). Management of medical and surgical patients: Consultation-liaison (C-L) psychiatry and clinical health psychology. In J . Milgrom & G. D. Burrows (Eds.), Psychology and psychiatry: Integrating medical practice (pp. 9 3 - 1 2 6 ) . Chichester, UK: Wiley. Stulp deGroot, C , Price, D. W., & Leslie, B. (1998). Lessons learned: A collaborative care demonstration project. Families, Systems, and Health, 16, 1 2 7 - 1 3 8 . Todd, T. (1994). Surviving and prospering in the managed mental health care environment. Sarasota, FL: Professional Resources Press. Winefield, H. R. (1998). Teaching and training other health disciplines. In A. S. Bellack & M . Hersen (Eds.), Comprehensive clinical psychology, Vol. 8: Health psychology (pp. 1 7 1 - 1 8 7 ) . Oxford, UK: Pergamon. Winefield, H. R. (2003). Work stress and its effects in general practitioners. In M. F. Dollard, A. H. Winefield, & H. R. Winefield (Eds.), Occupational stress in the human services professions (pp. 1 8 7 - 2 0 7 ) . London: Taylor & Francis.

CHAPTER

4

Motivational Enhancement Interventions and Health Behaviors THAD R . LEFFINGWELL

M

ost behavioral health specialists

variety o f interventions that alter the structure

are interested in how to encourage

and setting of the intervention, while retaining

change in health behaviors among

the fundamental principles and spirit of moti-

their patients. These behavior changes might

vational interviewing, have been developed

include reductions or cessations o f behaviors

and tested (Dunn, D e r o o , & Rivara, 2 0 0 1 ;

harmful to health, such as t o b a c c o use and

Rollnick et al., 2 0 0 2 ) .

excessive alcohol use, or adoption/enhance-

Before

considering

interventions

for

ment o f new or infrequent behaviors that may

enhancing motivation, it would be helpful to

improve or protect health, such as adhering

discuss what motivation is. Motivation is a

to a special diet and increasing physical

c o m p l e x concept that has intrigued psychol-

activity. Certainly, an individual's motivation

ogists for years. Motivation has most often

to make a behavior change may determine

been described as a property o f an individual.

whether or not change is attempted or imple-

F r o m this perspective, motivation may either

mented successfully. If motivation for change

be state-like (e.g., driven by transitory states

in important, the question for the behavior

o f deprivation or need) or trait-like (e.g.,

health specialist becomes " H o w can I

moti-

something a client either had or lacked). Both

vate my patients to make important behavior

of these perspectives place the responsibility

changes?" This chapter describes approaches

for modifying motivation in the hands o f the

to enhancing motivation and

patient (if motivation can be modified at all)

encouraging

behavior change based on principles o f moti-

and offer little guidance on h o w to enhance

vational

this critical ingredient for change. T h e guid-

interviewing,

a

patient-centered

(Miller 8c Rollnick,

ing conceptualization o f motivation in this

2 0 0 2 ) . Rather than focusing on "pure" moti-

chapter is more complex and is based on an

counseling approach

vational interviewing alone, this

chapter

focuses on a variety o f similar approaches and

assumption that motivation is dynamic and can

be

modified

by

social

interactions

strategies that are consistent with the princi-

(Miller, 1 9 8 5 , 1 9 9 9 ) . F r o m this perspective,

ples and spirit o f motivational interviewing. A

motivation is conceptualized as a product o f

Motivational an interpersonal

process between

Enhancement

Interventions

43

patient

many health behavior problems, they were

and provider, and certainly the j o b o f the

initially developed in the substance abuse field.

provider is to create conditions that m a x i -

At the time, the prevailing conceptualization o f

mize motivation (Miller & Rollnick, 2 0 0 2 ) .

motivation to change addictive behaviors was

deserve

based on a belief in trait-like motivation, and

mention at the outset. First, the motivational

resistance and denial were seen as common

enhancement interventions described in this

symptoms of substance dependence. T h e prin-

chapter focus on reducing ambivalence about

ciples and techniques o f motivational inter-

behavior change as a means to enhance moti-

viewing with alcoholics were first described

vation. With most health behaviors, the patient

during the early 1 9 8 0 s . Building on social-cog-

typically feels more than one way about chang-

nitive processes and a Rogerian counseling

Two

other fundamental

issues

ing the status quo; part o f the patient wants to

style, Miller ( 1 9 8 3 ) described a new approach

change, and another part does not. It is this

to patient motivation and a counseling style

ambivalence that has the patient stuck in his

that offered a compelling alternative to the pre-

or her current patterns of behavior. T h e practi-

vailing model. Miller described client motiva-

tioner can intervene in certain ways with the

tion as a product o f the interpersonal process

ambivalent patient to "tip the scales" in favor

or as "a product of the way in which coun-

of change. Second, contemporary models of

selors have chosen to interact with problem

behavior change have moved beyond simple

drinkers" (p. 1 5 0 ) . This recasting o f client

doing/not doing conceptualizations of change

motivation and related behaviors of resis-

and now acknowledge several stages in the

tance and denial required a different kind of

change process (Prochaska, DiClemente, &

approach

Norcross, 1 9 9 2 ) . These stages not only include

approach of direct persuasion, confrontation,

various active stages o f attempting change, such

and the "breaking through" of denial (e.g.,

as preparation, action, and maintenance, but

DiCicco, Unterberger, & M a c k , 1 9 7 8 ) . Further-

to counseling from the existing

also include differentiations among individuals

more, this new approach essentially implicated

not actively involved in change, such as precon-

the confrontational interpersonal approaches

templation and contemplation. This transtheo-

typically used by counselors for the frequent

retical model is well known to most behavioral

observation o f resistance and

health specialists and now guides most research

ambivalent individuals. Clearly, motivational

and clinical practice regarding health behavior

interviewing was a radical innovation

change. T h e interventions described in this

encouraging change in patient health behavior.

chapter are consistent with this model in that

The

they provide means for intervening appropri-

quickly gained popularity, perhaps due

ately with patients in nonactive stages and

frustration with then current approaches or the

maximize the probability o f moving patients

attractiveness o f the less confrontational style

along the stages o f change—ultimately toward

of the approach.

successful change.

motivational

denial

interviewing

with for

approach

Since its inception, motivational

to

inter-

viewing has undergone significant refinement and adaptation. T h e first text describing the

HISTORICAL BACKGROUND Clinical Development of Approach

approach in great detail appeared in 1 9 9 1 (Miller & Rollnick, 1 9 9 1 ) . Subtitled People

to Change

Addictive

Preparing

Behaviors,

this

manual focused specifically on how to effec-

Although the principles o f motivational

tively prepare individuals with substance abuse

interviewing are seen today as generalizable to

and dependence problems to make self-directed

PRACTICAL ISSUES or

new

J a c k s o n , W a n g , Dudley, 8c B a r a n o w s k i ,

approach was also described in a Treatment

assisted changes. This innovative

2 0 0 1 ; Resnicow et al., 2 0 0 0 ) , medication

Improvement Protocol (TIP) series manual

compliance (Schmaling, Blume, 8c Afari,

distributed by the U.S. Department of Health

2 0 0 1 ) , H I V infection protective behaviors

and Human Services (Miller, 1 9 9 9 ) , and a

(Carey et al., 2 0 0 0 ) , t o b a c c o use (Butler et al.,

treatment manual was prepared for the moti-

1 9 9 9 ) , mammography

screening (Ludman,

vational enhancement condition of Project

Curry, Meyer, 8c Taplin, 1 9 9 9 ) , engagement

MATCH

in treatment for bulimia nervosa (Treasure

(National Institute

on A l c o h o l

Abuse and Alcoholism, 1 9 9 5 ) . Building on

et

work to develop a brief method o f motiva-

Heckemeyer, Kratt, 8c M a s o n , 1 9 9 7 ) , dia-

tional interviewing for physicians counseling

betes self-care (Trigwell, Grant, 8c House,

patients

(Butler

et

al.,

1 9 9 9 ; Rollnick,

al.,

1999),

weight

control

(Smith,

1 9 9 7 ) , and even water disinfecting practices

Heather, 8c Bell, 1 9 9 2 ) , Rollnick, M a s o n , and

for

Butler ( 1 9 9 9 ) published a text describing a

sources (Thevos, Quick, 8c Yanduli, 2 0 0 0 ) .

model o f brief motivational

enhancement

individuals

living near unsafe

water

Reviews o f the available motivational

intervention for physicians that retains the

interviewing

spirit o f motivational interviewing while sim-

because motivational interviewing is more o f

plifying the technique for applications in more

a counseling style than a set of techniques

brief encounters. Finally, Miller and Rollnick

a collection o f tasks.

(2002)

ventions may vary significantly in

produced

an extensive revision o f

literature

are

challenging or

This means that interform,

the original motivational interviewing text,

including the setting for the intervention (e.g.,

this time reflecting the broad popularity o f

emergency room, therapy office, physician's

the

negotiating

style

by

describing

the

exam room) and structure (e.g., duration of

approach as a more general strategy appli-

interaction), while still retaining the style or

cable to patients who might be ambivalent

spirit

about any behavior change, not just changing

this flexibility almost certainly accounts for

addictive behavior.

some o f the popularity o f the motivational

o f motivational interviewing. Although

interviewing approach as a clinical tool, it creates difficulties for making

Empirical Support

inferences

about exactly which interventions have which

Since the release of the original detailed manual (Miller & Rollnick, 1 9 9 1 ) , numerous

effects. Nonetheless, three reviews o f this literature have been attempted.

clinical trials investigating motivational inter-

Noonan and Moyers ( 1 9 9 7 ) performed a

viewing interventions or related adaptations

qualitative review o f the available clinical trials

have appeared in the literature. A regularly

that

updated

of

substance use problems. They reviewed 11

motivational interviewing literature lists more

randomized trials and concluded that 9 studies

comprehensive

bibliography

applied motivational interviewing

to

than 6 0 reports of clinical outcome studies,

supported the efficacy of motivational inter-

and most o f these are randomized

viewing for substance abuse and dependence

(www.motivationalinterview.org).

trials

Although

problems.

the majority o f these reports focus on appli-

A more comprehensive review was con-

cations with substance use, applications o f

ducted by Dunn and colleagues ( 2 0 0 1 ) . They

interven-

attempted to capture the diverse nature of

tions to other behavioral problems include

brief motivational enhancement

motivational interviewing approaches while

problem

retaining internal validity o f the interventions

gambling

el-Guebaly,

2001),

(Hodgins, nutrition

Currie,

8c

(Resnicow,

by

defining Adaptations

o f Motivational

Motivational Interviewing (AMIs). T o qualify as an A M I ,

Enhancement

Interventions

\

treatment and a stand-alone treatment for

an intervention had to claim to adhere to

patients with alcohol problems. Studies o f

basic principles o f motivational interviewing.

A M I s applied to problems o f tobacco use,

Consistent with a definition o f motivational

illicit drug use, diet/exercise, and eating disor-

interviewing offered by Rollnick and Miller

ders were reported to be encouraging but too

( 1 9 9 5 ) , this meant that the intervention had to

sparse to make strong findings or recommen-

use a client-centered empathie style to reduce

dations. N o support was found for the use o f

resistance, develop motivational

A M I s to reduce H I V risk behaviors. T h e

discrepan-

cies, and support the patient's self-efficacy. A

authors concluded that reasonable evidence

structure most often used in A M I s incor-

supports the use o f A M I s as both a stand-

porates some sort o f review o f assessment

alone intervention and a treatment adjunct at

feedback as the focus o f the interview, while

the onset o f other treatment. Although the

the counselor uses an interpersonal style and

data are fairly consistent that A M I s are effica-

strategies consistent with motivational inter-

cious, the data are very unclear as to how,

viewing to facilitate the processing o f the feed-

why, and for w h o m the interventions work.

back and to elicit self-motivational statements (e.g., Miller, Sovereign, & Krege, 1 9 8 8 ) . Using this definition o f A M I s and other exclusion criteria regarding study design and outcome measurement, Dunn and colleagues ( 2 0 0 1 ) found 2 9 studies for inclusion in their review.

VARIATIONS OF MOTIVATIONAL ENHANCEMENT INTERVENTIONS As noted previously, motivational interviewing

T h e Dunn and colleagues ( 2 0 0 1 ) review

rarely exists in "pure" form in the empirical

included applications o f A M I s in four different

literature, and it seems likely that this is also

behavioral change contexts: substance use,

reflected in clinical practice. For example, the

tobacco use, H I V risk behaviors, and diet/

2 9 studies reviewed by Dunn and colleagues

exercise. These investigators found that 6 0 %

( 2 0 0 1 ) used eight different labels other than

of the studies reviewed had significant effect

"motivational interviewing" to describe their

sizes favoring the A M I . T h e most consistent

interventions. Furthermore, the durations of

evidence for A M I effectiveness was observed

the interventions ranged from 5 to 3 6 0 min-

where the A M I was used as an enhancement

utes. Clinicians in practice, receiving little

to standard treatment for substance use when

direct guidance from the heterogeneous empir-

delivered at the onset o f a treatment episode.

ical literature, are likely to create motivational

The findings for applications for t o b a c c o use,

enhancement motivations customized to their

H I V risk, and diet/exercise were more mixed

patient

but still encouraging, and more research was

encountered, and settings. T h e purpose of this

recommended.

section is to introduce a few prevailing models

T h e third review o f the motivational inter-

populations,

behavioral

of motivational enhancement

problems

interventions

viewing literature was conducted by Burke,

and to introduce key principles from motiva-

Arkowitz, and Dunn ( 2 0 0 2 ) . Using a similar

tional interviewing that would be required

approach to that used by Dunn and colleagues

to capture the spirit o f the

( 2 0 0 1 ) , but with slightly more restrictive

interviewing style.

motivational

inclusion criteria, these investigators identified

Rollnick and colleagues ( 2 0 0 2 ) attempted

2 6 randomized trials o f an A M I for review.

to add clarity to the varieties o f A M I s that

This review reached similar conclusions, with

exist in the literature and in practice. According

the most impressive findings emerging for

to their framework, brief motivational enhance-

A M I s as both a treatment adjunct to standard

ment interventions could be categorized as one

PRACTICAL ISSUES of three general types o f intervention: (a) brief

typically longer in duration and may involve

advice, (b) behavior change counseling, and

more than one problem area. T h e practitioner

(c) motivational interviewing. W h a t

these

and the patient typically share a more equal

share in c o m m o n could be considered the

role in the decision-making and goal-setting

core of effective motivational

process. Using a person-centered

enhancement

approach,

interventions—a nonconfrontational style and

the practitioner often uses open-ended ques-

a goal of eliciting change from within the

tions and reflection to understand the patient's

patient rather than imposing from the outside

perspective and to check for understanding.

via blaming, coercion, or direct persuasion.

Information typically flows in both directions

several

between the practitioner and the patient, in

domains, including the duration o f the consul-

contrast to the one-way flow seen with brief

tation, the role o f the practitioner, the use o f

advice. M o s t often, the goal is to elicit a deci-

The

approaches

may

differ

on

confrontation, and the use o f direct informa-

sion and plan for change in a more pragmatic

tion. Rollnick and colleagues also attempted

sense than in motivational interviewing, where

to describe the skill sets necessary for each o f

one tries to enhance the quality and commit-

these types o f intervention, with more com-

ment of the plans for change as well.

plex and varied skills necessary for the longer

Rollnick and colleagues ( 1 9 9 9 ) described a

and more complex interaction o f motivational

model o f behavior change counseling based on

interviewing.

earlier work trying to develop "brief motivational interviewing" (Rollnick et al., 1 9 9 2 ) . Designed for nonspecialists working in time-

Brief Advice

pressured settings such as primary care clinics,

Rollnick and colleagues ( 2 0 0 2 ) described

this model simplifies the goals and strategies of

brief advice as a typically brief (less than 15

the behavior change consultation. After estab-

minutes) opportunistic intervention delivered

lishing basic rapport and setting an agenda for

by nonspecialists in behavior change counsel-

the consultation, the practitioner's task is to

ing. T h e goals are typically to raise awareness

explore the patient's feelings about a behavior

of a behavioral problem and to initiate at

change using two dimensions: importance and

least contemplation of change.

Information

confidence. In this model, these two dimen-

exchange is largely one-way, from practitioner

sions adequately capture the nature o f ambiva-

to patient. Goals for behavior change are often

lence, and

suggested rather than elicited. Although the

likelihood of both a change attempt and a

enhancing

both

increases

the

with

successful outcome. Throughout the consulta-

motivational interviewing, the practitioner can

tion, the practitioner may exchange informa-

maximize the motivational impact of the infor-

tion (as in brief advice) or use interpersonal

inequality o f roles is not consistent

mation and advice by carefully choosing a good

strategies to reduce resistance (as in motiva-

opportunity for the intervention,

tional interviewing).

presenting

information in a respectful and compassionate

O n e very creative technique recommended

manner, and using at least some open-ended

as part o f this intervention model is the use o f

questions and reflections.

scaled questions (e.g., 1 to 1 0 0 ) for assessing the importance o f a behavior change and con-

Behavior Change Counseling Behavior change counseling, as described by Rollnick and colleagues ( 2 0 0 2 ) is an approach

fidence in making a change. For example, the practitioner might ask " I f 0 is 'not important at all' and 1 0 0 is 'very important,' number

would

you

say represents

what how

somewhere between brief advice and "pure"

important it is to you now to change

motivational interviewing. T h e consultation is

Whatever answers a patient might provide to

?"

Motivational

Enhancement

Interventions

|

these types o f questions, the answers provide

opportunistic planned encounters that normally

great fodder for reflection, amplification, and

last longer than 3 0 minutes and often span

investigation. T h e patient typically will give a

more than one session. Motivational inter-

number somewhere between the extremes.

viewing requires the full complement o f skills

For the question o f importance, this would

and strategies as well as adherence to the core

allow the practitioner

principles o f motivational interviewing (Miller

to follow up

this

answer to identify concerns the patient may

& Rollnick, 2 0 0 2 ) . Confrontational style is

have about his or her behavior (e.g., " Y o u

always avoided, and direct advice is usually

said ' 4 0 ' . W h y not lower? W h a t makes it ' 4 0 '

provided only when directly requested by the

in i m p o r t a n c e ? " ) o r to identify

in

patient. Communication is used more strategi-

knowledge/awareness or other priorities the

cally, with the goal o f creating motivational

patient may have (e.g., " W h y is the number

discrepancies, resolving ambivalence, and elic-

gaps

not higher? W h a t would it take for you to

iting self-motivational statements (or "change

increase the importance o f this change?"). For

talk") from the patient.

the response to a scaled question about confi-

Miller and Rollnick ( 2 0 0 2 ) defined moti-

dence, the practitioner may follow up with

vational interviewing as " a client-centered,

questions or reflections to explore barriers

directive method for enhancing intrinsic moti-

perceived by the patient (e.g., " Y o u rated

vation to change by exploring and resolving

your confidence as ' 6 0 ' . W h y not ' 7 0 ' or

ambivalence"

' 8 0 ' ? " ) or to identify skills or resources the

viewing has also been described as " a coun-

patient

may have available to support a

change effort (e.g., " Y o u rated your confi-

seling style

(p. 2 5 ) . Motivational

inter-

rather than a set o f techniques

applied to or on people" (Rollnick, 2 0 0 1 , p.

dence as ' 4 0 ' . Y o u must feel that there is some

1 7 6 9 , emphasis added). Although a number

chance you could do it if you tried. W h y ? " ) .

of

The Rollnick and colleagues ( 1 9 9 9 ) brief

techniques

and

strategies

are

recom-

mended as consistent with motivational inter-

other

viewing, other strategies could be used so

strategies for exploring importance, building

long as they are consistent with the principles

confidence, assessing readiness for change,

and style o f motivational interviewing. In

and making strategies for change. As with all

fact, adaptation and creative application of

intervention

model includes several

brief behavior change counseling A M I s , prac-

the principles are encouraged. Motivational

titioners are encouraged to capture the spirit

interviewing in practice, unlike other manual-

o f motivational interviewing in their interac-

ized treatments, might not necessarily have a

tions with clients by using a supportive and

structured beginning, middle, and end but

nonconfrontational

and

instead may occur at various times during a

style to minimize

are

treatment relationship between practitioner

encouraged to choose from the menus o f

and patient. It may be left and revisited or

strategies to create an adaptation that fits their

may be integrated with an ongoing treatment

needs and settings rather than adopting

plan. Motivational interviewing is not some-

respond

to

resistance.

Practitioners

a

thing to be done to patients but rather is a

formulaic treatment approach.

way of being with patients (Miller, 2 0 0 2 ) .

Motivational Interviewing Rollnick and colleagues ( 2 0 0 2 ) described "pure" motivational interviewing as the most c o m p l e x and

involved approach

to

brief

Fundamentals Motivational Essential

of Interviewing

Spirit. Miller and Rollnick ( 2 0 0 2 )

motivational enhancement. Applications o f

described the spirit o f motivational interview-

motivational interviewing are typically less

ing as "understanding and experiencing the

PRACTICAL ISSUES human nature that gives rise to that way o f

behavioral strategies to guide the practitioner.

being" and as absolutely fundamental to any

The principles are not necessarily meant to be

intervention that might claim to be motiva-

initiated in order or in equal amounts but

tional interviewing or a reasonable adapta-

rather are intended to be skillfully and ele-

tion. H o w the practitioner thinks about the

gantly woven together during and throughout

patient and the process is as important as any

the process o f the interview.

technique in determining the nature o f the intervention. Miller and Rollnick

further

The first principle is expressing

empathy.

Probably nowhere is it more important than

described the spirit of motivational interview-

here that one believes in the spirit of motiva-

ing as captured by three fundamental con-

tional interviewing. This principle builds on

siderations: (a) a collaborative relationship,

classic work by Rogers ( 1 9 5 1 , 1 9 6 1 ) and

rather than an authoritarian or prescriptive

assumes that acceptance of patients as they are

relationship, between the practitioner and the

paradoxically makes it easier for them to

patient; (b) an eliciting evocative approach

change. As with Rogers's approach, careful

rather than a persuasive or educative stance;

reflective listening is the key to communicating

and (c) a commitment to the ultimate auton-

empathy to the client. T h e practitioner may use

omy o f the patient to make decisions about

a number of familiar listening skills, including

change and to marshal personal resources for

open-ended questions, a variety o f reflective

change. These considerations are mutually

statements, and nonverbal behaviors. Reflec-

consistent in their respect for the patient's free-

tive listening simultaneously accomplishes

dom of choice as well as competence and

several goals, including encouraging elabora-

expertise in his or her own life.

tion by the patient (which aids in understanding by the practitioner by eliciting data) and

Phases

of the Interview.

A comprehensive

communicating to the patient both an effort to

and complete motivational interview would

understand and ultimately greater understand-

include two overlapping phases: increasing

ing for the practitioner o f the patient. This

motivation for change (Phase 1) and strength-

behavior often prevents resistance from the

ening commitment to a decision for change

outset o f the interview because typical behav-

(Phase 2 ) (Miller & Rollnick, 2 0 0 2 ) . Phase 1

iors that would be likely to elicit resistance

typically involves strategies for building rap-

(e.g., direct persuasion, confrontation, appeals

port; increasing problem recognition; and

to authority) are avoided altogether.

identifying, exploring, and resolving the vari-

How

one thinks about the nature o f

ous aspects o f patient ambivalence. Phase 2

ambivalence is a key to demonstrating empa-

typically involves tasks such as goal setting,

thy in motivational interviewing. Ambivalence

making behavioral plans, and negotiating time

about behavior change is normal and natural,

lines while being careful to avoid roadblocks

and it occurs for most behavior changes

to a successful change attempt (e.g., unrealis-

involving habitual behavior patterns, includ-

tic goals, underestimated

ing changing addictive behaviors. Change is

effort,

shallow

commitment).

difficult.

T h e status

quo is comfortable.

Patients have frequently had either direct or Refinements to Miller's

modeled failure experiences involving behav-

( 1 9 8 3 ) original description o f motivational

ior change. If one sees ambivalence about

interviewing have resulted in the distillation

change as normal and natural rather than as a

of four fundamental

sign o f pathology, immorality, or other unde-

Four

Principles.

principles (Miller

&

Rollnick, 2 0 0 2 ) . These principles help to trans-

sirable personality characteristics, it immedi-

late the spirit o f motivational interviewing into

ately becomes much easier to be comfortable

Motivational with

understanding

and

exploring

that

Enhancement

T h e final principle, supporting refers to communicating

experience.

|

Interventions

self-efficacy,

a belief in

the

discrepan-

patient's ability to be an agent o f change

cies, involves understanding and amplifying dif-

on his or her own behalf. This principle is

ferences between the patient's current behavior

sometimes manifest subtly by the

and his or her goals, values, and/or self-image

tioner's implicit belief in the patient's role in

(Miller &c Rollnick, 2 0 0 2 ) . This discrepancy

the change process. W h e n the patient

serves as a motivating force that can be used to

treated as the ultimate decision maker and as

elicit self-motivational statements. If an individ-

a collaborative partner in exploring change,

The second principle, developing

practiis

ual perceives a behavior as inconsistent with

a belief in the patient's ability to change is

other important

assumed.

goals, the probability o f

change increases. Enhancing

motivational

Also,

when

the

practitioner

inquires in a sincere way as to h o w a patient

the

might go about making a change, this implies

behaviors;

a belief in the patient's o w n resources and

increasing the importance of behaviors, values,

ideas. A number o f more explicit strategies

or goals inconsistent with this current behavior;

can also be employed, including reviewing

or both. T h e patient's current

past successes or models, amplifying

discrepancies may

involve decreasing

importance of current unhealthy

behavioral

sonal strengths, brainstorming

attempt among various behaviors, goals, and

and even occasionally giving direct advice

values that are often conflicting. T h e practi-

(Miller & Rollnick, 2 0 0 2 ) .

tioner's goal is to tip that balance in the direction o f change.

interviewing

itself,

most

resis-

investigations o f motivational enhancement

is a hallmark principle that truly sepa-

approaches have used assessment feedback

T h e third principle, responding tance,

ideas,

Although not inherent

Use of Feedback. to motivational

new

per-

patterns are seen as the result o f a balancing

to

rates motivational interviewing from

most

as part o f the process (Dunn et al., 2 0 0 1 ) .

other approaches and is probably the most

Feedback may include information

innovative aspect o f the approach. As men-

health status, presence or absence o f disease

tioned previously, resistance is viewed as the

states, and

result o f the interpersonal process, or the way

data. These data provide a useful start to

in which the practitioner is interacting with

conversations about change. Reviewing per-

the patient at that moment, rather than as a

sonalized feedback with a patient provides

comparisons

with

about

normative

characteristic o f the patient himself or herself.

many opportunities to explore concerns a

resistance; people are not

patient may have about his or her current

Interactions create

resistant. F r o m this perspective, it follows

behavior

or health

that the practitioner holds responsibility for

feedback

happens frequently

creating conditions in the interpersonal inter-

medicine settings, providing

action to reduce resistance. W h e n resistance is

with

encountered in the interview, the practitioner

motivational enhancement strategies. Objec-

sees that as a signal to change strategies rather

tive feedback alone, especially if it contains

than as a signal to press onward as in con-

bad or anxiety-provoking news, is likely to

numerous

status. T h i s type o f in

behavior

practitioners

rich opportunities

to

use

frontational or persuasive approaches. Because

be experienced by the patient as confrontive

of the paramount importance and complexity

and to elicit resistance. Use o f a motivational

of the task o f responding to resistance, Miller

interviewing style and strategies when review-

and Rollnick ( 2 0 0 2 ) offered several strategies

ing the feedback can aid in the patient's ability

for accomplishing this task. These are summa-

to process the information and use it effec-

rized in Table 4 . 1 .

tively to motivate change.

49

PRACTICAL ISSUES Table 4.1

Examples of Various Useful Methods for Responding to Resistance

Method

Description

Example

Reflective methods Simple reflection Amplified reflection

Double-sided reflection

Statement that reflects observed resistance Restatement of what was heard in exaggerated form Restatement of both sides of ambivalence

"You would rather not talk about your weight." "You would rather never talk about your weight. It doesn't concern you at all." "On the one hand, it's embarrassing to talk about your weight, and on the other, you are worried about it and would like to ask for help."

Strategic methods Shift focus

Change in focus of interaction

Reframe

Giving new interpretation to patient's perspective

Agree with a twist

Agreeing with part of patient's message while reframing another part

Emphasize personal control

Reaffirming patient's ultimate freedom of choice

Coming alongside

Taking patient's side of the ambivalence to encourage him or her to voice the other side

"Let's not worry about what I think right now; let's just talk about any concerns you might have." "You say you've tried and failed many times. It sounds like you have tremendous persistence and courage to keep trying." "Food is your favorite form of recreation, and it's important to enjoy life, even if it is causing you health problems." " O f course it's up to you what to do next. No one can make the decision for you." "You're right that it would be difficult to change—maybe impossible."

S O U R C E : Miller and Rollnick (2002). Reprinted with permission.

Training in Motivational Enhancement Interventions

behavior change counseling and motivational interviewing, require more complex skills and strategies that can probably be learned only

The varieties o f motivational enhancement

through training and supervision. Reflective

interventions require a diverse set o f skills that

listening alone is a deceptively complex set

vary in complexity depending on the type of

of skills to master and is made even more

intervention employed (Rollnick et al., 2 0 0 2 ) .

complex by the strategic use o f listening in

For very brief advice encounters, basic knowl-

motivational interviewing. In motivational

edge about risks of the current

interviewing, the practitioner is not simply

behavior,

behavior change strategies, and rudimentary

expected to mindlessly parrot

open-ended

appreciation for the spirit o f motivational

questions and reflections for the sake o f ongo-

interviewing likely are all that are required.

ing dialogue but rather is expected to ask

The more complex interventions, including

particular

questions

and

make

selective

Motivational

Enhancement

Interventions

reflective statements to promote motivation

deal o f thought and energy to training. Both

for change (Rollnick et al., 2 0 0 2 ) .

versions o f the motivational

Limited information

is available in the

empirical literature on appropriate

training

interviewing

text (Miller & Rollnick, 1 9 9 1 , 2 0 0 2 ) included sections on teaching and learning the approach.

or on the effects o f training. O f 2 9 studies

Over the past several years, Miller and

reviewed by Dunn and colleagues ( 2 0 0 1 ) , only

Rollnick have annually provided

1 0 reported the durations of training provided

training for professionals already proficient in

to practitioners in the studies, and the dura-

the method to become trainers in the tech-

intensive

tions o f that training ranged from 2 to 3 1

nique. M e m b e r s o f this group also stay in

hours. In addition, 11 o f the studies reported

regular contact with each other via an e-mail

providing training but offered few details, and

listserv, a regular newsletter, and an annual

8 of the studies did not include any informa-

meeting. A list o f these "trained trainers" is

tion about training. T w o other studies have

available on the motivational interviewing

examined the effects o f training on the knowl-

W e b site (www.motivationalinterview.org).

edge and skills of trainees directly. T h e first

Miller ( 2 0 0 2 ) proposed a tiered system o f

study found that professional participants did

training as shown in T a b l e 4 . 2 . This system

demonstrate

would allow individuals to tailor the neces-

increases in knowledge

about

motivational interviewing and basic listening

sary training for their setting and

skills in a simple pre-post

needs. Individuals interested in applying the

design (Rubel,

patient

Sobell, & Miller, 2 0 0 0 ) . A second study found

approach to a specific behavioral domain and

that a 2-day workshop on motivational inter-

narrowly defined patient population could do

viewing had significant effects on self-reports

with less training than those interested in a

of motivational interviewing by trainees and

more broad application o f the approach and

had modest gains in skill use demonstrated

certainly could do with less training than those

on observed practice samples, but expected

interested in having the expertise to provide

changes in client behavior were not observed

training.

(Miller &c M o u n t , 2 0 0 1 ) .

Unfortunately,

although participants in this study did modestly increase their frequency o f motivational interviewing consistent strategies, they did not necessarily decrease their use of

inconsistent

strategies. This is o f great concern because it may take only very few confrontational interactions to resurrect resistance and spoil the potential gains of motivational strategies. These preliminary results are

encouraging

but insufficient to make recommendations on empirical grounds for a necessary amount o f training

for

competent

practice.

Further

research is warranted and would be aided by the development o f reliable and valid methods for assessing skill acquisition (Barsky

&

Coleman, 2 0 0 1 ) .

At a minimum, any practitioner interested in applying an approach based on the principles o f motivational

interviewing

should

read one or m o r e o f the available manuals described earlier. Further training could be obtained via introductory workshops available at m a n y national and regional professional conferences. M o r e intensive training could be arranged from one o f the network of trainers. T h e best possible training will occur with opportunities for practice with feedback, both with role-play exercises and with actual cases (Miller & Rollnick, 2 0 0 2 ) . Finally, even after formal training in motivational interviewing, a great deal o f learning can occur by carefully observing the effect o f one's counseling approach on clients. Miller

other

( 1 9 9 6 ) described motivational interviewing

empirical treatments, the originators o f moti-

as an approach he "had learned from [his]

vational interviewing have devoted a good

clients" (p. 8 3 5 ) .

Unlike the originators

o f many

51

PRACTICAL ISSUES Table 4.2

Miller's Proposed Tiered System for Levels of Training in Motivational Interviewing

Type of Training

Goals

Approximate

Introduction to motivational interviewing

Learn about the basics of motivational interviewing and decide level of interest in learning more.

2 hours to 1 day

Application of motivational interviewing

Learn about more specific applications of motivational interviewing, including direct practice with a particular application.

1 hour to 1 day

Clinical training

Learn basic style of motivational interviewing, including extended practice. Strengthen empathie listening skills. Learn to recognize client cues for resistance and change talk.

2 to 3 days or several 4- to 8-hour seminars

Advanced training

Learn advanced clinical usefulness of motivational interviewing. Receive individual feedback on intensive practice. Learn methods of evaluating motivational interviewing. Update knowledge of research developments.

2 to 3 days (plus prior minimum proficiency)

Training for trainers

Learn a flexible range of skills for helping others learn motivational interviewing. Learn to assess needs of trainees and adapt accordingly. Update knowledge of research developments.

3 days

Length

S O U R C E : Miller (2002). Reprinted with permission.

SUMMARY Motivational

that the approach is deceptively complex and intricate, and training and supervision are enhancement

interventions

recommended for individuals interested in

based on the style and principles o f motiva-

developing

tional interviewing have enjoyed increasing

Creative adaptations

proficiency

in

the

methods.

popularity over the past decade. Some have

caution is also warranted before implementing

even expressed concern that the clinical pop-

radical departures (e.g., group motivational

ularity o f the approach may be inappropriate

interviewing, computer-guided

given the young nature o f the empirical

interviewing) until further research can evalu-

are encouraged,

but

motivational

literature (Dunn et al., 2 0 0 1 ) . Although the

ate whether these innovative adaptations can

extant empirical literature is encouraging

demonstrate similar efficacy. Practitioners are

and largely supportive o f the effectiveness o f

further cautioned that if aspects o f current

motivational

interventions,

intervention attempts with patients are incon-

much more research is needed to better under-

sistent with motivational interviewing style,

enhancement

stand how, why, when, and for w h o m the

it is unlikely that simply adding new strategies

approach can be effective.

to the repertoire will be effective. For some,

T h e clinical popularity o f this approach is

it may be necessary to abandon old strategies

expected to continue. Practitioners interested

of confrontation, coercion, and

in applying the principles o f motivational

to achieve better outcomes with motivating

persuasion

interviewing with their patients are cautioned

patient health behavior change.

Motivational

Enhancement

Interventions

REFERENCES Barsky, Α., & Coleman, H. (2001). Evaluating skill acquisition in motivational interviewing: The development of an instrument to measure practice skills. Journal of Drug Education, 31, 6 9 - 8 2 . Burke, B . L., Arkowitz, H., & Dunn, C. (2002). The efficacy of motivational interviewing and its adaptations: What we know so far. In W. R. Miller 8t S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (pp. 2 1 7 - 2 5 0 ) . New York: Guilford. Butler, C , Rollnick, S., Cohen, D., Russell, I., Bachmann, M., & Stott, N. (1999). Motivational consulting versus brief advice for smokers in general practice: A randomised trial. British Journal of General Practice, 49, 6 1 1 - 6 1 6 . Carey, M. P., Braaten, L. S., Maisto, S. Α., Gleason, J . R., Forsyth, A. D., Durant, L. E., &c Jaoworski, B . C. (2000). Using information, motivational enhancement, and skills training to reduce the risk of HIV infection for low-income urban women: A second randomized clinical trial. Health Psychology, 19, 3 - 1 1 . DiCicco, L., Unterberger, H., & Mack, J . E. (1978). Confronting denial: An alcoholism intervention strategy. Psychiatric Annals, 8, 5 9 6 - 6 0 6 . Dunn, C , Deroo, L., & Rivara, F. P. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains: A systematic review. Addiction, 96, 1 7 2 5 - 1 7 4 2 . Hodgins, D. C , Currie, S. R., &c el-Guebaly, N. (2001). Motivational enhancement and self-help treatments for problem gambling. Journal of Consulting and Clinical Psychology, 69, 5 0 - 5 7 . Ludman, E. J . , Curry, S. J . , Meyer, D., & Taplin, S. H. (1999). Implementation of outreach telephone counseling to promote mammography. Health Education and Behavior, 26, 6 8 9 - 7 0 2 . Miller, W . R. ( 1 9 8 3 ) . Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11, 1 4 7 - 1 7 2 . Miller, W. R. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98, 8 4 - 1 0 7 . Miller, W. R. (1996). Motivational interviewing: Research, practice, and puzzles. Addictive Behaviors, 21, 8 3 5 - 8 4 2 . Miller, W. R. (Ed.). (1999). Enhancing motivation for change in substance abuse treatment (Treatment Improvement Protocol Series, No. 3 5 , DHHS Publication No. (SMA) 0 0 - 3 4 6 0 ) . Rockville, M D : Center for Substance Abuse Treatment. Miller, W. R. (2002, January 1). From the desert. Motivational Interviewing Newsletter: Update, Education, and Training, pp. 1-2. (Albuquerque, N M : Motivational Learning Network of Trainers) Miller, W. R., & Mount, K. A. (2001). A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioral and Cognitive Psychotherapy, 29, 457—471. Miller, W. R., 8c Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviors. New York: Guilford. Miller, W. R., &C Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: Guilford. Miller, W. R., Sovereign, R. G., & Krege, B. (1988). Motivational interviewing with problem drinkers: II. The Drinker's Check-Up as a preventive intervention. Behavioural Psychotherapy, 16, 2 5 1 - 2 6 8 . National Institute on Alcohol Abuse and Alcoholism. (1995). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Project M A T C H Monograph

PRACTICAL ISSUES Series, NIH Publication No. 94-3723). Rockville, M D : U.S. Department of Health and Human Services. Noonan, W. C , & Moyers, T. B . (1997). Motivational interviewing: A review. Journal of Substance Misuse, 2, 8 - 1 6 . Prochaska, J . O., DiClemente, C. C , & Norcross, J . C. (1992). In search of how 47, people change: Applications to addictive behaviors. American Psychologist, 1102-1114. Resnicow, K., Jackson, Α., Wang, T., Dudley, W., & Baranowski, T. (2001). A motivational interviewing intervention to increase fruit and vegetable intake through black churches: Results of the Eat for Life trial. American Journal of Public Health, 91, 1 6 8 6 - 1 6 9 3 . Resnicow, K., Wallace, D. C , Jackson, Α., Digirolamo, Α., Odom, E., Wang, T., Dudley, W. N., Davis, M., Mitchell, D., & Baranowski, T. (2000). Dietary change through African American churches: Baseline results and program description of the Eat for Life trial. Journal of Cancer Education, IS, 1 5 6 - 1 6 3 . Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton Mifflin. Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin. Rollnick, S. (2001). Enthusiasm, quick-fixes and premature controlled trials. Addiction, 96, 1 7 6 9 - 1 7 7 0 . Rollnick, S., Allison, J . , Ballasiotes, S., Barth, T., Butler, C , Rose, G. S., & Rosengren, D. B. (2002). In W. R. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (pp. 2 7 0 - 2 8 3 ) . New York: Guilford. Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 2 5 - 3 7 . Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change. London: Churchill Livingstone. Rollnick, S., &c Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 3 2 5 - 3 3 4 . Rubel, E. C , Sobell, L. C , & Miller, W. R. (2000). Do continuing education workshops improve participants' skills? Effects of a motivational interviewing workshop on substance-abuse counselors' skills and knowledge. The Behavior Therapist, 23, 7 3 - 7 7 . Schmaling, K. B., Blume, A. W., & Afari, N. (2001). A randomized controlled pilot study of motivational interviewing to change attitudes to medications for asthma. Journal of Clinical Psychology in Medical Settings, 8(3), 1 6 7 - 1 7 2 . Smith, D. E., Heckemeyer, C. M., Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM: A pilot study. Diabetes Care, 20, 5 3 - 5 4 . Thevos, A. K., Quick, R. E., & Yanduli, V. (2000). Application of motivational interviewing to the adoption of water disinfection practices in Zambia. Health Promotion International, 15, 2 0 7 - 2 1 4 . Treasure, J . L., Katzman, M., Schmidt, U., Troop, N., Todd, G., & de Silva, P. (1999). Engagement and outcome in the treatment of bulimia nervosa: First phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy. Behaviour Research and Therapy, 37, 405—418. Trigwell, P., Grant, P. J . , 8c House, A. (1997). Motivation and glycémie control in diabetes mellitus. Journal of Psychosomatic Research, 43, 3 0 7 - 3 1 5 .

CHAPTER

5

Brief Psychotberapies and Group Treatments in General Health Care Settings DEBORAH J . WIEBE, LINDSEY BLOOR, AND TIMOTHY W . SMITH

O

ver the past 3 0 years, evidence has

application of basic research in behavioral

continued

demon-

medicine and health psychology has itself been

strating that medical conditions both

the focus of an expanding body o f research.

affect and are affected by psychosocial fac-

Although the findings are not uniformly sup-

tors. Behavioral habits o f daily life, such as

portive, there is clear evidence that psychother-

to

accumulate

physical activity, smoking, and diet, clearly

apy and other approaches to behavior change

affect the risk of developing the most c o m -

can be useful additions to routine medical care,

m o n sources o f morbidity and mortality (e.g.,

both in the reduction o f unhealthy risky behav-

coronary heart disease, cancer, diabetes) as

ior and in the management of the psychosocial

well as the course of such conditions. Other

impacts of medical conditions (Smith, Kendall,

psychosocial factors, such as stressful

life

& Keefe, 2 0 0 2 ) . In some cases, such interven-

personality

tions are useful as primary or secondary treat-

characteristics, and chronic negative emo-

ments for the underlying medical conditions

tions, affect the development and course o f

themselves.

circumstances, social support,

these same conditions through more direct

This

chapter

psychobiological mechanisms. Finally, most

approach

that

acute and chronic medical conditions influ-

efforts (i.e., the biopsychosocial model [Engel,

ence emotional adjustment, personal relation-

1977]) and provides examples o f the wide vari-

reviews

underlies

the

conceptual

such

intervention

ships, w o r k and other aspects o f functional

ety o f brief and group interventions used across

activity, and overall quality of life.

medical conditions and settings. A comprehen-

One clear implication of the bidirectional

sive review is clearly beyond the current scope,

associations between psychosocial factors and

but the chapter does describe the nature and use

physical health is that psychosocial interventions

of such interventions in general health care

might be useful in the prevention and man-

settings and also reviews evidence of their effi-

agement of medical conditions. This clinical

cacy and effectiveness. T h e skills and training

PRACTICAL ISSUES necessary for the translation of traditional brief

In an influential critique o f the prevailing

psychotherapy and group treatment interven-

biomedical model as t o o simplistic and reduc-

tions into the unique culture and context of

tionistic to accommodate this increasing role

medical care are also discussed. T h e chapter

of psychological and social factors in the

begins with a brief history o f the developments

major sources o f morbidity and mortality,

that have created the opportunity—and even

Engel ( 1 9 7 7 ) argued that a

demand—for the expansion of general health

alternative is more appropriate. In this view,

biopsychosocial

care to include interventions traditionally con-

based in part on the general systems theory o f

ceptualized as mental health services.

V o n Bertalanffy ( 1 9 6 8 ) , health and illness are seen as emerging from the reciprocal interplay of hierarchically arranged levels o f analysis,

HISTORICAL DEVELOPMENTS

ranging from the molecular to the individual to the sociocultural, with several levels in

The growth in the importance o f psychosocial

between. F r o m a biopsychosocial perspective,

interventions for the prevention and manage-

understanding the source o f illness

ment o f medical conditions was set into

designing optimal approaches to medical care

motion by changing patterns o f disease over

requires this multisystem analysis. In this

the last half o f the 2 0 t h century. Until that

expanded

time, acute medical conditions (e.g., infec-

interventions have an obvious place.

and

conceptual model, psychosocial

tious diseases) were the leading cause o f death

Influential predecessors to the current array

in the United States (National Office o f Vital

of psychosocial interventions began to appear

Statistics, 1 9 4 7 ) . By the end o f the 2 0 t h cen-

early in the development o f the fields of behav-

tury, chronic conditions had c o m e to account

ioral medicine and clinical health psychology.

for more than 7 0 % o f all deaths, primarily

Growing epidemiological evidence o f the role

due to the effects o f coronary heart disease,

of smoking, excess body weight, and physical

cancer, and cerebrovascular disease (Centers

inactivity in cardiovascular disease and cancer

for Disease Control and Prevention, 1 9 9 9 ) .

prompted the application o f existing behavior

Certain behaviors (e.g., smoking, activity

change techniques to these health-relevant

levels) contribute to the risk o f these diseases,

targets

and given advances in medical care, patients

Shnidman, 1 9 7 1 ; Stuart, 1 9 6 7 ) . Advances in

(e.g., Shapiro, Tursky, Stuart,

&

suffering from these conditions can expect to

the physiology o f stress and its role in the

live long enough that coping with their many

development o f several medical disorders (e.g.,

impacts will become an important challenge.

hypertension) combined with the available

Finally, the management o f these and other

operant behavioral change methods to form

increasingly prevalent

conditions

the basis o f early biofeedback treatments for

typically involves many behavioral processes

several chronic conditions (e.g., Pickering &

(e.g., adherence

chronic

to prescribed

regimens,

Miller, 1 9 7 7 ) . Early research demonstrating

exercise-based rehabilitation, stress manage-

that the preoperative psychological state (e.g.,

ment interventions). Hence, patterns o f mor-

anxiety, coping behaviors) influenced

bidity and mortality have changed over the

postoperative

past century in such a way as to make psycho-

prompted the development o f brief, structured

social interventions an important component

psychosocial interventions for this population

course o f surgical

the

patients

of current health care. T h e parallel rise in

(Janis, 1 9 5 8 ) . Similarly, operant concepts and

health care expenditures has created additional

behavior change technology were successfully

incentives for effective additions to traditional

applied to the conceptualization and treat-

medical care (Kaplan & Groessl, 2 0 0 2 ) .

ment

o f chronic pain

(Fordyce,

1976).

Brief Psychotherapies Table 5.1

and Group

Treatments

Outline for the Clinical Application of the Biopsychosocial Model

I. Illness Factors A. B. C. D. E.

Pathophysiology Risk factors Prognosis Diagnostic procedures Treatment procedures

II. Patient Factors A. B. C. D. E.

D S M conditions (Axis I and Axis II) Impact of illness on distress, social and occupational functioning, and quality of life Conceptualization of disease and treatment Personality traits and coping styles Educational and vocational status

III. Social, Family, and Cultural Factors A. B. C. D.

Quality of marital and family relationships Use and efficacy of social support Relationships with the health care team Cultural background

IV. Health Care System Factors A. Health care setting and culture B. Insurance coverage and disability benefits for medical condition C. Geographical, social, psychological, and monetary barriers to accessing services S O U R C E : Adapted from Smith and Nicassio (1995). Copyright © 1 9 9 5 by the American Psychological Association. Adapted with permission.

Together, these and other brief interventions

this assessment is presented

in T a b l e 5.1

provided clear evidence o f the promise o f

(Smith &c Nicassio, 1 9 9 5 ) . This outline is not

extending traditional medical care to include

a formal procedural protocol but instead pro-

psychotherapy

vides a general orientation or viewpoint that

and other behavior change

approaches. As reviewed in what follows, the

guides more specific informal and

subsequent 3 0 years o f research has produced

assessment procedures.

formal

many examples o f innovative and valuable

T h e first category involves information

extensions of this prior work (Smith, Nealey, &

about the patient's specific illness or condi-

Hamann, 2 0 0 0 ) .

tion. T h e pathophysiology, relevant risk factors, natural history and prognosis o f the

Clinical Application of the Biopsychosocial Model

condition, and diagnostic and treatment procedures typically comprising its medical management are essential elements o f the patient's

T o be feasible and effective, any brief psy-

context and may help to prioritize specific

chosocial intervention with medical patients

intervention targets that could be usefully

must begin with an assessment based on the

addressed

biopsychosocial model. T h e results of such an

tions. T h r o u g h general experience and spe-

assessment identify not only important targets

cific collaborative discussions with

for intervention but also important moderating

members o f the multidisciplinary health care

factors and contextual issues. An outline for

team, the clinical health psychologist must

through psychosocial intervenother

PRACTICAL ISSUES acquire adequate knowledge o f the general

each o f these four general categories o f the

condition and its typical management as well

patient's "biopsychosocial presentation" can

as o f the patient's specific case.

appropriate interventions be identified and

Similarly, characteristics o f the patient can guide the identification o f specific, potential

implemented in a manner most likely to m a x imize their potential benefits to the patient.

intervention targets (e.g., depression, limitations in functional activity, knowledge o f the disease and its medical/surgical management) or can suggest important moderators o f the likely impact o f the condition (e.g., coping

Intervention Options for Psychologists in Health Care Settings

styles, vocational history and status). This

Clinical health psychologists choose inter-

information, in turn, guides the selection and

ventions from the full range of therapeutic

implementation o f specific interventions.

options available to professional psychology,

Although often overlooked in traditional

but unique features o f the medical setting can

medical assessments, the patient's social,

challenge the psychologist and shape the form

family, and cultural contexts can also identify

that interventions take. T h e diversity of medi-

potential targets for intervention (e.g., social

cal and psychological problems seen across

isolation, serious relationship conflict)

or

health care settings, each o f which is associated

resources to maximize the benefits o f other

with a complex bundle of biopsychosocial

interventions

(e.g., social support).

The

issues, requires the psychologist to be a broadly

strengths and weaknesses o f the patient's rela-

trained generalist. T h e time demands of health

tionships with key members o f the health care

care settings and the cost containment features

team and the patient's skills for managing and

of the health care system push the clinician to

improving those relationships (e.g., assertive-

be increasingly brief, efficient, and account-

ness) are also important considerations in

able. T h e interdisciplinary nature o f care and

selecting targets or methods for intervention.

the psychologist's place in the medical hierar-

T h e patient's cultural/ethnic background is

chy challenge the psychologist to be collabora-

also an important consideration, especially if

tive and resourceful in the delivery o f services.

it is different from that o f key members o f the

These features have resulted in a strikingly het-

health care team given that it can complicate

erogeneous and creative array of treatments.

effective communication and collaboration

As outlined in Table 5 . 2 , this sometimes daunt-

over the long periods

ing set of treatment issues and options can be

o f time typically

involved in the care o f chronic disease.

structured by considering the level and mode

Finally, the specific health care setting (e.g., inpatient vs. outpatient care, brief vs.

of treatment in the context o f one's goals for intervening.

prolonged hospitalization) is likely to make some interventions more feasible than others, as are prevailing attitudes toward psychoso-

Goals

of

Intervention

cial interventions among members o f the

Psychologists working in health care settings

health care team within the culture o f a spe-

intervene to improve patients' health and well-

cific clinic or medical service. Insurance cov-

being across three broad and

erage and a variety o f potential barriers to

domains: (a) reducing the risk of developing dis-

psychosocial intervention (e.g., access to safe,

ease among healthy individuals, (b) improving

interrelated

adequately supervised exercise facilities) are

disease outcomes among those with developed

essential considerations in treatment

plan-

illnesses, and (c) enhancing the quality of life

ning. Only after a thorough consideration of

and emotional health of those experiencing

Brief Psychotherapies Table 5.2 I.

and Group

Treatments

Intervention Options in General Health Care Settings

Reasons for Intervention A. Risk reduction B. Disease outcomes C. Maximizing functioning/quality of life

II.

Levels of Intervention A. B. C. D.

Individual Couples/Family Group Health care team

III. Modes of Intervention A. Psychoeducation B. Cognitive behavioral therapies C. Interpersonal/Social support interventions

illness. Given compelling evidence that behavioral

mortality (e.g., Coyne et al., 2 0 0 1 ) . Hence,

and psychosocial processes are integral to the

interventions that involve families or spouses

development and course of many physical condi-

may be more effective than those that focus

tions, psychologists may intervene to reduce the

solely on the individual (e.g., Anderson, H o ,

incidence or progression of major illnesses.

Brackett, & Laffel, 1 9 9 9 ; Epstein, Valoski,

However, because illness can create profound

Wing, & McCurley, 1 9 9 0 ; Keefe et al., 1 9 9 6 ) .

psychosocial challenges, the goals of clinical

Group psychotherapy is also fairly com-

health psychologists extend beyond attempts to

m o n in medical settings. Group psychothera-

improve physical health to maximize the daily

pies tend to be cost- and time-efficient because

functioning of patients and their families.

m a n y educational, behavioral, and

inter-

personal issues can be addressed readily in a Levels

of

group format (Spira, 1 9 9 7 ) . Groups have the

Intervention

additional benefits o f bestowing a sense o f

These goals can be met by intervening at a

belonging for individuals dealing with the

variety o f levels. Individual therapy remains a

c o m m o n stress of illness and providing impor-

strong option for clinical health psychologists,

tant sources o f support, information,

but interventions involving larger social units

accountability for behavior change (Spira,

and

are increasingly c o m m o n . T h e family unit is

1 9 9 7 ; Spiegel & Diamond, 2 0 0 1 ) . Although

an important focus because illnesses can have

support groups have the potential to be iatro-

adverse effects on families, and risk reduction

genic (e.g., Helgeson, C o h e n , Schulz,

and illness management occur within this

Y a s k o , 2 0 0 0 ) , there is evidence that well-con-

&

broader family context. Family conflict and

ducted, structured groups can be as effective

marital strife appear to be particularly disrup-

as, or more effective than, individual therapy

tive to managing illness and

at

maintaining

quality of life among medical patients (e.g., Schafer, Keith, &

Schafer, 2 0 0 0 ;

promoting

and

maintaining

behavior

change (e.g., W i n g & Jeffery, 1 9 9 9 ) .

Zautra,

A level that may be somewhat unique to

Burleson, M a t t , R o t h , & Burrows, 1 9 9 4 ) and

medical settings involves interventions focus-

may even pose a risk for future morbidity and

ing on the health care team. As we witness a

PRACTICAL ISSUES gradual shift away from an "acute medical

but commonly adds in skill-building features

intervention" model toward a "chronic illness

such as goal setting, self-monitoring, problem

management" model, patients are required to

solving, stimulus control, relaxation and stress

assume new responsibilities for day-to-day ill-

management, and cognitive restructuring. It

ness management, and health care profession-

is also increasingly c o m m o n to include inter-

als are compelled to incorporate behavioral

personal skill acquisition such as assertion

interventions into medical practice (Gonder-

training and developing social support. C B T

Frederick, C o x , &i Ritterband, 2 0 0 2 ) . Health

overlaps with psychoeducation to the extent

care professionals might need the behavior

that both modes teach specific skills (e.g.,

change expertise o f psychologists to do this

relaxation training), but C B T is delivered in a

effectively. Furthermore, because health care

more progressive, individualized, and interac-

providers can be an efficient and powerful

tive manner to help patients not only recon-

source of advice and counseling for patients,

ceptualize their health problems and develop

interventions to promote physicians' commu-

new coping skills but also consolidate (e.g., via

nication skills and enhance the doctor-patient

rehearsal and role-play) and maintain these

relationship can have broad effects. Finally,

skills (e.g., relapse prevention).

the continuing need for pragmatic, cost-effec-

Given compelling evidence on the impor-

tive interventions may result in the training

tance of social relationships for one's physical

of nonpsychologists for the delivery of brief

health and psychological well-being, interper-

psychological interventions.

sonal/social support interventions are also commonly used in medical settings. Aside from

Modes

of

some well-defined interpersonal

Intervention

therapies,

however, many of these interventions have

Given the range o f issues and problems

not been described or studied systematically

likely to be encountered across health care set-

(Hogan, Linden, &c Najarian, 2 0 0 1 ) . Some

tings, psychologists cannot be wedded to any

social support interventions focus on providing

particular therapeutic orientation. This chap-

support during therapy per se. This may occur

ter focuses on three broad modes o f inter-

by direct support provision from the therapist;

vention that can be used across individual,

by simply including family, friends,

group, or family formats: psychoeducation,

peers in therapy; or by including therapeutic

and/or

cognitive-behavior therapy ( C B T ) , and inter-

activities that engage or promote support from

personal/social support. Psychoeducation gen-

important others. Other support interventions

erally provides patients with information (e.g.,

focus on developing patients' social skills,

information about health risks, illness, treat-

which can then

ments, or coping skills) to alter their attitudes

strengthen their naturally occurring social sup-

and behaviors in a direction that will improve

port networks. Support interventions can occur

adjustment.

at any level but most commonly capitalize on

Psychoeducation c a n

provide

patients with a medically accurate under-

be used to nurture and

the supportive features o f group therapy.

standing o f their condition and may be sufficient for some patients to adapt to

the

complex demands o f managing illness. C B T is pervasive in medical settings. These interventions include a myriad o f specific

EXAMPLES OF BRIEF PSYCHOLOGICAL INTERVENTIONS IN HEALTH CARE SETTINGS

behavioral and cognitive techniques that are often combined in a multicomponent fashion.

This section describes h o w these three modes

Multicomponent C B T begins with education

of intervention—psychoeducation, C B T , and

Brief Psychotherapies

and Group Treatments

|

interpersonal/social support—have been used

Health [ N I H ] , 1 9 9 7 ) . This external validation

to achieve the three treatment goals in clinical

of what behavioral scientists have known for

health psychology, namely reducing

risk,

years may increase the demands for integrat-

improving disease outcomes, and enhancing

ing lifestyle change interventions into general

quality o f life. This structure is one o f con-

health care. Psychosocial variables, such as

venience and should not be interpreted

personality, stress, negative emotions, and

as

implying independence across domains. For

impaired social relationships, are also emerg-

example, health behavior interventions

are

ing as important factors in the development

reduction

o f illness. T h u s , although they are not fully

discussed in the context o f risk

but may also improve disease outcomes (e.g.,

established, interventions

smoking cessation to reduce vascular compli-

chosocial risk profiles may become increas-

cations a m o n g

ingly relevant for risk reduction.

individuals

with

diabetes

to improve

psy-

[Gonder-Frederick et al., 2 0 0 2 ] ) and enhance quality o f life (e.g., exercise interventions to reduce depression

with

cancer

[Andersen,

2 0 0 2 ] ) . T h e approach taken for this limited

Psychoeducation Education and self-help information

are

review is to provide general themes from the

mainstays o f most effective risk

most well-developed literatures (e.g., interven-

interventions. In health care settings, psycho-

tions tested with randomized clinical trials) as

education can occur in person or via telephone,

well as salient examples across the range o f

print, or computer-generated

reduction

information

interventions. This section emphasizes brief

delivered to at-risk individuals

interventions but occasionally discusses more

Although generally considered necessary for

intensive therapies if their effects are particu-

risk reduction, education in isolation has fairly

larly impressive. Finally, despite clear advances

modest and short-term effects (Blumenthal,

in research on the efficacy

Sherwood, Gullette, Georgiades, & Tweedy,

o f behavioral

or

groups.

medicine interventions over the past decade,

2 0 0 2 ; Dubbert, 2 0 0 2 ; Niaura

one should note that the interventions dis-

2 0 0 2 ) . There is reason to believe that effec-

cussed here have often not been adequately

tiveness can be improved by including family

tested in the health care settings in which they

members in educational efforts (e.g., Morisky,

are likely to be used. Hence, for all o f these

D e M u t h , Field-Fass, Green, & Levine, 1 9 8 5 ) ,

&

Abrams,

interventions, there is more evidence o f their

and

efficacy in controlled trials than o f their effec-

patients' level o f readiness to change (Dubbert,

tiveness in the conditions and contexts o f their

2 0 0 2 ) . For example, Strecher and colleagues

typical clinical use during medical care.

by tailoring the information

to

the

( 1 9 9 4 ) found that smoking family practice patients reported a doubling o f 6-month quit

Reducing Risk of Developing Disease It is well known that modifiable risk fac-

rates when they received individually tailored smoking cessation letters rather than standard cessation letters (but see Curry,

McBride,

tors, such as smoking, inactivity, obesity, and

Grottos, Louie, & Wagner, 1 9 9 5 , for differing

risky sexual behaviors, play a major role in

results).

the health o f the U.S. population. Behavioral interventions to reduce obesity or stop smok-

A promising educational approach to risk reduction

involves training physicians

and

ing are supported well enough that they are

other health care professionals to

recommended options in the clinical practice

lifestyle change advice and counseling. Health

provide

guidelines emanating from federal agencies

care providers may be particularly persuasive

(e.g., Fiore et al., 1 9 9 6 ; National Institutes o f

messengers for risk reduction

given their

61

62

PRACTICAL ISSUES frequency of contact with high-risk individuals

of

and the importance o f physician advice in moti-

development o f disease was

such interventions

for preventing

the

vating interest to change. Controlled clinical

dramatically in the Diabetes Prevention Trial

demonstrated

trials suggest that physician advice and written

(National Institute o f Diabetes, Digestive,

or telephone follow-up are effective at increas-

and Kidney Disease, 2 0 0 1 ) . Although the

ing physical activity (e.g., Writing Group for

intervention was not brief, this multicenter,

the Activity Counseling Trial, 2 0 0 1 ) and smok-

randomized clinical trial clearly demonstrated

ing cessation (e.g., Ockene et al., 2 0 0 0 ; Pieterse,

that behaviorally based lifestyle interventions

Seydel, DeVries, Mudde, & K o k , 2 0 0 1 ) . There

can be as effective as, or more effective than,

is also evidence that interventions delivered by

medications at preventing the development o f

other health care providers

(e.g.,

nurses,

physician assistants) are effective and additive (Burns, Cohen, Gritz, & Kottke, 1 9 9 4 ) .

diabetes among high-risk individuals. Although impressive, such data must be interpreted and applied cautiously. In most

An area o f emerging interest involves incor-

cases, the interventions represent a bundle of

porating motivational interviewing into risk

educational, behavioral, and cognitive strate-

reduction advice and counseling (see Chapter

gies, making it impossible to evaluate which

4

for more details on motivational inter-

components are most important for reducing

viewing). Originally developed to enhance

risks. At best, this creates an inefficient

motivation to address addiction, motivational

approach to providing therapy in the time

interviewing represents a style o f providing

constraints o f m a n y health care settings

personalized behavior change feedback in an

(cf.

empathie, nonconfrontive, and

although multicomponent C B T appears to be

empowering

Coyne &

R a c i o p p o , 2 0 0 0 ) . Second,

manner (Miller & Rollnick, 1 9 9 1 ) . Although

quite effective at promoting initial behavior

somewhat mixed, preliminary data suggest

change, there is a serious problem

with

that motivational interviewing has the poten-

relapse. M o r e intensive interventions

(e.g.,

tial to be useful across a range o f health

more therapy sessions, multicomponent vs.

behaviors (for reviews, see Dunn, Deroo, &

single-component

Rivara, 2 0 0 1 ; Resnicow et al., 2 0 0 2 ) . If addi-

appear to produce more prolonged changes

therapy,

medication)

tional research supports these promising initial

(e.g., Blumenthal et al., 2 0 0 2 ; Naiura

data, motivational interviewing may be well

Abrams, 2 0 0 2 ; N I H , 1 9 9 7 ; Ockene et al.,

&

suited to medical settings because it is brief and

2 0 0 0 ) . O n the surface, such findings challenge

appears to be transportable across behavioral

the brief therapy

domains and health care professionals.

care. However, Wadden, Brownell, and Foster

environment o f medical

( 2 0 0 2 ) found that monthly 15-minute sessions conducted during patients' regular medication Cognitive-Behavioral

Therapy

Fairly standard group and individual C B T treatment programs are available for a variety

checks maintained weight loss as effectively as did a m o r e traditional

behavioral

group

therapy program, suggesting that prolonged

of health behaviors. Multicomponent C B T

behavioral interventions can be creatively

shows substantial improvement over minimal

incorporated into health care settings.

education interventions for improving H I V risk behaviors (Kelly & Kalichman, 2 0 0 2 ; NIH, 2002),

1 9 9 7 ) , physical inactivity (Dubbert, and

smoking cessation ( C o m p a s ,

Haaga, Keefe, Leitenberg, & Williams, 1 9 9 8 ; Niaura & Abrams, 2 0 0 2 ) . T h e importance

Interpersonal/Social Support

Interventions

Risk reduction interventions often include procedures

to

enhance

social

support.

Brief Psychotherapies

and Group Treatments

\

Although the methodology and resulting data

At a different level, psychobiological processes

are quite varied, there may be benefits to

related to stress, negative emotions, and social

socially based interventions for risk reduction.

relationships also influence disease progres-

For example, obesity treatments that include

sion. Thus, psychologists in medical settings

spouses result in more weight loss for up to 3

may be in a position to alter disease by inter-

months posttreatment (but not beyond) com-

vening to reduce stress, minimize negative

pared with those that do not (Black, Gleser, &c

emotions, or enhance social support.

Kooyers, 1 9 9 0 ) . Similarly, Epstein and colleagues' ( 1 9 9 0 ) family-based behavioral treatment for childhood obesity has

produced

Psychoeducation

remarkably sustained reductions in obesity

Psychoeducation is a necessary component

and improvements in physical activity for

in the comprehensive treatment o f chronic ill-

up to 1 0 years. Such studies demonstrate the

nesses. Such interventions provide information

utility o f embedding risk reduction into the

about the cause, course, and treatment o f dis-

broader

risk

eases as well as stress management (e.g., relax-

social

contexts

in

which

behaviors occur.

ation), coping, and illness management skills.

There also may be benefits to reducing

Although not sufficient for all patients, psy-

risk behaviors by promoting social support

choeducation improves adherence to treatment

more directly. Wing and Jeffery ( 1 9 9 9 ) found

recommendations

that support enhancement procedures (e.g.,

improves health outcomes (for a review, see

recruitment with friends, intragroup activities,

Roter et al., 1 9 9 8 ) . Such interventions have

and, to a lesser extent,

provision and receipt of support, intergroup

been reported to yield clinically meaningful

competitions) improved the effectiveness of

improvement in indexes o f blood glucose

behavioral group therapy for weight loss. In a

control among patients with type 2 diabetes

very different context, Kelly and colleagues

(i.e., at a magnitude

( 1 9 9 3 ) found that depressed patients with

diabetes complications [Norris, Lau, Smith,

that reduces serious

supportive-expressive

Schmid, & Engelgau, 2 0 0 2 ] ) and to decrease

group intervention with reductions in depres-

fatal and nonfatal myocardial infarction over a

H I V responded

to a

sion, maladaptive interpersonal insecurities,

10-year period among those with coronary

and unsafe sex as compared with controls

heart disease (Dusseldorp, van Elderen, M a e s , Meulman, & Kraaij, 1 9 9 9 ) . Dusseldorp and

with no treatment.

colleagues ( 1 9 9 9 ) specifically found that psychoeducation

Improving Disease Outcomes Psychosocial interventions with

improved

disease

outcomes

among coronary heart disease patients primarmedical

ily if it altered the behavioral or psychosocial

patients may also be aimed at improving hard

risk factors hypothesized to mediate interven-

indicators o f disease outcomes (e.g., mortality,

tion effects. Psychoeducation appears equally

cardiac events, blood glucose levels, immune

beneficial across group or individual formats

functioning) by targeting behavioral or psy-

and when delivered by different health care

chosocial risk. Because behaviors are integral

providers (e.g., Linden, Stossel, & Mourice,

to the treatment of many medical conditions,

1 9 9 6 ; Norris et al., 2 0 0 2 ; Roter et al., 1 9 9 8 ) .

psychologists may be called on to improve

These impressive findings are qualified by

adherence to medical interventions or to help

evidence that it is difficult to maintain positive

patients meet the complex self-regulatory and

outcomes over time and that such interven-

lifestyle demands o f chronic illness (e.g., dia-

tions are more effective with more intensive or

betes self-management, home dialysis skills).

prolonged interventions

(cf. Norris et al.,

63

64

PRACTICAL ISSUES 2 0 0 2 ; Roter et al., 1 9 9 8 ) . Innovative methods

(Linden et al., 1 9 9 6 ) . In addition, brief group

to maximize efficiency without limiting effec-

therapy employing multicomponent, cogni-

tiveness are currently being explored. Brief

tive-behavioral stress management

(CBSM)

office-based interventions that can readily be

(e.g., six to eight sessions o f illness education,

incorporated

cognitive restructuring, coping skills training,

appearing,

into routine visits are

now

sometimes taking advantage o f

interactive computer technology. For example,

relaxation or anxiety management,

and/or

provision o f social support) appears to be

Glasgow and colleagues ( 1 9 9 7 ) reported that

quite promising. As examples, group C B S M

having the health care team review individual-

has been found to (a) enhance blood glucose

ized, computer-generated information regard-

control at 1-year follow-up among patients

ing patient goals and motivation for dietary

with type 2 diabetes (Surwit et al., 2 0 0 2 ) ,

behaviors resulted in reduced serum choles-

(b)

terol levels over a 1-year period among patients

those with malignant melanomas (Fawzy et al.,

reduce

6-year mortality rates

among

1 9 9 3 ) , and (c) promote more positive emo-

with type 2 diabetes.

tional and immunological functioning among individuals infected with H I V (e.g., Antoni Cognitive-Behavioral

Therapy

et al., 2 0 0 0 ; Ironson et al., 1 9 9 4 ) . These

Several highly publicized studies

have

demonstrated that intensive, long-term C B T can improve disease processes. For example, Ornish and colleagues ( 1 9 9 0 , 1 9 9 8 ) found that a multicomponent behavioral intervention for C H D patients (i.e., stress management, group therapy, and intensive changes in diet and exercise) resulted in regression o f coronary atherosclerosis and reductions in the recur-

intriguing data are qualified by notable nonreplications and mixed results in the broader literature. Miller and Cohen ( 2 0 0 1 ) suggested that psychotherapy may have stronger effects when patients are highly distressed and when the disease condition is not overwhelming the psychobiological process. This possibility suggests that psychosocial interventions to improve disease outcomes should occur while

rence o f coronary events compared with usual

the biological system is still malleable among

care. Friedman and colleagues' ( 1 9 8 6 ) well-

patients who are seriously distressed.

known Recurrent Coronary Prevention Project

Brief C B T for depression (Beck, Rush, Shaw,

randomized cardiac patients to group C B T

8c Emery, 1 9 7 9 ) is also important for medical

consisting o f relaxation training, stress man-

populations. Although many patients adapt

agement, and cognitive restructuring to reduce

well to disease, depression is fairly common

coronary-prone behavior. T h e

among

intervention

primary

care patients

(Katon

8c

yielded diminished Type A behavior and a

Schulberg, 1 9 9 2 ) and is clearly associated with

4 4 % reduction in the recurrence o f nonfatal

poorer disease progression (e.g., Frasure-Smith,

cardiac events compared with usual care.

Lesperance, 8c Talajic, 1 9 9 5 ) . Brief C B T effec-

The intensity o f these interventions makes

tively reduces

depression

among

medical

it unlikely they can be used on a wide-scale

patients

(Coyne, Thompson, Klinkman,

basis, but their success has spurred attempts to

Nease, 2 0 0 2 ; Schulberg et al., 1 9 9 6 ) , with some

&

identify briefer interventions to improve dis-

evidence that it also improves medical out-

ease outcomes. Although single-component

comes. Lustman, Griffith, Kissel, and Clouse

stress management interventions (e.g., relax-

( 1 9 9 8 ) , for example, found that 1 0 weeks of

ation) are not broadly effective at altering dis-

individual C B T for depression among patients

ease progression (Linden 8c Chambers, 1 9 9 4 ) ,

with diabetes improved blood glucose control

they do appear to enhance the effectiveness o f

over the subsequent 6 months compared with

standard medical rehabilitation

diabetes education. Nevertheless, there are

programs

Brief Psycbotberapies

and Group Treatments

\

nonreplications o f the medical

psychosocial adjustment but did not prolong

effects o f C B T for depression. In a recently

survival (Goodwin et al., 2 0 0 1 ) . Additional

completed multicenter trial, cardiac patients

research will be necessary to détermine whether

disturbing

who met criteria for depression or low social

and when social support interventions in gen-

support were randomized to C B T or usual care

eral, and supportive-expressive group therapy

(National Heart, Lung, and Blood Institute,

in particular, improve disease outcomes.

2 0 0 1 ) . T h e intervention lessened depression and improved social support but did not have an overall effect on subsequent cardiac events.

T h e adaptive demands o f medical illnesses

Interpersonal/Social Support

and

Interventions

Interpersonal

Maximizing Functioning and Improving Quality of Life

therapy

treatments

can

be b u r d e n s o m e

for

patients and their families, exacting high depression

costs in their emotional, social, occupational,

(Klerman, Weissman, Rounsaville, & Chevron,

for

and financial well-being. T h e experience o f

1 9 8 4 ) also reduces depression among primary

illness and its treatments may cause pain and

care patients (Schulberg etal., 1 9 9 6 ) . T o the

disability, alter important social and occupa-

extent that such reductions can alter important

tional roles, erode

biobehavioral or psychobiological processes,

resources, and engender hopelessness, fear,

interpersonal therapy may eventually prove to

and depression. In some cases,

be useful for improving the health o f medical

medical management o f illnesses yields c o m -

financial and

coping

improved

patients. At a broader level, provision of social

parable declines in patients' quality o f life. In

support is a common feature o f the multicom-

other cases, illnesses cannot be changed, but

ponent C B S M therapies described earlier and is

suffering and disability c a n be reduced. T h u s ,

hypothesized to be vital to the success of C B S M

psychologists working in health care settings

in improving physical health. This possibility,

are often called on to improve patients' e m o -

however, has not been carefully evaluated; the

tional well-being (e.g., decrease depression

effects o f support enhancement on disease out-

and anxiety), symptom management

comes have primarily been studied in the con-

reduce pain or treatment side effects), and

text of multicomponent therapies designed to

m o r e general quality o f life (e.g., return to

improve psychosocial adjustment. There are, o f

activities o f daily living, decreased isolation).

(e.g.,

course, dramatic demonstrations that support interventions can improve disease. Goodkin and colleagues ( 1 9 9 9 ) recently reported that

Psychoeducation

HIV-positive gay men who randomly received

Educational interventions are commonly

1 0 weeks of group-based bereavement counsel-

used as a first step toward improving the func-

ing were buffered against the increase in H I V

tioning o f patients dealing with chronic or life-

viral load displayed by the normal care control.

threatening illnesses. These brief interventions

Spiegel, Bloom, Kraemer, and Gottheil ( 1 9 8 9 )

seek to improve patients' capacities for coping

found

that women with metastatic breast

by enhancing their understanding o f the cause,

cancer who engaged in 1 year o f supportive-

treatment, and course o f their diseases as well

expressive group therapy had longer survival

as of their coping options. Although the liter-

times than did those in the control group.

ature is difficult to evaluate given heterogene-

Nevertheless, a large randomized clinical trial

ity in method and quality, there is reason to

to replicate this effect recently revealed that sup-

believe that educational interventions

portive-expressive group

useful. Psychoeducation groups have been

therapy

improved

are

66

PRACTICAL ISSUES reported to have positive effects on emotional

For example, techniques such as relaxation,

and functional adjustment and/or pain and

biofeedback, guided imagery, and hypnosis

discomfort

appear to be useful for reducing pain and

among

patients

with

cancer

(Bottomley, 1 9 9 7 ; Helgeson & Cohen, 1 9 9 6 ;

nausea

Meyer & M a r k , 1 9 9 5 ) , diabetes (Clement,

(Compas et al., 1 9 9 8 ) . Specific behavioral

associated with cancer

1 9 9 5 ) , and coronary heart disease (Linden

techniques, such as relaxation, C B T , and

et al., 1 9 9 6 ) as well as potentially many

some

others. At least in the context o f cancer, these

deemed to be efficacious for treating migraine

effective

and tension headache pain (Holroyd, 2 0 0 2 ) ,

interventions appear to be more

forms

treatments

o f b i o f e e d b a c k , have

been

among those who are most in need (e.g.,

and multicomponent C B T (i.e., relaxation,

highly distressed) and when they are delivered

cognitive restructuring, coping skills training,

&

and goal setting) appear to be effective at

1 9 9 6 ; Kiecolt-Glazer, M c G u i r e ,

improving pain, physical activity, and psy-

early in the disease process (Helgeson Cohen,

Robles, & Glaser, 2 0 0 2 ) , suggesting that early

chological

screening to identify and then treat vulnerable

arthritis (for reviews, see Compas et al., 1 9 9 8 ;

distress

among

patients

with

patients may be useful.

Keefe et al., 2 0 0 2 ) .

Psychoeducational approaches have also

In contrast to their qualified success at

been developed to improve patients' reactions

improving disease outcomes, C B T for depres-

to stressful medical procedures and to inter-

sion and the multicomponent C B S M group

acting more generally with the health care

therapies

system. It is well established, for example, that

improve patients' psychosocial well-being.

orienting patients to painful

earlier

consistently

difficult

C B T is effective at treating major depression

(e.g., surgery, c h e m o -

among patients who seek treatment in pri-

therapy) via sensory, procedural, and coping

mary care, regardless o f whether or not there

information results in improved recovery (e.g.,

is a concomitant presenting medical condition

medical procedures

and

described

reduced hospital stays, pain medication, and

(Schulberg et al., 1 9 9 6 ) . Similarly, C B S M

anxiety [Contrada, Leventhal, & Anderson,

appears to enhance emotional functioning,

1 9 9 4 ] ) . Educational interventions to improve

coping abilities, functional abilities, and/or

patients' interactions with health care profes-

quality o f life among patients coping with

sionals have also shown benefits for patient

cancer (Meyer & M a r k , 1 9 9 5 ) and H I V (e.g.,

Brief interventions to improve

Lutgendorf et al., 1 9 9 8 ) . W e are also begin-

physician communication (Rutter, Iconomou,

ning to document the psychosocial processes

&C Quine, 1 9 9 6 ) and to help health care pro-

through which C B S M appears to be effective.

adjustment.

fessionals empower patients (Anderson et al.,

Lutgendorf and colleagues ( 1 9 9 8 ) found that

1 9 9 5 ; Gonder-Frederick et al., 2 0 0 2 )

the effects o f C B S M on depression were medi-

increase patient

satisfaction and

may

minimize

disease-induced functional limitations.

ated by altered coping (i.e., increased cognitive coping and social support) in a sample o f HIV-positive gay men.

Cognitive-Behavioral

Therapy

Medical patients often experience painful or debilitating symptoms

associated

with

Interpersonal/Social Support

Interventions

medical treatments and illness. Behavioral

There is a large enough literature with

and cognitive techniques have been used with

cancer patients to conclude that professionally

success to improve symptom management,

run support groups can improve patient qual-

often more effectively than education alone.

ity o f life (Compas et al., 1 9 9 8 ; Hogan et al.,

Brief Psychotherapies 2001;

Bottomley,

1997).

supportive-expressive group

In

particular,

therapy

(e.g.,

and Group Treatments

\

SPECIALIZED TRAINING AND SKILLS

encouragement o f emotional expression, provision and receipt of emotional support, hyp-

Given the complexity o f issues that psychol-

nosis for pain management) has been found to

ogists encounter when working in general

improve m o o d and pain reports among those

health care settings and the array o f treat-

with metastatic breast cancer (Goodwin et al.,

ment options that may be used to meet these

2 0 0 1 ; Spiegel, Bloom, & Y a l o m , 1 9 8 1 ) , and

challenges, h o w does one learn to translate

to be more effective than C B T at reducing

traditional psychological interventions into

m o o d disturbance among patients with H I V

the unique context o f medical care? Excellent

(Kelly et al., 1 9 9 3 ) . Broadly speaking, how-

guidelines for the training and skills neces-

ever, data on the effectiveness o f support

sary to function effectively as a clinical health

groups are fairly inconsistent. This may be

psychologist are available elsewhere (e.g.,

because o f heterogeneity in h o w

support

groups are conducted. For example, there is

Belar & Deardorff, 1 9 9 5 ; Belar et al., 2 0 0 1 ; M c D a n i e l , Belar, Schroeder, Hargrove,

&

reason to believe that peer-run support groups

Freeman, 2 0 0 2 ) and are described in detail in

can yield negative outcomes. Helgeson and

T a b l e 5 . 3 . T h e knowledge and skills most

colleagues ( 2 0 0 0 ) developed a group educa-

unique to the brief therapy environment o f

tion intervention for cancer patients that was

health care settings are highlighted here.

delivered either with or without peer discussion and opportunities

for peer

support.

Relative to controls, the peer support group displayed impaired psychosocial adjustment (e.g., increased negative affect and conflict with family and friends) that was maintained over 6 months.

A biopsychosocial perspective is fundamental to providing brief psychosocial treatments in medical settings. Although specific clinical assessment and intervention skills are necessary, they are woefully insufficient if delivered without consideration o f this broader context. Patients enter the medical system for a variety

Some treatments have focused on improving

of reasons, some of which may be only tan-

emotional well-being and quality of life by inter-

gentially related to their presenting complaints.

vening more directly with interpersonal pro-

Assessing patients as part o f a biopsychosocial

cesses. For example, interpersonal therapy for

system helps the psychologist to untangle the

depression enhances recovery from postpartum

complex web of issues that often present as

depression (O'Hara, Stuart, Goman, & Wenzel,

medical symptoms. Through this process, the

2 0 0 0 ) , a finding that is particularly important

psychologist can more effectively evaluate the

given that postpartum depression causes great

need and prioritize the goals for psychological

individual and family suffering and impairs

interventions and then implement the most

infant development but often is not treated

appropriate level and mode o f intervention. A

pharmacologically if women are breast-feeding.

biopsychosocial perspective is developed not

Relatedly, interventions that promote spousal

only through didactic knowledge of the bio-

caregiving or couples skills (e.g., communica-

logical,

tion, problem solving, engaging in the caregiving

aspects o f health and illness but also through

role) have the potential to aid in managing pain

mentored experiences in health care settings

and reducing depression (Keefe et al., 1 9 9 6 ) ,

serving various medical populations. Such

and an intervention to promote

experiential learning can be crucial to solidify-

teamwork

psychological,

and

sociocultural

between adolescents with diabetes and their

ing a sophisticated understanding

mothers lessens family conflict and improves

dynamic interrelationships among biomedical,

o f the

diabetes management (Anderson et al., 1 9 9 9 ) .

psychological, and sociocultural processes in

PRACTICAL ISSUES Table 5.3

Specialized Skills and Training for Providing Brief Interventions in Health Care Settings

I. In-Depth Knowledge of the Biopsychosocial Model A. Biological aspects of health and illness B. Psychological aspects of health and illness 1. Cognitive aspects of health and illness (e.g., illness models, irrational beliefs) 2. Affective aspects of health and illness (e.g., bidirectional associations between depression and disease) 3. Behavioral aspects of health and illness 4. Developmental aspects of health and illness C. Sociocultural aspects of health and illness D. Knowledge of the dynamic interrelationships among A, B, and C II. Knowledge of Common Conditions and Issues Seen Across Health Care Settings A. Pathophysiology B. Risk factors C. Presenting signs and symptoms D. Diagnostic and treatment procedures E. Prognosis F. Biopsychosocial issues involved in A to Ε III. Skills in the Biopsychosocial Assessment of Common Medical Conditions A. Traditional psychological assessment skills and knowledge of their limitations B. Skill at detecting mental health problems among medical patients C. Knowledge of specialized instruments (e.g., relevant personality traits, coping styles, patient conceptualizations of illness, disease-specific adjustment) D. Knowledge of medical assessment procedures E. Brief interviewing skills F. Triage skills IV. Clinical Skills for Brief Interventions in Health Care A. Individual, couples, family, and group therapy skills B. Psychoeducation knowledge and skills 1. Social learning theory 2. Motivational interviewing C. Multicomponent cognitive behavioral therapy 1. Relaxation training/stress management 2. Problem solving and coping skills training 3. Assertiveness training 4. Cognitive restructuring 5. Brief motivational interventions 6. Relapse prevention D. Supportive therapy skills E. Interpersonal and family systems theory/therapy F. Crisis management V. Interdisciplinary Collaboration Skills A. B. C. D.

Well-developed and positive professional identity as a psychologist Understanding the training, goals, and perspectives of other disciplines Familiarity with the languages of other disciplines Communication and social skills

VI. Awareness of Sociopolitical Issues Across Health Care Settings S O U R C E : Adapted from McDaniel, Belar, Schroeder, Hargrove, and Freeman (2002).

Brief Psychotherapies

and Group Treatments

\

general as well as their specific instantiation

who have not developed this broader expertise

with a given patient. Mentored experiences

may encounter patient problems that they are

across health care settings also provide invalu-

unequipped to handle (cf. Smith, in press).

able training on how to navigate the numerous

Patients with diabetes who have comorbid

challenges o f functioning as a clinical health

eating disorders require more than illness

psychologist in the culture o f medicine (e.g.,

management

communicating with physicians, getting paid

pathology among family members can com-

for psychological services).

pletely undermine the best that psychotherapy

interventions,

and

serious

also

has to offer if it is not recognized or addressed.

develop a detailed understanding o f the med-

Developing this broad expertise in traditional

ical conditions c o m m o n l y encountered across

areas o f clinical psychology can be difficult

Clinical health psychologists must

health care settings and their associated diag-

due to competing demands and the daunting

nostic and treatment procedures. Such infor-

challenges o f learning a rapidly expanding lit-

mation is integral to the patient's context and

erature and developing skills at the interface o f

allows psychologists to identify

psychology and medicine. T h e importance o f

important

biobehavioral or psychobiological processes

doing so, however, has been recognized in the

that may become targets for intervention, to

training guidelines for health psychology (e.g.,

anticipate stressful transitions in the disease

M c D a n i e l et al., 2 0 0 2 ) .

and treatment process, and to work more collaboratively with the interdisciplinary health care team. Nevertheless, clinical health psy-

CONCLUSION

chologists must embed this knowledge in the broader biopsychosocial context and not

Clinical health

lose sight o f their unique perspective on the

remarkable strides in integrating a biopsy-

psychosocial aspects o f medical care.

chosocial perspective into medical care and in

psychologists have

made

psychosocial

developing novel approaches to meet the

interventions in health care settings requires

unique challenges o f health care settings. As

The

delivery

o f effective

psychologists to work collaboratively with

reviewed in this chapter, brief and group

members of an interdisciplinary health care

psychotherapies hold considerable promise in

team—who themselves have unique and some-

this endeavor. Although the emerging litera-

times opposing perspectives on patient care—in

ture evaluating these interventions is favorable,

the context o f a health care system that might

there are nagging inconsistencies with few

not fully appreciate the systemic approach.

examples o f programmatic support for spe-

Although good social skills and knowledge of

cific interventions and few tests o f their effec-

the training and perspectives of other profes-

tiveness in the medical contexts where they are

sions are important, the development of a solid

typically used. In this climate o f hope and cau-

professional identity as a psychologist may be

tion, the biopsychosocial model provides an

most crucial to accomplishing this difficult task

invaluable framework. This model does not

(cf. McDaniel et al., 2 0 0 2 ) .

provide a prescriptive blueprint for working

In this context, one must remember that

with medical patients. Rather, its strength lies

the specialized skills o f the clinical health psy-

in its flexibility to be useful across patients and

chologist emerge out o f general core training

health care settings, its ability to accommo-

in the broader discipline o f psychology and its

date rapidly changing medical technology and

traditional

treatments, and the often necessarily novel

applications to mental

health.

Mental health problems are c o m m o n in health

and creative clinical interventions that emerge

care settings, and clinical health psychologists

from its application.

69

PRACTICAL ISSUES

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Brief Psychotherapies

and Group

Meyer, T. J . , St Mark, M . M . (1995). Effects of psychosocial interventions with adult cancer patients: A meta-analysis of randomized experiments. Health Psychology, 14, 1 0 1 - 1 0 8 . Miller, G., St Cohen, S. (2001). Psychological interventions and the immune system: A meta-analytical review and critique. Health Psychology, 20, 4 7 - 6 3 . Miller, W., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford. Morisky, D. M., DeMuth, N. M., Field-Gass, M., Green, L. W., St Levine, D. M . (1985). Evaluation of family health education to build social support for longterm control of high blood pressure. Health Education Quarterly, 12, 3 5 - 5 0 . National Heart, Lung, and Blood Institute. (2001). Study finds no reduction in deaths or heart attacks in heart disease patients treated for depression and low social support. [Online]. Retrieved on January 2 0 , 2 0 0 3 , from www.nhlbi.niv.gov/new/press/ 0 1 - l l - 1 3 . h t m . National Institute of Diabetes, Digestive, and Kidney Disease. (2001). Diet and exercise dramatically delay Type 2 diabetes: Diabetes medication Metformin also effective. [Online]. Retrieved on January 2 0 , 2 0 0 3 , from www.niddk. nih.gov/welcome/ releases/8_8_01 .htm to National Institutes of Health. (1997). NIH consensus statement: Interventions prevent HIV risk behaviors. Bethesda, M D : U.S. Public Health Service. National Office of Vital Statistics. (1947). Deaths and death rates for the 10 leading causes of death by sex. Washington, DC: U.S. Department of Health and Human Services. Niaura, R., St Abrams, D. B . (2002). Smoking cessation: Progress, priorities, and prospectus. Journal of Consulting and Clinical Psychology, 70, 4 9 4 - 5 0 9 . Norris, S. L., Lau, J . , Smith, S. J . , Schmid, C. H., St Engelgau, M. (2002). Self-management education for adults with type 2 diabetes: A meta-analysis of the effects on metabolic control. Diabetes Care, 25, 1 1 5 9 - 1 1 7 1 . Ockene, J . K., Emmons, K. M., Mermelstein, R. J . , Perkins, Κ. Α., Bonollo, D. S., Voorhees, C. C , St Hollis, J . F. (2000). Relapse and maintenance issues for smoking cessation. Health Psychology, 19, 1 7 - 3 1 . O'Hara, M . W., Stuart, S., Gorman, L. L., 8t Wenzel, A. (2000). Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry, 57, 1 0 3 9 - 1 0 4 5 . Ornish, D., Brown, S. E., Scherwitz, L. W., Billings, J . H., Armstrong, W. T., Ports, Τ. Α., Gould, K. L., McLanahan, S. M., Kirekeeide, R. L., St Brand, R. J . (1990). Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 336, 1 2 9 - 1 3 3 . Ornish, D., Scherwitz, L. W., Billings, J . H., Brown, S. E., Gould, K. L., St Merritt, T. A. (1998). Intensive lifestyle changes for reversal of coronary heart disease. Journal of the American Medical Association, 280, 2 0 0 1 - 2 0 0 7 . Pickering, T. G., St Miller, Ν. E. (1977). Learned voluntary control of heart rate and rhythm in two subjects with premature ventricular contractions. British Heart Journal, 39, 1 5 2 - 1 5 9 . Pieterse, M. E., Seydel, E. R., DeVries, H., Mudde, A. N., St Kok, G. J . (2001). Effectiveness of a minimal contact smoking cessation program for Dutch general practitioners: A randomized controlled trial. Preventive Medicine, 32, 1 8 2 - 1 9 0 . Resnicow, K., Dilorio, C , Soet, J . E., Borelli, B., Hecht, J . , St Ernst, D. (2002). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21, 4 4 4 - 4 5 1 . Roter, D. L., Hall, J . Α., Merisca, R., Nordstrom, B., Cretin, D., St Svarstad, B . (1998). Effectiveness of interventions to improve patient compliance: A metaanalysis. Medical Care, 36, 1 1 3 8 - 1 1 6 1 . Rutter, D. R., Iconomou, G., St Quine, L. (1996). Doctor-patient communication and outcome in cancer patients: An intervention. Psychology and Health, 12, 5 7 - 7 1 .

Treatments

PRACTICAL ISSUES Schafer, R. B . , Keith, P. M., & Schafer, E. (2000). Marital stress, psychological distress, and healthful dietary behavior: A longitudinal analysis. Journal of Applied Social Psychology, 30, 1 6 3 9 - 1 6 5 6 . Schulberg, H. C , Block, M . R., Madonia, M. J . , Scott, C. P., Rodriguez, E., Imber, S. D., Pere, I. J . , Lave, J . , Houck, P. R., & Loulehan, J . L. (1996). Treating major depression in primary care practice: Eight-month clinical outcomes. Archives of General Psychiatry, 53, 9 1 3 - 9 1 9 . Shapiro, D., Tursky, B . , Schwartz, G. E., & Shnidman, S. R. (1971). Smoking on cue: A behavioral approach to smoking reduction. Journal of Health and Social Behavior, 12, 1 0 8 - 1 1 3 . Smith, T. W. (in press). On being careful when you get what you wish for: Commentary on "Self-Assessment in Clinical Health Psychology." Prevention and Treatment. Smith, T. W., Kendall, P. C , & Keefe, F. J . (Eds.). (2002). Behavioral medicine and clinical health psychology [special issue]. Journal of Consulting and Clinical Psychology, 70(3). Smith, T. W., Nealey, J . R., & Hamann, H. A. (2000). Health psychology. In C. R. Snyder & R. E. Ingram (Eds.), Handbook of psychological change: Psychotherapy processes and practices for the 21st century (pp. 5 6 2 - 5 9 0 ) . New York: John Wiley. Smith, T. W., & Nicassio, P. M . (1995). Psychological practice: Clinical application of the biopsychosocial model. In P. M. Nicassio &C T. W. Smith (Eds.), Managing chronic illness: A biopsychosocial perspective (pp. 1 - 3 4 ) . Washington, DC: American Psychological Association. Spiegel, D., Bloom, J . R., Kraemer, H. C , & Gottheil, E. (1989). Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 2, 8 8 8 - 9 0 1 . Spiegel, D., Bloom, J . R., & Yalom, I. (1981). Group support for patients with metastatic cancer: A randomized outcome study. Archives of General Psychiatry, 38, 5 2 7 - 5 3 3 . Spiegel, D., & Diamond, S. (2001). Psychosocial interventions in cancer group therapy techniques. In A. Baum & B. L. Andersen (Eds.), Psychosocial interventions for cancer (pp. 2 1 5 - 2 3 4 ) . Washington, DC: American Psychological Association. Spira, J . L. (1997). Group psychotherapy for medically ill patients. New York: Guilford. Strecher, V. J . , Kreuter, M., DenBoer, D. J . , Kobrin, S., Hospers, H. J . , & Skinner, C. S. (1994). The effects of computer-tailored smoking-cessation messages in family practice settings, journal of family Practice, 39, 2 6 2 - 2 7 0 . Stuart, R. B. (1967). Behavioral control of overeating. Behavioral Research and Therapy, 5, 3 5 7 - 3 6 5 . Surwit, R. S., van Tilburg, M . A. L., Zucker, N., McCaskill, C. C , Parekh, P., Feinglos, M., Edwards, C. L., Williams, P., & Lane, J . D. (2002). Stress management improves long-term glycémie control in type 2 diabetes. Diabetes Care, 1, 3 0 - 3 7 . Von Bertalanffy, L. (1968). General systems theory. New York: Braziller. Wadden, T. Α., Brownell, K. D., & Foster, G. D. (2002). Obesity: Responding to the global epidemic. Journal of Consulting and Clinical Psychology, 70, 5 1 0 - 5 2 5 . Wing, R. R., & Jeffery, R. W. (1999). Benefits of recruiting participants with friends and increasing social support for weight loss and maintenance, journal of Consulting and Clinical Psychology, 67, 1 3 2 - 1 3 8 . Writing Group for the Activity Counseling Trial. (2001). Effects of physical activity counseling in primary care. Journal of the American Medical Association, 286, 677-687. Zautra, A. J . , Burleson, M. H., Matt, K. S., Roth, S., & Burrows, L. (1994). Interpersonal stress, depression, and disease activity in rheumatoid arthritis and osteoarthritis patients. Health Psychology, 13,139-148.

Part II BEHAVIORS THAT COMPROMISE OVERALL HEALTH STATUS Introduction

to Part II

T

Ihe next seven chapters switch focus from practical issues that clinical health psychologists face in the workplace to patient behaviors that may impair their

-A.

overall health status. M o r e than 2 5 years o f research, clinical practice, and

community-based interventions have shown that positive behavioral changes help people t o feel better physically and emotionally, improve their health status, increase their self-care skills, and improve their ability to live with chronic illness. Behavioral medicine interventions have been shown to reduce health-compromising behaviors and improve clinical outcomes in patients with a variety o f medical problems. This part o f the h a n d b o o k targets specific health-compromising behaviors, such as alcohol and nicotine use, as well as more general health-compromising behaviors that are important to virtually all service areas, such as dealing with medication-seeking behavior and adherence to medical recommendations. In Chapter 6, Erblich and Earleywine review what is k n o w n about genetic, constitutional, and environmental factors that have been implicated in the development o f alcohol dependence. In addition, they discuss the available yet imperfect treatment options for those suffering from alcohol dependence. It is noted that until recently, progress in this field was impeded by the lack o f transdisciplinary idea sharing and

75

T H E HEALTH PSYCHOLOGY HANDBOOK collaboration among behavioral scientists, molecular geneticists, and neuroscientists. Clearly, for a complete and balanced understanding o f this classic biobehavioral phenomenon, expertise from each o f these fields is required. F r o m the standpoint o f clinicians, working with individuals suffering from alcohol dependence can be quite difficult, yet many have improved their health status by eliminating the problems related to alcohol use. In Chapter 7, Cohen and his colleagues describe and define the construct o f nicotine dependence and provide guidance on intervention strategies for treating individuals addicted to nicotine. T h e y note that nicotine dependence appears to develop via the interaction between neurobiological substrates and cognitive, behavioral, and e m o tional domains. Given this multifaceted presentation, clinicians are encouraged to employ a stepped care approach, which begins with brief interventions and progresses to more intensive interventions. Given the pervasiveness o f tobacco use disorders among various patient populations and the health consequences associated with these disorders, treatment o f nicotine dependence is one area in which clinical health psychologists can have a positive impact on their patients' overall health status. In Chapter 8, Faith and T h o m p s o n explore current etiological models, assessment strategies, and intervention methodologies that inform the behavioral management of obesity. In addition, they highlight the importance o f targeting body image disturbances in the treatment o f obesity given that many obese individuals do not achieve their desired weight loss. T h u s , clinicians are encouraged to be honest about the weight loss their patients can expect, and they need to address goals that seem unachievable. Clinicians are encouraged t o be sensitive to their patients' motivation and t o collaboratively establish attainable weight loss goals that will foster a sense o f mastery and self-efficacy. Ultimately, such treatment can lead to personal satisfaction, self-respect, and healthy interpersonal relationships. In Chapter 9 , Barbour, Houle, and Dubbert review the evidence suggesting that physical activity is beneficial in terms o f the prevention and treatment o f disease. Despite such benefits, physical inactivity continues to be a pervasive problem that requires consideration o f environmental factors (e.g., decreases in activity required on the j o b , consuming larger portions during meals) in addition to individual factors. T h e authors also point out that a weakness in this field is the scarcity o f research examining underrepresented populations. T h i s is a major problem given that certain diseases are more prevalent among ethnic minorities. Clinicians are encouraged to promote physical activity in their practice because this could significantly reduce the prevalence of chronic disease and could improve the quality o f life o f their patients. In Chapter 1 0 , Collins and his colleagues define the c o m p l e x construct o f stress, highlighting the key models addressing this health concern, and incorporate h o w these models can be translated into treatment. Although they note that stress in itself may not cause disease, stress has been established as a significant risk factor in the development o f numerous illnesses and has been implicated in aggravating existing diseases. T h e authors note that stress is a significant problem facing clinical health psychologists given that it has been shown to reduce patient compliance, which directly affects treatment outcomes. T h e y also include an overview o f the available treatments for the stress disorders, including cognitive strategies as well as techniques designed to lower and control physiological arousal, anxiety, and muscular tension.

Behaviors

That Compromise

Health

In Chapter 1 1 , Gulliver, Wolfsdorf, and M i c h a s define the problem o f medication seeking, propose a conceptual framework

for understanding

this construct, and

describe assessments and treatments designed to address this troublesome behavior. T h e y point out that clinical health psychologists are frequently called on to intervene not only with patients but also with providers and health care systems to effectively extinguish the problem behavior. T h e chapter concludes with a synopsis o f what is k n o w n and what still needs to be explored so as to meet the field's broad objective o f optimal clinical care. Finally, in Chapter 1 2 , Berlant and Pruitt expand the traditional conceptualization o f adherence to include multiple levels, including patients, providers, and health care organizations. T h e y note that there are numerous influences on patients' behavior within each o f these levels that could m a k e the challenge o f improving adherence appear to be overwhelming. As a result, the case study in the chapter focuses on a multilevel approach to treatment. T h e authors conclude that although it is impossible to have complete control o f patients' behavior, consistent consideration o f the significance o f events that precede and follow behavior at the three levels mentioned will advance adherence enhancement efforts and ultimately affect health outcomes.

5

CHAPTE R

Alcohol

Problems

Causes, Definitions, and Treatments JOEL ERBLICH AND MITCH EARLEYWINE

W

hat causes alcoholism? O r, put

etiologic model s o f addiction and to review

a n o t h er

what is know n about som e o f the more com -

although

way ,

wh y

is it

that

so many people con-

m o n genetic, constitutional, and

learned/

sum e alcohol on a regular basis, only a small

environmental factors that have been impli-

minority becom e dependent? Thi s seemingl y

cated in the pathogenesis of alcohol depen-

straightforward question has bewitche d clini-

dence. A rapprochement of these diverse factors

cians and researchers fo r centuries. Only

may result in a clinically useful workin g mode l

recently, wit h generous help from the disci-

of understanding the risk fo r alcoholism.

plines o f molecular genetics and neuroscience, have behavioral scientists begun to piece together this age-old puzzle . Part of the prob-

DEFINITION S AN D

lem lies in the way in whic h alcohol depen-

DESCRIPTIO N OFA L C O H O L I S M

dence is defined and conceptualized. Anothe r concern is that w e have ye t to identify the

A nosologic consensus is the outcom e of clari-

proverbial "switch"—tha t functional entity

fyin g an etiologic disease pathway. Unfortu-

(biological, psychological, or otherwise) that

nately, the classification of alcoholism, lik e

"transforms" a nondependent consume r of

many other multisymptomati c behavioral dis-

alcohol into one wh o is alcoholic. Bu t perhaps

orders, has been a matter o f som e debate. T h e

mos t critically, the parallel paths of behavioral

classic medical approach employ s the categorical

scientists, molecular geneticists, and neurosci-

disease mode l in whic h alcoholism is concep-

entists have until recently severely limite d the

tualized as being qualitatively distinct relative

transdisciplinary idea sharing and collabora-

to normal "social" drinking (Meyer , 2 0 0 1 ) .

tions that are essential to gaining a complet e

Theorists espousing a categorical point of vie w

and balanced understanding o f the etiology

woul d consider abstinence/nonuse, use, abuse,

of

this classic biobehavioral

phenomenon .

and dependence as conceptually distinct states.

Thi s chapter attempts to provide som e unify -

Als o consistent wit h this approach is Cloninger

ing theme s that appear to be c o m m o n to all

and colleagues' ( 1 9 8 8 ) classic description of

BEHAVIORS THAT COMPROMISE HEALTH "types" o f alcoholics, an approach that has

meaningful distress and occur within the same

support

year. T h e diagnosis requires judgment on the

(Sannibale & Hall, 1 9 9 8 ) . Concerns regard-

clinician's part, but the symptoms tend to be

ing the limited nature o f such categorical

obvious. Each symptom reflects the idea that

received

only

mixed

empirical

approaches have led many to adopt a quantita-

a person requires the drug to function and

tive approach, which stresses that alcohol use

makes maladaptive sacrifices to use it. T h e

lies on a continuum from nonuse to depen-

current diagnosis focuses on consequences

dence (Meyer, 2 0 0 1 ) . Factors such as quantity

rather than on the amount or frequency of

of alcohol consumed, frequency of consump-

consumption. These consequences are (a) tol-

tion, and variability (i.e., regularity with which

erance and (b) withdrawal, which were once

drinking

considered the hallmarks o f dependence. T h e

occurs) move people along

this

continuum, the extreme of which is alcohol

additional symptoms are (c) use that exceeds

dependence (Streissguth, Martin, & Buffington,

initial intention, (d) persistent desire for the

1 9 7 6 ) . Recent discussions about the existence

drug or failed attempts to decrease consump-

of a "switch" that is responsible for transform-

tion, (e) loss o f time related to use, (f) reduced

ing a "normal drinker" into an "alcoholic"

activities because o f consumption, and (g)

(e.g., Tsuang, Bar, Harley, & Lyons, 2 0 0 1 ) , as

continued use despite problems.

well as data suggesting that there is great

Tolerance serves as a hallmark of physiolog-

individual variability within the subset of alco-

ical dependence. It occurs when repeated use of

holics, have led to a blending o f the two

the same dose no longer produces the same

approaches. By the prevailing view, alcoholism

effect. This symptom often indicates extensive

is seen as a qualitatively distinct state, but there

drinking and may motivate continued con-

is a continuum of symptom severity within

sumption. People do not grow tolerant to a

the subgroup of alcoholics (Meyer, 2 0 0 1 ) . In

drug; rather, they grow tolerant to its effects.

addition, quantitative drinking factors (e.g.,

After repeated use, some of the effects of a drug

quantity, frequency, variability) are necessary

may

predictors o f the development o f alcoholism.

Tolerance to the desired effects o f alcohol may

That being said, it must also be acknowledged

encourage people to drink more, and increased

that the putative switch has not yet been identi-

use may coincide with a greater chance for

fied, and as such, most researchers have relied

problems.

on studying quantitative drinking factors as a reasonable surrogate. Therefore, the preponderance of theoretical grist has aimed at understanding why some would drink more than others rather than at directly addressing why some people become alcoholics. For now, the proverbial lamppost shines down on the quantitative approach.

decrease, whereas

others

may

not.

T h e second symptom o f dependence, withdrawal, refers to the discomfort associated with an absence o f the drug. N o two people experience withdrawal

in the same way.

Hallmark signs can range from mild irritability to full-blown hallucinations. Alcohol withdrawal frequently includes tremor, anxiety, craving, and troubled sleep. A severe, palsylike tremor with frequent perceptual aberrations, k n o w n

Alcohol Dependence T h e D S M - I V (Diagnostic

as delirium tremens,

often

accompanies severe withdrawal. and

Statistical

The

DSM-IV

distinguishes

between

fourth edition)

dependence with physiological aspects and

(American Psychiatric Association, 1 9 9 4 )

dependence without physiological aspects. If

Manual

of Mental

Disorders,

defines drug dependence as a collection o f any

tolerance or withdrawal appears among the

three o f seven symptoms. All must create

three required

symptoms, a diagnosis o f

Alcohol

Problems

81

appropriate.

legal, users might not spend considerable time

Nevertheless, even without the presentation

in search of it. Hence, the number of hours

o f tolerance o r withdrawal, individuals m a y

required to qualify for a meaningful loss of time

still receive a diagnosis o f alcohol depen-

remains unclear, making this symptom quite

dence without the specifier "with physiolog-

subjective. A clear-cut case would be anyone

ical dependence." This change in procedure

whose day is devoted to obtaining alcohol,

physiological dependence

is

has made the diagnosis o f alcohol depen-

drinking to the point o f intoxication, and recov-

dence potentially m o r e c o m m o n .

ering from the effects o f alcohol. An individual

The third symptom o f dependence involves

who spends even a portion o f the day (e.g., a few

use that exceeds initial intention. This symp-

hours) on these activities would also qualify. In

tom suggests that individuals may plan to

contrast, an individual who consumes several

have only a couple o f drinks but then drink

drinks an hour before going to bed each night

markedly more once they become intoxicated.

might argue that he or she has lost little time and

Use that exceeds intention was once known as

should not qualify for this symptom. Thus, sub-

"loss o f control." M a n y people misinterpreted

jective assessment o f a meaningful amount of

the idea o f loss o f control, suggesting that it

time may contribute to problems with the diag-

referred to an unstoppable

nosis o f dependence.

compulsion to

drink everything available. Based on this interpretation, people who drank to the point o f

The

sixth symptom

o f dependence

is

reduced activities because o f drinking. This

blackout but still had liquor in the house the

symptom focuses on work, relationships, and

next morning might have claimed that they did

leisure. T h e presence o f this symptom suggests

not show loss of control. Today, use that

that alcohol has taken over so much of one's

exceeds intention does not imply this dramatic

daily life that the user would qualify as depen-

unconscious consumption. This symptom sim-

dent. Any impairment in j o b performance

ply suggests that dependent users may have

because o f intoxication, hangover, or devoting

trouble drinking only a small amount if that is

work hours to obtaining alcohol would qualify

what they intend to do. Ironically, people who

for this symptom. Individuals missing work

never intend to drink a small amount might

every M o n d a y to recover from weekend binges

not get the opportunity to qualify for this

might also qualify. Sufficient functioning at

symptom.

work, however, does not indicate that one is

Dependence also includes failed attempts to

not dependent. Even with phenomenal j o b

decrease use, or a constant desire for the drug,

performance, impaired social functioning may

as the fourth symptom. An inability to reduce

be indicative of problems. If a drinker's only

drinking despite a wish to do so certainly sug-

friends are drinking buddies and they only

gests that the drug has altered behavior mean-

socialize while intoxicated, the substance has

ingfully. Y e t people with no motivation to quit

obviously had a marked impact on friendships.

would likely never qualify for failed attempts.

Recreational functioning is also important to

Thus, people who have not attempted to quit

the diagnosis. A decrease in leisure activities

may still qualify for this symptom if they show

suggests impaired recreation. A drinker who

a persistent continuous craving. An inability to

formerly enjoyed hiking, reading, and theater

stop drinking or a constant desire to consume

but who now spends all o f his or her free time

alcohol suggests dependence.

intoxicated in front o f the television would

The fifth symptom of dependence involves

qualify for this symptom. This approach to the

loss o f time related to use. T h e time lost can be

diagnosis implies that drinkers who are not

devoted to experiencing intoxication, recovering

experiencing multifaceted lives can improve the

from it, or seeking the drug. Because alcohol is

way in which they function by drinking less.

82

BEHAVIORS T H A T C O M P R O M I S E HEALTH The final symptom of dependence requires continued use despite problems. People who

recovery

from

i n t o x i c a t i o n , and/or

time

devoted to searching for liquor. T h e definition

persist in using the drug despite obvious nega-

is necessarily broad so as to include people

tive consequences would qualify for this symp-

with a variety o f responsibilities. Specifically,

tom. Recurrent use regardless of continued

this symptom applies to employees who miss

occupational, social, interpersonal, psychologi-

work because they have hangovers, students

cal, and/or health problems obviously shows

w h o fail tests because they attend classes

dependence. M a n y of these difficulties involve

intoxicated, and parents w h o neglect their

meaningful

children so that they can spend time in bars.

others

in

the

drinker's

life.

Continued consumption despite conflicts with

T h e second symptom requires intoxication

loved ones, employers, and/or family members

in unsafe settings. T h e D S M - I V specifically

might qualify for this symptom. This situation

lists driving a car and operating machinery as

supports the idea that anyone who continues to

hazardous

use despite negative consequences (e.g., stom-

could

situations in which intoxication

create

dangerous

negative

conse-

ach ulcers, feelings of guilt, loss of self-respect)

quences. M a n y experienced drinkers claim

must have a strong commitment to alcohol.

that their intoxicated driving differs little from their sober driving. Such statements

may

reflect poorly on their driving abilities in

Alcohol Abuse

general, but people w h o tremble as a result o f

A subset of individuals may experience neg-

withdrawal might actually drive better after a

ative consequences from alcohol that do not

couple o f drinks. Despite this fact, driving a

qualify for a diagnosis o f dependence but that

car while drunk, even for only a few blocks,

meet criteria for a diagnosis o f abuse. This diag-

qualifies as alcohol abuse.

nosis requires significant impairment or distress

T h e intoxicated performance o f any task

directly related to drinking. A diagnosis of

can lead to a diagnosis o f abuse if impair-

alcohol abuse requires only one of the four

ment may lead to negative consequences.

symptoms that appear in the D S M - I V : (a) inter-

This action need not be as elaborate as

ference with major obligations, (b) intoxication

scaling a skyscraper or handling a firearm.

in unsafe settings, (c) legal problems, and

Driving a forklift or using power tools might

(d) continued use in the face o f problems. Each

qualify. N o t e that no negative consequences

of these signs requires some interpretation on

actually need to occur; their increased likeli-

the part of the individual making a diagnosis;

h o o d alone can qualify for abuse. Thus,

however, most experienced diagnosticians

those w h o drive drunk but never receive tick-

agree on who meets criteria for substance abuse

ets or have accidents would still qualify for

and who does not (Ustiin et al., 1 9 9 7 ) . Abuse

abuse due to the fact that they increase

remains distinctly separate from dependence,

their likelihood o f experiencing negative

which requires different symptoms and more of

consequences.

them. Although a diagnosis of abuse clearly

T h e third symptom included in the diag-

serves as a sign of genuine troubles, many clin-

nosis o f alcohol abuse concerns legal prob-

icians consider dependence to be more severe.

lems. T h i s symptom may say as much about

Thus, those who qualify for dependence would

society's values as it does about an individ-

not receive the diagnosis of abuse.

ual's behavior (Brecher, 1 9 7 2 ; Grilly, 1 9 9 8 ) .

T h e first symptom o f abuse, interference with major obligations, requires

impaired

Any legal troubles related to public intoxication, driving while intoxicated, drunk and

performance at work, home, and/or school.

disorderly behavior, alcohol-related aggres-

Impairments may arise due to intoxication,

sion, or underage drinking would qualify.

Alcohol Finally, the fourth

Problems

83

symptom of alcohol

someone is an addict. Instead, the clinician

abuse concerns consistent use despite problems.

and the client can focus on reducing the harm

Note that recurrent use in the face o f occupa-

that alcohol may cause.

tional, social, interpersonal, psychological, and/or health problems qualifies as abuse. MODELS OF ALCOHOLISM

Alcohol Problems

As with many other topics in psychology, there

Describing alcohol-related difficulties as

are nearly as many theories of the development

addiction, abuse, or dependence creates certain

of alcohol problems as there are theorists. By

misunderstandings. All three words may sound

and large, however, there is agreement that

deprecating (Eddy, Halbach, Isbell, & Seevers,

people drink alcohol because it makes them feel

1 9 6 5 ; Miller, Gold, & Smith, 1 9 9 7 ) , and each

good. Principles o f operant conditioning sug-

lacks clarity; however,

gest that either positive reinforcement, negative

addiction

has

no

accepted definition. As noted previously, abuse

reinforcement, or a combination o f the two

and dependence have formal definitions, but

play a role in drinking behavior. Some data

the specific diagnosis does not reveal an indi-

support the role o f positive reinforcement in

vidual's actual problems. Anyone who qualifies

alcohol consumption. For example, Newlin

for abuse may have one or more o f the four

and Thomson (1990) argued that individuals

symptoms required, meaning that an individual

with a positive family history for alcoholism

with such a diagnosis could be experiencing any

may be more sensitive to the positive/stimulant

one o f more than a dozen combinations of

effects o f alcohol, and several studies support

symptoms. Likewise, dependence requires three

this supposition

of seven symptoms, providing more than 3 0

Erblich, & Bovbjerg, in press). Research in this

(e.g., Erblich, Earleywine,

potential combinations o f symptoms. These

area has also underscored the importance of

terms may also encourage the rmnimization o f

negative reinforcement in understanding alco-

problems that do not qualify for a diagnosis,

hol consumption. Nearly a half century ago,

and this can interfere with treatment.

Conger

( 1 9 5 6 ) advanced the n o w

classic

People experiencing negative consequences

"tension reduction hypothesis," which speaks

from alcohol may prove to be unwilling to

broadly to alcohol's negatively reinforcing

limit consumption if they do not qualify for

properties.

addiction, abuse, or dependence. This limita-

the tension reduction hypothesis have focused

M o r e recent modifications

to

tion has inspired an approach that emphasizes

on alcohol's ability to dampen the human

problems rather than diagnoses or diseases.

stress response (Levenson, Sher, Grossman,

Thus, instead o f worrying about whether a

Newman, &c Newlin, 1 9 8 0 ) , and further mod-

specific user qualifies for a disorder, time

ifications

might be better spent identifying individual

response dampening may be mediated by alco-

have

demonstrated

that

stress

problems related to drinking. For example, a

hol's impairment o f cognitive processes (Erblich

client may report frequent stomach pains. A

& Earleywine, 1 9 9 5 ; Josephs & Steele, 1 9 9 0 ) .

survey o f this person's drinking may reveal

Regardless o f the mechanism, reinforcement

that the pain often follows a binge. Although

appears to play a central role in the initiation

this problem might not interfere enough to

and maintenance of drinking behavior.

qualify for abuse, the client may benefit from

Over the past two decades, Schuckit and

drinking less or quitting. This emphasis on

colleagues (e.g., Schuckit, 1 9 9 4 ; Schuckit,

problems may allow the clinician to avoid

Tsuang, Anthenelli, Tipp, &

pointless arguments about whether or not

1 9 9 6 ) have presented considerable empirical

Nurnberger,

84

BEHAVIORS THAT C O M P R O M I S E HEALTH evidence (both cross-sectional and longitudinal)

account for some o f the observed intergenera-

indicating that drinkers w h o experience lower

tional transmissibility o f alcoholism, the

levels o f response to alcohol consumption are

confluence o f these epidemiological and quan-

more likely to experience problem drinking.

titative genetic studies suggests a preeminent

They have suggested that such

individuals

may need to drink more than others to achieve

role o f genetics in conferring vulnerability to problem drinking.

a desirable level of reinforcement or that such

In 1 9 9 0 , Blum and colleagues became the

individuals' lower interoceptive responses to

first to discover a relationship between a spe-

the substance make it more difficult for them

cific genotype and alcoholism. A long tradition

to regulate intake appropriately. Conversely,

of research in neuroscience has implicated

others have suggested that those w h o experi-

dopamine as the central nervous system (CNS)

ence higher levels of response to alcohol con-

neurotransmitter o f reward, and studies have

sumption are more likely to develop problem

demonstrated that drug use is associated with

drinking

increased C N S dopamine release. Based on this

(e.g., Nagoshi &

Wilson, 1 9 8 7 ) .

These theorists have proposed that the more

research, Blum and colleagues ( 1 9 9 0 ) tested

reinforcing the effects o f alcohol, the more

the possibility that polymorphisms (i.e., geno-

likely one is to consume. Newlin and T h o m s o n

typic variants) in the dopamine D

( 1 9 9 0 ) proposed that both may be the case;

gene ( D R D 2 ) would be related to alcoholism.

that is, lower levels o f response to the aversive

Indeed, they found

effects o f alcohol, coupled with higher levels

were significantly more likely to carry the

of response to its positive effects, create a

D R D 2 " A l " allele compared with controls.

"double w h a m m y " risk factor for problem

They suggested that this locus may be related

drinking. Subsequent empirical studies have

to a lower number o f D

provided some support for their model (e.g.,

in hypodopaminergic function that could be

Erblich et al., in press). T h e prevailing view

alleviated by, among other things, alcohol con-

remains that

the reinforcement

that

2

2

receptor

severe alcoholics

receptors, resulting

value o f

sumption. This suggestion may be consistent

alcohol figures prominently in understanding

with the overall reinforcement model o f risk

problem drinking. extension, would

A critical question,

by

for alcoholism, such that carriers o f this

be the following: W h a t

polymorphism may find consuming alcohol

factors contribute to differential

levels o f

alcohol's reinforcement value?

more rewarding than do noncarriers. Whether or not this is the case remains to be seen. Strikingly, studies o f genetics have typically not included assessments o f perceived levels

Specific Genetic Factors

of reinforcement, so that intuitive relations

Quantitative genetic studies have demon-

between genotype and reinforcement remain

strated in a compelling fashion that alcoholism

largely speculative. Another concern is that

has a substantial, but not an

exhaustive,

molecular biology has, to date, procured only

heritable component.

Troughton,

Cadoret,

sketchy evidence that the D R D 2

polymor-

O ' G o r m a n , and Heywood ( 1 9 8 6 ) estimated

phism is functional; that is, carrying the A l

that up to 6 0 % o f the population's variability

allele does not necessarily translate to fewer D

in alcoholism is attributable to genetic factors.

receptors. Therefore, the mechanism through

Other epidemiological studies have estab-

which D R D 2 - A 1 confers increased risk for

lished that individuals w h o have an alcoholic

alcoholism remains unclear.

parent are three to four times more likely to develop

alcoholism themselves.

exogenous

Although

(i.e., nongenetic) factors

may

2

Nevertheless, Blum and colleagues' ( 1 9 9 0 ) initial findings have spurred an intensive search for other candidate genotypes that may predict

Alcohol problem drinking. Blum and colleagues ( 2 0 0 0 ) have since tested other

dopamine-related

genotypes, including polymorphic loci

Problems

renders some drinkers particularly susceptible to chronic hypodopaminergic

states. This

on

possibility is particularly intriguing as data

D R D 4 and S L C 6 A 3 , a gene that generates the

emerge suggesting that, within the dopamine

protein responsible for regulating presynaptic

system, the D

dopamine reuptake. Other candidate genes

liking, whereas D

(e.g., S L C 6 A 4 , 5 H T - 1 B , GABA-A, m u O R ,

wanting (Berridge & Robinson, 1 9 9 8 ; Self,

t

subsystem is associated with 2

is more associated with

P E N K ) include those related to serotonin func-

1 9 9 8 ) . T h e convergence o f these data may

tion, G A B A function, and opioid release (for a

suggest that psychopharmacological agents

review, see Blum et al., 2 0 0 0 ) . Studies have

with differential affinities to D j and D

provided mixed results, and even the positive

prove to be selectively efficacious depending

2

may

studies account for only a small proportion o f

on the particular need o f the drinker (e.g., a D

variance in alcoholism or drinking, with sub-

genetically "vulnerable" person may

stantial heterogeneity. Findings underscore the

more craving management).

importance o f polygenic or gene-environment interactions

in

better

understanding

this

complex behavioral disorder. Indeed, early biochemical research (Davis & Walsh, 1 9 7 0 ) has suggested that by-products o f alcohol's metabolism (i.e., tetrahydroisoquinolines) may cause a cascade that directly impinges on opioid receptors but that also indirectly affects the breakdown and availability o f synaptic dopamine. Although not yet tested, w o r k by Berridge and Robinson ( 1 9 9 8 ) raised the possibility that genes related to dopamine function may operate by increasing the motivational salience o f the substance (e.g., craving or "wanting"), whereas relevant polymorphisms in opioid genes may operate by increasing the hedonic value o f consumption (e.g., actual reward or "liking"). Although perhaps a way off, possession o f these genotypes may suggest distinct loci o f intervention

(i.e., craving

management therapy for carriers o f dopaminerelated high-risk genotypes vs. opiate antago-

A final set of candidate genotypes that has been examined include those genes responsible for generating alcohol metabolic enzymes (e.g., alcohol dehydrogenase, acetaldehyde dehydrogenase, P 4 5 0 liver enzymes in the cytochrome system) (Higuchi, Muramatsu,

Matsushita,

Murayama, & Hayashida, 1 9 9 6 ) . Polymorphic loci on these genes (e.g., A L D H 2 , A D H 2 , A D H 3 , C Y P 2 E 1 ) are subjects o f continued scrutiny and may also relate to the magnitude of the hedonic response to alcohol consumption. Because stress is a potent antecedent o f alcohol consumption, examination o f genetic factors that relate to the stress response (e.g., Cortisol regulation) may be a promising avenue in the future. Clearly, the preliminary search for candidate genotypes has yielded only modest

results. Genome-wide

microarray

technology may prove to be highly useful in elucidating the roles o f multiple genes in animal models o f alcoholism.

nist therapy or counterconditioning for carriers

Cognitive Factors

o f opioid-related high-risk genotypes). Along similar lines, recent studies charac-

There is currently a large body o f research

terizing the dysregulation o f C N S functional

demonstrating that individuals with a genetic

systems through chronic alcohol use have

predisposition to alcoholism display substan-

demonstrated

of

tial cognitive and neuropsychological deficits.

both the D j and D receptor systems (Self &

Giancola and M o s s ( 1 9 9 8 ) argued that cogni-

striking down-regulation 2

2

need

Nestler, 1 9 9 8 ) . T o the extent that genetics

tive and neuropsychological deficits, especially

may play a role in receptor density, a potential

those related to executive functioning

gene-environment interaction may exist that

predate drinking experiences (e.g., attention,

that

86

BEHAVIORS THAT C O M P R O M I S E HEALTH appropriate

which problem drinking develops. Speculation

inhibition), may somehow be related to the

aside, the precise mechanism through which

development

cognitive and neuropsychological deficits lead

planning,

Alterman,

cognitive flexibility,

o f alcoholism. F o r example,

Gerstley, Goldstein, and

Tarter

to alcoholism remains unclear. In addition,

( 1 9 8 7 ) reported that "children o f alcoholics"

whether these deficits are genetic or environ-

perform more poorly on tasks that putatively

mental in origin is also unclear. Nevertheless,

assess frontal lobe functioning such as the

these factors are important to consider when

Stroop task, the Trail M a k i n g task, and the

developing an etiologic model o f alcoholism.

Wisconsin Card Sort task. Studies of stimulusevoked potentials, especially the P 3 0 0 component (Rodriguez, Porjesz, Chorlian, Polich, & Begleiter, 1 9 9 9 ) , have provided

Characterologic Factors

converging

It is now well established that specific

biological support for the notion that children

personality factors are strongly predictive of

of alcoholics display poorer attentional capac-

drinking behavior. Nearly four decades ago,

ities than do other children. In contrast to the

MacAndrew

predictors mentioned previously, these cogni-

items on the Minnesota Multiphasic Personality

tive predictors

Inventory

do not necessarily directly

(1967)

(MMPI),

identified primarily

clusters o f related

to

operate through differential reinforcement. A

deviance proneness, that significantly differen-

likely explanation is that although

tiated alcoholics from

drinkers

with cognitive deficits experience comparable

nonalcoholics. This

early research was one o f the first systematic

levels o f reinforcement from alcohol to those

investigations of the potential role of personal-

of drinkers without such deficits, the former

ity characteristics in problem drinking. Since

lack the cognitive resources to regulate their

then, the MacAndrew Alcoholism Scale and

intake or to say " n o " when offered a drink.

the Holmes Alcoholism Scale have become

This problem may become particularly pro-

mainstays of risk assessment for alcoholism.

nounced when high-risk drinkers, w h o are

Recent modifications have found that shorter

already mildly cognitively deficient, become

versions of these scales (7 to 13 items) may be

intoxicated, further undermining their ability

even more strongly related to alcoholism

to process information or to attend to internal

(Conley

or external intake regulation cues. T h e possi-

Lumry, Harrison, & Lessard, 1 9 8 4 ) . Problem

bility also exists that cognitive deficits are

drinking has been related to other measures

&

Kammeier,

1980;

Hoffman,

epiphenomenal to a broader relation between

of deviance proneness as well. For example,

chronic hypofrontality (which may, in fact, be

several studies

related to the reinforcement value o f alcohol)

drinkers, alcoholics, and children o f alcoholics

and future drinking behavior. Alternatively,

score significantly more pathologically on the

Erblich and Earleywine ( 1 9 9 9 ) suggested that

Socialization scale of the California Personality

have found

that

problem

such deficits may also stem from the more

Inventory (e.g., Finn, Sharkansky, Brandt, &

general effects o f growing up with an alco-

Turcotte, 2 0 0 0 ) . In addition, symptoms of

holic parent. Poorer nutrition,

antisocial and borderline personality disorders

educational

opportunities, and physical abuse have been

are c o m m o n among problem drinkers, alco-

reported among children of alcoholics ( R a o ,

holics, and children o f alcoholics. Indeed, Sher

Begum, Venkataramana, &

Gangadharappa,

and Trull ( 2 0 0 2 ) reviewed the literature on

2 0 0 1 ) . O n e could speculate that growing up in

personality

such an environment may lead to the observed

although substance abuse is related to many

cognitive deficits and, as indicated previously,

personality symptoms, including those o f para-

may be an important

noid and avoidant personality disorder, the

mechanism

through

disorders

and

concluded

that

Alcohol

Problems

largest consistent set o f findings is in antisocial

a "hungry" brain in dramatically increasing the

and borderline symptoms.

incentive salience and reward value o f alcohol

Problem drinking appears to be related to

consumption.

other personality constructs as well. Studies have demonstrated repeatedly that high scores on Zuckerman's Sensation Seeking Scale (and

Exogenous Factors

other similar scales) predict drinking behavior

Stress is the most consistently reported

(e.g., Finn, Earleywine, & Pihl, 1 9 9 2 ) . Other

antecedent to drinking behavior. Naturalistic

studies o f novelty seeking using similar instru-

studies o f stress have found strong relations

ments provide additional support for such a

between a number o f stressors (e.g., social,

relation (Hesselbrock & Hesselbrock, 1 9 9 2 ) .

medical, trauma) and drinking behaviors. As

A longitudinal study o f children's novelty

one example, Seeman and Seeman ( 1 9 9 2 )

seeking found that those w h o scored highly

found that chronic stress associated with work

were more likely to become alcoholics as

predicted later alcoholism. Indeed, anecdotal

adults (Cloninger et al., 1 9 8 8 ) . Interestingly,

clinical reports consistently support the con-

one o f the relatively few

transdisciplinary

tention that acute stress is a powerful proximal

studies performed (Laine, Ahonen, Rasanen,

determinant of drinking episodes. T o ascertain

& Tiihonen, 2 0 0 1 ) revealed that individuals

a causal relation between stress and drinking,

high in novelty-seeking personality traits also

investigators have employed laboratory-based

have higher densities o f C N S dopamine trans-

studies o f experimental stressors (Stewart,

porter ( D A T ) . This finding is consistent with

2 0 0 0 ) . Findings have demonstrated that social,

genetic hypotheses that high levels o f D A T

cognitive, and physical stressors can induce

(which clears dopamine from the synapse)

alcohol craving, potentiate the hedonic impact

would relate to problem drinking.

of consumption, and increase the amount of

Still other studies have examined the role of

alcohol

consumed

post-stressor

(Stewart,

traits such as disinhibition, reward dependence,

2 0 0 0 ) . Interestingly, the magnitudes o f stress

external locus o f control, and negative self-

reactions also predict drinking behavior, such

concept and have found significant relations

that the previously mentioned drinking param-

with drinking behavior (e.g., Hesselbrock 8 t

eters are more severe for those who have

Hesselbrock, 1 9 9 2 ) . Interestingly, neurophysio-

stronger stress reactions (Sinha & O'Malley,

logical studies have linked many of these per-

1 9 9 9 ) . This finding is important because it

sonality traits, especially sensation seeking,

suggests not only that stress is a predictor o f

disinhibition, and deviance, to chronic hypo-

drinking but also that some who are pre-

perfusion of the orbitofrontal cortex (Friedman,

disposed to more powerful stress reactions

Cycowicz, &c Gaeta, 2 0 0 1 ) . Theorists have sug-

(through some genetic factor or otherwise) are

gested that these personality traits may repre-

at a particularly high risk for problem drink-

sent part of a broader syndrome related to

ing. T h e classic stress vulnerability model may

cortical underarousal

(Brennan 8c R a i n e ,

be particularly appropriate for understanding

1 9 9 7 ) . The localization o f these traits in the

alcoholism. Specifically, constitutional factors,

CNS

is particularly intriguing because the

orbitofrontal

c o r t e x is precisely the

area

involved in the cognitive deficits mentioned pre-

such as genetics, personality characteristics, neuropsychological dysfunction,

and

stress

reactivity, may render some individuals partic-

viously. Furthermore, this region of the brain is

ularly vulnerable to the effects o f stress and

highly dopaminergic. T h e physiological conver-

place them at high risk for dependence.

gence of these biogenetic, cognitive, and per-

If stress predicts drinking behavior, coping

sonality factors speaks to the preeminent role of

skills should moderate the degree to which

BEHAVIORS T H A T C O M P R O M I S E HEALTH stress has an impact. Indeed, studies have

friends, work, and the law), the more one will

demonstrated that coping skills can buffer the

drink. Studies have shown repeatedly that the

effects o f stress on drinking behavior (Wills,

Alcohol Expectancy Questionnaire, a classic

8c Yaeger, 2002). Darwin, Freud, and

instrument used to assess positive expectancies,

(most recently) Bandura have underscored the

predicts drinking behavior (e.g., Williams &

Sandy,

importance of coping in adapting to stressful

Ricciardelli,

1996). Similarly, the more recently

situations. T h e Darwinian model o f homeo-

developed

Negative

static maintenance would predict that

an

Questionnaire has been found to negatively

organism would consume alcohol to return

correlate with drinking variables ( M c M a h o n

t o a baseline "pre-stress state"

(Darwin,

8c Jones, 1994). Recent innovations have iden-

1859/1998). Indeed, ethologists have specu-

tified powerful ingrained cognitive schemata

lated that animals may take laborious detours

that

from traditional migratory paths to find psy-

Goldman, Roehrich,

choactive substances. It is thought that this may

these are especially strong among those at risk

serve to maintain homeostasis during the stress-

for

ful process o f migration. Freud

(1901) formu-

underlie

Alcohol E x p e c t a n c y

these expectations (Rather,

alcoholism

8c Brannick, 1992), and

(Erblich, Earleywine,

8c

2001). In an intriguing study, Smith

Erblich,

lated the role o f coping in terms of "defense

(1994) found that expectations o f favorable

mechanisms." He argued that those who are

drinking

consequences predated

drinking

"orally fixated" (i.e., those w h o experienced

experiences, suggesting that such expectancies

some sort o f developmental arrest in early life

may be learned relatively early in life and are

when oral pleasure dominated) might use alco-

not simply a readout o f people's actual experi-

hol to cope with stressors in favor of other

ences with alcohol.

healthier coping mechanisms. Finally, Bandura

(1969) argued in his social learning theory that use o f alcohol as a coping mechanism may stem from imitative learning processes. Drinkers may have observed their parents use alcohol as a method o f "unwinding" after a long day, or they may have observed similar media representations of alcohol (e.g., "Miller time"). All of these theorists share the notion that management o f stress is a critical moderator o f drinking behavior and must be considered when trying to understand the effects o f stress on the development o f alcoholism. Another major predictor of drinking behav-

Modeling is another critical component in the development o f drinking behavior, according to

Bandura's

social learning

theory.

Children and teens often rely on role models when

developing

behavioral

repertoires,

especially regarding health behaviors (Yancey, Siegel,

&

McDaniel,

2002).

Observing

parents, siblings, and other peers consume alcohol may play a powerful role in shaping future behavior (Roski et al.,

1997). Other role

models, including those seen in advertisements, television programs, and movies, can have a profound influence as well. Thompson and Yokota

(2001) found that although the trend

ior is one's expectations of the consequences o f

has been decreasing, a substantial number of

drinking (e.g., Keane, Lisman, & Kreutzer,

G-rated movies depict alcohol and/or drug use.

1980). T h e more one expects alcohol con-

Social support is yet another factor found to

sumption to lead to positive outcomes (e.g.,

be involved in the development of problem

better social performance, better sexual perfor-

drinking. Individuals who report low levels o f

mance, more tension reduction, euphoria), the

social support are more likely to report prob-

more one will drink. Similarly, the less one

lem drinking than are others (Green, Freeborn,

expects alcohol consumption to lead to nega-

8c Polen, 2001). In a longitudinal study, (2001) found that even

tive consequences (e.g., hangover; excessive

Schuckit and Smith

sedation; sluggishness; trouble with family,

among individuals at high risk for alcoholism,

Alcohol

Problems

89

high levels of social support protected against

consequences o f alcohol: cognitive-behavioral

developing alcoholism 15 years later. Marlatt

therapy (CBT), motivational interviewing, and

(1996) discussed numerous "proximal determi-

12-step facilitation. C B T focuses on changing

nants" or factors that contribute to the decision

the thoughts and situations that previously led

to consume alcohol "in the moment." H e sug-

to the use of alcohol. Motivational interviewing

gested that those individuals with poor social

uses assessments and interpersonal interactions

skills, especially those who are uncomfortable

to enhance decisions to alter problem behaviors.

with saying " n o , " are more likely to consume

Finally, 12-step facilitation employs specific

alcohol (see also Smith & McCrady, 1 9 9 1 ) .

techniques to help people make good use of

In addition, those who have lower levels o f

12-step treatment.

self-efficacy, especially regarding the willpower to abstain or moderate drinking

Each treatment has its strengths. An enor-

behavior,

mous project that contrasted the outcomes o f

are more likely to consume alcohol. Taken

these three treatments for alcohol-dependent

together, stress, coping, expectancies, modeling,

individuals found that all three were compa-

social support, social skills, and self-efficacy can

rably effective

be conceptualized as necessary, but not suffi-

Group, 1 9 9 8 ) . T h e treatments share several

cient, moderators o f risk for developing alco-

factors, and this may help to explain their

(Project M A T C H Research

holism, such that the presence o f these factors

similar outcomes. Each emphasizes the client's

may determine whether or not someone who is

responsibility for change, each treats alcohol

vulnerable (by virtue o f genetics, personality, or

use as a phenomenon independent o f the indi-

cognitive functioning) will develop alcoholism.

vidual's value as a person, and each stresses

It should be noted that although these concepts

regular attendance and active participation in

are being presented independently, there is a

treatment.

sizable literature suggesting complex interrelationships between factors that is beyond the scope of this chapter. An illustration of this point is that coping, social skills, and selfefficacy all may be related and may be affected by expectancies (Marlatt & Gordon, 1 9 8 5 ) . Nevertheless, we believe that the current body o f literature on predictors o f drinking behavior points to a classic stress vulnerability model, whereby constitutional factors such as genetics, personality, and cognitive capacities can render an individual vulnerable to the effects of numerous exogenous factors. In sum, the available data

suggest that

the stress

vulnerability

approach provides a clinically useful working model o f the pathogenesis o f alcoholism.

Descriptions of these therapies do not reveal all o f their nuances, and even the best attempt to reduce a treatment to a few pages o f text invariably fails. Academic descriptions of psychotherapy often miss its potential for intimate and curative interactions, whereas stereotypical depictions o f the process often emphasize education,

empathy,

encouragement,

and

occasional insights. Ideally, these descriptions combine to alter actions, diminish problems, and increase happiness. T h e techniques and rationales o f each o f the treatments discussed in what follows provide only a limited picture of the ways in which they actually proceed. Although treatments differ in their methods and strategies, most require a

meaningful

relationship with a therapist. Therapists often believe that techniques create change, but the

PSYCHOLOGICAL TREATMENTS FOR ALCOHOL PROBLEMS

relationship may serve as an equally important

At least three different approaches have shown

strategies may help to explain some of the simi-

considerable promise in minimizing the negative

lar

contributor (Strupp, 1989). T h e idea that the relationship is more important than specific outcomes created by different

therapies

BEHAVIORS T H A T C O M P R O M I S E HEALTH (Wampold et al., 1997). Manualized treatments,

The situations that precede drinking often

which clearly delineate specific material for

appear to be diverse. For example, an assess-

each session, can lead to different outcomes

ment might reveal dramatic drinking at a sport-

with different therapists. Although the thera-

ing event, after conflict at home, and every

peutic relationship may account for these

Friday night. T h e commonalities among these

differences, it does not mimic the friendship

situations are obscure. T h e cognitive-behavioral

and coaching c o m m o n outside o f therapy.

model suggests that thoughts about the situa-

D a t a clearly support psychotherapy's efficacy,

tions may contribute more to drinking than do

but the mechanisms that

the circumstances themselves. Thus, each envi-

lead to success

remain unclear (Dawes, 1 9 9 4 ) . Space

limitations

ronment may elicit specific thoughts. A com-

preclude

a

lengthy

mon thought in all of these situations might

description o f all available treatments for alco-

be that "alcohol is the only way in which to

hol-related problems. Given the widespread

enhance this experience." These types o f

familiarity and availability o f 12-step pro-

thoughts are probably easier to alter than are the

grams, this chapter focuses on

C B T and

motivational interviewing. T h e reader

who

is interested in facilitating participation

in

12-step programs is encouraged to read the work o f Nowinski and Baker ( 1 9 9 2 ) .

situations, so the thought rather than the environment becomes the focus of C B T . T h e cognitive-behavioral model

suggests

that people carry a set o f underlying beliefs into each situation. Certain situations activate these beliefs, eliciting specific thoughts

that

subsequently lead to action. F o r example, a

Cognitive-Behavioral Therapy

problem drinker might believe that alcohol

C B T for alcohol problems focuses on alter-

provides the only way in which to relax. T h e

ing environments, thoughts, and actions associ-

drinker may interpret a situation as stressful,

environments

leading to the activation of the belief that he

may trigger undesired problematic consump-

or she needs alcohol to relax. This belief

tion. These triggers involve both external and

would likely lead to thoughts of drinking,

internal factors. External factors include any

which might inspire all o f the actions required

ated with drinking. Different

person, location, or object associated with alco-

to get a drink. In C B T , the client would learn

hol. A beer mug, a rock song, or a swizzle stick

to challenge his or her beliefs in an effort to

may easily trigger a desire to drink. Internal fac-

minimize or eliminate drinking. Thus, the

tors include thoughts and feelings linked to

client may develop skills enabling him or her

alcohol. Some triggers are direct and some are

to see the situation as less stressful, thereby

indirect. Direct factors, such as craving and

altering the belief that drinking is the only

urges, are close to drinking. Indirect factors also

effective way in which to relax (Beck et al.,

increase the chance of drinking,

1 9 9 3 ) . Instead o f drinking, the client might

but

their

import is less obvious. These include frustration, anger, and even delight. C B T suggests

listen to music, meditate, or exercise. Therapists have developed

many

tech-

that problem drinkers learn to use alcohol in

niques for altering these beliefs. M o s t require

reaction to these triggers in much the same way

identifying the underlying

as people learn any behavior. Therefore, they

looking for evidence to support or dispute it.

belief and

then

can learn to engage in new behaviors instead o f

A c o m m o n strategy that cognitive-behavioral

problematic drinking

therapists employ includes Socratic question-

by altering

environ-

ments, thoughts, and actions (Beck, Wright,

ing, a method

Newman, & Liese, 1 9 9 3 ) .

clients through a series o f questions so that

by which therapists

guide

Alcohol they might arrive at their own

answers.

Problems

limits. T h e abstinence violation effect

91 may

Instead of providing information, this strategy

occur when a small thoughtless sip o f beer turns

teaches a process for discovery. Eventually,

into a full weekend binge. It is as if people

clients can learn to ask these sorts o f questions

say, "Well, I wrecked my abstinence, so I might

of themselves so that they can maintain sobri-

as well drink the whole bottle." Minimizing

ety without therapists.

the impact of small slips is essential to relapse

This process also elicits the thoughts and

prevention. Although many believe that the

feelings most important to clients. For example,

pharmacology o f alcohol makes a single dose

those who believe that alcohol provides the

inevitably turn into a relapse, changes in think-

only way in which to relax might respond

ing can actually prevent these slips from creat-

particularly well to questions about alternative

ing further problems. In fact, it has been shown

ways in which to unwind. Questions about

that the interpretation o f the slip appears to

restful recreation in general may prove helpful.

contribute more to relapse than does the

Queries about favorite activities before clients

actual occurrence o f the slip itself (Marlatt &

began drinking may also work. As clients gen-

Gordon, 1 9 8 5 ) .

erate their own list o f preferred ways in which

There is no doubt that intoxicated individu-

to soothe themselves without alcohol, the belief

als can make poor decisions about continued

that alcohol is the sole source o f relaxation

drinking and that the pharmacological effects

weakens. It is important to note that clients find

of

their own examples more compelling than any

Nevertheless, many individuals who relapse

list of relaxation techniques that

report

therapists

might generate. This approach also respects

alcohol contribute abstinence

to these

violation

decisions.

effects

that

occurred at extremely low doses. A single sip

clients' ability to present evidence to alter their

of liquor or smell o f wine often lead to the

beliefs (Overholser, 1 9 8 7 ) . In sum, changing

decision to binge. Pharmacology might not

the thoughts about situations that previously

play a particularly strong role in these relapses.

led to drinking can help to decrease problem-

Marlatt, Demming, and Reid ( 1 9 7 3 ) revealed

atic consumption.

that alcoholics who drank alcohol but were

C B T relies on other techniques that are too

not aware o f doing so did not show the absti-

numerous to list here, but one key set of strate-

nence violation effect and did not continue

gies concerns relapse prevention. M a n y people

drinking after the initial dose. In contrast,

can quit drinking briefly but cannot maintain

alcoholics given a placebo believed to be alco-

abstinence. Thus, many cognitive-behavioral

hol did show the abstinence violation effect

techniques focus not only on quitting

and did consume considerably more alcohol

but

also on avoiding relapse to alcohol. Thoughts

after the placebo. These findings indicate that

and beliefs remain important

thoughts also play an important role in relapse

in preventing

relapse given their relevance to a phenomenon

prevention.

known as the abstinence violation effect. T h e

In sum, C B T relies on the principles o f

abstinence violation effect concerns the way in

learning theory to treat alcohol-related prob-

which people cope with backsliding once they

lems. T h e treatment may w o r k by altering

have committed to altering their alcohol

beliefs about

consumption.

quences. It also focuses on the prevention o f

M o s t people who decide to eliminate or decrease their use of alcohol subsequently make

alcohol use and

relapse by identifying

its conse-

situations that

may

increase the risk o f drinking and then teach-

mistakes. They use alcohol when they intended

ing alternative ways in which to act under

to quit, or they use more than their established

those conditions.

92

BEHAVIORS T H A T C O M P R O M I S E HEALTH

Motivational Interviewing

qualities with the stages o f change model to

Motivational interviewing involves brief interactions with a therapist to help the client decrease alcohol-related problems. T h e treatment enhances motivation before attempting any changes in behavior because in the absence of motivation, any efforts to teach techniques for limiting alcohol consumption are typically an inefficient use o f time for both the client and the therapist. Motivational interviewing focuses on identifying clients' own reasons to quit. Once these reasons help to increase desire, clients often develop their own strategies for eliminating alcohol from their lives. M a n y people stop drinking on their own, and motivational interviewing essentially enhances the chances that a client will join this group. (For a more detailed discussion o f motivational interviewing, see Chapter 4.) Motivational interviewing relies on principles designed to help the client decrease alcohol problems. First, the therapist behaves in a manner that will increase the likelihood o f change such as listening attentively without judgment

or blame. Second, the

therapist

employs the "stages o f change" model, which views change as a fluid process that requires a different intervention for each stage o f the client's willingness to act. In motivational interviewing, the behaviors employed by the therapist that are most likely to induce behavior change on the part o f the client (e.g., empathy,

nonpossessive w a r m t h ,

genuineness)

were originally emphasized in client-centered therapy (Rogers, 1 9 5 0 ) .

decrease problem drinking. T h e stages of change model describes specific steps that individuals appear

t o take when

they alter

problem

behaviors (Prochaska & DiClemente, 1983). The researchers proposed six stages: (a) precontemplation, (b) contemplation, (c) determination, (d) action, (e) maintenance, and (f) relapse (Prochaska, Norcross, & DiClemente, 1994). Precontemplation

describes the

period

before individuals consider altering behavior. Drinkers in precontemplation

have

never

considered cutting down or quitting. An adept therapist would not waste time attempting to teach these individuals h o w to quit because they currently lack the motivation to do so. Instead, the therapist assesses clients' quantity and frequency of drinking in an effort to get them

to

contemplate

change.

The

best

approach for this assessment is the time line "followback" (Sobell & Sobell, 1 9 9 5 ) , a calendar

technique that asks drinkers to go

through each day for the previous 3 months and list the number o f drinks consumed. T h e therapist would also ask about any associated consequences such as negative

emotions,

fatigue, hangovers, accidents, and liver troubles. This assessment often leads clients to make the connection between their drinking and the consequences o f their drinking. If these connections are made and they lead clients to consider change in any way, clients have entered the contemplation stage. Contemplation includes the weighing of the pros and cons o f altering actions or continuing the same behavior. T h e motivational interviewer encourages drinkers in this stage to candidly report all o f the positive and neg-

T H E STAGES O F CHANGE M O D E L

ative experiences they attribute to their use o f alcohol. Initial assessments o f pros and cons

As mentioned in the previous section, empathy,

often

warmth, and genuineness lay the foundation for

desires to continue drinking as well as equally

reveal ambivalence, that

is,

strong

any productive therapeutic interaction. M a n y

strong desires to stop. Ambivalence serves as

therapies rely on these aspects of the thera-

a c o m m o n important component o f contem-

peutic relationship to help support growth.

plation. Other approaches t o treatment may

Motivational

see ambivalence as denial. T h e stages o f

interviewing

combines

these

Alcohol change model emphasizes ambivalence as an

Problems

relapse. T h e y identify situations that

93 put

further

the drinkers at high risk for relapse, and they

discussion, the therapist respectfully reflects

plan ways in which to avoid problematic

drinkers' concerns back to them, emphasizing

alcohol

the negative consequences that they generated

example, clients m a y decide to avoid parties

earlier. This process often leads

problem

where alcohol is present. T h e y m a y role-play

drinkers to a decision to change. A firm

refusing drinks if they are offered them. T h e y

inherent

part o f change. During

use in these c i r c u m s t a n c e s . F o r

decision to change qualifies as a step toward

may practice relaxation techniques if tension

determination.

often precedes their drinking. T h e y may call

Determination begins with a clearly stated

a hotline or a friend during times o f tempta-

desire to alter actions. This stage serves as the

tion. It is important to note that these tech-

appropriate time for drinkers to formulate a

niques for preventing relapse are consistent

plan for limiting alcohol consumption. T h e

with 12-step and C B T approaches.

plan often stems from brainstorming between

Occasional backsliding occurs in many

the interviewer and the drinkers and may

efforts to alter maladaptive drinking behav-

include any options that look promising. F o r

ior. T h e stages o f change model considers

example, the strategy for change may rely on

lapses and relapses as another category o f

techniques from C B T such as altering beliefs

change. Discussing this fact with clients

and preventing relapse. In addition, drinkers

may help to normalize the occasional slip.

may decide that membership in a 12-step

Considering lapses as a part o f the change

program sounds appropriate.

process may decrease the chances o f an absti-

O n c e clients regularly limit their drinking

nence violation effect transforming a slip into

or abstain, they have entered the action stage.

a full-blown relapse. T h e key to the lapse

T h e y no longer merely consider change; they

stage parallels the key to the maintenance

actually make the desired change. This stage

stage—preventing

proves to be particularly informative as the

immediate action. Lapsing drinkers can pre-

genuine experience o f new habits and actions

vent relapse by rapidly exiting the situation

reveal valuable information

and removing the chance o f continued drink-

unanticipated

relapse. Lapses

require

during the contemplation and determination

ing. M a n y w h o lapse berate themselves, but

stages. Clients may find

situations

their time and energy m a y be better spent in

to be easier or m o r e difficult than they

identifying the precursors to the slips. A

expected. T h e motivational interviewer will

frank examination m a y reveal a new high-

some

offer reassurance about the process becom-

risk situation, providing the opportunity to

ing less difficult with the passing o f time and

formulate a plan for h o w to handle this

more practice. T h e interviewer helps clients

predicament in the future. F o r example, a

to solve problems related to their alcohol

former drinker may find himself or herself

use and listens attentively to clients' detailed

lapsing after a fight with a family member.

descriptions o f their difficulties and successes.

This situation might not be one that the

After a steady period o f action, clients

drinker had identified as high risk before.

increased confidence in their

N o w the drinker k n o w s that he or she needs

skills. This sense o f efficacy, an optimism in

to plan new ways in which to deal with con-

may report

their o w n ability to continue the new behav-

flict. T h e drinker can turn this lapse into a

iors, serves as a hallmark o f the maintenance

learning experience to prevent future drink-

stage. Self-efficacy and sustained change are

ing. T h u s , lapses remain a part o f the change

the keys to maintenance. T h e therapist and

process, and planning for them may mini-

the clients will n o w w o r k together to prevent

mize problems.

94

BEHAVIORS T H A T C O M P R O M I S E HEALTH

CASE S T U D Y "Bob,"

a 54-year-old Caucasian

male t r u c k

driver,

c a m e to

a

Veterans

Administration hospital after falling in his driveway. H e had seriously injured his face and hands. A breath alcohol monitor suggested that his blood alcohol level was approximately . 2 0 . Surgeons removed small rocks from his face and hands and referred him t o the chemical dependency treatment program. Assessment revealed that B o b had been drinking alcohol regularly for 4 1 years, since the age o f 13 years, and had his first drink at age 1 0 years. A time line followback assessment suggested that B o b had consumed between 2 0 and 2 4 beers per day over the past 9 0 days, a pattern he said went b a c k for at least 7 years. H e had been in treatment twice previously, once in his late 2 0 s and once approximately 8 years ago. H e had maintained complete abstinence for approximately a year each time. Both treatments focused on 12-step interventions, but B o b was unwilling to return t o meetings or inpatient treatment. H e did, however, agree to attend a 1-hour outpatient appointment the following week. B o b missed the first outpatient meeting, rescheduled after a telephone call, and missed the second meeting as well. A phone call after his second missed appointment revealed that he was willing to discuss the pros and cons of attending an outpatient appointment. B o b confessed that he thought that the hospital only offered 12-step interventions and that he thought he would be "strong-armed" into going back to " G o d meetings." W i t h the promise that there would be no discussion o f steps or deities, he agreed to attend an outpatient interview the following week. T h e fact that he was willing t o reschedule illustrates the importance o f follow-up calls after missed appointments. B o b would have undoubtedly never returned t o treatment if he had not been phoned after missing appointments. B o b arrived promptly at an afternoon appointment with a breath alcohol concentration of . 0 6 . H e stated that he had consumed 4 beers at lunch but that he was doing much better than he had been doing when he came to the hospital after his fall. He claimed to drink 1 2 beers per day over the previous 3 weeks and again declined inpatient treatment. O n reflection, he admitted that he had cut down to 1 2 beers per day in the past but had eventually increased back to his usual case o f 2 4 per day. He was unwilling to discuss abstinence but agreed to list the pros and cons o f decreasing his drinking to 6 beers per day. This approach is consistent with motivational interviewing interventions for people in the contemplation stage. B o b was surprised when the therapist asked him to first list the disadvantages of drinking only 6 beers per day. T h e most salient disadvantage to him was that he would be forced to drink them all at once on an empty stomach to notice any subjective effects. H e also mentioned that he might receive ribbing from cronies for not "keeping up" when they watched sporting events or went fishing. T h e only advantages to decreasing to 6 beers per day that B o b could generate were financial. With some prompting, he decided that he might also have fewer conflicts with his adult children if he decreased

Alcohol

Problems

his drinking. T h e therapist pointed out several other potential advantages. Specifically, Bob's liver enzymes suggested the potential for medical problems, and these would eventually improve with a decrease (although they would not improve as much as they would with abstinence). In addition, B o b would be less likely to run into problems while driving his truck for work. Mentioning this potential advantage prompted several tales of bravado about his tolerance. With reflection, these eventually turned to a revealing disclosure about a blackout experience. B o b had arrived in a location more than 3 0 0 miles from his home and could not recall any aspect o f the trip. H e feared that he could have had an accident and killed another driver or himself. H e expressed considerable shame, guilt, and fear. Reflection o f these emotions appeared to inspire a willingness to limit consumption to 6 beers per day and to drink these only during the evening when it was unlikely that he would drive. B o b also agreed to three more outpatient visits during the next 3 weeks. The therapist called B o b after 4 days to confirm his next appointment. W h e n asked how he was doing, B o b replied, " I f I can't have a 12-pack, I really don't see the point o f drinking at all." W h e n asked to elaborate, B o b explained that 6 beers provided little change in his state o f mind. H e agreed to stick to the limit but implied that he might experiment with an occasional day o f abstinence. W h e n he arrived for his next appointment, his breath alcohol was . 0 0 . H e had consumed 6 beers per day on each day, but he drank only 1 during the evening that the therapist had called. W h e n asked why, B o b said that he felt "silly" drinking at all after what he had said about requiring 1 2 beers to feel any subjective effects. W h e n asked what subjective effects o f alcohol he preferred, B o b focused on tension reduction. T h e session then turned to standard progressive muscle relaxation training. B o b found relaxing in session to be a bit cumbersome but agreed to listen to a relaxation tape at home. T h e following week, B o b decreased his drinking to an average o f 4 beers per day, with 1 day o f abstinence. W h e n asked h o w he felt about it, he claimed little change in his o w n experience but some tentative changes in those around him. His adult children had commented that it was nice to see him drinking less. H e said that this did n o t matter to him much, but his affect certainly seemed improved. H e had been listening to the relaxation tape daily and agreed to discuss complete abstinence. T h e therapist reviewed some relapse prevention strategies and sent B o b h o m e with a list o f responses he had generated himself for handling difficult situations. H e had focused on drink refusal with friends and stressful situations as his target high-risk situations. B o b generated the expression "I've already had my share" as a response for refusing drinks when offered. H e also agreed to listen to the relaxation tape daily in an effort to reduce stress. H e discussed looking at things differently in an effort to cope, and he agreed to attend a stress management seminar conducted in another area o f the hospital. At 1 month follow-up, B o b had lapsed one time. H e attended a barbecue where an acquaintance handed him an open 4 0 - o u n c e bottle o f beer. B o b stated that he took a drink from the bottle automatically. H e then reported that he excused

BEHAVIORS T H A T C O M P R O M I S E HEALTH

himself to go to the bathroom and poured most o f the beer into the sink. H e reported that he then carried the partially empty bottle around the party for a while for reasons he could not explain. B o b exhibited signs o f disappointment regarding this event. T h e therapist emphasized that it was a single slip, that B o b had not turned it into an excuse to start a binge, and that B o b did not drink again. B o b seemed happy with the interpretation. H e agreed to go back to his favorite "I've already had my share" response if a similar experience arose in the future. T h e therapist called once the following week to confirm abstinence. At 3 months, B o b reported no new lapses and was happy to report that his liver enzymes had improved. At 9 months, he had continued his abstinence and reported even more improvement on his liver enzymes. Although 9 months o f follow-up is not a long time, these initial results were encouraging for this combined approach o f motivational interviewing and C B T .

CONCLUSIONS

imperfect but useful treatments have proved to

Alcohol can create numerous problems in the

for many individuals: C B T , motivational inter-

be effective in alleviating alcohol problems lives o f drinkers. Different genetic and environ-

viewing, and 12-step facilitation. These thera-

mental factors interact in the creation o f alco-

pies have many overlapping characteristics

hol abuse, dependence, and problems. A family

but also employ techniques specific to each

history o f alcoholism, a combination o f person-

approach that are designed to decrease alcohol-

ality traits, and a set o f cognitive factors all can

related problems. Although the road to sobriety

combine with various life stressors to lead

is fraught with difficulties, many people have

people to turn to alcohol for relief of stress.

changed their lives by eliminating the problems

Consistent use o f large quantities may lead to

related to their continued alcohol use. Putting

alcohol abuse. It can further lead to alcohol

an end to problem drinking can have a dra-

dependence or to other life problems. Three

matic impact on health and happiness.

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CHAPTER

5

The Etiology and Treatment of Nicotine Dependence A Biopsychosocial

Perspective

LEE M . COHEN, DENNIS E . MCCHARGUE, MONICA CORTEZ-GARLAND, ERIC H . PRENSKY, AND SADIE EMERY

C

hronic

use

products,

of

tobacco-containing

particularly

cigarettes,

smoke include lung cancer, asthma, respiratory infections, and decreased pulmonary function

remains one of the most avoidable

( D H H S , 1 9 9 9 ) . Despite public health efforts to

causes of death and illness in the United States

reduce tobacco use in the United States, adult

and claims the lives o f more than 4 3 0 , 0 0 0 indi-

prevalence rates have not changed

viduals each year (U.S. Department o f Health

cantly, and

and H u m a n Services [ D H H S ] , 1 9 9 9 ) . T h e

observed during the 1 9 9 0 s ( C D C , 2 0 0 2 ) . For

number

alone

example, the overall rate of adult cigarette

exceeds that o f deaths due to AIDS, murders,

smokers has decreased slightly from 2 5 . 0 % to

o f tobacco-related

deaths

in some cases increases

signifiwere

other drugs, alcohol, car crashes, fires, and sui-

2 3 . 3 % across all age groups except that of 1 8 -

cides combined (Centers for Disease Control

to 24-year-olds ( C D C , 2 0 0 2 ) , whereas the use

and Prevention [ C D C ] , 2 0 0 2 ) . Illnesses associ-

of smokeless (spit) tobacco and cigars has

ated with tobacco use include, but are not

increased substantially (U.S. Department o f

limited t o , laryngeal cancer, oral

cancer,

esophageal cancer, obstructive pulmonary disease, growth

cardiovascular retardation,

disease, and

intrauterine

low birth

weight

Agriculture,

1 9 9 7 ) . T o date, 6 5 . 5 million

Americans continue to use tobacco products on a regular basis ( C D C , 2 0 0 2 ) and appear to be more difficult to treat than their counter-

( D H H S , 1 9 9 9 ) . Evidence o f significant health

parts o f the

risks due to environmental tobacco smoke has

Brandon, 2 0 0 0 ) . As such, tobacco use contin-

1970s

and

1980s

(Irvin

&

also been documented. Adverse health risks

ues to represent an important health behavior

caused by exposure to "secondhand" tobacco

that faces health care professionals.

101

BEHAVIORS THAT COMPROMISE HEALTH

102

DEFINITIONS AND DESCRIPTION OF NICOTINE DEPENDENCE

physiological adaptation

The addictive process associated with tobacco

sea, and vomiting are associated with initial

following

repeated

has been

exposure

to

shown nicotine

(Balfour, 1 9 9 1 ) . F o r example, dizziness, nauuse has been studied primarily with cigarette

exposure t o cigarette smoking;

smoking, but there is a growing body o f litera-

these symptoms disappear rapidly following

however,

ture examining this process in spit tobacco (e.g.,

habitual exposure (Benowitz, 1 9 9 0 ) . For the

Hatsukami & Severson, 1 9 9 9 ; McChargue &

most part, tolerance to nicotine

Collins, 1998) and cigar use (e.g., Henningfield,

quickly, sometimes within

Fant, Radzius, & Frost, 1 9 9 9 ) . T h e D S M - I V -

administration (Porchet, Benowitz, & Sheiner,

TR

(Diagnostic

Mental

and

Disorders,

Statistical

Manual

develops

3 5 minutes o f

of

1 9 8 8 ) . Once tolerance is developed, certain

fourth edition, text revision

effects (e.g., dizziness) are more transient and

2000])

dissipate rapidly following a short period of

classifies chronic tobacco use as a significant

[American Psychiatric Association,

abstinence (Benowitz, 1 9 9 0 ) , whereas toler-

clinical impairment

because of the psycho-

ance to most o f the subjective and behavioral

logical and neurobiological effects caused by

effects appears to be more long term (Perkins

nicotine—the presumed

addictive

ingredient

et al., 2 0 0 1 ) . Researchers have suggested that

found in tobacco products (Henningfield &

the rapid "re-sensitization" o f the more tran-

Heishman,

sient effects, such as the "rush" one experi-

1 9 9 5 ; Robinson &

Pritchard,

1 9 9 2 ) . As a clinical disorder, chronic tobacco

ences from the first cigarette o f the day, may

when

partially explain why tobacco users tend to

use is classified as nicotine

dependence

three of seven criteria are met within the same

show stable use patterns without progressively

12-month period. In particular, the four most

increasing their dose amounts

prominent criteria of nicotine dependence are

(Benowitz, 1 9 9 0 ) .

over

time

(a) developing a tolerance to nicotine, (b) experiencing nicotine withdrawal,

(c) showing a

persistent desire or unsuccessful efforts to quit or cut down the use of nicotine, and (d) continuing to use nicotine despite the development o f physical or psychological problems that are likely to have been caused or exacerbated by tobacco

products

(American

Psychiatric

Association, 2 0 0 0 ) . Other general criteria for nicotine dependence

include

using

larger

amounts over a longer period o f time; spending a great deal of time in activities necessary to obtain, use, or recover from nicotine; and experiencing

impaired

functioning

(American

Psychiatric Association, 2 0 0 0 ) .

Nicotine Withdrawal Nicotine withdrawal is defined as the manifestation o f behavioral, subjective, physiological, and biochemical changes that occur when a person abruptly cuts down or quits using nicotine-containing products (Hughes, Higgins, &c Hatsukami, 1 9 9 0 ) . T h e withdrawal syndrome includes four or more o f the following symptoms: (a) dysphoric or depressed mood; (b) insomnia; (c) irritability, frustration,

or

anger; (d) anxiety; (e) difficulty in concentrating; (f) restlessness; (g) decreased heart rate; and

(h) increased appetite

or weight

gain

(American Psychiatric Association, 2 0 0 0 ) . In

Tolerance Simply stated, tolerance is viewed as a

addition, these symptoms cause clinically significant distress or impairment in social, occupational,

or

other

important

areas

of

diminished response or an adaptation to a

functioning, and the symptoms are not better

given dose after repeated use (Balfour, 1 9 9 1 ;

accounted for by another mental

Benowitz, 1 9 9 0 ) . Subjective, behavioral, and

(American Psychiatric Association, 2 0 0 0 ) .

disorder

Etiology

and Treatment

of Nicotine

Dependence

\

Declining blood levels o f nicotine have been

anxiety is reported, it could be a function of

associated with the onset of nicotine with-

brief lapses in their abstinence (e.g., periodically

drawal; however, it is not clear whether the

smoking one cigarette and then resuming absti-

duration and severity of these symptoms are

nence [West

entirely attributable to the rate at which nico-

sive symptoms may persist beyond 1 month,

tine dissipates from a person's system. For

especially among people who have experienced

8c Hajek, 1997]). Finally, depres-

example, nicotine reaches the brain within 10

a major depressive episode in the past (Borrelli

to 19 seconds after smoking a cigarette, with

et al.,

brain levels o f nicotine declining rapidly over

least a 33% chance that people with a history of

20 to 30 minutes (Benowitz, 1990). O n the

major depression will experience clinically sig-

other hand, nicotine levels in the brain from spit

nificant levels o f depressive symptoms at any

tobacco tend to increase gradually, reaching

time across the first 12 months of nicotine absti-

their peak about 30 minutes after administra-

nence (Borrelli et al.,

1996). In fact, data suggest that there is at

1996; Tsoh et al., 2000).

tion, and decline slowly over 2 hours or more (Benowitz, Porchet,

8c J a c o b , 1990). Despite

the differing rates of nicotine absorption and depletion observed across these two modes o f administration, spit t o b a c c o users consistently report

similar experiences o f

Other Prominent Criteria for Nicotine Dependence Individuals w h o

use nicotine-containing

withdrawal,

products also show signs and symptoms associ-

both in terms o f the types o f symptoms expe-

ated with the remaining criteria for nicotine

rienced (Hatsukami, Gust, 8c Keenan, 1987;

dependence. Specifically, a strong and persis-

McChargue 8c Collins, 1998;

McChargue,

tent desire to use t o b a c c o maintains

use

8c Cohen, 2002) and in terms of the level of severity (McChargue 8c Collins, 1998).

Tiffany, 1990) and contributes to difficulties in

Thus, the severity o f withdrawal

quitting (e.g., Tracy,

Collins,

symptoms

may be dictated by a variety o f individual differences, including tobacco use patterns (Killen,

patterns

(Baker, M o r s e , 8c Sherman,

1986;

1994). Researchers ques-

tion whether nicotine's ability to alter emotions (Baker et al., 1986; Carmody, 1990; Hall,

8c Varady, 1991), psy-

Munoz, Reus, 8c Sees, 1993) drives the motiva-

chiatric comorbidities (Pomerleau, Marks, 8c

tion to use tobacco products or whether this

Fortmann, Newman,

2000), and personality factors (Gilbert 8c Gilbert, 1995; Madden et al., 1997).

Pomerleau,

In general, nicotine withdrawal occurs within

increased

motivation

is

more

automatic

(Tiffany, 1990) and independent from emotion (Robinson

8c Berridge, 2000). Nevertheless,

24 hours of abruptly reducing or quitting nico-

nicotine administration appears to create an

tine use, peaks between 48 hours (Hughes 8c

intense motivation to use tobacco products that

Hatsukami, 1986) and 2 weeks (Shiffman, Paty,

is difficult to break regardless o f the mechanism

Guys, Kassel, Sc Elash, 1995; West, Hajek, 8c

that promotes the powerful desire to continue

Belcher,

1989), and resolves after 1 month of abstinence (Hughes, 1992). However, similar

tobacco use.

to withdrawal severity, the duration o f with-

experience extreme difficulty in quitting, and

Individuals who use tobacco also tend to

drawal patterns are also variable. For example,

unsuccessful efforts usually are made before

increases in hunger and weight gain are the most

they are able to quit permanently. In fact, less

persistent symptoms, lasting as long as 6 months

than 5%

to

1 year (Hughes, 1992; Klesges etal., 1997).

of individuals who meet criteria

for nicotine dependence are able to quit on

1990). This percentage

In addition, individuals who quit using nicotine-

their own (Fiore et al.,

containing products

increases to as high as 30%

do not always

report

increased anxiety; however, in cases where

with assisted

treatment for nicotine dependence (Fiore et al.,

104

BEHAVIORS THAT C O M P R O M I S E HEALTH fewer

the brain (Rose & Levin, 1991) and sensitization

people have quit using tobacco products over

of some neurobiological systems (Robinson &

the past decade ( C D C , 2 0 0 2 ) as compared

Berridge, 2 0 0 0 ; Watkins, K o o b , & Markou,

with previous decades (Emmons, Kawachi, &

2 0 0 0 ) . In general, tobacco use behaviors are

Barclay,

T h e apparent plateau o f

maintained by nicotine's ability to enhance

cigarette smoking rates and the increase of spit

desirable effects (positive reinforcement) and to

2 0 0 0 ) . As stated earlier, fewer and

1997).

tobacco and cigar use may suggest that today's

dispel undesirable effects (negative reinforce-

tobacco users are more resistant to treatment

ment). Over time, frequent and repeated use of

efforts and may even possess underlying vul-

tobacco products in specific situations, environ-

nerabilities that further establish tobacco use

ments, and emotional states may automatically

patterns (Gilbert & Gilbert, 1 9 9 5 ) .

trigger tobacco use (secondary conditioning

Finally, it is not uncommon for nicotine-

and

sensitization)

(Rose &

Levin, 1 9 9 1 ;

use

Shiffman, 1 9 9 1 ) . For example, a person who

tobacco products despite physical or psycho-

typically smokes while talking on the phone

logical problems that may result from chronic

may light another cigarette when the phone

nicotine exposure. Familiar examples include

rings without realizing that he or she already

the patient with emphysema w h o continues

had a cigarette lit.

dependent individuals

to continue to

to smoke while attached to an oxygen tank despite the inherent danger o f doing so and the patient

who

smokes through

a

tra-

cheotomy tube. Overall, there is anecdotal and empirical evidence suggesting that many patients with cardiovascular disease, chronic

Positive Reinforcement and Sensitization: A Story of Rewarding Properties The most widely studied neurobiological

obstructive pulmonary disease, and/or cancer—

substrate

all o f which are related to chronic t o b a c c o use

positive reinforcement is dopamine

associated with

nicotine-related (Wise,

( D H H S , 1 9 9 9 ) — c o n t i n u e their patterns o f

1 9 9 8 ) . T h e mesolimbic dopamine system has

use

long been touted as the reward center o f the

(Gritz,

Kristeller, &

Burns,

1993).

Moreover, continued use is associated with a

brain

heightened mortality rate, whereas cessation

(Olds &

post-disease diagnosis may improve

prog-

noses (Gritz et al., 1 9 9 3 ) .

that

shapes goal-directed Milner,

behavior

1 9 5 4 ; Stein, Belluzzi,

Ritter, & Wise, 1 9 7 4 ) , including drug use behavior

(Di C h i a r a ,

Moal, 1997).

1998; Koob &

Consistent with the

Le

reward

hypothesis of dopamine, nicotine's preferenA BIOPSYCHOSOCIAL

tial binding to nicotinic cholinergic receptors

LEARNING MODEL OF

within

NICOTINE DEPENDENCE

(Clarke & Pert, 1 9 8 5 ) and nicotine's reliable

the m e s o l i m b i c dopamine

system

activation o f dopamine release within

the

Nicotine dependence is a complex biopsy-

same system (Pomerleau & Pomerleau, 1 9 8 4 )

chosocial phenomenon that originates from

suggest that

learning theory. The most parsimonious expla-

rewarding effects for people w h o use t o b a c c o .

nation is that nicotine's effects on neurobiological substrates interact with

behavioral,

nicotine produces

powerful

The rewarding effects of nicotine become more powerful over time due to the biphasic

emotional, and cognitive domains to create

nature o f nicotine's influence on

dependence.

release. During nicotine administration, the

Evidence

also

suggests

that

chronic use patterns may produce secondary

dopaminergic

conditioning o f the pharmacological effects on

rather

than

system

becomes

habituated

(e.g.,

dopamine sensitized tolerance)

Etiology

and Treatment

of Nicotine

j

Dependence

2000; Watkins et al.,

These long-lasting memories may help to

2000). In other words, dopamine release is

explain the incongruent psychosocial findings

enhanced,

related to the reward obtained from nicotine

(Robinson & Berridge, rather

than

diminished,

from

repeated exposure to nicotine. As levels o f

administration.

A standard

assumption

has

abstinence,

been that self-reported pleasure (e.g., positive

dopamine also shows neuroadaptative effects.

affect or euphoria) acts as a substitute for the

nicotine are

during

depleted

progressive

rewarding effects of nicotine. However, empiri-

dopamine

cal evidence has not consistently produced data

(Epping-Jordan, Watkins, K o o b , & M a r k o u ,

to support this assumption. If self-reported plea-

1998). T h e ever-growing disparity between

sure mimicked the neurobiological substrates,

sensitized dopamine

one would expect that pleasure would show

Neuroadaptation blunting

reflects the

o f naturally

occurring

release from

nicotine

administration and blunted naturally occur-

sensitizing effects (i.e., more and more pleasure

ring dopamine release during nicotine absti-

from repeated exposure) after nicotine adminis-

nence

tration and would show acute decreases in

is

hypothesized

to

alter

reward

2000), presumably

pleasure during nicotine abstinence. Although

making it very difficult for tobacco users

research shows the expected decrease in plea-

to experience pleasure without the aid o f

sure following nicotine abstinence (Hughes &

nicotine.

Hatsukami,

thresholds (Watkins et al.,

1986), euphoric effects during nico-

Glutamate functioning also appears to play

tine administration are minimal (Pomerleau &

an important role in the positive reinforcement

Pomerleau, 1992) and may further diminish,

of nicotine via its symbiotic relationship with

rather than increase, with repeated exposure

dopamine. As discussed earlier, dopaminergic

(Robinson & Berridge, 2000). If pleasure dimin-

functioning is regarded as the primary mecha-

ishes with chronic nicotine use and is not linked

nism that accounts for the rewarding properties

with dopamine sensitization, memories about

of nicotine. However, glutamate may actually

the pleasure-enhancing effects of nicotine may

strengthen nicotine's rewarding properties and

be sufficient for continued motivation to self-

permanently implant the effect o f such reward

administer nicotine.

into long-term memory. For instance, nicotine

As noted earlier, the rewarding effects o f

administration has been shown to increase glu-

nicotine are long-lasting in a t o b a c c o user's

tamate release within the mesolimbic dopamine

memory system. A plausible psychosocial

system (Garcia-Munoz, Patino, Y o u n g , &

mechanism that takes into account these

Groves, 1996) as well as within hippocampal

embedded reward effects is positive smoking

neurons associated with memory and learning

expectancies or the belief that smoking will

1999). Given

lead to a positive outcome (e.g., relaxation).

that glutamate is strongly linked to learning and

F o r decades, positive drug expectancies have

(Radcliffe, Fisher, Gray, & Dani, memory (Goda & Stevens,

1996), it has been

been shown to reflect long-term drug use pat-

8c T u c k e r , 1988). In fact, a

hypothesized that the simultaneous activation

terns (Vuchinich

of the hippocampal and dopaminergic systems

recent study showed that smoking outcome

solidifies the rewarding properties of nicotine

expectancies combine with one's tendency

(Mansvelder &c McGehee,

2000). Even after

long periods o f abstinence, the responsiveness

to experience negative affective states

to

predict smoking behavior over time (Cohen,

8c Myers, 2002). These

of these systems to nicotine remains abnormal,

McCarthy, Brown,

suggesting that these neurotransmitters play a

findings indicate that at least part o f the

substantial role in the long-lasting, enduring

c o m m o n l y observed

changes associated with nicotine dependence

negative affect and smoking behavior can be

(Pulvirenti & Diana,

2001).

relationship

explained by smoking expectancies.

between

105

106

BEHAVIORS T H A T C O M P R O M I S E HEALTH

Negative Reinforcement: A Story of Emotion Regulation

Specifically, older heavy smokers show dosedependent relief from

stress and

following nicotine administration

anxiety (Gilbert,

When considering negative reinforcement

Robinson, Chamberlin, & Spielberger, 1 9 8 9 ) ,

associated with tobacco use disorders, nicotine

with higher doses o f nicotine producing the

administration is believed to have negative

greatest m o o d relief

mood-alleviating properties via its manipula-

Perkins e t a l . , 1 9 9 3 ) . In addition, nicotine

(Gilbert et al., 1 9 8 9 ;

tion o f neurotransmitters such as serotonin

replacement therapy produces clinically signifi-

(Carmody, 1 9 9 0 ; Hall e t a l . , 1 9 9 3 ) . Specifi-

cant reductions in symptoms of depression

cally, low levels of serotonin have been strongly

among nonsmokers suffering

associated with negative mood states (Maes &

depression

Meltzer, 1 9 9 5 ) , and nicotine administration

Genchi, & Rivera-Meza, 1 9 9 6 ) . Nevertheless,

appears to increase levels o f this neurotrans-

mood responses that are not shown to be

mitter (Kenny, File, & Neal, 2 0 0 0 ) . In fact,

related to nicotine withdrawal

nicotine's ability to elevate serotonin levels

variable. For instance, some evidence actually

from

major

(Salin-Pascual, Rosas, Jimenez-

are highly

may partially explain why people report that

indicates that nicotine creates higher levels of

using nicotine-containing products alleviates

anxiety and stress (Parrott, 1 9 9 9 ; Piasecki &

negative affective states (Carmody, 1 9 9 0 ; Hall

Baker, 2 0 0 0 ) . Similarly, smoking in response to

etal., 1 9 9 3 ) . Consistent with the serotonin

depression may increase, rather than decrease,

hypothesis o f nicotine dependence, when one

symptoms of depression among smokers with

abstains

a ruminative coping style (Richmond, Spring,

from

nicotine, medications

that

improve the efficiency of serotonin (e.g., sero-

Sommerfeld, & McChargue, 2 0 0 1 ) .

tonin reuptake inhibitors such as fluoxetine)

Despite the apparent inconsistencies shown

prolong short-term abstinence (Niaura etal.,

among studies examining negative mood relief

2 0 0 2 ) , particularly among smokers with high

from nicotine administration, the importance

baseline levels o f depression (Hitsman etal.,

of the negative reinforcing properties of nico-

1 9 9 9 ) . Moreover, once people abstaining from

tine should not be minimized. In fact, if only a

nicotine are taken off o f this type of medication,

fraction of individuals achieve negative mood

there is an increased likelihood that they will

relief from the administration of nicotine, nega-

experience a major depressive episode (e.g.,

tive affect's role in the maintenance of tobacco

Borrelli et al., 1 9 9 6 ) . Hence, this depressive vul-

use behaviors

nerability during nicotine abstinence is particu-

example, both baseline and post-quit negative

larly salient for depression-prone individuals.

remains

quite

salient. F o r

affect predict relapse (Pomerleau, Adkins, &

Although many people report using tobacco

Pertschuk, 1 9 7 8 ; Swan, Ward, & Jack, 1 9 9 6 ;

products due to their negative mood-alleviating

West et al., 1 9 8 9 ) . Furthermore, a large portion

properties (Spielberger, Foreyt, Reheiser, 8 t

of tobacco users suffer from psychological

Poston, 1 9 9 8 ) , psychosocial research investigat-

problems that are associated with affective dys-

ing this hypothesis is mixed. It is clear that after

regulation (Breslau, 1 9 9 5 ) . Finally, personality

short-term abstinence, nicotine administration

traits that increase the likelihood of experienc-

will reverse any negative affective symptoms

ing frequent and persistent bouts of negative

associated with the nicotine withdrawal syn-

affect predict tobacco use behaviors and relapse

drome. However, it remains unclear whether

(Gilbert & Gilbert, 1 9 9 5 ) . Although it remains

nicotine has the same effect on negative affect

unclear as to the properties o f nicotine that neg-

that is not associated with nicotine withdrawal.

atively reinforce tobacco use, there is sufficient

In some studies, administration of nicotine exhi-

evidence to implicate the importance o f nega-

bits the expected mood-alleviating properties.

tive reinforcement in nicotine dependence.

Etiology

Classical Conditioning: A Story of Automatic Processes

psychological and

(unconditioned

physiological

response)

that

are

repeatedly paired with neutral stimuli (conditioned stimulus). In other words, chronic nicotine administration elicits many reinforcing properties that eventually become conditioned to environmental and psychological stimuli (Iwamoto, Fudala, Mundy, &

Williamson,

1 9 8 7 ; R o s e & Levin, 1 9 9 1 ) . Over time, the repeated pairings between the once neutral stimuli and nicotine administration

Dependence

\

biologically based predispositions that produce

tine administration (unconditioned stimulus) states

of Nicotine

qualitatively different

Classical conditioning occurs when nicoproduces

and Treatment

produce

conditioned responses that initiate and maintain tobacco use behavior (Rose & Levin, 1 9 9 1 ) . Conditioned responses from emotional and environmental cues reflect the activation of cognitive (Tiffany, 1 9 9 0 ) , emotional (Baker et al., 1 9 8 6 ) , and physiological (Robinson &c

reinforcement

from

nicotine administration (Pomerleau & Kardia, 1 9 9 9 ) . Evidence supporting the notion that genetic factors dictate who is likely to become nicotine dependent comes from a variety of sources. For example, twin studies have shown greater concordance rates in monozygotic twins than in dizygotic twins, with heritability estimates o f 5 3 % for tobacco use (see review by Hughes, 1 9 8 6 ) . In addition, certain individuals may be more sensitive to nicotinic properties than are others. A selective sensitivity to nicotine is hypothesized to produce more rapid tolerance and more extensive self-administration patterns (Pomerleau, 1 9 9 5 ) . As such, genetic factors may help to explain why certain subgroups o f smokers become more dependent at earlier ages (e.g., Madden et al., 1 9 9 9 ) and have extreme difficulties in quitting (e.g., Lerman et al., 1 9 9 9 ) .

Berridge, 2 0 0 0 ) domains. Exposure to such cues evokes strong tobacco use motivation or urges. S o m e researchers hypothesize

that

this increase in motivation reflects the desire to evoke a pleasant feeling or to take away unpleasant states (Baker et al., 1 9 8 6 ) , whereas others view this increased motivation as more automatic (Tiffany, 1 9 9 0 ) , that is, driven by sensitized neurobiological systems (Robinson & Berridge, 2 0 0 0 ) .

Gender and Ethnicity Rates of nicotine dependence appear to differ across gender and ethnic groups. In addition, the proportions of men and women who use tobacco products vary greatly in some countries, such as Japan and Greece, but not in others, such as the United States and the United Kingdom (Grunberg, Winders, 8 t Wewers, 1 9 9 1 ) . Thus, it may be that tobacco use is reinforced differently for women in countries where as many women use tobacco products as do

OTHER IMPORTANT FACTORS IN NICOTINE DEPENDENCE RESEARCH

men. In addition, certain minority populations (e.g., African Americans) within the United States report higher rates of tobacco use than do Caucasians ( C D C , 1 9 9 9 ) , and women and

Genetics

minorities appear to be less successful at quit-

The development o f nicotine dependence cannot result entirely from random actions between neurobiological and

interpsy-

ting (Piper, F o x , Welsch, Fiore, & Baker, 2 0 0 1 ) . Therefore, these individuals

are at

greater risk for contracting smoking-related ill-

chosocial factors. It has been suggested that

nesses, making it very important to consider

individuals who use tobacco and become nico-

how gender and ethnicity influence the recruit-

tine dependent may be different from individu-

ment, retention, and treatment o f nicotine-

als w h o

dependent individuals (Piper et al., 2 0 0 1 ) .

do not use t o b a c c o because o f

107

BEHAVIORS T H A T C O M P R O M I S E HEALTH

108

M o r e is known about the etiology and

nicotine dependence

(Hughes,

Hatsukami,

treatment of nicotine dependence for women

Mitchell, & Dahlgren, 1 9 8 6 ) . Comorbid psy-

than for different ethnic groups. The scarcity of

chopathology represents an important issue

research on minorities that use tobacco products

to address in nicotine dependence research

has led many researchers and practitioners to

because these individuals report excessive

examine nicotine dependence among minority

dependence levels and have extreme difficulty

populations. Contemporary knowledge regard-

in quitting (Hughes et al., 1 9 8 6 ; McChargue,

ing what motivates U.S. women to use tobacco

Gulliver, & Hitsman, 2 0 0 2 a , 2 0 0 2 b ) . M o r e -

products, particularly cigarettes, has focused on

over, psychiatric smokers are at a heightened

two primary issues: (a) affect regulation and

risk of smoking and psychiatric-related health

(b) weight control. In general, women are more

problems as compared with nonsmoking psy-

affectively vulnerable than men, and it is

chiatric patients and nonpsychiatric smokers

believed that this vulnerability is well suited for

(Jeste, Gladsjo, Lindamer, & Lacro, 1 9 9 6 ;

nicotine's mood-alleviating effects. As such,

Linkins & Comstock, 1 9 9 0 ) . Prevalence rates

women may receive greater mood regulatory

of smoking among this population range from

benefits from smoking than do men, and this is

3 1 % to 9 0 % , depending on the psychiatric

believed to partially explain why women have

disorder (Beckham et al., 1 9 9 7 ; de Leon et al.,

more difficulty in quitting (Piper et al., 2 0 0 1 ) . In

1 9 9 5 ; Hughes et al., 1 9 8 6 ) .

addition, women frequently express concern

It has been hypothesized

that chronic

about gaining weight after they quit smoking

tobacco use observed among individuals with

(Klesges & Klesges, 1 9 8 8 ) . This concern is not

psychopathological problems reflects self-

surprising given that individuals who are absti-

medicating behaviors. According to the self-

nent for 1 year will gain an average of 13

medication hypothesis, psychiatric patients

pounds (Klesges et al., 1 9 9 7 ) .

smoke in part because nicotine helps to regulate their symptomatology (Gilbert & Gilbert,

Comorbid Personality and Psychopathology The influence o f personality on tobacco use

1995).

F o r example, patients with

major

depression may smoke to improve depressed m o o d states (Hall et al., 1 9 9 3 ) . Similarly, patients with schizophrenia may find

that

is based on the belief that traits predispose

smoking helps to reduce negative symptoms

people to frequent

such as anhedonia, apathy, blunted affect, and

and persistent aversive

mood states (Cloninger, 1 9 8 7 ; Tellegen, 1 9 8 5 ;

emotional withdrawal

Tomkins & McCarter, 1 9 6 4 ) . As such, many

2 0 0 2 a , 2 0 0 2 b ) . Finally, patients with posttrau-

( M c C h a r g u e et al.,

theorize that chronic exposure to mood dysregu-

matic stress disorder and other anxiety disor-

lation provides ample opportunity for people to

ders may smoke to cope with emotional and

learn that tobacco products are an efficient

physiological distress (Beckham et al., 1 9 9 7 ) .

source of relief from these problematic affective

This self-medication process

transforms

states. Traits that are associated with compro-

tobacco use into an extremely

mised affective systems and tobacco use behav-

behavior for psychiatric individuals as com-

ior

pared

include sensation seeking, neuroticism,

with

nonpsychiatric

rewarding

cohorts

who

extroversion, and psychoticism (Gilbert 8 t

report similar tobacco use patterns (Spring,

Gilbert, 1 9 9 5 ; Spielberger & Jacobs, 1 9 8 2 ) .

Pingitore, & McChargue, in press). As such,

Contemporary research has identified an

the goal o f complete abstinence might not

overwhelming proportion o f patients with psy-

be

chiatric mood, anxiety, and psychotic prob-

subgroups (e.g., individuals diagnosed with

lems as possessing high levels o f comorbid

schizophrenia). These individuals may require

initially possible for some psychiatric

Etiology a stepped care approach

and Treatment

of Nicotine

Dependence

\

that focuses on

most comprehensive evaluation possible. The

reducing exposure to tobacco toxins until the

evaluation should include the assessment o f

individuals are able to stabilize lower rates o f

physiological, psychological, and social factors

tobacco use and learn adequate coping skills

that appear to influence the patient's tobacco

(McChargue et al., 2 0 0 2 a , 2 0 0 2 b ) .

use patterns (Ockene, Kristeller, &c Donnelly, 1 9 9 9 ) . Pertinent information may be acquired via a clinical interview, self-report measures, a chart review, and corroboration from behav-

ASSESSMENT AND T R E A T M E N T

ioral medicine staff. Ockene and colleagues As discussed earlier, nicotine dependence is

( 1 9 9 9 ) noted that, at the very least, an assess-

maintained by many factors across diverse

ment of nicotine dependence starts with a

patient populations. Another issue that leads

clinical interview. During this interview, physi-

to difficulties in the treatment and assessment

ological assessment questions should include

of nicotine dependence is the pervasive nature o f

past quit attempts, withdrawal symptoms expe-

tobacco use. Specifically, the widespread use o f

rienced during past quit attempts, and the

tobacco products forces clinical health psychol-

patient's

ogists to address issues related to this construct

Questions within the social domain should

in a variety of settings and situations. Hence,

include the number of friends, family members,

perceived addiction

to nicotine.

clinicians are encouraged to be mindful o f the

and coworkers who use tobacco products; the

settings or situations in which they deliver their

expected amount o f social support or nonsup-

interventions (Collins etal., 1 9 9 9 ) . Overall,

port; and the degree to which the patient can be

it is recommended that a multidisciplinary

assertive at rebuffing pressure from others to

approach to the assessment and treatment o f

smoke (Ockene et al., 1 9 9 9 ) . Included within

nicotine dependence be used if long-term absti-

the psychological assessment should be ques-

nence is to be achieved (Fagerstrôm, 1 9 9 1 ) .

tions related to emotional problems (e.g., stress, depression), behavioral indexes (e.g., extent to which person will go to have a cigarette), and

Assessment of Nicotine Dependence

cognitive factors (e.g., self-efficacy beliefs about

T h e assessment o f nicotine dependence m a y take many forms at differing levels o f intensity within behavioral medicine settings. F o r example, the approach to assessments o f nicotine dependence in an emergency r o o m is likely to differ from the approach to assessments used in outpatient settings. Therefore, the assessment should be tailored to the specific setting. Prior to beginning an assessment,

the clinician should

consider

the

purpose for the assessment, the environment

quitting [Ockene etal., 1999]). Ockene and colleagues ( 1 9 9 9 ) also noted that gathering information about a patient's smoking history, as well as having the patient self-monitor his or her smoking behavior, can provide useful data that may aid in treatment specificity. Finally, health factors that may be a consequence of chronic use patterns should also be assessed, and patients who present with physical complaints (e.g., shortness of breath) should be referred to a physician (Ockene et al., 1 9 9 9 ) .

where the assessment will take place, and the

Pretreatment assessment can be as brief as a

form o f intervention conducive to the setting.

10-minute clinical interview or as long as a 2V2hour structured assessment. Again, the setting

Pretreatment To

provide

essential t h a t

and purpose of the assessment should dictate

Assessments adequate the

treatment,

clinician c o n d u c t

the type o f assessment administered. For a relait is

tively brief assessment or for information that

the

will be incorporated within a larger assessment,

109

110

BEHAVIORS THAT C O M P R O M I S E HEALTH there are a variety o f standardized self-report measures that can be used to assess level o f dependence, self-efficacy, readiness to quit, general reasons for use, and perceptions of what tobacco products do for the person. For more comprehensive interviews, several

structured

and semistructured interviews are available, including the Diagnostic Interview Schedule (Malgady, Rogler, & Tryon, 1 9 9 2 ) and the Structured Clinical Interview for the D S M - I V Axis I Disorders-Clinician Version (First, Spitzer, Gibbon, & Williams, 1 9 9 7 ) . Most self-report measures have adequate psychometric properties and have been used with a

4. The Contemplation Ladder (Biener &c Abrams, 1991): This is a measure of readiness to consider tobacco cessation. It is designed to assess a tobacco user's position on a continuum ranging from having no thoughts of quitting to being engaged in action to change one's tobacco use. The ladder is consistent with Prochaska and DiClemente's (1983) model, which states that tobacco cessation is the culmination of an extended process of behavior change. The measure employs a picture of a ladder, where each rung has an associated number that the patient is instructed to circle representing where he or she is in thinking about quitting.

variety of populations. Although a detailed description of all tobacco-related measures available is beyond the scope of this chapter, the following measures are recommended.

Posttreatment

Assessments

Posttreatment assessment allows the clinician to measure and adjust treatment efforts as

1. The Fagerstrôm Test of Nicotine Dependence (Heatherton, Kozlowski, Frecker, & Fagerstrôm, 1991): This is a 6item, self-report questionnaire designed to assess various components of smoking behavior, including an estimate of daily intake, difficulty in refraining, and other aspects related to the pattern of intake.

necessary. Issues that may arise include treatment compliance, sudden exacerbation o f clinical disorders

(e.g., major

depression),

severe tobacco withdrawal, intense and persistent urges to use nicotine, weight gain, brief smoking lapses, and abstinence status. M a n y o f these issues can be assessed using clinical interviews. A supplementary self-report measure is Scale

2. The Smoking Self-Efficacy Questionnaire (Colletti, Supnick, St Payne, 1985): This is a 17-item questionnaire designed to assess respondents' beliefs about their ability to control their urges to smoke in a variety of situations.

the Minnesota Nicotine Withdrawal

3. The Smoking Consequences Questionnaire (Brandon & Baker, 1991): The Smoking Consequences Questionnaire (SCQ) is a 50item measure designed to assess expectations associated with cigarette smoking. It has four factors: negative consequences (e.g., health risks), positive reinforcement/sensory satisfaction (e.g., taste, relaxation), negative reinforcement/negative affect reduction (e.g., reduction of sadness and anxiety), and appetite/weight control. The SCQ-Adult (Copeland, Brandon, Si Quinn, 1995) is an extension of the SCQ for use with an older population of dependent smokers.

cian may assess tobacco use daily, weekly, or at

(Hughes & Hatsukami, 1 9 8 6 ) , which assesses withdrawal severity. This measure may be used repeatedly to assess withdrawal across time. For purposes of assessing treatment compliance, lapsing, and abstinence status, the clinidesignated follow-up times. Self-reported lapses and relapses in isolation or combined with biochemical verification have been used. A detailed description of the utility of biochemical markers o f tobacco and cessation as well as recommendations for their application in clinical practice is beyond the scope of this chapter. However, the Society for Research on Nicotine and T o b a c c o Subcommittee on Biochemical Verification

( 2 0 0 2 ) recently published

an

overview of this subject. In general, the committee noted that there are currently three

Etiology biomarkers used to assess whether a person has

and Treatment

Brief

of Nicotine

Dependence

|

Interventions

been abstinent from nicotine: thiocyanate (SCN), cotinine, and expired carbon monoxide

Brief interventions are designed to be used

( C O ) . S C N and cotinine are metabolites of

in a variety o f settings and should not take

nicotine that indicate tobacco use over the

more than 3 to 1 0 minutes. Brief interventions

past week, and C O (as obtained via expired air)

include assessing tobacco use patterns and will-

indicates smoked tobacco use within the past

ingness to quit, advising the patient to make a

2 4 hours. T h e committee also noted

quit attempt, assisting the patient in quitting,

that

the standard indication o f tobacco use has

and scheduling follow-up sessions (Fiore et al.,

been cotinine levels above 15 nanograms per

2 0 0 0 ) . Unfortunately, not all tobacco-using

milliliter, carbon monoxide levels above 8 to 1 0

patients are highly motivated to quit. In cases

parts per million, and S C N levels of 7 8 to 8 4

where the patient is not so motivated, it is rec-

micromoles per liter. (For a more in-depth

ommended that the clinician use an empathetic

review o f biochemical verification recommen-

therapeutic

dations, see Society for Research on Nicotine

increases self-efficacy, and encourages adaptive

and T o b a c c o Subcommittee on Biochemical

skills at quitting (Prochaska 8c Goldstein,

style that

avoids

arguments,

1 9 9 1 ) . Confrontational and punitive styles may

Verification, 2 0 0 2 . )

have the opposite effect by further decreasing

Treatment of Nicotine Dependence T h e treatment

o f nicotine dependence

the patient's motivation to quit (Miller

&

Rollnick, 2 0 0 2 ) . Brief assistance that has been shown to

multidisciplinary

increase abstinence rates may be as simple as

stepped care approach. T h e stepped care

providing the patient with self-help material

approach starts with the assessment o f the

combined with recommending approved phar-

patient's motivation to quit and progresses to

macological

the implementation o f brief interventions. For

Newman, 8c Varady, 1 9 9 0 ) . Other brief tech-

should

be viewed as a

treatment

(Killen,

Fortmann,

example, routine screening and brief counsel-

niques include (a) helping to identify upcoming

ing (less than 3 minutes) within emergency

challenges, (b) processing helpful skills from

rooms increase long-term abstinence rates

prior quit attempts, (c) reducing alcohol con-

from 3 % (usual care) to 8 % to 1 1 % (Bernstein

sumption during the first month of abstinence,

& Becker, 2 0 0 2 ) . If the patient is unmotivated

(d) encouraging others w h o use tobacco within

t o quit, the clinician should

incorporate

the same household to quit as well, (e) provid-

motivational enhancing techniques within the

ing social support within the clinical environ-

brief intervention. Only after brief

ment, and (f) helping the patient to find another

inter-

ventions are unsuccessful should the clinician

supportive environment (Fiore et al., 2 0 0 0 ) .

refer the patient to more intensive treatments.

T h e first follow-up session should be sched-

As discussed in the next two subsections, all

uled approximately 1 week after the quit date,

recommendations for brief and intensive inter-

with the second scheduled 1 to 3 weeks later

ventions are consistent with the clinical prac-

(Fiore et al., 2 0 0 0 ) . During the follow-up, the

tice guidelines for treating nicotine dependence

clinician should remain supportive, highlight

(Fiore e t a l . , 2 0 0 0 ) . It should be noted that

successes (no matter h o w small), and encour-

both brief and intensive interventions recom-

age problem solving. T h e patient may have a

mend the inclusion o f pharmacological treat-

tendency to overemphasize an aspect o f the

ment.

However,

pharmacological

agents

quit attempt that is linked to failure (Shiffman

associated with treating nicotine dependence

et a l , 1 9 9 6 ) . If so, the clinician should try to

are discussed in a separate subsection.

reframe the perceived failure as a learning

111

112

BEHAVIORS T H A T C O M P R O M I S E HEALTH experience and reengage the patient in prob-

Before a patient attempts to quit, the patient is encouraged to gather as much about his or

lem solving (Fiore et al., 2 0 0 0 ) .

her smoking habit as possible. T h e patient is Intensive

asked to pay attention to specific triggers that

Treatments

he or she believes will challenge the attempt

It is recommended that intensive treat-

at quitting. Tobacco-related triggers include

ments be offered to all tobacco users because,

situations, emotions, thoughts, and places

on average, such interventions are more effec-

that evoke strong urges to use tobacco. Self-

tive than

monitoring smoking behavior prior to a quit

brief interventions

(Fiore et al., however,

attempt often will help the patient to identify

might not be feasible. Thus, for each individ-

tobacco-related triggers that are relevant to his

2000).

This

recommendation,

ual w h o wishes to quit, the clinician is

or her life. However, it is not atypical for many

encouraged to use a stepped care approach

other "unexpected" triggers to arise once the

that starts brief and progressively increases in

patient has achieved abstinence. Thus, it is

intensity. T h e reason for this is that, under

important to continue monitoring triggers long

certain circumstances, brief interventions can

after the quit date. It is also suggested that the

be more effective than intensive interventions

clinician provide the patient with education

(Smith e t a l . , 2 0 0 1 ) , and brief interventions

regarding the withdrawal symptoms that he or

are more practical in a variety o f settings (e.g.,

she may experience as well as the addictive

primary care facilities).

nature o f tobacco because this information can aid the patient in understanding the process o f

Treatment Treatments.

Format

for

Intensive

T o qualify as an intensive treat-

ment, there must be a minimum of four sessions lasting more than 1 0 minutes each (Fiore et al., 2 0 0 0 ) . If feasible, group sessions o f 8 to 10 people are recommended over individual sessions because the group setting fosters social support (Ockene et al., 1 9 9 9 ) . Sessions should be scheduled on a weekly basis during the initial 4 weeks o f treatment and then biweekly for the next 4 weeks (Ockene et al., 1 9 9 9 ) . Finally,

addiction (Fiore et al., 2 0 0 0 ; Kozlowski et al., 2 0 0 1 ) . For example, skills training focused on problem solving and symptom management are helpful (Fiore e t a l . , 2 0 0 0 ) . In addition, there are several nonspecific treatment factors that the clinician should provide during treatment. These treatment factors include discussing and eliciting positive expectancies, being supportive and understanding, and providing a time line for the quit attempt (Fiore et al., 2 0 0 0 ; Kozlowski et al., 2 0 0 1 ) .

posttreatment follow-ups should be scheduled

Once the patient quits, he or she may expe-

6 to 1 2 months after the quit date (Kozlowski,

rience a variety o f nicotine withdrawal symp-

Henningfield, & Brigham, 2 0 0 1 ) .

toms that undermine

quit attempts. It is

important for the clinician to assist the patient M a n y o f the psy-

in coping with these symptoms, particularly

chosocial components used in tobacco cessation

during the first month o f abstinence. T h e clin-

treatment packages are cognitive-behavioral in

ician should encourage the patient to use the

nature. T h e purpose of these components is to

skills he or she learned during the pre-quit ses-

Treatment

Components.

break the association between smoking and

sions. For example, encouraging the use o f

other life activities and to increase the patient's

relaxation techniques (e.g., removing oneself

ability to cope during abstinence. As stated

from

earlier, pharmacological therapies are highly

provides an alternative means by which to

recommended

cope with stressful situations and negative

in

conjunction

psychosocial interventions.

with

these

stressful

situations, deep

affect associated with tobacco

breathing)

withdrawal

Etiology

and Treatment

of Nicotine

Dependence

\

(Dziegielewski & Eater, 2 0 0 0 ; Hatsukami &

have been shown to approximately double

Lando, 1 9 9 9 ) . T h e use o f accessible substi-

abstinence rates when compared with placebo

tutes, such as chewing gum, may also help the

treatments.

patient to cope with withdrawal

symptoms

Second-line treatments

have also been

(Cohen, Britt, Collins, al'Absi, & McChargue,

found to be efficacious, but the use o f these

2 0 0 1 ; Cohen, Britt, Collins, Stott, & Carter,

medications is limited due to the lack o f F D A

1 9 9 9 ; Cohen, Collins, & Britt, 1 9 9 7 ) . In addi-

approval as treatment for nicotine depen-

tion, encouraging the patient to avoid situa-

dence as well as concerns about potential

tions where tobacco use is likely to occur (e.g.,

side effects. Second-line treatments include

bars, bowling alleys) as well as to engage in

fluoxetine, clonidine, nortriptyline, and

healthy alternative behaviors (e.g., exercise)

combination o f nicotine replacement thera-

may help to prolong abstinence (Dziegielewski

pies. M e n t i o n o f second-line therapies is lim-

& Eater, 2 0 0 0 ; Ockene et al., 1 9 9 9 ) .

ited to this paragraph because such therapies

a

Finally, working with the patient to develop

are not viable treatment options at this time.

the requisite skills to elicit social support from

T h u s , this subsection limits further discus-

others outside o f treatment is integral to suc-

sion o f pharmacology to first-line treatments.

cessful tobacco cessation (Fiore et al., 2 0 0 0 ) . O n e type o f social support outside o f therapy

Nicotine

Replacement

Therapy.

Nicotine

that should be suggested is Nicotine Anony-

replacement therapy ( N R T ) is intended to

mous (NicA). These mutual-help groups pro-

break the conditioning o f nicotine with envi-

vide social and emotional support for many

ronmental cues by making nicotine intake

sufferers o f addictive disorders through per-

independent

sonal sharing on a weekly basis (Lichtenstein,

(Glover & Glover, 2 0 0 1 ) . Although N R T

1 9 9 9 ) . It has been suggested that N i c A may be

provides lower doses o f nicotine than

most effective for highly dependent smokers or

other t o b a c c o products, it can be used to

o f events in the environment do

those who also abuse another substance (e.g.,

decrease the severity o f withdrawal

alcohol). At the very least, patients who do not

toms by providing a slow consistent dose o f

have a significant outside support system may

nicotine through an alternate administration

symp-

need more frequent contact from a clinician

route

to support them during their quit attempts

comes in many different forms, including

(Ockene et al., 1 9 9 9 ) .

gums, patches, nasal sprays, and inhalers.

(Jarvis &

Sutherland,

1998).

NRT

Nicotine Polacrilex (gum) was the first Pharmacological

NRT

Interventions

According to the Clinical Practice

approved

by

the

FDA

(Jarvis &

Sutherland, 1 9 9 8 ) . T h e absorption rate is fairly Guidelines

rapid, and peak nicotine levels are reached

(Fiore et al., 2 0 0 0 ) , many first-line medications

within 2 0 to 3 0 minutes

exist for the treatment of nicotine dependence,

Lando, 1 9 9 9 ) . Use is recommended for 3

(Hatsukami &

as do several second-line medications. First-line

months (Hatsukami & Lando, 1 9 9 9 ) . Although

medications have been established as efficacious

nicotine gum can be used on an as-needed basis

through clinical trials and have been approved

to control t o b a c c o urges, a fixed schedule has

by the Food and Drug Administration (FDA)

been shown to be more effective in dealing

for

use with nicotine dependence. First-line

with withdrawal symptoms (Ockene et al.,

medications include nicotine replacement prod-

1 9 9 9 ) . Nicotine gum is dispensed in 2 - or

ucts (e.g., gums, patches, nasal sprays, inhalers)

4-milligram doses, with the 4-milligram dose

and buproprion-SR (sustained release). With the

recommended for heavily dependent smokers

exception of nicotine gum, these interventions

(Fiore et al., 2 0 0 0 ) .

BEHAVIORS THAT C O M P R O M I S E HEALTH

114

The nicotine patch has a passive delivery system. T h e absorption of nicotine is slower than with the gum (Jarvis 8 t Sutherland, 1 9 9 8 ) , resulting in peak levels of nicotine 4 to 9 hours after administration

(Hatsumaki &

Lando,

1 9 9 9 ) . T h e patch is available in either 24-hour (Habitrol, Nicoderm, and Nicoderm C Q ) or 16-hour doses (Nicotrol). Typically, 24-hour patches have 2 1 or 2 2 milligrams of nicotine, whereas patches designed for 16-hour use have 15

milligrams o f nicotine (Hatsukami &

Lando, 1 9 9 9 ; Ockene et al., 1 9 9 9 ) . A nicotine nasal spray is available with a prescription

(Fiore

et al.,

2000)

and

decreases craving within minutes o f use due to rapid

absorption

rates

(Hatsukami &

If All Else Fails.

. .

If all else fails, the clinician is advised to lower tobacco use behavior when abstinence appears to be initially unattainable (McChargue etal., 2 0 0 2 a , 2 0 0 2 b ) and/or pharmacological therapies are not suitable (Ockene etal., 1999). Reducing tobacco use may be accomplished via nicotine fading. Nicotine fading involves switching to a brand with lower nicotine levels as well as gradually decreasing the quantity of tobacco used (Ockene et al., 1 9 9 9 ) . For example, once cigarette consumption has been decreased to 5 to 1 0 cigarettes per day and has been stabilized at this level, a quit date should be reestablished (Ockene etal., 1 9 9 9 ) .

Lando, 1 9 9 9 ; Jarvis & Sutherland, 1 9 9 8 ; O c k e n e et al., 1 9 9 9 ) . Treatment is typically 6 to 8 weeks but can be extended to 3 months

CONCLUSIONS

in severe cases (Hatsukami & Lando, 1 9 9 9 ; O c k e n e et al., 1 9 9 9 ) . It is important to note

Chronic use o f tobacco products has been

that the nasal spray may be more effective in

linked to a number o f serious health problems

situations where instant relief from nicotine

that

craving is a priority (Hurt et al., 1 9 9 8 ) .

world. It appears that nicotine dependence

affect many people throughout

the

Finally, the nicotine inhaler dispenses 1 0 mil-

develops via the interaction between neurobi-

ligrams of nicotine per inhaler cartridge (Eissen-

ological substrates and cognitive, behavioral,

berg, Stitzer, & Henningfield, 1999; Hatsukami

and emotional domains. Although there are a

& Lando, 1999). A unique feature of the inhaler

variety o f factors that contribute to the devel-

is that it provides oral and tactile reinforcement

opment o f nicotine dependence, once people

because it consists of a mouthpiece and a nicotine

are dependent, it is clear that they have

cartridge as well as nicotine (Hatsukami

extreme difficulty in quitting. For the most

&

Lando, 1999; Ockene etal., 1999).

part, treatment o f nicotine dependence takes a stepped care approach, which begins with

Buproprion is

brief interventions and progresses to more

an antidepressant medication that has been

intensive interventions. T h e goal of this chap-

shown to aid in the management o f nicotine

ter was to increase knowledge about nicotine

Non-nicotine

Therapies.

withdrawal symptoms (Johnston, R o b i n s o n ,

dependence and to provide guidance on inter-

Adams, Glassman, & Covey, 1 9 9 9 ) . Although

vention strategies for treating individuals with

the mechanism o f buproprion is not c o m -

nicotine dependence. Given the pervasiveness

pletely clear (Johnston et al., 1 9 9 9 ) , it is pre-

of t o b a c c o use disorders

sumed to block neural reuptake o f dopamine

patient populations and the health conse-

among

various

and/or norepinephrine (Fiore et al., 2 0 0 0 ) .

quences associated with these disorders, treat-

Buproprion remains the only non-nicotine

ment o f nicotine dependence is one area in

medication used in t o b a c c o cessation pro-

which clinical health psychologists can have a

grams that is approved by the F D A (Fiore

positive impact on their patients'

et al., 2 0 0 0 ; J o h n s t o n et al., 1 9 9 9 ) .

health status.

overall

Etiology

and Treatment

of Nicotine

Dependence

CASE STUDY This case study illustrates an intensive smoking treatment. T h e client, " B e t t y , " was a 67-year-old Caucasian female w h o was referred by her primary care physician for individual smoking treatment. Betty presented with complaints o f having " n o c o n t r o l " over her smoking behavior but having a strong desire to quit smoking. She also reported that her health was "failing" and that her physician would not perform " a necessary medical procedure" unless she quit. Specifically, Betty noted that she suffered from numerous medical problems, including chronic bronchitis, asthma, and emphysema. Medical concerns had reduced her independence by causing her to rely on a motorized scooter for community mobility. Betty reported that she lived in an apartment by herself and noted that she had very little local social support. She did indicate, however, that she had several relatives w h o lived "out o f state" with w h o m she talked via phone on a weekly basis. During Betty's intake session, she was asked to exhale into a C O monitor and to complete the Fagerstrôm Test o f Nicotine Dependence. Results revealed a C O reading of 4 8 parts per million (indicating heavy smoking rates) and a test score o f 9 (indicating a high level o f nicotine dependence). In addition to these measures, a detailed account o f her smoking history and quit attempts was obtained via clinical interview. In sum, Betty reported smoking her first cigarette at the age of 1 2 years and progressing to daily cigarette smoking by the age o f 1 4 years. She noted that when she was smoking at her heaviest rate, she smoked two packs ( 4 0 cigarettes) per day, but she was currently smoking 2 5 cigarettes per day. Betty reported that she had tried unsuccessfully to quit smoking many times in her life, noting that she could recall four occasions when she made "serious attempts" to quit by using group smoking cessation programs, using nicotine replacement patches, and stopping "cold turkey." Betty made it clear to the therapist that she did not want to use nicotine replacement patches this time because she had "vivid disturbing dreams" the last time she had used them. She noted that her previous quit attempts resulted in temporary cessation, with her longest period o f abstinence being a little more than Wi years. She also noted, on a scale o f 1 to 1 0 , that she had a strong desire to quit smoking ( 1 0 / 1 0 ) , that it was very important that she quit smoking ( 1 0 / 1 0 ) , but that she was only somewhat confident in her ability to quit (5/10). Betty agreed to attend weekly sessions for the next 8 weeks. Betty and the therapist collaboratively planned to reduce her nicotine intake and to have her learn m o r e about her smoking behavior (e.g., when she smoked, where she smoked, why she smoked) during the first 4 weeks o f treatment. A quit date was set for W e e k 5, and during W e e k s 6 to 8 it was decided that the focus o f treatment would be on issues related to relapse prevention. Betty left the intake session with two " h o m e w o r k " assignments, namely (a) to attempt to reduce smoking intake by 1 0 % during the week and (b) to keep a written record o f her smoking behavior. Specifically, each time she was about to smoke a cigarette, Betty was asked to write down the time o f day, any emotions she was feeling at the time, and the situational circumstances that occurred just prior to her smoking.

115

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BEHAVIORS THAT C O M P R O M I S E HEALTH

Betty presented

for her second session on time and

indicated that

she

had reduced her smoking intake successfully and kept accurate records o f her smoking behavior. She was eager to report that by the end o f the week, she was able to reduce her smoking t o 1 0 cigarettes per day (a far greater reduction than the agreed-on 1 0 % ) . She also noted that she wanted to smoke more frequently than she actually did; however, she "got s i c k " o f writing down all o f the requested information before each cigarette. She noted that tracking her smoking behavior allowed her to cut out many cigarettes that she did n o t "really need." She also indicated that in reducing her smoking intake, she learned that the "cravings" she had to smoke throughout the day would not "last forever" and in fact passed rather quickly, usually within 1 0 t o 1 5 minutes. After praising Betty on the progress she had made during the past week, the therapist reviewed the "smoking record sheets" that Betty had completed in an attempt to identify commonalities in her smoking behavior. E x a m i n a t i o n o f the smoking record sheets revealed that Betty smoked most often after eating meals and during times o f perceived stress. In an attempt to aid Betty during these difficult times, urge control strategies were discussed. O n e o f the keys t o success in smoking cessation is learning h o w to get through urges or cravings to smoke. Given that Betty had already learned h o w to get through some o f her urges to smoke, the therapist enlisted Betty's help to get a sense o f what worked for her during the past week. Betty noted that if she just waited long enough, her urge to smoke would go away (although she was quick to point out that the urges would return). Building on Betty's success, the therapist noted that delaying smoking might not w o r k in all situations and taught Betty a number o f other urge control strategies that might prove to be useful in situations where delaying smoking was t o o difficult. T h e therapist outlined five basic strategies that Betty could pull from her " t o o l b o x " when faced with difficult urges: (a) delaying smoking, (b) escaping from situations or events that may contribute to the urge, (c) avoiding situations where the temptation t o smoke may be t o o great, (d) ί/istracting herself by thinking about or doing other things that she enjoys doing, and (e) substituting something else for a cigarette such as sugarless gum, candy, or sunflower seeds. (All o f these strategies can be remembered by the simple yet appropriate acronym o f D E A D S . ) T h e therapist encouraged Betty to continue doing what worked for her the previous week and to try some o f the other strategies that were taught when the urge to smoke surfaced. F o r " h o m e w o r k , " Betty was again encouraged to reduce her smoking by 1 0 % . T h e therapist also encouraged Betty to pick a "smoking p l a c e " in her h o m e where she usually did not smoke and did not engage in other activities such as talking on the phone, socializing, eating, watching television, and reading mail. It was suggested that she smoke only in this place, with the idea being that she would not associate smoking in this place with any other kind o f activity. Also, it would mean that she would have t o stop what she was doing so as to smoke a cigarette.

Etiology

During

the third

and

fourth

and Treatment

weeks o f treatment,

of Nicotine

Betty w a s

Dependence

able

to

reduce her smoking to 4 cigarettes per day using the strategies discussed earlier. In anticipation o f the W e e k 5 quit date, most o f the fourth session was centered on preparing Betty for her quit attempt. She was instructed to have her final cigarette no later than before she went to bed on the night before she was to attend her fifth session. She was also encouraged to "seek out and destroy" all o f the cigarettes that remained in her apartment that evening so as to be sure that there would not be any cigarettes readily available to her when she w o k e up the next morning. She was also educated a b o u t w h a t types o f withdrawal symptoms she might expect (e.g., depressed m o o d , irritability, anxiety) so that they would not catch her " o f f guard." In addition, detailed plans were made outlining h o w she would deal with her cravings to smoke so that she had a "plan o f a t t a c k " if a craving surfaced. She was also encouraged to start thinking a b o u t h o w to reward herself once she quit. During the fifth session, Betty was n o t as animated as she had been during the previous 4 weeks o f treatment. She reported that she had n o t s m o k e d a cigarette since before she went to bed the previous evening; however, she noted that she "really wanted o n e . " T h e therapist reinforced Betty for all o f her hard w o r k and reminded her that her cravings would pass and that the intensity and frequency o f the cravings would dissipate over time. T h e remainder o f the session was spent discussing the health benefits that she could expect over the n e x t several weeks (e.g., decrease in coughing and sinus congestion, increase in overall energy level). Finally, Betty was informed that she might " s l i p " and s m o k e a cigarette during the course o f the n e x t w e e k . She was told that this is " n o r m a l " and that if it happens, she should l o o k at it as just a " s l i p , " n o t a " t o t a l relapse." She was encouraged to get b a c k to being " s m o k e free" after the slip rather than to give herself permission to s m o k e as m a n y cigarettes as she w a n t e d and view her efforts as a failure. Sessions 6 to 8 began with Betty exhaling into the C O monitor to s h o w her that her C O levels were decreasing, thereby increasing the amount o f oxygen that was circulating throughout her body. H e r readings were 1 1 , 8, and 7, respectively. In addition, these sessions centered on ways in which Betty could prevent relapse. She had done exceptionally well and did not experience a slip during these 3 weeks. Betty and the therapist worked on anticipating difficult situations and planned ahead as to h o w she would cope with these situations if and when they arose. Betty was particularly concerned about w h a t she would do in stressful situations that were bound to arise in the future. It was discussed h o w she could take a "time out," removing herself from the situation, taking deep breaths, and/or thinking o f something fun she had recently done rather than smoking. At the end o f Session 8, Betty was commended for her hard w o r k , given information about local support groups (in case she desired additional help), and was scheduled for three " b o o s t e r sessions" 1, 3 , and 6 months later.

117

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At 1-month follow-up, Betty reported that she had one slip during the holidays as she was caught off guard by her " e m o t i o n s . " She noted that she recognized what she was doing and immediately put out the cigarette and did not allow herself to smoke again. She noted that she repeatedly reminded herself o f her hard w o r k and told herself that she refused to "go b a c k to Square O n e . " She also noted that this slip was a "reality c h e c k " and reminded her that she should n o t get overconfident about her progress and that she had to continue to w o r k on her addiction to nicotine. Betty admitted that she "would be lying" if she said she did not want a cigarette. But she added that the cravings were not occurring as often and that they were not as severe when they did occur. Betty was praised by the therapist and was encouraged to "keep her guard up." At the 3- and 6-month follow-ups, Betty reported that she had not slipped again and that her energy levels were up. At the 6-month follow-up, she reported that it looked as though her physician was considering performing the medical procedure she needed.

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Etiology

and Treatment

of Nicotine

Dependence

Perkins, Κ. Α., Grobe, J . E., Epstein, L. H., Caggiula, Α., Stiller, R. L., Sc Jacob, R. G. (1993). Chronic and acute tolerance to subjective effects of nicotine. Pharmacology Biochemistry and Behavior, 45, 3 7 5 - 3 8 1 . Piasecki, T. M., & Baker, T. (2000). Does smoking amortize negative affect? American Psychologist, 55, 1 1 5 6 - 1 1 5 7 . Piper, M. E., Fox, B. J . , Welsch, S. K., Fiore, M . C , & Baker, T. B . (2001). Gender and racial/ethnic differences in tobacco-dependence treatment: A commentary and research recommendations. Nicotine and Tobacco Research, 3, 2 9 1 - 2 9 7 . Pomerleau, C. S., Marks, J . L., Sc Pomerleau, O. F. (2000). Who gets what symptom? Effects of psychiatric cofactors and nicotine dependence on patterns of smoking withdrawal symptomatology. Nicotine and Tobacco Research, 2, 2 7 5 - 2 8 0 . Pomerleau, C. S., St Pomerleau, O. F. (1992). Euphoriant effects of nicotine in smokers. Psychopharmacology, 108, 4 6 0 - 4 6 5 . Pomerleau, O. F. (1995). Individual differences in sensitivity to nicotine: Implications for genetic research on nicotine dependence. Behavior Genetics, 25, 1 6 1 - 1 7 7 . Pomerleau, O., Adkins, D., Se Pertschuk, M . (1978). Predictors of outcome and recidivism in smoking cessation treatment. Addictive Behaviors, 3, 6 5 - 7 0 . Pomerleau, O. F., Se Kardia, S. L. R. (1999). Introduction to the featured section: Genetic research on smoking. Health Psychology, 18, 3 - 6 . Pomerleau, O. F., Sc Pomerleau, C. S. (1984). Neuroregulators and the reinforcement of smoking: Towards a biobehavioral explanation. Neuroscience and Biobehavioral Reviews, 8, 5 0 3 - 5 1 3 . Porchet, H. C , Benowitz, N. L., Se Sheiner, L. B . (1988). Pharmacodynamic model of tolerance: Application to nicotine. Journal of Pharmacology and Experimental Therapeutics, 244, 2 3 1 - 2 3 5 . Prochaska, J . O., Sc DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 3 9 0 - 3 9 5 . Prochaska, J . , Sc Goldstein, M . G. (1991). Process of smoking cessation. Implications for clinicians. Clinical Chest Medicine, 12, 7 2 7 - 7 3 5 . Pulvirenti, L., Sc Diana, M. (2001). Drug dependence as a disorder of neural plasticity: Focus on dopamine and glutamate. Reviews in the Neurosciences, 12, 1 4 1 - 1 5 8 . Radcliffe, Κ. Α., Fisher, J . L., Gray, R., Sc Dani, J . A. (1999). Nicotinic modulation of glutamate and GABA synaptic transmission of hippocampal neurons. Annals of the New York Academy of Sciences, 868, 5 9 1 - 6 1 0 . Richmond, M., Spring, B . , Sommerfeld, Β. K., Sc McChargue, D. E. (2001). Rumination and cigarette smoking: A bad combination for depressive outcomes? Journal of Consulting and Clinical Psychology, 69, 8 3 6 - 8 4 0 . Robinson, J . H., Se Pritchard, W. S. (1992). The role of nicotine in tobacco use. Psychopharmacology, 108, 3 9 7 - 4 0 7 . Robinson, T. E., Sc Berridge, K. C. (2000). The psychology and neurobiology of addiction: An incentive-sensitization view. Addiction, 95, S 9 1 - S 1 1 7 . Rose, J . E., Sc Levin, E. D. (1991). Inter-relationships between conditioned and primary reinforcement in the maintenance of cigarette smoking. British Journal of Addiction, 86, 6 0 5 - 6 0 9 . Salin-Pascual, R. J . , Rosas, M., Jimenez-Genchi, Α., Se Rivera-Meza, B . L. (1996). Antidepressant effect of transdermal nicotine patches in nonsmoking patients with major depression. Journal of Clinical Psychiatry, 57, 3 8 7 - 3 8 9 . Shiffman, S. (1991). Refining models of dependence: Variations across persons and situations. British Journal of Addiction, 86, 6 1 1 - 6 1 5 . Shiffman, S., Hickcox, M., Paty, J . Α., Guys, M., Kassel, J . D., Sc Richards, T. J . (1996). Progression from a smoking lapse to relapse: Prediction from abstinence violation effects, nicotine dependence, and lapse characteristics. Journal of Consulting and Clinical Psychology, 64, 9 9 3 - 1 0 0 2 .

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BEHAVIORS T H A T C O M P R O M I S E HEALTH Shiffman, S., Paty, J . Α., Guys, M., Kassel, J . D., & Elash, C. (1995). Nicotine withdrawal in chippers and regular smokers: Subjective and cognitive effects. Health Psychology, 14, 3 0 1 - 3 0 9 . Smith, S. S., Jorenby, D. E., Fiore, M. C , Anderson, J . E., Mielke, M . M., Beach, K. E., Piasecki, T. M., & Baker, T. B . (2001). Strike while the iron is hot: Can stepped-care treatments resurrect relapsing smokers? Journal of Consulting and Clinical Psychology, 69, 4 2 9 - 4 3 9 . Society for Research on Nicotine and Tobacco Subcommittee on Biochemical Verification. (2002). Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research, 4, 1 4 9 - 1 5 9 . Spielberger, C. D., Foreyt, J . P., Reheiser, E. C , & Poston, W. S. C. (1998). Motivational, emotional, and personality characteristics of smokeless tobacco users compared with cigarette smokers. Personality and Individual Differences, 25, 8 2 1 - 8 3 2 . Spielberger, C. D., St Jacobs, G. A. (1982). Personality and smoking behavior. Journal of Personality Assessment, 46, 3 9 6 - 4 0 3 . Spring, B., Pingitore, G., & McChargue, D. E. (in press). Reward value of cigarette smoking for comparably heavy smoking schizophrenic, depressed, and nonpatient smokers. American Journal of Psychiatry. Stein, L., Belluzzi, J . D., Ritter, S., St Wise, C. D. (1974). Self-stimulation reward pathways: Norepinephrine vs. dopamine. Journal of Psychiatric Research, 11,115-124. Swan, G. E., Ward, M . M., & Jack, L. M . (1996). Abstinence effects as predictors of 28-day relapse in smokers. Addictive Behaviors, 21, 4 8 1 - 4 9 0 . Tellegen, A. (1985). Structures of mood and personality and their relevance to assessing anxiety, with an emphasis on self-report. In H. Tuma St J . Maser (Eds.), Anxiety and anxiety disorders (pp. 6 8 1 - 7 0 6 ) . Hillsdale, NJ: Lawrence Erlbaum. Tiffany, S. T. (1990). A cognitive model of drug urges and drug-use behavior: Role of automatic and nonautomatic processes. Psychological Reviews, 97, 1 4 7 - 1 6 8 . Tomkins, S., St McCarter, R. (1964). What and where are the primary affects? Some evidence for a theory. Perception and Motor Skills, 18, 1 1 9 - 1 5 6 . Tracy, J . I. (1994). Assessing the relationship between craving and relapse. Drug and Alcohol Review, 13, 7 1 - 7 7 . Tsoh, J . Y., Humfleet, G. L., Munoz, R. F., Reus, V. L, Hartz, D. T., & Hall, S. M. (2000). Development of major depression after treatment for smoking cessation. American Journal of Psychiatry, 157, 3 6 8 - 3 7 4 . U.S. Department of Agriculture. (1997). Tobacco situation and outlook report (Series TBS, No. 2 3 9 ) . Washington, DC: U.S. Department of Agriculture, Economic Research Service, U.S. Department of Health and Human Services. (1999). Tobacco Use: United States, 1 9 0 0 - 1 9 9 9 . Morbidity and Mortality Weekly Report, 48, 9 8 6 - 9 9 3 . Vuchinich, R. E., St Tucker, J . A. (1988). Contributions from behavioral theories of choice to an analysis of alcohol abuse. Journal of Abnormal Psychology, 97, 181-195. Watkins, S. S., Koob, G. F., & Markou, A. (2000). Neural mechanisms underlying nicotine addiction: Acute positive reinforcement and withdrawal. Nicotine and Tobacco Research, 2, 1 9 - 3 7 . West, R., & Hajek, P. (1997). What happens to anxiety levels on giving up smoking? American Journal of Psychiatry, 154, 1 5 8 9 - 1 5 9 2 . West, R., Hajek, P., & Belcher, M. (1989). Severity of withdrawal symptoms as a predictor of outcome of an attempt to quit smoking. Psychological Medicine, 19, 9 8 1 - 9 8 5 . Wise, R. A. (1998). Drug-activation of brain reward pathways. Drug and Alcohol Dependence, 51, 1 3 - 2 2 .

CHAPTER

5

Obesity and Body Image Disturbance MYLES S. FAITH AND J . KEVIN THOMPSON

O

besity in the United States and other

divided by the square o f height in meters

countries is a significant and grow-

(w/h ). This method is also referred to as

ing public health problem. T h e U.S.

Quetelet's index (Garrow & Webster, 1 9 8 5 ) .

surgeon general recently released a report

B M I can also be computed from pounds and

referring to the current rates o f obesity as a

inches: weight (in pounds) divided by height

2

"public health epidemic" (Centers for Disease

(in inches) times 7 0 4 . 5 .

Control

weight classification are presented in Table

and

Prevention, 2 0 0 2 ) .

Obesity

B M I cutoffs for

among adults, adolescents, and children is

8 . 1 . N o t e that a B M I between 2 5 . 0 and 2 9 . 9

increasingly encountered in clinical settings,

connotes an overweight status, with

and

greater than 3 0 indicating obesity.

an

awareness

o f current etiological

models, assessment strategies, and interven-

BMIs

Despite its widespread use, there are limits

tion methodologies is necessary for the opti-

to

mal management o f this important

health

(Heymsfield et al., 2 0 0 0 ) . F o r instance, it

problem. This chapter explores these issues,

c a n n o t be used as a specific indicator o f the

with an emphasis on the practical strategies

level o f body fat on the individual, and it is

that may inform the behavioral management

influenced by factors such as age, gender,

B M I as a measure

o f weight

status

of obesity. It also provides a brief discussion

and exercise status (i.e., sedentary vs. active).

o f targeting body image in obesity treatment.

Specifically, w o m e n tend to have a higher percentage o f body fat than do men given the same B M I . In addition,

older

individuals

DEFINITIONS AND DESCRIPTION OF OBESITY

tend to have a higher percentage o f body fat

A consensus has emerged during recent years

cially those w h o lift weights) may have a

that one o f the best methods for clinically

lower percentage o f body fat than do indi-

defining obesity is the body mass index ( B M I ) .

viduals w h o are less athletic for a specific

T h e formula for B M I is weight in kilograms

BMI.

than do younger individuals for a given B M I , and people w h o w o r k out regularly (espe-

226

BEHAVIORS T H A T C O M P R O M I S E HEALTH Table 8.1

Classification of Overweight and Obesity by BMI Obesity

Underweight Normal Overweight Obesity

Class

I II III

Extreme obesity

BMI < 18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40.0

high blood pressure, high blood cholesterol, gout,

and

Colditz,

gallstones (Field, B a r n o y a , 2002).

(More

information

& on

physical problems relevant to the assessment o f obesity c a n be found later in this chapter.)

Psychological and Psychosocial Problems A wide variety of psychological problems

S O U R C E : N I H / N H L B I (1998).

have been examined as a concomitant of obesity, and perhaps even more research efforts during

Prevalence statistics reported during the past few years reveal an astonishing increase in the level o f overweight and obese individuals in the United States (Centers for Disease Control and Prevention, 2 0 0 2 ;

Mokdad,

B o w m a n , & Ford, 2 0 0 1 ; M o k d a d , Serdula, &

Dietz, 1 9 9 9 , 2 0 0 0 ) . Currently, 6 1 % o f

U.S. adults ages 2 0 to 7 4 years are either overweight or obese. T h e level o f obesity increased from 1 2 % o f the U.S. population in 1 9 9 1 to 1 9 . 8 % in 2 0 0 0 . Thus, an estimated 3 8 . 8 million adults in the United States met the B M I cutoff o f 3 0 . 0 for obesity in the year 2 0 0 0 . T a b l e 8.2 displays these data by gender and ethnicity. These data reflect the particularly high levels o f obesity in

African

American and Hispanic populations.

recent years have focused on the psychosocial "consequences" of obesity. Psychosocial consequences entail the specific interpersonal, social, and occupational problems encountered by the obese individual specifically due to an elevated weight status such as being teased about one's size, facing societal prejudice against obesity (which may have economic consequences), and encountering physical barriers (e.g., plane seats that are too small). Somewhat surprisingly, the common assumption that an elevated weight must necessarily be associated with a plethora of psychological problems is not supported by the literature (Faith &c Allison, 1 9 9 6 ) . Early work in the area did not confirm the expected finding that obese individuals were more depressed than nonobese individuals. Recently, however, a nationally representative sample of more than 4 0 , 0 0 0 people were evaluated via structured interviews for level

PHYSICAL AND PSYCHOLOGICAL PROBLEMS ASSOCIATED WITH OBESITY

of depression (Carpenter, Hasin, Allison, & Faith, 2 0 0 0 ) . Obese women were 3 7 % more likely to have met D S M - I V (Diagnostic Statistical

Physical Problems

edition)

Manual criteria

of Mental

Disorders,

(American

and fourth

Psychiatric

A wide variety o f health problems are

Association, 1 9 9 4 ) for major depression during

associated with obesity. It has been estimated

the previous year compared with women of

that

325,000

deaths could be

attributed

average weight. O n the other hand, obese men

(Allison, F o n t a i n e ,

had a significantly reduced risk for depression.

M a n s o n , Stevens, & Vanltallie, 1 9 9 9 ) . A n

Interestingly, for men, being underweight was

to obesity each year

overweight or obese status has been linked to

associated with greater depression. Research

such seemingly disparate health problems as

into the reasons behind such a dramatic gender

heart disease, cancer, type 2 diabetes, stroke,

difference in the psychosocial consequences of

arthritis, breathing problems (sleep apnea),

obesity is an active area of inquiry.

Obesity and Body Image Disturbance

\

Increasing; Adult Obesity Prevalence: Obesity Trends (percentages)

Table 8.2 Sample

1991

1995

1998

2000

Total Gender Men Women Ethnicity White, non-Hispanic Black, non-Hispanic Hispanic

12.0

15.3

17.9

19.8

11.7 12.2

15.6 15.0

17.7 18.1

20.2 19.4

11.3 19.3 11.6

14.5 22.6 16.8

16.6 26.9 20.8

18.5 29.3 23.4

S O U R C E : M o k d a d , B o w m a n , Ford, Vinicor, M a r k s , and K o p l a n (2001).

disturbances

obese individuals is, o f course, that they live in a

with obesity has been a controversial area.

society that glorifies the antithesis of obesity—

T h e comorbidity o f eating

Obesity is not a diagnosable psychiatric condi-

a slender, nonfat, "ideal" body (Thompson,

tion, and it is not listed as an eating disorder in

Heinberg, Altabe, & Tantleff-Dunn,

the D S M - I V (nor has it been labeled as such in

Pressure and information related by the media,

previous editions o f the D S M ) . However, the

family, and peers may be a constant reminder

association o f a particular type o f eating dis-

of the unacceptable nature of the physicality of

1999).

turbance—binge eating—has been noted as an

obese individuals. For instance, negative verbal

associate of obesity for many years (Stunkard,

commentary in the form o f teasing or criticism

2 0 0 2 ) . During recent years, binge eating disor-

of appearance is a c o m m o n experience o f obese

der has been proposed as a new entry in the

individuals. Some studies have shown

D S M and is currently included in the D S M - I V

more than 9 0 % o f obese individuals have been

that

as a disorder in need of further study. T h e issue

teased about their appearance (Thompson &c

is relevant for obesity because perhaps 3 0 % to

Smolak, 2 0 0 1 ) . Interestingly, teasing may be a

4 0 % o f individuals with binge eating disorder

more direct influence on body dissatisfaction

In

than is weight. In fact, Thompson, Coovert,

addition, individuals with binge eating dis-

Richards, Johnson, and Cattarin ( 1 9 9 5 ) found

order have higher levels of depression than do

that B M I had no direct effect on body image

non-binge eating controls (Wadden, W o m b l e ,

but was mediated through teasing history.

are also obese (Johnson 8 t Torgrud, 1996).

Anderson, 2 0 0 2 ) . Recently,

T h a t is, only those individuals with an elevated

Bulik, Sullivan, and Kendler ( 2 0 0 2 ) examined

B M I who had been teased developed body

the prevalence o f binge eating and obesity in a

dissatisfaction.

Stunkard,

&

population-based

sample o f female twins.

Occupational and

social discrimination

Obese women with binge eating disorder had

against obese individuals is also widely sup-

higher levels o f health dissatisfaction, major

ported

medical disorders, major depression, panic

Gortmaker, Must, Perrin, Sobol, and Dietz

disorder, phobias, and alcohol dependence.

by survey and

laboratory

studies.

( 1 9 9 3 ) evaluated more than 1 0 , 0 0 0 overweight

O n e of the most consistent findings related

and normal-weight adolescents for 7 years. At

to body image dissatisfaction is that obese

the conclusion of the study, overweight females

individuals are more dissatisfied with their

were less likely to be married and also had lower

appearance than are nonobese individuals. One

incomes, whereas overweight males were only

possible reason for the greater dissatisfaction of

less likely to be married. Experimental designs

127

128

BEHAVIORS T H A T C O M P R O M I S E HEALTH have also demonstrated that job applicants'

scores. Finally, urban planning and

weight has a powerful effect on factors such as

often do not include sidewalks or bike paths to

sprawl

selection for a particular j o b , promotion, and

encourage exercise, and residents who perceive

dismissal (e.g., Pingitore, Dugoni, Tindale, &

their neighborhoods to be unsafe may be

Spring, 1 9 9 4 ; Roehling, 1 9 9 9 ) .

reluctant to leave their homes. Horgen and Brownell ( 2 0 0 2 ) referred to the "toxic environment" as a primary cause o f the emerging problem of obesity. Support for

MODELS OF OBESITY

this position is enhanced not only by the recent Genetic,

and

epidemic in the United States but also by

offered

the burgeoning problem worldwide, leading

metabolic, environmental,

developmental

models have been

to explain the onset and maintenance o f

the World Health Organization ( 1 9 9 8 )

obesity. T o date, evidence supports each as a

declare that a global epidemic exists. Obesity

potentially relevant factor. T h e r e is, how-

now appears to be increasing in every country

to

ever, a great deal o f variability across indi-

that has been surveyed. Migration, urbani-

viduals, making unitary models limited in

zation,

their explanatory value. Given the tremen-

"Americanization" o f food selections and eat-

dous increase in the prevalence o f obesity

ing habits in other countries, have been sug-

over the past 1 0 years, it is understandable

gested as dominant, large-scale, environmental

and

affluence, coupled

with

the

that environmental causes have received con-

factors (Vanltallie, 1 9 9 4 ) . In the United States,

siderable examination (Hill & Peters, 1 9 9 8 ) .

the pervasiveness o f the "toxic environment" is apparent from even a superficial examination of the strategies of food marketing. Fast-food

Environmental Factors

restaurants offer options to "bigger size" one's

Environmental models address factors that promote the intake of excessive energy (calo-

meals, inducing even greater consumption o f meals already high in fat content.

ries) as well as those variables that promote a reduction of energy expenditure via exercise. The ready availability of energy-dense foods,

Genetic Factors

advent of larger portion sizes at restaurants,

Mapping o f the human genome has gener-

increased use o f fast foods, and decreased

ated interest in studying the genetic factors for

preparation o f meals are environmental factors

a variety o f psychological and physical disor-

that may promote weight gain (French, Story,

ders. Analysis o f the genomic regions with link-

& Jeffery, 2 0 0 1 ) . In addition, there have been

age to obesity is at a relatively early stage of

numerous environmental modifications as a

scientific development (Price, 2 0 0 2 ) , although

result of technological advances that

molecular studies are identifying an ever-

have

enhanced the sedentary nature of many indi-

growing list o f genes that may confer increased

viduals' lifestyles both at home and in the work-

risk for obesity in humans (Rankinen et al.,

place. Computers, video games, and television

2 0 0 2 ) . M o r e traditional work in this area has

are often selected to the exclusion of recre-

focused on the analysis o f familial/genetic

ational activities that burn calories (Dowda,

influence by examining monozygotic and dizy-

Ainsworth, Addy, Saunders, & Riner, 2 0 0 1 ) ,

gotic twins. Specifically, examination of body

whereas physical education is increasingly elim-

composition among twins has revealed that

inated or downsized in schools due to liability

monozygotic twins have correlations ranging

concerns or increased emphasis on classroom

from . 6 0 to . 7 0 , higher than the . 2 0 to . 3 0

activities to

observed among dizygotic twins (Price, 2 0 0 2 ) .

enhance standardized

testing

Obesity

and Body Image Disturbance

\

Recent summaries of the work in this area

7 0 % chance o f becoming overweight or obese

suggest that 6 7 % o f the variation in B M I

adults. Interestingly, the contribution o f the

among monozygotic twins may be attribut-

parents' weight, along with the child's weight,

&

m a y depend on the child. F o r instance,

Ravussin, 2 0 0 2 ) . This genetic influence may

Whitaker, Wright, Pepe, Seidel, and Dietz

manifest

( 1 9 9 7 ) looked at the weight o f both the parents

able to genetics (Price, 2 0 0 2 ; Tataranni in physiological and

behavioral

effects such as different resting metabolic rates,

and the child to determine whether one or both

reduced physical activity (e.g., fidgeting), and

contributed to the development o f obesity in

excessive food consumption.

a

the child. They found that very young children

"thrifty" gene has long been hypothesized to

(ages 1 to 2 years) who were obese and had

Although

lie at the roots of the elevated obesity rates

an overweight parent had a fourfold risk for

(e.g., among the Pima

adult obesity as compared with overweight

Indians), no such single gene has been detected.

children of the same age w h o had average-

Even among such subgroups, however, rates of

weight parents. However, by age 1 0 years, the

obesity have increased along the lines o f other

effect was independent o f the parents' weight.

in some subgroups

population groups over the past 5 0 years, suggesting more than a genetic influence (Price,

Other early developmental factors

that

have received examination include type o f

Charles, Pettitt, & Knowler, 1 9 9 3 ) . Hence,

infant feeding (breast vs. bottle), feeding style,

obesity is most likely a "polygenic trait," influ-

and parental control over feeding. Each o f

enced by multiple genes that interact among

these areas is receiving a great deal o f atten-

themselves as well as by environmental inputs

tion, and the findings are often inconclusive.

(Comuzzie &c Allison, 1 9 9 8 ) .

However, it appears that, despite the widely

An interesting question in this area is

held view to the contrary, there is no differ-

whether genes have a direct biological effect

ence

on obesity and perhaps drive an individually

feeding in terms o f the later development o f

between

breast-feeding

based response to specific environmental fac-

obesity

Feeding style involves the study o f factors

Johnson, & Allison, 1 9 9 7 ; Keller, Pietrobelli,

such as rapid eating and the vigor o f the suck-

Must, & Faith, 2 0 0 2 ) . Put more clearly, are

ing response during infancy. Findings in this

genes partly responsible for those gaining the

area are intriguing. For example, Stunkard,

m o s t weight

Berkowitz, Stallings, and

toxic

environment?

Stunkard,

bottle-

tors (e.g., low activity, excessive eating) (Faith,

in our

(Berkowitz &

and

Schoeller

2002).

(1999)

Bouchard and colleagues ( 2 0 0 0 ) overfed iden-

found that the infant offspring o f overweight

tical twins for 3 months and found

that

mothers had a more vigorous sucking style

although there were large differences in the

than did the infants o f control mothers.

levels o f weight added across pairs, within-

Importantly, the authors also found that they

pair gains were similar. Therefore, it is possi-

could predict level o f fatness at age 1 year by

ble that gene-environment interactions exist

an examination o f the sucking style. Finally,

with respect to weight gain.

parental control is the degree to which a parent, typically the mother, attempts

Developmental Factors There is strong support for the prediction of

to

manage or direct the child's intake. Birch and colleagues have pioneered

work

in

this

area and found intriguing results suggesting

obese status in adulthood from an examina-

that parental control may influence not only

tion of the weight o f the individual during

weight gain but, in certain circumstances,

childhood and adolescence (Thompson S t

restriction o f intake

Smolak, 2 0 0 1 ) . Overweight adolescents have a

Birch, 2 0 0 1 ) .

as well

(Fisher

&

129

BEHAVIORS THAT C O M P R O M I S E HEALTH

130

Assessment

Summary Prevalence rates o f obesity have increased

W i t h approximately half o f the U.S. popu-

drastically during the past few decades in

lation overweight or obese, it is important to

children, adolescents, and adults as well as

determine when treatment is warranted. T w o

among

all ethnicities

measurements that are practical for clinical

both

genders

and

evaluated. This "epidemic" has generated a

settings are recommended as first-step screen-

wealth o f research into associated health

ing instruments: B M I and the waist circumfer-

and physical conditions as well as strategies

ence. As described previously (Table 8.1),

to understand causal variables. T o

date,

B M I can be used to define degree o f obesity.

etiological models are inconclusive, but c o m -

Waist circumference, as determined by a tape

pelling

points

measure, is suggested because B M I alone does

toward a " t o x i c " environment that sets the

not provide an informative index of so-called

stage for the development and

"abdominal fat." Abdominal fat is important

epidemiological

evidence

perpetuates

for

the maintenance o f obesity.

assessment

because higher

levels o f

abdominal fat are an independent predictor of health complications related to obesity ASSESSMENT AND

(Pi-Sunyer, 1 9 9 3 ) . Hence, an individual who

TREATMENT OF OBESITY

is "overweight" but has excess abdominal fat may be at greater risk for various diseases

This section summarizes approaches for the

(e.g., cardiovascular disease, type 2 diabetes)

assessment and

than is another individual who is "obese"

treatment

o f obesity in

adults. General guidelines and strategies are

with lower levels o f abdominal fat.

detailed

Waist circumference is measured by a stan-

descriptions are provided elsewhere (Foreyt

dard protocol (NIH/NHLBI, 1 9 9 8 ) and should

provided &

here;

however,

more

Goodrick, 1 9 9 2 ; Kirschenbaum, 1 9 9 4 ;

be performed by trained staff. Expert guide-

Wadden & Vanltallie, 1 9 9 2 ) . In particular,

lines suggest that waist circumference measure-

clinicians specializing in this area are encour-

ments should be taken among persons with

Clinical

B M I s between 2 5 . 0 and 3 4 . 9 . For individuals

Evaluation,

with B M I s greater than or equal to 3 5 . 0 , or

Obesity

who are "short" in stature, waist circumfer-

(National Institutes o f Health/

ence may be minimally informative beyond

aged to read the seminal report, Guidelines and

on the Identification,

Treatment

in Adults

of Overweight

and

National Heart, Lung, and Blood Institute

BMI

[ N I H / N H L B I ] , 1 9 9 8 ) . This report provides

adults with B M I s between 2 5 . 0 and 3 4 . 9 ,

alone ( N I H / N H L B I , 1 9 9 8 ) .

Among

the most authoritative, comprehensive, and

waist circumferences greater than 1 0 2 centi-

empirically based guidelines to date

for

meters ( 4 0 inches) in men and greater than 88

obesity treatment. M o s t o f the guidelines

centimeters (35 inches) in women have been

these

proposed as "high-risk" cutoffs for disease.

This section is broken down into assess-

with increased risk for type 2 diabetes, dyslipi-

provided

herein

are adapted from

Elevated waist circumferences are associated

expert recommendations. ment

and

treatment.

Within

treatment,

demia, hypertension, and cardiovascular dis-

brief

ease. Table 8.3 summarizes the relative risk o f

surgical

disease as a function of B M I and waist circum-

interventions are discussed. This is followed

ference profiles and illustrates how abdominal

behavioral/lifestyle interventions and updates on pharmacological and

up with a discussion o f the role o f body image

fat levels can amplify or attenuate the health

enhancement in obesity treatment.

risks associated with elevated B M I .

Obesity and Body Image Table 8.3

Disturbance

Risk of Type II Diabetes, Hypertension, and Cardiovascular Disease as a Function of Weight Class and Waist Circumference

Weight Class

"Normal" Waist Circumference

"High-Risk" Waist Circumference

Underweight Normal Overweight Obesity-I Obesity-II Extreme obesity

Increased High Very high Extremely high

High Very high Very high Extremely high

S O U R C E : Adapted from N I H / N H L B I (1998).

Beyond

B M I and waist circumference

overweight, or have a high risk waist circum-

assessment, expert guidelines pinpoint addi-

ference in conjunction

tional clinical markers that may

indicate

tors, development of a treatment plan for weight

individuals at a "very high absolute risk" of

control and risk factor reduction is warranted.

with at least two risk fac-

disease. T h e presence of one or more o f these

Individuals who meet these criteria but do not

conditions may suggest the need for more

want to lose weight may be advised to maintain

aggressive obesity intervention. T a b l e 8.4

their current weight or address concurrent risk

summarizes these diseases or target

factors until they are sufficiently motivated to

organ

damages that should be considered when eval-

lose weight. Treatment generally encompasses

uating obese patients ( N I H / N H L B I , 1 9 9 8 ) .

dietary, physical activity, and lifestyle changes, with appropriate assessment of barriers to treatment and periodic weight checks.

Treatment Obesity

Treatment

Algorithm

Intervention

T h e N I H / N H L B I ( 1 9 9 8 ) report provides a concrete algorithm

to guide

the

Components

A well-established literature indicates that

obesity

behavioral/lifestyle approaches t o obesity

evaluation-treatment interface, and is depicted

treatment are effective for inducing weight

in Figure 8 . 1 .

loss, although relapse is very c o m m o n (Faith,

The heuristic begins with assessment o f family

Fontaine, Cheskin, & Allison, 2 0 0 0 ; Wadden,

history of obesity. If there is no history of obesity,

Sternberg, Letizia, Stunkard, & Foster, 1 9 8 9 ) .

experts recommend 2-year intervals for the

Enhanced dietary quality is a hallmark feature

assessment of changes in B M I . At 2-year assess-

of behavioral treatment, as patients are tradi-

ments (or more frequent assessments if obesity is

tionally prescribed a "low-calorie diet" that is

familial), health professionals are advised to cal-

generally 8 0 0 to

1 , 5 0 0 calories per

day.

culate B M I as well as to measure weight, height,

Features o f the American Heart Association's

and waist circumference. For patients who are

Low-Calorie Step I Diet are summarized in

overweight or obese, or who have a high-risk

Table 8.5 ( N I H / N H L B I , 1 9 9 8 ) .

waist circumference (greater than 88 centimeters

Reducing total caloric intake by 5 0 0 to

in females, greater than 1 0 2 centimeters in

1,000 calories per day, assuming no changes in

males), a thorough

physical activity levels, is expected to induce

medical assessment is

warranted that assesses the conditions listed in

weight loss o f approximately 1 to 2 pounds per

Table 8.4. For patients who are obese, are

week. Reducing total caloric intake by 3 0 0 to

[

BEHAVIORS THAT C O M P R O M I S E HEALTH

Table 8.4

Diseases and Target Organ Damages for Potential Assessment in Obese Adults

1. Identification of patients at very high absolute risk: l a . Established CHD History History History History

of of of of

myocardial infraction angina pectoris (stable or unstable) coronary artery surgery coronary artery procedures (angioplasty)

l b . Presence of other atherosclerotic disease Peripheral arterial disease Abdominal aortic aneurysm Symptomatic carotid artery disease Type 2 diabetes Sleep apnea 2. Identification of other obesity-associated diseases: 2a. Gynecological abnormalities 2b. Osteoarthritis 2c. Gallstones and their complications 2d. Stress incontinence 3. Identification of cardiovascular risk factors that impart a high absolute risk (patients can be classified as being at high absolute risk for obesity-related disorders if they have three or more of the multiple risk factors listed below): 3a. Cigarette smoking 3b. Hypertension: A patient is classified as having hypertension if systolic blood pressure is > 140 millimeters of mercury or diastolic blood pressure is > 9 0 millimeters of mercury or if the patient is taking antihypertensive agents. 3c. High-risk LDL cholesterol: A high-risk LDL cholesterol is defined as a serum concentration of > 160 milligrams per deciliter. A borderline high-risk LDL cholesterol (130 to 159 milligrams per deciliter), together with two or more other risk factors, also confers high risk. 3d. Low H D L cholesterol: A low H D L cholesterol is defined as a serum concentration of < 35 milligrams per deciliter. 3e. Impaired fasting glucose: The presence of clinical type 2 diabetes (fasting plasma glucose of > 126 milligrams per deciliter or 2 hours postprandial plasma glucose of > 2 0 0 milligrams per deciliter) is a major risk factor for CVD, and its presence alone places a patient in the category of very high absolute risk. Impaired fasting glucose (fasting plasma glucose 110 to 125 milligrams per deciliter) is considered by many authorities to be a risk factor for cardiovascular disease. 3f.

Family history of premature CHD

3g. Age (males > 45 years or females > 55 years or postmenopausal) 4. Other risk factors: 4a. Physical inactivity 4b. High triglycerides (400 to 1,000 milligrams per deciliter = "high", > 1,000 milligrams per deciliter = "very high") S O U R C E : N I H / N H L B I (1998). N O T E : C H D = coronary heart disease; L D L = low-density lipoprotein; H D L = high-density lipoprotein; C V D = cardiovascular disease.

Obesity and Body Image

Figure 8.1

Disturbance

The Obesity Evaluation-Treatment Interface

S O U R C E : National Institutes of Health/National Heart, Lung, and Blood Institute (1998).

5 0 0 calories per day (the equivalent of approxi-

everyday living. Examples include parking far-

mately two soft drinks) is expected to induce

ther away in the parking lot so that one needs

weight loss o f Vi to 1 pound per week, assum-

to walk farther to the office/shop, taking daily

ing no changes in physical activity. For these

walks, cleaning the house regularly, moving

reasons, obese adults are typically prescribed

while talking on the phone, and taking stairs

to consume 1,000 to 1,200 calories per day

instead o f elevators whenever one has a choice.

(women) or 1,200 to 1,500 calories per day

A study by Andersen and colleagues ( 1 9 9 9 )

(men) to achieve weight loss.

compared weight loss among 4 0 obese women

Physical activity is another pillar of obesity

who were randomized to a weight loss group

treatment. Physical activity without concurrent

that incorporated a structured aerobic exercise

improvements in diet quality will have a less

regimen versus a lifestyle activity regimen.

potent effect on weight loss than will changes

Although the two groups lost comparable

in diet plus physical activity ( N I H / N H L B I ,

amounts of weight during the 16-week inter-

1 9 9 8 ) . During recent years, research

vention, the aerobic exercise group regained

has

focused on the beneficial effects o f so-called

significantly more weight on average (1.6 kilo-

"lifestyle activity" changes compared

grams) than did the lifestyle intervention group

with

more regimented and structured exercise pro-

(0.08 kilograms). Data from the W o m e n ' s

grams. Lifestyle programs teach individuals

Healthy Lifestyle Project Clinical Trial (Kuller,

how to program physical activity changes into

Simkin-Silverman, Wing, Meilahn, & Ives,

133

134

BEHAVIORS T H A T C O M P R O M I S E HEALTH Table 8.5

Low-Calorie Step I Diet

Nutrient

Recommended

Calories

Approximately 5 0 0 to 1,000 calories per day reduction from usual intake < 3 0 % of total calories 8% to 1 0 % of total calories < 1 5 % of total calories < 1 0 % of total calories < 3 0 0 milligrams per day Approximately 1 5 % of total calories 5 5 % or more of total calories No more than 100 millimoles per day (approximately 2.4 grams of sodium or approximately 6 grams of sodium chloride) 1,000 to 1,500 milligrams 2 0 to 30 grams

Total fat Saturated fatty acids Monounsaturated fats Polyunsaturated fats Cholesterol Protein Carbohydrates Sodium chloride Calcium Fiber

Intake

S O U R C E : N I H / N H L B I (1998).

2001)

also confirm that prescriptions

for

Behavioral

Techniques

lifestyle physical activity, in conjunction with the aforementioned dietary prescriptions, can pre-

Descriptions o f the behavioral treatment of

vent excess weight gain and elevations in low-

obesity can be traced back to classical articles

density lipoprotein (LDL) cholesterol among

by Ferster, Nurnberger, and Levitt (1962) and

women as they progress from perimenopause

Stuart ( 1 9 6 7 ) . Between the 1 9 7 0 s and the 1 9 9 0 s , classical experiments tested behavioral

to postmenopause. daily

treatments for obesity among a range o f obese

physical activity can be personally tailored to

patients. As the methodological rigor of these

accommodate individual lives. " M o d e r a t e "

studies

intensity physical activity is conceptualized as

lengths, and follow-up lengths)

activities that translate to an energy deficit of

over time, so did the efficacy o f treatment

1 5 0 calories per day, which would sum to

(Faith et al., 2 0 0 0 ; Wadden & Foster, 2 0 0 0 ) .

On

a practical level, increasing

(including sample sizes, treatment improved

1,000 calories per week (NIH/NHLBI, 1 9 9 8 ) .

Whereas intervention studies published

The amount of time needed to achieve this

1 9 7 4 achieved a mean weight loss o f 3.8 kilo-

in

deficit each day will depend on the nature of

grams (or approximately 8.5 pounds), those

the activity and the individual's weight. Expert

published between 1 9 8 5 and 1 9 8 7 achieved a

guidelines suggest that initially the obese

mean weight loss o f 8.4 kilograms (or approx-

patient should engage in moderate activity lev-

imately 1 8 . 5 pounds). Unfortunately, a cardi-

els for 3 0 to 4 5 minutes per day on 3 to 5 days

nal disappointment of these same weight loss

per week (NIH/NHLBI, 1 9 9 8 ) . According to

studies—and a finding that transcends decades

the surgeon general's report, most adults

of research—is an excessive rate of recidivism

should ultimately strive to accumulate at least

(Wadden et al., 1 9 8 9 ; Wilson, 1 9 9 4 ) .

3 0 minutes of moderate-intensity physical

Specific components o f the

activity on most, if not all, days o f the week.

behavioral

treatment o f obesity have been outlined in

Table 8.6 illustrates the different ways in

detail elsewhere (Foreyt & Goodrick, 1 9 9 2 ;

which an adult can achieve moderate physical

Kirschenbaum, 1 9 9 4 ; Wadden & Vanltallie,

activity levels each day, varying the time spent

1 9 9 2 ) . Critical concepts reviewed by expert

doing the activity and the strenuousness of

guidelines ( N I H / N H L B I , 1 9 9 8 ) include the

the activity.

following.

Obesity and Body Image Disturbance Table 8.6

Examples of Moderate Amounts of Physical Activity

Activity

Requirements

Washing or waxing a car for 4 5 to 60 minutes

Less vigorous/More time

Washing windows or floors for 4 5 to 60 minutes Playing volleyball for 4 5 minutes A

Playing touch football for 30 to 4 5 minutes Gardening for 3 0 to 4 5 minutes Wheeling self in wheelchair for 3 0 to 4 0 minutes Walking 1% miles in 35 minutes Playing basketball for 30 minutes Bicycling 5 miles in 30 minutes Dancing fast (socially) for 3 0 minutes Pushing a stroller V/z miles in 3 0 minutes Raking leaves for 30 minutes Walking 2 miles in 3 0 minutes Engaging in water aerobics for 3 0 minutes Swimming laps for 2 0 minutes Playing a basketball game for 15 to 2 0 minutes Bicycling 4 miles in 15 minutes Jumping rope for 15 minutes

More vigorous/Less time

Running Wi miles in 15 minutes Shoveling snow for 15 minutes Stair walking for 15 minutes

Self-Monitoring

and

(Faith, Allison, & Geliebter, 1 9 9 7 ) . Teaching

Recording in detail what

obese individuals coping strategies to deal

one eats every day can provide revealing

with stress without eating c a n be an impor-

insights into the environmental, emotional,

tant component o f treatment. Exercise can be

and/or interpersonal circumstances that may

an effective stress management technique that

prompt intake o f particular foods. Keeping

also confers benefits for weight management.

Physical

Activity.

of

Eating

such recordings with standard

Habits

paper-and-

pencil methods or with novel palm comput-

Stimulus

Control.

Unhealthy food selec-

ers can bring patterns o f eating and inactivity

tions and/or overeating can be stimulated by

to consciousness and help m a k e them the

foods that are more readily accessible and

target o f treatment.

conveniently ready for eating. For example, homes that do not keep an ample supply o f prompt

fresh fruits and vegetables for snacking are less

overeating in certain obese individuals, espe-

conducive to weight control than are homes in

cially those with

which these foods are readily available.

Stress

Management.

Stress can

binge eating

tendencies

\

135

136

BEHAVIORS THAT C O M P R O M I S E HEALTH Therefore, behavioral interventions focus on

pressure, coronary heart disease, congestive heart

barriers to restructuring the environment in

failure, arrhythmias, or stroke should not take

ways

sibutramine. All patients taking the medication

that

stimulate

healthy

eating

and

physical activity.

are encouraged to have their blood pressure monitored regularly (NIH/NHLBI, 1998). Rewards for

Orlistat exerts its effects by inhibiting

behavioral changes can be an effective c o m -

pancreatic lipase and thereby decreasing fat

ponent o f treatment. Rewards can be tangi-

absorption. T h e effectiveness of orlistat for

Contingency

Management.

ble gifts for oneself or praise from family

inducing long-term (i.e., 2-year) weight loss

members and friends (i.e., social support).

compared with controls was documented in two sets o f multisite studies: one conducted in

Cognitive statements

Positive self-

Restructuring. that

challenge defeating

Europe (Rossner, Sjôstrôm, N o a c k , Meinders,

self-

& Noseda, 2 0 0 0 ) and one conducted in the

statements can be effective for teaching obese

United States (Davidson et al., 1 9 9 9 ) . Orlistat

patients to cope with treatment "failures" (e.g.,

can also have beneficial effects on blood

periods of weight regain) or other unexpected

glucose levels and diabetes-related risk factors

challenges during treatment. These matters can

(Heymsfield et al., 2 0 0 0 ) . T h e fact that orlis-

be especially important

for obese patients

tat's principal mechanism o f action does not

lacking in self-acceptance or self-esteem due to

involve brain neurotransmitters represents a

limited weight loss or weight regain (Wilson,

distinct advantage over sibutramine. O n the

1 9 9 6 ) . Recent advances in treatment are focus-

other hand, orlistat has its own

ing on promotion of more realistic weight loss

effects, including a decrease in absorption o f

expectations to promote better psychological

fat-soluble vitamins, soft stool and anal leak-

well-being and perhaps even weight loss.

age in some individuals, and a possible link to

adverse

breast cancer ( N I H / N H L B I , 1 9 9 8 ) . Pharmacological

Therapy

In sum, there are currently two F D A -

Detailed reviews of the drug treatment literature have been published

elsewhere (e.g.,

approved drug options for obese individuals who may need additional help to achieve weight

Haddock, Poston, Dill, Foreyt, & Ericsson,

loss. However, these pharmacological agents

2 0 0 2 ) . There are currently two prescription med-

can have adverse effects and so require careful

ications that are approved by the Food and Drug

medical supervision if they are to be taken.

Administration (FDA) for obesity treatment:

Expert guidelines propose these alternatives as

sibutramine (Meridia) and orlistat (Xenical).

possible options only after a patient has tried

Sibutramine is an anorexiant (or appetite

6 months o f behavioral intervention, including

suppressant) that exerts its effect by inhibiting

diet and exercise, without success. Even then,

the reuptake of norepinephrine,

these alternatives are recommended only for

dopamine,

and serotinin in the brain. Controlled clinical

patients with BMIs greater than or equal to 3 0

trials document the clinical effectiveness o f

without

sibutramine for weight loss (Berube-Parent,

or for patients with BMIs greater than or equal

Prudhomme, St-Pierre, Doucet, & Tremblay,

to 2 7 with

2 0 0 1 ; Fanghanel, Cortinas, Sanchez-Reyes, &

factors or diseases (NLH/NHLBI, 1 9 9 8 ) .

obesity-related risk factors or diseases concomitant obesity-related risk

Berber, 2 0 0 1 ; Wirth & Krause, 2 0 0 1 ) . O n the other hand, a major concern surrounding sibutramine is the potential for increased heart rate

Surgical

Approaches

and blood pressure (Bray et al., 1996). For these

Surgical approaches to obesity are generally

reasons, individuals with a history of high blood

recommended only for the most severe cases in

Obesity and Body Image Disturbance

\

which other behavioral and pharmacological

numerous prejudices and forms of discrimination

approaches have failed. These approaches are

that

recommended only for individuals with B M I s

Brownell, 2 0 0 1 ) . T o this end, consideration o f

greater than or equal to 4 0 or for individuals

a patient's body image both at the beginning

with B M I s greater than or equal to 3 5 plus

and over the course of treatment is an impor-

comorbid medical conditions (NIH/NHLBI,

tant consideration. There are at least two ways

confront

obese individuals

(Puhl

&

1 9 9 8 ) . Current surgical approaches include

in which body image issues might be built into

so-called "gastric restriction" (vertical gastric

treatment programs: (a) body image as an out-

banding) and "gastric bypass" (Roux-en Y ) ,

come measure index to be targeted in addition

which can achieve sizable weight loss and

to other traditional health risk factors and

improvements in comorbidities. T h e most

(b) body image and size acceptance as a poten-

striking data documenting these effects come

tial mediator o f weight change.

from the Swedish Obesity Study, initiated in 1 9 8 7 , that has prospectively followed 1,000 obese patients who underwent surgical treatment compared with 1,000 obese patients who received conventional nonsurgical

interven-

tion. A decade after the treatment was initiated, long-term results provided compelling data

favoring surgical treatment. Surgical

patients lost an average o f 2 8 kilograms (or approximately 6 1 pounds)

compared

with

0.5 kilograms (or approximately 1 pound) lost by nonsurgical controls. Compared with the control group, surgical patients had a 32-fold reduction in 2-year diabetes incidence and a 5-fold reduction at 8-year follow-up (Torgerson &c Sjostrom, 2 0 0 1 ) . Surgical patients were also more likely to show reduced time on sick leave and disability pension (Narbro et al., 1 9 9 9 ) .

Body

Image

as a Treatment

Outcome.

Assessing body image changes is justified based on the frequency with which obese individuals report dissatisfaction with their bodies. A detailed list o f validated body image measures for obese individuals is available elsewhere (Thompson et al., 1 9 9 9 ) . Results from behavioral interventions indicate that body image is significantly enhanced when

patients

lose

weight (Foster, Wadden, & Vogt, 1 9 9 7 ; Sarwer, Wadden, & Foster, 1 9 9 8 ) . Hence, clinicians can anticipate improvement in body image as an additional benefit of weight loss. Given the challenges o f achieving weight loss, other investigators have attempted to develop cognitivebehavioral interventions that target psychological well-being and body image without neces-

At the same time, surgery-related complica-

sarily inducing weight loss. M a n y of these

tions can be c o m m o n and should be moni-

treatments stem from the so-called "anti-diet"

tored. Side effects noted in one surgical study

framework. Examples include Ciliska's (1990)

(Pories et al., 1 9 9 5 ) included Vitamin Β defi-

program, which attempted to help patients

ciency ( 3 9 . 9 % of patients), depression ( 2 3 . 7 %

"reestablish normal eating, improve self-esteem,

of patients), gastritis ( 1 3 . 2 % of patients), and

and learn to deal with negative messages about

dehydration/malnutrition ( 5 . 8 % o f patients).

our body shape in order to be more accepting of ourselves" (p. 4 9 ) , and Polivy and Herman's (1992) "Undieting" program.

Targeting Body Image in Obesity Treatment

In one o f the most comprehensive programs to date, Rosen and colleagues (Rosen, 1 9 9 6 ;

Body image disparagement, or dissatisfac-

Rosen, Orosan, & Reiter, 1 9 9 5 ) developed a

tion with one's body, is one o f the more com-

treatment that targeted negative body image

mon psychological hardships o f obesity (Faith

among

& Allison, 1 9 9 6 ; Friedman & Brownell, 1 9 9 5 ) .

assigned to either a no-treatment control group

This is readily understandable

or a cognitive-behavioral intervention

given

the

obese

women.

Individuals

were that

137

138

I

BEHAVIORS THAT C O M P R O M I S E HEALTH

Table 8.7

Sample Questions to Probe Patient Weight Loss Expectations

1. What is your target weight loss goal? Why? 2. What would you consider to be an acceptable weight loss goal? Why? 3. What would you consider to be a disappointing but somewhat acceptable weight loss goal? Why? 4. What would you consider to be your dream weight loss goal? Why? 5. How would you feel about a weight loss of [10%]? Why? S O U R C E : These questions were modeled after Foster, Wadden, Vogt, and Brewer (1997).

included exploration of the social consequences

55-pound) weight loss was considered to be an

of obesity, factors that cause and maintain

acceptable but not particularly happy weight

negative body image, stress management sur-

loss, and a 17-kilogram (or approximately

rounding

37.5-pound) weight loss was considered to be a

physical

appearance,

cognitive of

disappointment. At the end of treatment, none

physical appearance, and body image exposure

of the patients had achieved his or her "dream"

restructuring

surrounding

assumptions

in stressful social situations. Results indicated

weight, 9 % had attained a "happy weight,"

that the treatment group showed significant

2 0 % had attained a "disappointing" weight,

improvements on most psychological and body

2 4 % had attained an "acceptable" weight, and

image measures as compared with the control

4 7 % had lost less weight than what they

group. Details of this treatment protocol are

defined as a disappointing weight. T o put these

provided elsewhere (Rosen et al., 1 9 9 5 ) ; how-

numbers into context, behavioral interventions

ever, these data indicate that body image

currently strive to induce weight loss of approx-

enhancement can be a viable treatment goal for

imately 8 % to 1 0 % . Although a 1 0 % weight

certain obese patients.

reduction is less than what patients might desire, it can confer important health benefits

Body

Image

and Size Acceptance

as

Possi-

(NIH/NHLBI, 1 9 9 8 ) .

Studies

Based on these data, Foster, Wadden, Vogt,

by Foster and colleagues revealed that many

and Brewer ( 1 9 9 7 ) concluded, "It seems more

ble

Mediators

of

Weight

Loss.

obese patients hold vastly unrealistic expecta-

appropriate to help patients accept

tions about the amount of weight loss they

est weight

can achieve through current

loss outcomes

more

mod-

rather than attempt

intervention

to devise treatments to increase weight loss"

approaches (Foster, Wadden, Phelan, Sarwer,

(p. 8 5 , emphasis in original). Indeed, Cooper

& Sanderson, 2 0 0 1 ; Foster, Wadden, Vogt, &

and Fairburn ( 2 0 0 1 ) called for novel behav-

enrolling

ioral treatments that assess patients' baseline

in a university-based weight loss program were

treatment expectations and that use cognitive

asked to define the amounts of weight loss they

strategies to promote more realistic treatment

defined as a goal or target weight loss, accept-

goals. T h e underlying hypothesis is that help-

Brewer, 1 9 9 7 ) . Obese individuals

able but not particularly happy weight loss, and

ing patients to adopt more realistic treatment

disappointing weight loss. Results indicated

expectations will ultimately promote better

that most patients brought unrealistic weight

treatment outcomes given that

loss goals to treatment. (See Table 8.7) Patients

associated with modest weight loss will be

defined a 3 2 % reduction in weight as their

reduced. This hypothesis awaits empirical

target goal. A 25-kilogram (or approximately

evaluation.

frustrations

Obesity and Body Image

Disturbance

CASE S T U D Y T h e case o f "Virginia M . " is a useful one that illustrates the many facets o f human obesity and reminds us that obese individuals are no different from nonobese individuals in many respects. Obese individuals lead complicated and busy lives, and they desire professional success and achievement as well as gratifying interpersonal relationships. Obese individuals have a genetic constitution, however, that makes weight gain easier when they engage in behaviors that favor excess energy intake (overeating high-fat foods) and reduced energy expenditure (being sedentary). Virginia's background

fits this description reasonably well. A 37-year-old

divorced attorney, Virginia is a professionally active w o m a n w h o "lives on the run" and perceives there to be limited time to lead a healthier life. Weighing 2 0 0 pounds (or approximately 9 1 kilograms) and measuring 5 feet 5 inches in height, her B M I is 3 3 . 3 , putting her in the Obesity-I category. Virginia has a waist circumference o f 9 2 centimeters, putting her at elevated risk for obesity-related complications (according to the guidelines reviewed herein). Obesity runs on the maternal side o f her family but not on the paternal side. Although Virginia says that she feels fine, a recent medical examination suggested slightly elevated total and L D L ( " b a d " ) cholesterol and blood pressure. Based on the treatment algorithm reviewed herein, Virginia would benefit from weight loss. W h e n Virginia was asked what her "ideal" weight would be, she indicated 1 8 5 pounds. Such a 15-pound weight loss (from 2 0 0 to 1 8 5 pounds) would represent an 8 % weight reduction, which is reasonable given current behavioral interventions. Fortunately, her expectations do not appear to be unrealistically high, and this can be used clinically to enhance her motivation to m a k e changes. If Virginia had defined her ideal weight to be 1 6 0 pounds, it might have been necessary to explore more attainable goals before beginning treatment. Virginia sought behavioral therapy, and a treatment program was developed that targeted healthier eating, increased physical activity, and reduced j o b stress. O n e o f the most critical themes in her treatment was that o f building structure into her life. Structure was operationalized as planning and preparing appropriate meals ahead o f time (something Virginia avoided previously), planning ways in which to increase lifestyle physical activity that would be compatible with her active professional goals, and joining and working out in a gym. T o modify her diet, Virginia began keeping a food record and self-monitored her dietary intake several days each week. Keeping this record revealed important patterns (e.g., snacking on highfat foods during afternoons when she skipped lunch, eating fast foods when she was feeling lonely during the evenings). Based on these insights, she began to structure lunches more regularly, even when she was busy. She also began to find substitute activities during the evening to replace snacking (e.g., movies, walks, social events for singles). In terms o f physical activity, she began 3 0 minutes o f fast-pace walking 3 days per week, and this was gradually increased to 5 days per week

139

240

BEHAVIORS T H A T C O M P R O M I S E HEALTH

before she joined a gym. She also began lessons in relaxation training and began reading books on time management to better balance her daily activities. T o date, Virginia has lost nearly 1 0 pounds and continues toward her goal. She recognizes that "treatment" will require lifelong lifestyle modification. Given that Virginia's j o b is central t o her self-image, she will continue to w o r k hard; however, she recognizes the potential health complications o f her weight and will be especially attentive to cardiovascular disease and type 2 diabetes symptoms. These serious medical conditions cannot be discarded. At the same time, Virginia better prioritizes personal happiness and relationships. She is increasingly recognizing that beauty, like body weight, can c o m e in different sizes.

Collectively, these data speak to the utility

daily caloric intake. O n a broader environ-

about

mental level, changes appear to be occurring

weight loss goals. Health care professionals

that put the entire population at increased

should be candid about the types o f weight

risk for obesity. Indeed, the population preva-

loss that patients can expect, given the cur-

lence o f obesity has increased dramatically

rent data, and may wish to address weight

during the past several decades.

of

assessing patients'

expectations

loss goals that seem unattainable. At the

T h e diagnosis and treatment o f obesity

same time, clinicians should be sensitive t o

starts at the simplest level with assessment

patients' motivations and should collabora-

of B M I , although this is hardly the place to

tively establish attainable weight loss goals

stop. Because obesity is associated with many

that will foster a sense o f mastery and self-

health complications, it is important that these

efficacy. T a b l e 8.7 illustrates questions that

be assessed especially among the heaviest indi-

clinicians may wish to ask as part o f an

viduals. High blood pressure, elevated total

assessment o f weight loss expectation.

and L D L cholesterol, and type 2 diabetes are just a few o f the health complications that must be considered. Psychosocial factors, such as poor self-esteem and poor body image, also

CONCLUSIONS

deserve consideration. Because body image Obesity is one o f the most pressing public

and obesity are so strongly intertwined, it is

health disorders confronting Western soci-

important that the overall life satisfaction of

eties. It is a multifaceted problem in terms o f

obese individuals be assessed.

its causes and consequences. Obesity is deter-

Behavioral treatments that target lifestyle

mined by genetic and environmental factors

changes compatible with everyday life, promote

that are poorly understood. It seems appar-

healthier food choices and reduced fat intake,

ent that one's genetic background will affect

and increase physical activity most days of the

weight gain in response t o eating. Certain

week are generally the first intervention strategy.

resist

Pharmacological agents can be used to assist

weight gain, whereas others readily put on

with weight loss, although potential side effects

weight in response to modest elevations in

need to be considered carefully. Each of the two

individuals

inherit a propensity t o

Obesity

and Body Image Disturbance

\

current FDA-approved drugs, sibutramine and

The high recidivism rate for obesity treatment

orlistat, has its own side effects that render it

indicates that many obese individuals will

prohibitive for many obese adults. Surgical

not achieve their desired weight loss. This

treatments have encouraging outcome results

underscores the importance o f helping obese

for severe obesity. For those morbidly obese

individuals to achieve personal satisfaction,

individuals who have obesity-related com-

self-respect, and healthy interpersonal rela-

plications and cannot lose weight through other

tionships through the highs and lows o f

prescribed methods, surgery may be a consider-

weight management.

ation when evaluated judiciously.

REFERENCES Allison, D. B., Fontaine, K. R., Manson, J . E., Stevens, J . , &C Vanltallie, T. B. (1999). Annual deaths attributable to obesity in the United States. Journal of the American Medical Association, 282, 1 5 3 0 - 1 5 3 8 . American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Andersen, R. E., Wadden, Τ. Α., Bartlett, S. J . , Zemel, B . , Verde, T. J . , &c Franckowiak, S. C. (1999). Effects of lifestyle activity vs. structured aerobic exercise in obese women: A randomized trial. Journal of the American Medical Association, 281, 3 3 5 - 3 4 0 . Berkowitz, R. I., &t Stunkard, A. J . (2002). Development of childhood obesity. In T. A. Wadden &C A. J . Stunkard (Eds.), Handbook of obesity treatment (pp. 5 1 5 - 5 3 1 ) . New York: Guilford. Berube-Parent, S., Prudhomme, D., St-Pierre, S., Doucet, E., & Tremblay, A. (2001). Obesity treatment with a progressive clinical tri-therapy combining sibutramine and a supervised diet-exercise intervention. International Journal of Obesity & Related Metabolic Disorders, 25, 1 1 4 4 - 1 1 5 3 . Bouchard, C , Rankinen, T., Chagnon, Y . C , Rice, T., Perusse, L., Gagnon, J . , Borecki, I., An, P., Leon, A. S., Skinner, J . S., Wilmore, H. H., Province, M., & Rao, D. C. (2000). Genomic scan for maximal oxygen uptake and its response to training in the HERITAGE Family Study. Journal of Applied Physiology, 88, 551-559. Bray, G. Α., Ryan, D. H., Gordon, D., Heidingsfelder, S., Cerise, F., & Wilson, K. (1996). A double-blind randomized placebo-controlled trial of sibutramine. Obesity Research, 4, 2 6 3 - 2 7 0 . Bulik, C. M., Sullivan, P. F., 8t Kendler, K. S. (2002). Medical and psychiatric morbidity in obese women with and without binge eating. International Journal of Eating Disorders, 32, 7 2 - 7 8 . Carpenter, K. M., Hasin, D. S., Allison, D. B., & Faith, M. S. (2000). Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: Results from a general population study. American Journal of Public Health, 90, 2 5 1 - 2 5 7 . Centers for Disease Control and Prevention. (2002). Surgeon general's report on obesity. Atlanta, GA: Author. Retrieved on January 2 0 , 2 0 0 3 , from www.cdc.gov Ciliska, D. (1990). Beyond dieting: Psychological interventions for chronically obese women—A non-dieting approach. New York: Brunner/Mazel. Comuzzie, A. G., & Allison, D. B. (1998). The search for human obesity genes. Science, 280, 1 3 7 4 - 1 3 7 7 .

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Haddock, C. K., Poston, W. S., Dill, P. L., Foreyt, J . P., 8c Ericsson, M. (2002). Pharmacotherapy for obesity: A quantitative analysis of four decades of published randomized clinical trials. International Journal of Obesity, 26, 2 6 2 - 2 7 3 . Heymsfield, S. B . , Segal, K. R., Hauptman, J . , Lucas, C. P., Boldrin, M . N., Rissanen, Α., Wilding, J . P., 8c Sjôstrôm, L. (2000). Effects of weight loss with orlistat on glucose tolerance and progression to Type 2 diabetes in obese adults. Archives of Internal Medicine, 160, 1 3 2 1 - 1 3 2 6 . Hill, J . O., & Peters, J . C. (1998). Environmental contributions to the obesity epidemic. Science, 280, 1 3 7 1 - 1 3 7 4 . Horgen, Κ. B . , 8c Brownell, K. D. (2002). Confronting the toxic environment: Environmental public health actions in a world crisis. In T. A. Wadden 8c A. J . Stunkard (Eds.), Handbook of obesity treatment (pp. 9 5 - 1 0 6 ) . New York: Guilford. Johnson, W. G., Se Torgrud, L. J . (1996). Assessment and treatment of binge eating disorder. In J . K. Thompson (Ed.), Body image, eating disorders, and obesity: An integrative guide for assessment and treatment (pp. 3 2 1 - 3 4 3 ) . Washington, DC: American Psychological Association. Keller, K. L., Pietrobelli, Α., Must, S., Sc Faith, M . S. (2002). Genetics of eating and its relation to obesity. Current Atherosclerosis Reports, 4, 1 7 6 - 1 8 2 . Kirschenbaum, D. S. (1994). Weight loss through persistence. Oakland, CA: New Harbinger. Kuller, L. H., Simkin-Silverman, L. R., Wing, R. R., Meilahn, E., Sc Ives, D. G. (2001). Women's Healthy Lifestyle Project: A randomized clinical trial— Results at 5 4 months. Circulation, 103, 3 2 - 3 7 . Mokdad, A. H., Bowman, Β . Α., 8c Ford, E. S. (2001). The continuing of obesity and diabetes in the United States. Journal of the American Medical Association, 286, 1 1 9 5 - 1 2 0 0 . Mokdad, A. H., Bowman, Β. Α., Ford, E. S., Vinicor, F., Marks, J . S., 8c Koplan, J . P. (2001). Journal of the American Medical Association, 286, 1 1 9 5 - 1 2 0 0 . Mokdad, A. H., Serdula, M., 8c Dietz, W. (1999). The spread of the obesity epidemic in the United States. Journal of the American Medical Association, 282, 1519-1522. Mokdad, A. H., Serdula, M., Sc Dietz, W. (2000). The continuing obesity epidemic in the United States. Journal of the American Medical Association, 284, 1650-1651. Narbro, K., Agren, G., Jonsson, E., Larsson, B . , Naslund, I., Wedel, H., 8c Sjôstrôm, L. (1999). Sick leave and disability pension before and after treatment for obesity: A report from the Swedish Obese Subjects (SOS) study. International Journal of Obesity & Related Metabolic Disorders, 23, 6 1 9 - 6 2 4 . National Institutes of Health/National Heart, Lung, and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, M D : Author. Retrieved on January 2 0 , 2 0 0 3 , from www.nhlbi.nih.gov/ guidelines/obesity/practgde.htm Pingitore, R., Dugoni, B . L., Tindale, R. S., 8c Spring, B . (1994). Bias against overweight job applicants in a simulated employment interview. Journal of Applied Psychology, 79, 9 0 9 - 9 1 7 . Pi-Sunyer, F. X . (1993). Medical hazards of obesity. Annals of Internal Medicine, 119, 655-660. Polivy, P., 8c Herman, C. P. (1992). Undieting: A program to help people stop dieting. International Journal of Eating Disorders, 11, 2 6 1 - 2 6 8 . Pories, W. J . , Swanson, M . S., MacDonald, K. G., Long, S. B . , Morris, P. G., Brown, Β. M., Barakat, Η. Α., deRamon, R. Α., Israel, G., 8c Dolezal, J . M. (1995). Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Annals of Surgery, 222, 3 3 9 - 3 5 0 .

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BEHAVIORS THAT C O M P R O M I S E HEALTH Price, R. A. (2002). Genetics and common obesities: Background, current status, strategies, and future prospects. In T. A. Wadden & A. J . Stunkard (Eds.), Handbook of obesity treatment (pp. 7 3 - 9 4 ) . New York: Guilford. Price, R. Α., Charles, Μ. Α., Pettitt, D. J . , & Knowler, W. C. (1993). Obesity in Pima Indians: Large increases among post-World War II birth cohorts. American Journal of Physiological Anthropology, 92, 4 7 3 - 4 7 9 . Puhl, R., & Brownell, K. D. (2001). Bias, discrimination, and obesity. Obesity Research, 9, 7 8 8 - 8 0 5 . Rankinen, T., Perusse, L., Weisnagel, S. J . , Snyder, E. E., Chagnon, Y . C , & Bouchard, C. (2002). The human obesity gene map: The 2 0 0 1 update. Obesity Research, 10, 1 9 6 - 2 4 9 . Roehling, M . V. (1999). Weight-based discrimination in employment: Psychological and legal aspects. Personnel Psychology, 52, 9 6 9 - 1 0 1 6 . Rosen, J . C. (1996). Improving body image in obesity. In J . K. Thompson (Ed.), Body image, eating disorders, and obesity: An integrative guide for assessment and treatmenr (pp. 4 2 5 - 4 4 0 ) . Washington, DC: American Psychological Association. Rosen, J . C , Orosan, P., &c Reiter, J . (1995). Cognitive behavior therapy for negative body image in obese women. Behavior Therapy, 26, 2 5 - 4 2 . Rossner, S., Sjôstrôm, L., Noack, R., Meinders, A. E., & Noseda, G. (2000). Weight loss, weight maintenance, and improved cardiovascular risk factors after 2 years treatment with orlistat for obesity: European Orlistat Obesity Study Group. Obesity Research, 8, 4 9 - 6 1 . Sarwer, D. B., Wadden, T. Α., &C Foster, G. D. (1998). Assessment of body image dissatisfaction in obese women: Specificity, severity, and clinical significance. Journal of Consulting and Clinical Psychology, 66, 6 5 1 - 6 5 4 . Stuart, R. B . (1967). Behavioral control of overeating. Behaviour Research and Therapy, 5, 3 5 7 - 3 6 5 . Stunkard, A. J . (2002). Binge-eating disorder and night-eating syndrome. In T. A. of obesity treatment Wadden & A. J . Stunkard (Eds.), Handbook (pp. 1 0 7 - 1 2 1 ) . New York: Guilford. Stunkard, A. J . , Berkowitz, R. L, Stallings, V. Α., &c Schoeller, D. A. (1999). Energy intake, not energy output, is a determinant of body size in infants. American Journal of Clinical Nutrition, 69, 5 2 4 - 5 3 0 . Tataranni, P. Α., & Ravussin, E. (2002). Energy metabolism and obesity. In T. A. Wadden & A. J . Stunkard (Eds.), Handbook of obesity treatment (pp. 4 2 - 7 2 ) . New York: Guilford. Thompson, J . K., Coovert, M., Richards, K. J . , Johnson, S., & Cattarin, J . (1995). Development of body image, eating disturbance, and general psychological functioning in female adolescents: Covariance structure modeling and longitudinal investigations. International Journal of Eating Disorders, 18, 2 2 1 - 2 3 6 . Thompson, J . K., Heinberg, L. J . , Altabe, M . N., &c Tantleff-Dunn, S. (1999). Exacting beauty: Theory, assessment, and treatment of body image disturbance. Washington, DC: American Psychological Association. Thompson, J . K., & Smolak, L. (2001). Body image, eating disorders, and obesity treatment, and prevention. Washington, DC: American in youth: Assessment, Psychological Association. Torgerson, J . S., &t Sjôstrôm, L. (2001). The Swedish Obese Subjects (SOS) Study: Metabolic Rationale and results. International Journal of Obesity & Related Disorders, 25, S2-S4. Vanltallie, T. B. (1994). Worldwide epidemiology of obesity. Pharmacoeconomics, 5, 1. Wadden, Τ. Α., & Foster, G. D. (2000). Behavioral treatment of obesity. Medical Clinics of North America, 84, 4 4 1 - 4 4 6 .

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145

CHAPTER

Physical Inactivity as a Risk Factor for Chronic

9

Disease

KRISTA A . BARBOUR, TIMOTHY T . HOULE, AND PATRICIA M . DUBBERT

T

he health benefits of physical activity

activity for good health. T h e report included

have been demonstrated repeatedly over

recommendations for the intensity, duration,

the past several decades, and engaging in

and frequency o f physical activity sufficient for in the

regular physical activity has been recommended

meeting the goal o f disease prevention

as one effective way in which to decrease

general population. A primary conclusion of

both morbidity and mortality (U.S. Department

the report was that a moderate level of activity

of Health and Human Services, 1996). Unfor-

(e.g., 3 0 minutes of walking on most days o f

tunately, current guidelines for leisure time

the week) is an appropriate goal for most

physical activity are not met by the majority of

Americans in terms o f realizing health benefits.

individuals in the United States. Indeed, a signifi-

However, the report also emphasized

cant percentage of the population is considered

6 0 % o f American adults are not physically

that

sedentary or ^sufficiently active (Centers for

active on a regular basis and that 2 5 % are

Disease Control and Prevention [CDC], 2 0 0 1 ) .

sedentary (e.g., report no leisure time physical

Because of its status as a primary risk factor in

activity). A recent, population-based telephone

physical

survey o f American adults found that rates o f

must be addressed in any effort to

physical activity remained stable during the

the development of chronic disease, inactivity

reduce rates of illness and early mortality.

years of 1 9 9 0 to 1 9 9 8 ( C D C , 2 0 0 1 ) , a finding that was disappointing and somewhat surprising given the increased emphasis on public

DEFINITIONS AND DESCRIPTIONS OF PHYSICAL ACTIVITY AND INACTIVITY

health initiatives to increase physical activity rates in the United States. Perhaps even more discouraging are the results o f studies focusing on demographic

In 1 9 9 6 , the U.S. surgeon general issued a

differences

report outlining the importance o f physical

physical activity. These findings indicate that

in the prevalence o f

regular

Physical Inactivity

|

the percentage o f active adults is considerably

becoming active if one is sedentary or by

smaller among ethnic minorities (particularly

increasing one's activity level. For most of the

Hispanic Americans) relative to Caucasians. In

remainder of the chapter, the focus will shift

addition, women are generally less physically

from physical activity as a primary prevention

active than men, and physical activity decreases

strategy to physical activity as it relates to

with age. Other predictors o f an inactive

specific chronic diseases.

lifestyle include lower income, lesser educa-

T o discuss the role that physical activity

tional attainment, and living in the southern or

plays in chronic disease, it is useful to first

midwestern

address the issue o f assessment

United States (Schoenborn

&

Barnes, 2 0 0 2 ) .

o f physical

activity. This includes the methods

com-

According to an American College o f Sports

monly used to measure activity as well as

Medicine ( 1 9 9 8 ) position stand, healthy adults

recent trends in assessment (for a review o f

should engage in 2 0 to 6 0 minutes (which may

the major developments in physical activity

be continuous or accumulated in several shorter

research during the past decade, see Dubbert,

bouts) of aerobic activity 3 to 5 days per week

2 0 0 2 ) . T h e following section addresses the

to improve cardiorespiratory fitness. For most

numerous ways in which physical activity

people, a moderate intensity level o f physical

has been conceptualized by researchers.

activity is recommended to decrease the likelihood of exercise-induced injury. In addition to aerobic exercise, individuals are encouraged to incorporate both resistance (e.g., set o f exercises that are designed to condition major muscle

OVERVIEW OF RESEARCH IN THE ASSESSMENT OF PHYSICAL ACTIVITY

groups two or three times per week) and flexibility (e.g., stretch major muscle groups two or

T h e measurement

three times per week) training into their exercise

received increasing attention during the past several decades. T h e task o f

programs. However, as already noted, most American adults do not meet this level o f physical activity. Given this unfortunate

fact, it is important

to consider the potential negative consequences of physical inactivity.

o f physical activity has

For example, a lack of

physical activity has been clearly linked to an increased risk of all-cause mortality (see, e.g., Blair et al., 1 9 8 9 ; Wei et al., 1 9 9 9 ) . In addition, a sedentary lifestyle has been shown to predict the nation's number one cause of death: cardiovascular disease (CVD) (Farrell et al., 1 9 9 8 ) . Indeed, a large percentage of the population is

quantifying

physical activity across various populations, settings, and purposes

has proved

to

be

particularly daunting. In the subsections that follow, the methods that have been used to measure physical activity in both the laboratory and community settings are summarized, with special emphasis on each method's particular strengths and weaknesses. T h e issues involved with the assessment o f physical activity in specialized populations and settings are also discussed along with future directions o f physical activity assessment.

at increased risk of disease morbidity and mortality because of insufficient physical activity. The surgeon general's report and the body of scientific knowledge it represents suggest that many individuals will acquire illnesses that can

Physical Activity: What to Measure? Physical activity has been characterized as

be prevented by physical activity. In addition, it

"any bodily movement resulting in energy

is possible that the progression of many diseases

expenditure above resting levels" (Freedson &

and conditions can be slowed or halted by

Miller, 2 0 0 0 , p. 2 1 ; see also Caspersen, 1 9 8 9 ) .

147

148

BEHAVIORS T H A T C O M P R O M I S E HEALTH This definition logically leads to the goal o f

cost. In a recent review of self-report measures

quantifying energy expenditure as the target o f

used during the 1 9 9 0 s ,

Sallis and Saelens

measurement. Indeed, the methods described

(2000) found that, in general, adult self-report

in this section are often compared with simul-

measures were more valid for reports o f

taneous measures of energy expenditure as

vigorous activity than for reports of moderate

indexes o f validity. However, physical activity

intensity activity. In addition, they found that

is more accurately conceptualized as multidi-

interview measures had stronger psychometric

mensional in nature, with frequency, intensity,

properties than did self-administered measures

duration, and circumstance as relevant vari-

and that self-report measures did not provide

ables (Bassett, 2 0 0 0 ) . This is intuitively the

accurate estimates o f absolute amounts o f

case given that two very different activities,

physical activity; in fact, most self-report mea-

such as swimming and walking, may have the

sures

same net energy expenditure for a given time;

physical activity. In general, simple self-report

even if one is o f greater intensity, the other can

measures, although known to be less than per-

be engaged in for longer duration or greater

fectly accurate, remain extremely valuable in

frequency. Given

overestimated

absolute

amounts o f

many public health surveys and particularly in the

multidimensional

nature o f

clinical applications.

physical activity, no single assessment method provides valid and reliable measurement over

Pedometer.

A pedometer measures vertical

the possible range o f populations, settings, and

acceleration using a spring-loaded lever arm

uses (Wood, 2 0 0 0 ) . These limitations are made

that records motion either mechanically or

more complex when combined with the current

by closing an electrical circuit. Sophisticated

limitations of technology and logistical con-

pedometers have a digital output that can rep-

cerns, which preclude the use o f certain

resent activity either in number of steps or in

methods when assessing certain activities.

mileage estimates. Electronic pedometers are

Thus, when selecting a method for the assess-

extremely portable and are available for less

ment o f physical activity, a researcher must

than $ 2 0 (for a list and review, see Freedson &

clearly define the purpose of measurement and

Miller, 2 0 0 0 ) . Recent studies have shown that

the application for which it is to be used.

pedometers are fairly accurate at counting steps

Methods for Assessing Physical Activity

running (Bassett, 2 0 0 0 ) . Furthermore, pedome-

but cannot distinguish between walking and

Self-Report.

ters have little data storage capabilities and do not allow for the recording o f specific activity

Self-report instruments are the

patterns throughout the day. Despite these lim-

most widely used instruments in the assessment

itations, pedometers are widely used as a low-

of physical activity (Sallis & Saelens, 2 0 0 0 ) .

cost method o f collecting objective physical

These instruments include measures such as

activity data and in interventions that target

activity logs, self-administered questionnaires,

increased walking- and running-type activities.

interview-administered

questionnaires,

and

proxy reports (for detailed lists and reviews, see

Accelerometer.

Accelerometers measure

Kriska & Caspersen, 1 9 9 7 ; Montoye, Kemper,

acceleration in either the vertical (uniaxial) or

Saris, &

three-dimensional (triaxial) plane. T h e funda-

Washburn,

1 9 9 6 ; Sallis, 1 9 9 1 ;

Sallis & Saelens, 2 0 0 0 ) . M a n y o f these mea-

mental assumption behind an accelerometer is

sures have adequate reliability and validity and

that acceleration is directly proportional to

also provide assessment o f multiple activity

muscle forces; the greater the acceleration o f

modalities over a range o f situations at a low

the limb, torso, or the like, the more energy

Physical

Inactivity

|

expended by the organism. Accelerometers are

physical activity. However, recent attention has

extremely portable but can be quite expensive,

been given to the special assessment problems

with triaxial accelerometers costing more than

presented by certain subgroups and especially

$ 5 0 0 (for a list and review, see Freedson &

lifestyle-related activities. For example, the

Miller, 2 0 0 0 ) .

Accelerometers have

large

assessment of physical activity in older adults

capacities for data storage and are able to

using self-report instruments is made more

record the amount and intensity o f activity as

complicated by the fact that this group tends

well as the specific activity patterns over days

to engage in primarily light- and moderate-

or weeks. Although too expensive for many

intensity

clinical applications, accelerometers might be

Washburn, 2 0 0 0 ) . There is as yet a paucity

activity

(Bernstein e t a l . , 1 9 9 8 ;

of value in specialized programs such as for

of age-specific questionnaires to assess this

treatment o f chronic pain and cardiopulmo-

population (Washburn, 2 0 0 0 ) . T h e combina-

nary rehabilitation.

tion o f the types o f activities engaged in by older adults, the measures used to assess them, Heart rate monitors

and the potential unreliability o f recall for these

generally consist o f a chest strap transmitter

types of activities supports the need for more

and

refined assessment tools for older adults.

Heart a

Rate

Monitor.

wristwatch

receiver

for

storage.

Monitors vary in quality but can be purchased

Traditional assessment o f physical activity

for between $ 2 0 0 and $ 5 0 0 (for a list and

has focused on participation in structured,

review, see Freedson & Miller, 2 0 0 0 ) . Under

time-limited bouts o f activity (i.e., "exercise").

normal conditions, heart rate is linearly related

For example, researchers may measure the

to energy expenditure, but many sources o f

number o f miles walked on the treadmill or

error can elevate heart rate even at rest and

the number o f minutes spent on a stationary

can obscure the relationship between energy

bicycle. M o r e recently, however, the definition

expenditure and heart rate (Freedson & Miller,

o f what should constitute physical activity has

2 0 0 0 ) . G o o d heart rate monitors have storage

been broadened. O n e such change has been

capacity to record heart rate over extended

to challenge the notion that physical activity

periods of time and allow for patterns of activ-

must occur in one episode o f long duration

ity over time. These monitors might not be

(i.e., 2 0 to 3 0 minutes) to be beneficial. It is

practical for many clinical applications but

n o w generally agreed that the accumulation o f

could be valuable for cardiac patients.

activity throughout one's day may be sufficient to realize improved health. Such activiand

ties may include walking the stairs instead o f

weaknesses o f each type o f field measure

riding the elevator and walking short distances

described in this section. Recently, researchers

instead o f driving a car.

Table 9.1 highlights the strengths

aware of the limitations o f any single type o f

In addition to the more inclusive definition

assessment modality have focused on combin-

of physical activity, other difficulties remain in

ing the methods to sample more of the quali-

measurement.

ties of physical activity. T h e use o f multiple

activity is often neglected in surveys o f physical

For example,

occupational

modalities and complex calibration techniques

activity. Because most occupations today are

can increase measurement accuracy, and they

primarily sedentary, most physical activity

are often recommended for the assessment o f

questionnaires inquire about leisure time activ-

physical activity. The complex and multidimensional nature

ity only. This is problematic because those individuals most likely to be characterized as

o f various forms o f physical activity is sufficient

sedentary during leisure time are also more

to complicate the accurate assessment o f

likely to engage in job-related physical activity

149

150

BEHAVIORS THAT C O M P R O M I S E HEALTH Table 9.1

Field Methods for the Assessment of Physical Activity

Modality

Cost

Patterns of Activity?

Self-report

Low

Pedometer

Accelerometer Uniaxial

Triaxial Heart rate

Accuracy

Comments

Yes

Good for relative amounts

Many different options available

Low

No

Good for walking

Unable to distinguish instensity of physical activity

Medium

Yes

Measures both amount and intensity

Might not measure light activities in multiple planes

High

Yes

As above

Measures multiple planes of movement

Medium-High

Yes

Good

Multiple sources of measurement error

( C D C , 2 0 0 1 ) . Thus, it may be that some

Traditionally, individuals who had experi-

respondents who are classified as sedentary are

enced heart attacks were prescribed bed rest as

actually active, but only on the j o b . T h e failure

a significant part of their cardiac rehabilita-

of many studies to capture physical activity

tion. However, as the medical and psycholog-

obtained through employment is a weakness

ical benefits of being active were documented

that needs to be addressed in future research.

PHYSICAL ACTIVITY INTERVENTION IN C H R O N I C DISEASE

Cardiovascular Disease and Physical Activity Physical activity has clearly been shown to

for this population (for a review o f this evidence, see Dubbert, Rappaport, &

Martin,

1 9 8 7 ) , physical activity became a

primary

focus o f treatment for those with C V D . T h e recommended

intensity, duration, and

fre-

quency o f physical activity to be prescribed in cardiac rehabilitation programs are described in Leon ( 2 0 0 0 ) . In sum, sessions o f aerobic exercise should include both warm-up and cool-down periods and should be o f an inten-

reduce the risk o f cardiovascular morbidity

sity o f between 4 0 % and 8 5 % o f V 0

and mortality (e.g., Berlin & Colditz, 1 9 9 0 )

widely used measure of maximal oxygen con-

and, as a result, has been recommended in

sumption at a given workload). These sessions

2 m a x

(a

the primary prevention o f C V D . However,

should occur three times per week and last for

because most Americans do not acquire a

at least 2 0 to 6 0 minutes each session. W h e n

level o f physical activity that is sufficient to

health psychologists consider physical activity

decrease the risk o f C V D , research has focused

in C V D rehabilitation, they must keep in mind

prevention following cardiovas-

that participation in a physical activity pro-

cular events (e.g., chest pain, heart attack).

gram should be supervised by a medical expert

T h e purpose of secondary prevention is to

such as a physician or an exercise professional

prevent further cardiac events in individuals

(American Association o f Cardiovascular and

who already manifest some degree o f C V D .

Pulmonary

on secondary

Rehabilitation, 1 9 9 9 ; Dubbert

Physical et al., 1 9 8 7 ) . This is a necessity because

rehabilitation

although events are infrequent, patients with

Caucasian

research

men,

has

future

Inactivity focused

research

on

should

C V D are at increased risk for experiencing

address the effectiveness of physical activity in

cardiac events as a result o f participation in

ethnic minorities and women who have devel-

physical activity relative to their disease-free

oped C V D . (For a more complete discussion

counterparts.

of coronary heart disease, see Chapter 15.)

M a n y observational studies have demonstrated

a significant relationship

between

physical activity and cardiovascular mortality. In

a large-scale prospective

Hypertension and Physical Activity

investigation,

Hypertension, or elevated blood pressure

(2000)

(BP), affects approximately 5 0 million adults

Wannamethee, Shaper, and Walker

examined the association between physical

in the United States (Kaplan, 1 9 9 8 ) . Hyper-

activity and mortality in older men with C V D .

tension is a major health issue in the United

These men were followed up approximately 13

States, representing the most significant risk

years subsequent to a baseline assessment. M e n

factor for the development o f C V D , including

who participated in physical activity experi-

both

enced significant reductions in both all-cause

( M a c M a h o n et al., 1 9 9 0 ) . Current guidelines

coronary

heart

disease and

stroke

and cardiovascular mortality relative to seden-

(Joint National

tary individuals, importantly, several types o f

Evaluation, and Treatment o f High Blood

physical activity (e.g., gardening, walking) were

Pressure Q N C ] , 1 9 9 7 ) dictate that the optimal

shown to have a beneficial effect on mortality

level o f BP should be 1 2 0 / 8 0 m m Hg (milli-

Committee on Detection,

rates. In addition, those men who were seden-

meters of mercury) or lower. Values o f 1 4 0 / 9 0

tary at baseline but who later became active

or higher are considered to be high or in the

demonstrated significantly lower levels of mor-

hypertensive range.

tality than did those men who remained inactive throughout the follow-up period.

Given that m a n y hypertensive patients' BP

Randomized clinical trials of physical activ-

levels are n o t consistently controlled

with

antihypertensive

medication

(most

ity in the treatment o f C V D have generally

likely due to poor compliance with medica-

shown that physical activity is effective

tions

at

reducing cardiovascular mortality (for a review

[ M a n c i a , Sega, M i l e s i ,

C e s a n a , 8c

Zanchetti, 1 9 9 7 ] ) , decades o f research have

Guyatt,

been devoted to the investigation o f the non-

Fischer, & R i m m , 1 9 8 8 ) . In addition, physical

pharmacological treatment o f hypertension.

of

these

studies,

see

Oldridge,

activity interventions have resulted in increased

Examples

exercise endurance, decreased chest pain, and

include relaxation, biofeedback, and stress

o f widely

studied

treatments

reduced progression of atherosclerosis (Leon,

management (for a review o f these treat-

2 0 0 0 ) . Finally, as discussed elsewhere in this

ments, see Linden & Chambers, 1 9 9 4 ) .

chapter, physical activity also improves several

Physical activity has also been examined as a

conditions that are known risk factors for

treatment for hypertension. It has been recom-

C V D such as obesity and hypertension.

mended that for individuals classified as mildly

In conclusion, physical activity has been

hypertensive, initial treatment consisting o f

shown to be effective in the secondary preven-

"lifestyle changes," including physical activity,

tion o f C V D (i.e., reduction o f cardiac events).

should be implemented for the first 6 to 12

Regular physical activity should be recom-

months ( J N C , 1 9 9 7 ) . In this subsection, the

mended for all individuals with C V D who do

efficacy of physical activity for the treatment of

not have conditions that would limit or pro-

hypertension is explored. In general, the desired

hibit their participation. Because most cardiac

outcome of a physical activity intervention

152

BEHAVIORS T H A T C O M P R O M I S E HEALTH would be the decreased use of medications used

characteristics such as gender and ethnicity

to control BP or the elimination of the need for

(Lesniak & Dubbert, 2 0 0 1 ) . Regarding gender

antihypertensive medication altogether, along

differences in the effectiveness o f physical

with a possible improvement in other C V D risk

activity in treating hypertension, the data have

factors related to physical activity.

generally shown

no significant

differences

In a recent review o f 1 5 studies o f exercise

between women and men. Studies examining

training in hypertensive individuals, Hagberg,

the effectiveness o f physical activity in lowering

Park, and Brown ( 2 0 0 0 ) found that approxi-

BP in African Americans are

mately

experienced

important because o f the high prevalence of

significant decreases in B P . In addition, the

hypertension within this group. In addition,

hypotensive effect o f physical activity was

hypertension in African Americans is more

shown to occur quickly (within 1 to 1 0 weeks)

severe and less well controlled relative to other

and at low to moderate levels o f intensity.

ethnic groups. Unfortunately, the relationship

Interestingly, the reduction in BP levels was

between hypertension

not related to the amount o f weight lost

in African Americans has not been studied

7 5 % o f participants

particularly

and physical activity

adequately (Lesniak & Dubbert, 2 0 0 1 ) . Encour-

during the various training programs. In a meta-analysis o f 2 9 randomized clin-

agingly, the data that do exist suggest that

ical trials o f aerobic physical activity, it was

physical activity is an effective treatment for

demonstrated that participation in a training

hypertension

program averaging 1 9 weeks resulted in a 4 -

Kokkinos et a l , 1 9 9 5 ) .

point decrease in systolic BP and a 3-point

in African

Americans (e.g.,

In summary, physical activity has been

decrease in diastolic BP ( H a l b e r t et al.,

shown to be an effective treatment for hyper-

1 9 9 7 ) . Although this change in BP was signifi-

tension. However, it should also be noted that

cantly more than that achieved by partici-

the hypotensive effect o f physical activity has

pants in the control groups, it is lower than

been shown to be modest in several studies (for

that reported in other studies.

a review, see Blumenthal, Sherwood, Gullette,

Consistent

colleagues

(2000)

Georgiades, & Tweedy, 2 0 0 2 ) . Although the

review, however, the improvement

in B P

BP reduction achieved by physical activity may

levels occurred in the absence o f weight loss.

appear to be minimal, epidemiological data

with

the Hagberg

and

appears

indicate that small drops in BP are accompa-

to have a beneficial effect on reducing BP

nied by an impressive decrease in the risk of

in individuals with hypertension.

(However,

stroke and C V D . For example, a 5- to 6-point

not all studies have found significant effects

reduction in diastolic BP has been associated

[Blumenthal, Siegal, &

Appelbaum, 1 9 9 1 ;

with a 3 5 % to 4 0 % decrease in stroke and

Nami et al., 2000].) Although the majority o f

with a 2 0 % to 2 5 % decrease in heart disease

Thus, aerobic exercise training

training programs examined have aerobic exer-

(Collins e t a l . , 1 9 9 0 ) . (For a more complete

cise (e.g., walking, cycling), recent evidence sug-

discussion of hypertension, see Chapter 14.)

gests that nonaerobic

forms o f physical activity,

such as resistance training, may also be useful in the treatment of hypertension. A recent metaanalysis (Kelley &

Kelley, 2 0 0 0 )

showed a

small but statistically significant decrease in BP

Chronic Obstructive Pulmonary Disease and Physical Activity Chronic obstructive pulmonary

disease

following resistance training two to five times

(COPD) is a condition in which there is an

per week for an average o f 1 4 weeks.

impaired ability o f the lungs to take in sufficient

The ability of a physical activity program to

air. T h e primary symptoms of the disease con-

decrease BP may depend, in part, on individual

sist o f difficulty in breathing and a long-term

Physical cough. C O P D may result from a variety of lung

Inactivity

Physical activity has been shown to improve

disorders such as asthma and emphysema. A

the cognitive test performance

in C O P D

common corollary o f C O P D is exercise intoler-

patients. For example, Emery, Schein, Hauck,

ance. This often is a result of a vicious cycle in

and Maclntyre ( 1 9 9 8 ) found that, in addition

which the individual, on experiencing breathing

to improvement in exercise endurance, some

difficulties (dyspnea) while exercising, perceives

aspects o f cognitive functioning (e.g., verbal

the dyspnea as threatening and so avoids engag-

fluency) were improved in a sample o f c o m -

ing in physical activity. Eventually, decondi-

munity adults (over age 5 0 years) diagnosed

tioning occurs and leads to exercise intolerance.

with C O P D . In this study, the physical activity

In an effort to target the exercise intolérance

component consisted of 4 5 minutes o f aerobic

that often accompanies the disease, many

activity on 5 days per week for 5 weeks (fol-

treatment

for C O P D include a

lowed by a 5-week period o f lower intensity

physical activity component. T h e physical

activity on 3 days per week). As with the

activity offered is typically in the context of a

improvement

pulmonary

programs

exhibited in physical

health,

(which

these changes in cognitive functioning were

might also include topics such as health educa-

demonstrated after a relatively brief physical

tion and stress management). There is much

activity intervention.

evidence

rehabilitation program

activity

In sum, the evidence clearly supports the use

improves the exercise tolerance o f C O P D

showing

of physical activity in the treatment o f C O P D .

patients. In addition,

inclusion of a physical activity component in

demonstrated

that

after

(Laçasse et al., 1996).

physical

improvement can be 4

weeks

of

training

pulmonary rehabilitation programs has been

Specifically, physical

shown repeatedly to increase exercise endurance

activity decreases dyspnea, decreases leg fatigue,

and may result in fewer complications and

and enhances health-related quality o f life (for

hospitalizations related to the disease. In addi-

a review o f this literature, see Bourjeily&

tion, there is some evidence to suggest that

Rochester, 2 0 0 0 ) .

physical activity improves the cognitive func-

C O P D is a disease that is characterized by intermittent exacerbations (e.g., upper

tioning o f individuals with C O P D . Further

and

research is needed to determine the optimal

lower respiratory tract infections). In general,

dose o f physical activity necessary to produce

the available evidence suggests that participa-

sufficient

tion in a pulmonary rehabilitation program

health and cognitive performance.

improvements

in b o t h

physical

that includes a physical activity component is associated with a reduction in COPD-related exacerbations and hospitalizations

(Berry &

OBESITY AND PHYSICAL ACTIVITY

Walschlager, 1 9 9 8 ) . Unfortunately, it has been difficult to identify the specific components of

Obesity in the United States has achieved the

rehabilitation programs that may lead to this

status o f a public health crisis (for a recent

improvement in health. Further research is nec-

review

essary to determine whether or not physical

Foster, & Brownell, 2 0 0 2 ) . This is due to the

activity alone leads to better health outcomes.

fact that excess weight represents a major risk

of

the

problem,

see

Wadden,

In addition to the physical limitations experi-

factor for chronic disease development (e.g.,

enced by C O P D patients, impaired cognitive

hypertension, C V D , type 2 diabetes mellitus).

functioning is sometimes associated with the

M o s t clinicians are n o w encouraged to evalu-

disease (Prigatano, Parsons, Wright, Levin, &

ate weight status using the body mass index

Hawryluk, 1983) and may result from decreased

( B M I ) . B M I , the most commonly used mea-

blood oxygenation levels (Grant et al., 1 9 8 7 ) .

sure o f healthy versus unhealthy

weight,

154

BEHAVIORS T H A T C O M P R O M I S E HEALTH assesses body weight in relation to height and

minimal effect o f physical activity alone on

is defined as weight in kilograms divided by

body weight is the duration o f most exercise

height in meters squared. Current guidelines

programs. It may be that the 4 to 6 months

define "overweight" as B M I values in the

of training typical of physical activity studies

range o f 2 5 . 0 to 2 9 . 9 , with "obesity" consid-

is not sufficient for realizing the benefits o f

ered to be any value o f 3 0 . 0 or higher

physical activity (Wing, 1 9 9 9 ) . Findings from

(National Institutes o f Health, 1 9 9 8 ) . It has

longitudinal investigations of physical activity

been estimated that approximately 5 0 % o f

and weight have suggested that long-term

U.S. adults are overweight or obese (World

physical activity is effective in slowing and

Health Organization, 1 9 9 8 ) , and the preva-

minimizing subsequent weight gain (but might

lence appears to be rising (Bouchard, 2 0 0 0 ) .

not result in weight loss or even prevent

Body weight is determined by energy (food) intake and energy expenditure; however, this is

weight gain [Grundy et al., 1 9 9 9 ] ) . Thus, maintaining

participation in an exer-

a simplified definition o f an extremely complex

cise program is key to successful weight loss. In

set o f biological, behavioral, and environmen-

general, treatment programs for obesity (typi-

tal variables (the complexities of the issue

cally including physical activity accompanied

are addressed in Salbe 8c Ravussin, 2 0 0 0 ) . If

by dietary changes) induce an initially rapid

energy intake and expenditure are in balance,

weight loss followed by a steady reduction in

no significant weight loss or gain should occur.

the amount o f weight lost long term (Jeffery

However, a situation in which food intake is

etal., 2 0 0 0 ) . Perri and colleagues (2001) com-

consistently higher than energy expended will

pared a standard weight loss intervention (20

result in weight gain. T w o primary contribu-

weeks of educational sessions, dietary changes,

tors to the energy imbalance evident in the

and moderate-intensity physical activity) with

United States are a sedentary lifestyle and poor

extended

dietary habits. T h e focus of the remainder o f

occurred for 1 2 months following the comple-

this section is on the relationship between

tion of the standard intervention and included

obesity and the expenditure

the use o f exercise diaries. It was found that

of energy, that is,

physical activity (or exercise).

treatment.

Extended

participants assigned to extended

treatment

treatment

Observational studies have demonstrated a

(after completing the standard program) main-

significant relationship between physical activ-

tained the weight lost during the standard treat-

ity and obesity, with more active individuals

ment, whereas those completing the standard

being less likely to be obese. In addition, there

treatment alone regained approximately half of

exist prospective studies suggesting that

the weight initially lost (Perri et al., 2 0 0 1 ) .

a

lack o f physical activity is a predictor of obe-

There is also evidence that tailoring a

sity (for a review, see J e b b 8c M o o r e , 1 9 9 9 ) .

physical activity program to an individual's

However, isolating the effects o f physical

specific needs may result in higher levels o f

activity interventions for obesity is difficult

exercise maintenance. For example, Bock,

because most studies also include a dietary

Marcus, Pinto, and Forsyth ( 2 0 0 1 ) found that

modification component such as a low-calorie

participants who received individualized feed-

diet. It has been shown that weight loss pro-

back regarding their exercise program were

grams using physical activity alone are effec-

significantly more likely to maintain treatment

tive in producing

modest weight loss (as

levels o f physical activity at follow-up (12

compared with control groups) but do not

months) than were participants who com-

result in as much weight loss as does exercise

pleted a standard physical activity intervention.

combined with dietary changes (Wing, 1 9 9 9 ) .

In conclusion, weight loss programs that

O n e possible explanation for the relatively

include a physical activity component have

Physical generally been shown to lead to a clinically

Mockett, &

Inactivity

\

Fentem, 2 0 0 1 ) . T h e potential

significant weight reduction. However, the

role o f physical activity in the development o f

challenge o f maintaining this weight loss fol-

osteoarthritis has increased in importance

lowing treatment remains. Future research

with the surgeon general's report calling for

should focus on the factors related to contin-

adults to increase their levels o f physical activ-

ued participation in physical activity. F o r

ity (U.S. Department of Health and H u m a n

example, understanding the behavioral vari-

Services, 1 9 9 6 ) .

ables that differentiate individuals w h o main-

Recent research has shown that engaging in

tain physical activity (and weight loss) from

low- to moderate-intensity levels o f physical

those w h o regain the weight initially lost

activity does not increase the risk o f the devel-

during treatment is a high priority (Marcus

opment o f osteoarthritis in the knee or hip

et al., 2 0 0 0 ) . (A more complete discussion o f

(Cheng et al., 2 0 0 0 ; Sutton et al., 2 0 0 1 ) . T h e

obesity and body image disturbances was

risk o f developing osteoarthritis from high-

provided in Chapter 8.)

intensity activities is not so clear, however, with some studies showing increased risk (Cheng e t a l . , 2 0 0 0 ;

OSTEOARTHRITIS AND

Cooper,

McAlindon,

PHYSICAL ACTIVITY

Dieppe,

1 9 9 4 ) and

Cooper et al., 1 9 9 8 ; Coggon, others

Egger, &

not

showing

increased risk (White, Wright, &

Hudson,

Arthritis is one o f the leading causes o f chronic

1 9 9 3 ) . W h a t is clear from the studies involv-

pain

and

ing intense physical activity is that joint injury

decreased quality o f life. Osteoarthritis can be

greatly increases the risk o f osteoarthritis

and

often results in disability

divided into two conceptual types: primary

(Cheng e t a l . , 2 0 0 0 ; Sutton e t a l . , 2 0 0 1 ) and

osteoarthritis, which is thought to be related

that perhaps the higher risk o f developing

to aging and heredity, and secondary osteo-

osteoarthritis associated with intense physical

arthritis, which is caused by conditions such as

activities may be explained by those activities'

obesity, joint trauma, and repetitious joint use

greater association with injury.

(Cheng et al., 2 0 0 0 ) . It is estimated that the

There are several reasons to believe that

prevalence o f arthritis is increasing, with

increased physical activity is beneficial in pre-

1 5 . 0 % o f the population affected in 1 9 9 0 but

venting

an expected prevalence o f 1 8 . 2 % by 2 0 2 0

osteoarthritis (Cheng e t a l . , 2 0 0 0 ) . Activity

(Wang, Helmick, M a c e r a , Zhang, &

and

reducing

the

symptoms

of

Pratt,

strengthens the muscular support surrounding

2 0 0 1 ) . Furthermore, the disability rates pro-

joints and consequently reduces the risk o f

duced from arthritis also appear to be grow-

injury. Furthermore, physical activity improves

ing,

more

and maintains joint mobility. Physical activity

suffering from arthritis (Wang et al., 2 0 0 1 ;

is also effective at reducing many of the other

Yelin, 1 9 9 2 ) .

risk factors o f osteoarthritis such as obesity,

with

those affected reporting

Traditionally, physicians have suggested the

avoidance

o f vigorous

activity

and

hypertension, hypercholesterolemia, and high blood glucose (Hart, Doyle, & Spector, 1 9 9 5 ) .

encouraged physical inactivity for the treat-

Finally, physical activity increases the nourish-

ment o f osteoarthritis, reflecting a belief

ment of joint cartilage through the diffusion of

that joint use exacerbates the condition. This

nutrients via joint fluid (Cheng et al., 2 0 0 0 ;

"wear-and-tear"

Hall, Urban, & Gehl, 1 9 9 1 ) .

hypothesis persists

even

today, as studies examining the role o f physical activity

in producing

osteoarthritis

have

been somewhat inconsistent (Sutton, M u i r ,

In 1 9 9 9 , the Arthritis Foundation, C D C , and

9 0 other organizations

National

Arthritis

Action

released

Plan:

A

the Public

155

156

BEHAVIORS T H A T C O M P R O M I S E HEALTH Callahan, &

showing a negative dose-response to increasing

Helmick, 1 9 9 9 ; W a n g e t a l . , 2 0 0 1 ) . Among

levels o f physical activity (Friedenreich, 2 0 0 1 ) .

Health

Strategy

(Meenan,

the recommendations included in this publica-

The

evidence supporting risk

reduction

tion was the need to decrease the rates of

from physical activity in other cancers is

physical inactivity in adults with

not as compelling, but there is substantial

arthritis

( 3 4 . 8 % ) , which are higher than those in adults

evidence

without arthritis ( 2 7 . 7 % ) (Wang et al., 2 0 0 1 ) .

prostate cancer (Friedenreich, 2 0 0 1 ) . Further-

Others have also recommended the use o f

more, preliminary evidence has been gather-

physical

ing to indicate that physical activity may be

activity

in

the

management

of

supporting the association

with

osteoarthritis, and its positive effects have

negatively related to lung cancer, testicular

received empirical support (Ettinger & Afable,

c a n c e r , ovarian

1 9 9 4 ; Ettinger et al., 1 9 9 7 ; Minor, 1 9 9 1 ) .

cancer (Friedenreich, 2 0 0 1 ) . However, there

cancer, and

endometrial

is also compelling evidence to indicate that physical activity is not at all associated with rectal cancer (Friedenreich, 2 0 0 1 ) .

CANCER AND PHYSICAL ACTIVITY

T h e role o f exercise in cancer treatment has not been well researched, yet physical

Recently, Friedenreich ( 2 0 0 1 ) summarized the current

literature

about

the

association

activity can help to reduce the loss o f lean muscle mass during treatment, improve func-

between physical activity and cancer. She con-

tional

cluded that there is growing evidence for a pro-

enhance quality o f life (for a review, see

capacity,

increase

appetite,

1997).

and

Furthermore,

tective effect resulting from physical activity.

Oliveria 8c Christos,

However, the evidence considered was entirely

physical activity has been shown to be help-

dependent on epidemiological research. Frieden-

ful in reducing other forms o f risk in the

reich expounded on the need for randomized,

development o f cancer such as obesity and

controlled intervention trials, which will allow

other lifestyle-related health conditions.

the underlying mechanisms o f the association between physical activity and cancer to be better understood. Y e t even with the lack of controlled research, the negative association between physical activity and certain cancers

DIABETES MELLITUS AND PHYSICAL ACTIVITY

supports the role o f physical activity in the

Diabetes is a heterogeneous group o f disorders

prevention o f many forms of cancer.

characterized

by hyperglycemia

or

higher

The strongest evidence o f the negative asso-

than normal levels o f blood glucose. Type 1

ciation between physical activity and cancer

diabetes, commonly referred to as "insulin-

exists for colon cancer and, to a somewhat

dependent diabetes," occurs as a result of

lesser degree, breast cancer

autoimmune

(Friedenreich,

2 0 0 1 ) . In both forms o f cancer, the risk reduc-

destruction

o f the

pancreas,

leading to a deficiency in insulin production

tion for the most physically active has been

(Peirce,

as high as 7 0 % (for reviews, see Colditz,

accounts for 9 0 % to 9 5 % o f all diabetic cases

Cannuscio, 8c Frazier, 1 9 9 7 ; Friedenreich,

in the United States (Kriska, Blair, 8c Pereira,

2001;

8c

1 9 9 4 ) , occurs as a result o f altered insulin

Britton,

secretion, elevated hepatic glucose production,

Friedenreich,

Thune,

Brinton,

Albanes, 1 9 9 8 ; Gammon, John, &

1999).

Type

2

diabetes,

which

1 9 9 8 ; Lattika, Pukkala, & Vihko, 1 9 9 8 ) . T h e

and/or diminished glucose use in skeletal mus-

average risk reduction in colon cancer is 4 0 %

cle (Wallberg-Henriksson, Rincon, 8c Zierath,

to 5 0 % , with risk for both forms o f cancer

1 9 9 8 ) . Prolonged hyperglycemia leads to the

Physical glycation o f tissues, causing organ

damage

and other negative health effects.

Inactivity

|

can also have a beneficial effect on glucose regulation (Wallberg-Henrikssonetal., 1 9 9 8 ) .

The past decade witnessed an increase in the

Increasing physical activity in

patients

prevalence of diabetes. It is estimated that in

with type 1 diabetes is a complicated issue

1 9 9 5 , 4 . 0 % o f the world's population

was

because o f the necessary self-regulation o f

afflicted, and this prevalence was projected to

insulin levels. Hypoglycemia is a potentially

increase to 5 . 4 % by 2 0 2 5 (Peirce, 1 9 9 9 ) . How-

life-threatening

ever, these reported case estimates may be low

after exercise. T h u s , the use o f physical activ-

given that there may be no symptoms at the

ity in the regulation o f type 1 diabetes must

onset o f the disease, causing many early cases to

be conducted with careful consideration o f

state that can be induced

elude detection (Kriska etal., 1 9 9 4 ) . T h e inci-

the potential

dence o f type 2 diabetes increases with age and

glycemia or ketosis. However, exercise has

for exercise-induced

hypo-

is greatly increased in obese individuals, with a

been shown to decrease the daily insulin

reported 6 0 % to 9 0 % of type 2 diabetic patients

regimens o f type 1 diabetics by increasing

being obese at onset (Kriska et al., 1 9 9 4 ) .

insulin-independent glucose transport and by

Physical inactivity has been shown to affect the physiological mechanisms thought

increasing insulin sensitivity (Peirce, 1 9 9 9 ) .

to

An overwhelming body o f evidence exists to

underlie diabetes. A total o f 3 5 days o f induced

suggest that increased physical activity should

physical inactivity caused a decrease in glucose

be recommended not only as a fundamental

tolerance in eight healthy males (Lipman et al.,

management strategy for physician-diagnosed

1 9 7 2 ) . Furthermore, individuals with spinal

diabetes but also as a strategy for the preven-

cord injury had higher blood glucose levels

tion of type 2 diabetes. (For a more complete

than did age-matched controls (Duckworth

discussion o f type 2 diabetes, see Chapter 16.)

e t a l . , 1 9 8 0 ) . Although a complete review of the physiological effects of physical activity on glucose regulation is beyond the scope o f this chapter, substantial evidence exists supporting the use of physical activity in the

PSYCHOLOGICAL FUNCTIONING AND PHYSICAL ACTIVITY

management and prevention o f type 2 diabetes

In addition to the widely studied effects of

(for

physical activity on physical functioning, partic-

reviews, see Peirce, 1 9 9 9 ; Wallberg-

Henriksson et al., 1 9 9 8 ) .

ipation in physical activity has been shown to

Exercise has been shown to lower blood glu-

play a role in emotional well-being. W h e n dis-

cose levels in diabetics (Hubinger, Franzen, &

cussing the relationship between physical activ-

Gries, 1 9 8 7 ; Peirce, 1 9 9 9 ) . It is estimated that

ity and emotions, it is necessary to consider both

9 0 % of glucose clearance occurs in skeletal

acute and

muscle, and

improvement of mood (e.g., depression) follow-

this process can

be

greatly

chronic effects.

Regarding

the

enhanced with increased energy use created

ing a single bout of exercise, the evidence is

through

mixed, with some studies finding no effect and

physical

Exercise can

activity

enhance

(Peirce,

1999).

insulin-independent

others demonstrating

significantly enhanced

transport o f glucose into cells (Peirce, 1 9 9 9 )

mood. However, the results do indicate that

and can increase insulin sensitivity (Burstein,

dose of exercise (i.e., physical activity o f varying

Epstein, Shapiro, Charuzi, & Karnieli, 1 9 9 0 ) .

intensities) does play a role in subsequent mood

Furthermore, regular exercise programs have

(for a review of these studies, see Rejeski, 1 9 9 4 ) .

been shown to improve metabolic control,

In addition to mood improvement,

one

especially in the young (Wallberg-Henriksson,

must consider the possible inducement o f

1 9 9 2 ) . Exercise-related decrease in body weight

negative m o o d following a session o f physical

157

158

BEHAVIORS T H A T C O M P R O M I S E HEALTH activity. Results of several studies have shown

depression than did those receiving medication

that high-intensity exercise bouts may lead

( 3 0 % vs. 5 0 % , respectively). In addition, par-

to an increase in feelings o f anxiety and

ticipants in the physical activity group were sig-

depressed m o o d in some individuals (Rejeski,

nificantly more likely to have recovered from

1 9 9 4 ) . There is some evidence t o suggest that

major depressive disorder (partially or fully)

individuals w h o are predisposed to negative

than were those in the medication group

m o o d states are more likely to experience anx-

(Babyak et al., 2 0 0 0 ) . Regarding maintenance

iety as a result o f engaging in physical activity

of physical activity, 6 4 % o f participants who

(Cameron & Hudson, 1 9 8 6 ) . However, this

received the physical activity treatment contin-

issue is complex, and

further

research is

needed to increase our understanding o f the

ued to exercise following completion of the 1 6 week program.

role that physical activity plays in short-term

In sum, it appears that physical activity has

changes in m o o d . It has been found that in

the potential to improve m o o d both immedi-

women with normal mood at baseline, m o o d

ately following a bout of exercise (i.e., acute

after exercise improves most for those w h o felt

effects) and after participation in a long-term

worse previous to engaging in physical activity

program (i.e., chronic effects). Thus, physical

(Rejeski, Gauvin, H o b s o n , &c Norris, 1 9 9 5 ) .

activity may be an effective means of enhanc-

Given that the U.S. population is aging,

ing mental health as well as physical health. In

the treatment o f depressive disorders in older

individuals experiencing a m o o d disorder (e.g.,

adults is becoming increasingly important.

depression), physical activity has been shown

Blumenthal and colleagues ( 1 9 9 9 ) examined

to be a practical alternative to medication and

the use o f physical activity as a treatment for

should be recommended as either a primary

major depressive disorder in older adults. In

treatment or an adjunctive treatment (assum-

their work, they compared participation in a

ing no physical limitations that would con-

physical activity program with the use o f a

traindicate exercise).

c o m m o n l y prescribed antidepressant medication (sertraline hydrochloride). Participants in the study were randomly

assigned

to

CONCLUSIONS

receive either the medication, a physical activity intervention, or a c o m b i n a t i o n o f

T h e purpose o f this chapter was to review the

physical activity and medication. T h e 1 6 -

evidence that physical activity is beneficial in

week physical activity treatment consisted o f

terms o f the prevention and treatment o f dis-

three 45-minute sessions o f aerobic activity

ease. It was shown that the literature sup-

per week. It was found that both the medica-

ports engaging in physical activity as an

tion group and the physical activity group

effective means to reducing morbidity and

experienced a reduction in their levels o f

mortality. Unfortunately, most

depression

do not achieve an adequate level o f physical

(Blumenthal et al., 1 9 9 9 ) . T h e

individuals

t w o types o f treatment did not differ signifi-

activity. Understanding this pervasive lack of

cantly from one another

physical activity participation requires con-

in effectiveness.

These results suggest that physical activity is

sideration o f the role that environmental fac-

a viable alternative t o medication in the

tors play in our society.

treatment o f depression in older adults. In a 6-month follow-up study o f the same

As indicated in a recent review (Dubbert et al., 2 0 0 2 ) ,

it is clear that the inactive

participants, it was demonstrated that those

lifestyle that characterizes many individuals in

individuals who were assigned to the physical

the United States is due partly to a decrease in

activity treatment experienced lower rates o f

activity required on the j o b as well as to the

Physical

Inactivity

CASE S T U D Y " L . B . " was a 56-year-old married Caucasian male who was referred for evaluation by his primary care physician. At the time o f the evaluation, L . B . was 4 0 pounds overweight and was at the borderline o f requiring medication to control his blood glucose levels. H e was also experiencing low to moderate levels of chronic pain in his lower back, and this pain was reportedly aggravated by exertion. H e was referred for evaluation o f potential behavioral and lifestyle interventions to place his blood sugar levels under better control and help him to lose weight. L. B . was screened for depression, anxiety, and other psychopathology during his initial visit using a standard battery o f self-report assessment instruments in combination with a clinical interview. T h e assessment revealed that L . B . was generally well adjusted but that he was reporting low levels o f dysphoria and poor m o o d . Specifically, he reported a lack o f energy, difficulty in sleeping, and a loss o f interest in pleasurable activities. T h e s e symptoms were severe enough to warrant discussion but appeared to be on the sub-threshold o f a clinical diagnosis. L . B . appeared to be motivated to address his current medical problems, stating that he was quite concerned about developing diabetes. L. B.'s lifestyle was initially assessed during the interview using questions such as "Describe a typical day." F r o m this line o f questioning, it was apparent that his lifestyle largely consisted o f eating meals out, working long hours at his desk, and enjoying his weekend and after-work time by watching sports and being sedentary. W h e n asked about his levels o f physical activity, L . B . reported that he used to enjoy being active but that his lower b a c k pain had forced him to "take it easy" because it usually hurt when he engaged in even moderate levels o f activity. T o further examine his levels o f physical activity, he was given a pedometer to wear throughout the next week and was instructed to engage in his usual schedule. It should be noted that L . B . ' s primary care physician had cleared him medically for all forms o f physical activity and that L . B . had no detectable structural damage in his lower back. In addition, circulation and sensation in his lower extremities and feet were not impaired (walking ability may be limited in those with foot complications secondary to diabetes). H e agreed to record the number o f steps each evening in a log as well as to keep a food diary. Figure 9.1 displays L . B . ' s baseline levels o f physical activity as recorded by a pedometer. These baseline levels o f activity were discussed in the session, and L . B . reported surprise at the low levels o f activity in which he was engaging. His beliefs about increasing his levels o f physical activity were discussed. T h e rationale behind the positive benefits o f physical activity for m o o d , glucose regulation, and chronic pain was explained. L . B . felt that walking would not aggravate his back and stated that he was willing to begin a walking regimen. It was decided that L . B . would attempt to walk during his lunch hour but that if he were unable to do so, he would walk after w o r k with his wife. He also agreed to continue to m o n i t o r his activity but decided to discontinue his food log.

159

160

BEHAVIORS T H A T C O M P R O M I S E HEALTH

12000 10000 8000 6000 4000 2000 r

Figure 9.1

L. B.'s Steps as a Function of Time

L. B . called the clinic after his first day o f walking t o report that he had greatly increased pain (which he described as 8 on a 10-point scale) and that he wanted to discontinue the regimen. H e further stated that he was n o t wearing the pedometer (he had called in sick t o w o r k because o f the pain) and that he planned on not moving for the remainder o f the day. After a discussion o f some o f L . B . ' s frustrations, he was persuaded t o continue to wear the pedometer for the remainder o f the week, even if he did n o t continue to implement a walking regimen. At the next clinic visit, L . B . ' s log was reviewed, and as can be seen in Figure 9 . 1 , his increased pain was attributed t o his "overdoing i t " on the first day o f his regimen. M a n y o f his pain beliefs regarding his physical limitations were discussed in the c o n t e x t o f pacing himself. L . B . was persuaded to attempt his walking regimen again, but this time with some restrictions set by the therapist. Specifically, during the first week, he should not walk beyond 4 , 5 0 0 steps (as indicated on the pedometer). H e agreed t o this but felt that this walking regimen was t o o little t o be o f benefit. Throughout the next few weeks, L . B.'s therapist-imposed upper limits o f pedometer readings were allowed to increase (Figure 9 . 1 ) . L . B . reported success with the regimen, stating that it allowed him extra time with his wife, w h o was also enjoying walking with him. T h e goal o f 1 0 , 0 0 0 steps daily was discussed, and L. B . felt that this goal could be accomplished. H e soon reached the goal and discontinued recording his activity, although he purchased his own pedometer. H e was also implementing changes in his diet that greatly facilitated his sense o f efficacy in changing his lifestyle. By the end o f treatment, L . B . had succeeded in losing 1 5 pounds and was extremely proud o f this accomplishment. H e had increased his activity to 1 0 , 0 0 0 steps daily, with no increase in lower back pain. (It should be noted that individuals

Physical

Inactivity

with foot or knee pain might not be able to attain this level o f activity.) In fact, he reported that his back "has not felt better in 1 5 years." Furthermore, his primary care physician believed that if L . B . were able to maintain his lifestyle changes, he would not have to pharmacologically manage L . B.'s blood sugar levels. L . B . was confident that he would be able to maintain his increased levels o f physical activity, stating that he particularly liked the accompanying increased levels o f energy and would like to lose more weight.

availability o f sedentary leisure time activities

availability o f informational

for both children and adults. Americans are

languages other than English).

also dining out more often and are consuming

materials

in

Recent studies have examined physical activ-

larger portions during meals. In addition, the

ity versus physical fitness.

physical environment plays a role in physical

attempted to make this distinction because it is

activity participation. For example, in a sam-

possible, for example, that two

ple o f women age 4 0 years or over, it was

engaging in the same dose (including intensity,

Researchers have individuals

found that the lack o f enjoyable scenery and

duration, and frequency) of physical activity

hills in the neighborhood was associated with

may have different levels o f physical fitness.

less leisure time activity (King et al., 2 0 0 0 ) .

Blair, Cheng, and Holder ( 2 0 0 1 ) sought to

Although more recent studies have included

address the issue o f whether physical activity or

men and women o f color, the majority o f

fitness is more important for good health. After

research has been with Caucasians. Because

reviewing the evidence from 6 7 studies that

certain diseases are more prevalent in ethnic

assessed physical activity, fitness, and a health

minorities

African

outcome, they concluded that it is not possible

Americans), it is crucial to focus attention on

to determine whether activity or fitness is more

(e.g., hypertension

in

these groups. In addition, consideration should

important in terms o f producing health bene-

be given to subgroups within ethnic minority

fits. Instead, they found a consistent dose-

groups. Crespo, Smit, Carter-Pokras,

response relation between physical activity and

and

Andersen ( 2 0 0 1 ) found that degree o f accul-

fitness and health outcomes across studies

turation (i.e., the extent to which an ethnic

included in the review. T h a t is, at both higher

group adopts the customs and traditions o f the

activity and fitness levels, there was a reduction

majority culture) was associated with leisure

in disease morbidity and mortality.

time physical activity in M e x i c a n Americans.

Blair and colleagues ( 2 0 0 1 ) recommended

Specifically, it was shown that inactivity was

that researchers begin to define more specifi-

significantly more likely in those individuals

cally the nature o f the dose-response relation-

who spoke primarily Spanish in the home (a

ship.

sign o f less acculturation to American society).

difference in health outcomes in an individual

In contrast, those who spoke primarily English

who exercises for 1 5 minutes per day versus

For example, what

would

be

the

had physical activity rates that were similar to

an individual who engages in 6 0 minutes o f

those o f the general (majority) population.

physical activity per day? Whether or not such

Thus, it may be useful to tailor physical activ-

a difference in activity duration translates into

ity promotion in such a way as to target less

significantly

acculturated individuals (e.g., by increasing the

unknown. In addition, although the focus has

different

health

outcomes is

162

BEHAVIORS THAT C O M P R O M I S E HEALTH been on cardiorespiratory fitness, other possible

published, further examination of the factors

types o f fitness should be considered

that may increase physician prescription of

studied more widely. These might metabolic, flexibility, cognitive

and

include

physical activity is needed.

functioning,

Finally, more research is needed on effec-

and mental health. As other types o f fitness

tive strategies for promoting physical activity

become better defined, it may be possible to

in adults. As illustrated in the preceding case

tailor physical activity to an

study, cognitive-behavioral strategies such as

individual's

needs. For example, an individual might be

self-monitoring and goal setting can be very

prescribed a specific type o f physical activity

effective

to address his or her particular risk factors.

physical activity behaviors. In

Another

important

area

of

continued

in helping individuals

medicine

settings

with

to

change

behavioral

chronic

disease

research should focus on the maintenance o f

patients, health psychologists work with exer-

physical activity. W h y is it so difficult to main-

cise professionals and other experts who pre-

tain this behavior? W h y is engaging

in

physical activity pleasurable for some individ-

scribe the

appropriate

activity regimens.

Psychologists are often responsible for assist-

uals but not for others? One step in answering

ing patients in developing motivational strate-

the question o f why some individuals are more

gies and self-management programs to build

likely to maintain a program o f physical activ-

physical activity into their lifestyles and sus-

ity might be to examine emotions related to

tain the change over time. Psychologists may

exercise. Although much has been written o f

also assist with assessing mood and cognitive

the emotions that occur as a result o f physical

states that could affect ability to carry out pre-

activity participation, one aspect o f the rela-

scribed physical activity programs.

tionship between physical activity and emo-

Recent reviews (e.g., Blair & Morrow, 1 9 9 8 ;

tion that has received little attention is the

Dubbert, 2 0 0 2 ; Sallis &

importance o f the emotional changes

Department of Health and Human Services,

that

Owen, 1 9 9 8 ; U.S.

occur during physical activity (Rejeski, 1 9 9 4 ) .

1996) have described successful physical activity

Researchers should also continue to investi-

promotion projects and intervention strategies

gate the role of medical professionals in physical

in a variety o f populations

and

settings.

activity participation. In a recent telephone sur-

Participation in physical activity is a powerful

vey of nearly 2 , 0 0 0 U.S. adults, only 2 8 % of the

tool in the prevention of many of the diseases

respondents reported receiving advice from their

covered in this chapter. By increasing the

physicians

to

increase

physical

activity

numbers of individuals who regularly engage in

(Glasgow, Eakin, Fisher, Bacak, & Brownson,

physical activity, we could significantly reduce

2 0 0 1 ) . Although there has been increased

the chronic disease burden and improve the

interest in this area and several studies have been

quality o f life of millions of Americans.

REFERENCES American Association of Cardiovascular and Pulmonary Rehabilitation. (1999). Guidelines for cardiac rehabilitation and secondary prevention programs (3rd ed.). Champaign, IL: Human Kinetics Press. American College of Sports Medicine. (1998). The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness and flexibility in healthy adults. Medicine & Science in Sports & Exercise, 30, 9 7 5 - 9 9 1 .

Physical Babyak, M., Blumenthal, J . Α., Herman, S., Khatri, P., Doraiswamy, M., Moore, K., Craighead, W. E., ÔC Baldewicz, T. T. (2000). Exercise treatment for major depression: Maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine, 62, 6 3 3 - 6 3 8 . Bassett, D. R. (2000). Validity and reliability issues in objective monitoring of physical activity. Research Quarterly for Exercise and Sport, 71(2), 3 0 - 3 6 . Berlin, J . Α., & Colditz, G. A. (1990). A meta-analysis of physical activity in the prevention of coronary heart disease. American Journal of Epidemiology, 132, 612-628. Bernstein, M., Sloutskis, D., Kumanyika, S., Sparti, Α., Schultz, Y . , & Morbiana, A. (1998). Data-based approach for developing a physical activity frequency questionnaire. American Journal of Epidemiology, 147, 1 4 7 - 1 5 4 . Berry, M . J . , Si Walschlager, S. A. (1998). Exercise training and chronic obstructive pulmonary disease: Past and future research directions. Journal of Cardiopulmonary Rehabilitation, 18, 1 8 1 - 1 9 1 . Blair, S. N., Cheng, Y . , &c Holder, J . S. (2001). Is physical activity or physical fitness more important in defining health benefits? Medicine & Science in Sports & Exercise, 33, S 3 7 9 - S 3 9 9 . Blair, S. N., Kohl, H. W., Paffenbarger, R. S., Clark, D. G., Cooper, Κ. H., & Gibbons, L. W. (1989). Physical fitness and all-cause mortality. Journal of the American Medical Association, 262, 2 3 9 5 - 2 4 0 1 . Blair, S. N., & Morrow, J . R. (1998). Cooper Institute/American College of Sports Medicine 1 9 9 7 Physical Activity Conference. American Journal of Preventive Medicine, 15, 2 5 5 - 2 5 6 . Blumenthal, J . Α., Babyak, Μ . Α., Moore, Κ. Α., Craighead, W. E., Herman, S., Khatri, P., Waugh, R., Napolitano, Μ . Α., Forman, L. M., Appelbaum, M., Doraiswamy, M., & Krishnan, R. (1999). Effects of exercise training on older patients with major depression. Archives of Internal Medicine, 159, 2349-2356. Blumenthal, J . Α., Sherwood, Α., Gullette, E. C. D., Georgiades, Α., & Tweedy, D. (2002). Biobehavioral approaches to the treatment of essential hypertension. Journal of Consulting and Clinical Psychology, 70, 5 6 9 - 5 8 9 . Blumenthal, J . Α., Siegal, W. C , & Appelbaum, M. (1991). Failure of exercise to reduce blood pressure in patients with mild hypertension. Journal of the American Medical Association, 266, 2 0 9 8 - 2 1 0 4 . Bock, B . C., Marcus, Β . H., Pinto, Β. M., & Forsyth, L. H. (2001). Maintenance of physical activity following an individualized motivationally tailored intervention. Annals of Behavioral Medicine, 23, 7 9 - 8 7 . Bouchard, C. (2000). Introduction. In C. Bouchard (Ed.), Physical activity and obesity. Champaign, IL: Human Kinetics Press. Bourjeily, G., & Rochester, C. L. (2000). Exercise training in chronic obstructive pulmonary disease. Clinics in Chest Medicine, 21, 7 6 3 - 7 8 0 . Burstein, R., Epstein, Y . , Shapiro, Y . , Charuzi, I., & Karnieli, E. (1990). Effect of an acute bout of exercise on glucose disposal in human obesity. Journal of Applied Physiology, 69, 2 9 9 - 3 0 4 . Cameron, O. G., & Hudson, C. J . (1986). Influence of exercise on anxiety level in patients with anxiety disorders. Psychosomatics, 27, 7 2 0 - 7 2 3 . Caspersen, C. J . (1989). Physical activity epidemiology: Concepts, methods, and applications to exercise science. In K. Pandolf (Ed.), Exercise and sports science reviews (Vol. 17, pp. 4 2 3 - 4 7 3 ) . Baltimore, M D : Williams & Wilkins. Centers for Disease Control and Prevention. (2001). Physical activity trends: United States, 1 9 9 0 - 1 9 9 8 . Morbidity and Mortality Weekly Report, 50, 1 6 6 - 1 6 9 . Cheng, Y . , Macéra, C. Α., Davis, D. R., Ainsworth, Β . E., Troped, P. J . , & Blair, S. N. (2000). Physical activity and self-reported, physician-diagnosed

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Physical Gammon, M . D., John, E. M., & Britton, J . A. (1998). Recreational and occupational physical activities and risk of breast cancer. Journal of the National Cancer Institute, 90, 1 0 0 - 1 1 7 . Glasgow, R. E., Eakin, E. G., Fisher, E. B., Bacak, S. J . , & Brownson, R. C. (2001). Physician advice and support for physical activity. American Journal of Preventive Medicine, 21, 1 8 9 - 1 9 6 . Grant, I., Prigatano, G. P., Heaton, R. K., McSweeney, A. J . , Wright, E. C., & Adams, Κ. M . (1987). Progressive neuropsychologic impairment and hypoxemia. Archives of General Psychiatry, 44, 9 9 9 - 1 0 0 6 . Grundy, S. M., Blackburn, G., Higgins, M., Lauer, R., Perri, M . G., & Ryan, D. (1999). Physical activity in the prevention and treatment of obesity and its comorbidities. Medicine & Science in Sports & Exercise, 31, S 5 0 2 - S 5 0 8 . Hagberg, J . M., Park, J . , & Brown, M . D. (2000). The role of exercise training in the treatment of hypertension. Sports Medicine, 30, 1 9 3 - 2 0 6 . Halbert, J . Α., Silagy, C. Α., Finucane, P., Withers, R. T., Hamdorf, P. Α., & Andrews, G. R. (1997). The effectiveness of exercise training in lowering blood pressure: A meta-analysis of randomised controlled trials of 4 weeks or longer. Journal of Human Hypertension, 11, 6 4 1 - 6 4 9 . Hall, A. C., Urban, J . P. G., & Gehl, K. A. (1991). The effects of hydrostatic pressure on matrix synthesis in articular cartilage. Journal of Orthopedic Research, 9, 1-10. Hart, D. J . , Doyle, D. V., & Spector, T. D. (1995). Association between metabolic factors and knee osteoarthritis in women. Journal of Rheumatology, 22, 1118-1123. Hubinger, Α., Franzen, Α., & Gries, F. A. (1987). Hormonal and metabolic response to physical exercise in hyperinsulinemic and non-hyperinsulinemic Type 2 diabetics. Diabetes Research, 4(2), 5 7 - 6 1 . Jebb, S. Α., & Moore, M. S. (1999). Contribution of a sedentary lifestyle and inactivity to the etiology of overweight and obesity: Current evidence and research issues. Medicine & Science in Sports & Exercise, 31, S 5 3 4 - S 5 4 1 . Jeffery, R. W., Drewnowski, Α., Epstein, L. H., Stunkard, A. J . , Wilson, G. T., Wing, R. R., & Hill, D. R. (2000). Long-term maintenance of weight loss: Current status. Health Psychology, 19, 5 - 1 6 . Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. (1997). The sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI). Archives of Internal Medicine, 157, 2 4 1 3 - 2 4 4 6 . Kaplan, N. W. (1998). Clinical hypertension (7th ed.). Baltimore, M D : Williams & Wilkins. Kelley, G. Α., & Kelley, K. S. (2000). Progressive resistance exercise and resting blood pressure: A meta-analysis of randomized controlled trials. Hypertension, 35, 8 3 8 - 8 4 3 . King, A. C , Castro, C , Wilcox, S., Eyler, Α. Α., Sallis, J . F., & Brownson, R. (2000). Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychology, 19, 3 5 4 - 3 6 4 . Kokkinos, P. F., Narayan, P., Coleran, J . Α., Pittaras, M., Notargiacomo, Α., Reda, D., & Papademetriou, V. (1995). Effects of regular exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension. New England Journal of Medicine, 333, 1462-1467'. Kriska, A. M., Blair, S. M., & Pereira, M. A. (1994). The potential role of physical activity in the prevention of non-insulin-dependent diabetes mellitus: The epidemiological evidence. Exercise and Sport Science Review, 22, 1 2 1 - 1 4 3 . Kriska, A. M., & Caspersen, C. J . (Eds.). (1997). A collection of physical activity questionnaires for health related research. Medicine & Science in Sports & Exercise, 29, S 1 - S 2 0 5 .

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BEHAVIORS THAT C O M P R O M I S E HEALTH Laçasse, Y . , Wong, E., Guyatt, G. H., King, D., Cook, D. J . , & Goldstein, R. S. (1996). Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet, 348, 1 1 1 5 - 1 1 1 9 . Lattika, P., Pukkala, E., &c Vihko, V. (1998). Relationship between the risk of breast cancer and physical activity. Sports Medicine, 26, 1 3 3 - 1 4 3 . Leon, A. S. (2000). Exercise following myocardial infarction. Sports Medicine, 29, 301-311. Lesniak, K. T., & Dubbert, P. M . (2001). Exercise and hypertension. Current Opinion in Cardiology, 16, 3 5 6 - 3 5 9 . Linden, W., & Chambers, L. (1994). Clinical effectiveness of non-drug treatment for hypertension: A meta-analysis. Annals of Behavioral Medicine, 16, 3 5 - 4 5 . Lipman, R. L., Raskin, P., Love, T., Triebwasser, J . , Lecocq, F. R., & Schnure, J . J . (1972). Glucose intolerance during decreased physical activity in man. Diabetes, 21(2), 1 0 1 - 1 0 7 . MacMahon, S., Peto, R., Cutler, J . , Collins, R., Sorlie, P., Neaton, J . , Abbott, R., Godwin, J . , Dyer, Α., & Stamler, J . (1990). Blood pressure, stroke, and coronary heart disease: I. Prolonged differences in blood pressure: Prospective observational studies corrected for the regression dilution bias. Lancet, 335, 765-774. Mancia, G., Sega, R., Milesi, C , Cesana, G., & Zanchetti, A. (1997). Blood-pressure control in the hypertensive population. Lancet, 349, 4 5 4 - 4 5 7 . Marcus, Β. H., Dubbert, P. M., Forsyth, L. H., McKenzie, T. L., Stone, E. J . , Dunn, A. L., & Blair, S. N. (2000). Physical activity behavior change: Issues in adoption and maintenance. Health Psychology, 19, 3 2 - 4 1 . Meenan, R. F., Callahan, L. F., & Helmick, C. G. (1999). The National Arthritis Action Plan: A public health strategy for a looming epidemic. Arthritis Care Research, 12, 7 9 - 8 1 . Minor, M . A. (1991). Physical activity and management of arthritis. Annals of Behavioral Medicine, 13, 1 1 7 - 1 2 4 . Montoye, H. J . , Kemper, H. C. G., Saris, W. Η. M., & Washburn, R. A. (1996). Measuring physical activity and energy expenditure. Champaign, IL: Human Kinetics Press. Nami, R., Mondillo, S., Agricola, E., Lenti, S., Ferro, G., Nami, N., Tarantino, M., Glauco, G., Spano, E., & Gennari, C. (2000). Aerobic exercise training fails to reduce blood pressure in non-dipper-type hypertension. American journal of Hypertension, 13, 5 9 3 - 6 0 0 . National Institutes of Health. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. Obesity Research, 6, S 5 1 - S 2 0 9 . Oldridge, Ν. B . , Guyatt, G. H., Fischer, M . E., & Rimm, A. A. (1988). Cardiac rehabilitation after myocardial infarction: Combined experience of randomised clinical trials, journal of the American Medical Association, 260, 9 4 5 - 9 5 0 . Oliveria, S. Α., & Christos, P. J . (1997). The epidemiology of physical activity and cancer. Annals of the New York Academy of Sciences, 833, 7 9 - 9 0 . Peirce, N. S. (1999). Diabetes and exercise. British Journal of Sports Medicine, 33, 161-172. Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. Α., & Viegener, B . J . (2001). Relapse prevention training and problem-solving therapy in the long-term management of obesity. Journal of Consulting and Clinical Psychology, 69, 7 2 2 - 7 2 6 . Prigatano, G. P., Parsons, O., Wright, E., Levin, D. C , & Hawryluk, G. (1983). Neuropsychological test performance in mildly hypoxemic patients with chronic obstructive pulmonary disease. Journal of Consulting and Clinical Psychology, 51, 1 0 8 - 1 1 6 .

Physical Rejeski, W. J . (1994). Dose-response issues from a psychosocial perspective. In C. Bouchard, R. T. Shephard, & T. Stephens (Eds.), Physical activity, fitness, and health (pp. 1 0 4 0 - 1 0 5 5 ) . Champaign, IL: Human Kinetics Press. Rejeski, W. J . , Gauvin, L., Hobson, M. L., & Norris, J . L. (1995). Effects of baseline responses, in-task feelings, and duration of activity on exercise-induced feeling states in women. Health Psychology, 14, 3 5 0 - 3 5 9 . Salbe, A. D., & Ravussin, E. (2000). The determinants of obesity. In C. Bouchard (Ed.), Physical activity and obesity (pp. 6 9 - 1 0 2 ) . Champaign, IL: Human Kinetics Press. Sallis, J . F. (1991). Self-report measures of children's physical activity. Journal of School Health, 61, 2 1 5 - 2 1 9 . Sallis, J . F., & Owen, N. (1998). Physical activity and behavioral medicine. Thousand Oaks: CA: Sage. Sallis, J . F., 8c Saelens, Β . E. (2000). Assessment of physical activity by self-report: Status, limitations, and future directions. Research Quarterly for Exercise and Sport, 71(2), 1-14. Schoenborn, C. Α., & Barnes, P. M. (2002). Leisure-time physical activity among adults: United States, 1997-98 (advance data from Vital and Health Statistics, No. 3 2 5 ) . Hyattsville, M D : National Center for Health Statistics. Sutton, A. J . , Muir, K. R., Mockett, S., & Fentem, P. (2001). A case-control study to investigate the relation between low and moderate levels of physical activity and osteoarthritis of the knee using data collected as part of the Allied Dunbar National Fitness Survey. Annals of Rheumatic Disease, 60, 7 5 6 - 7 6 4 . U.S. Department of Health and Human Services. (1996). Physical activity and health: Report of the surgeon general. Washington, DC: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Wadden, Τ. Α., Foster, G. D., & Brownell, K. D. (2002). Obesity: Responding to the global epidemic. Journal of Consulting and Clinical Psychology, 70, 510-525. Wallberg-Henriksson, H. (1992). Interaction of exercise and insulin in type 2 diabetes mellitus. Diabetes Care, 15, 1 7 7 7 - 1 7 8 2 . Wallberg-Henriksson, H., Rincon, J . , & Zierath, J . R. (1998). Exercise in the management of non-insulin-dependent diabetes mellitus. Sports Medicine, 25(1), 25-35. Wang, G., Helmick, C. G., Macéra, C , Zhang, P., & Pratt, M. (2001). Inactivityassociated medical costs among U.S. adults with arthritis. Arthritis Care & Research, 45, 4 3 9 - 4 4 5 . Wannamethee, S. G., Shaper, A. G., & Walker, M . (2000). Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation, 102, 1 3 5 8 - 1 3 6 3 . Washburn, R. A. (2000). Assessment of physical activity in older adults. Research Quarterly for Exercise and Sport, 71(2), 7 9 - 8 8 . Wei, M., Kampert, J . B . , Barlow, C. E., Nichaman, M . Z., Gibbons, L. W., Paffenbarger, R. S., Gibbons, L. W., & Blair, S. N. (1999). Relationship between low cardiorespiratory fitness and mortality in normal weight, overweight, and obese men. Journal of the American Medical Association, 282, 1547-1553. White, J . Α., Wright, V., & Hudson, A. M. (1993). Relationship between habitual physical activity and osteoarthritis in aging women. Public Health, 107, 459-470. Wing, R. R. (1999). Physical activity in the treatment of the adulthood overweight and obesity: Current evidence and research issues. Medicine & Science in Sports & Exercise, 31, S 5 4 7 - S 5 5 2 .

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BEHAVIORS T H A T C O M P R O M I S E HEALTH Wood, T. M. (2000). Issues and future directions in assessing physical activity: An introduction to the conference proceedings. Research Quarterly for Exercise and Sport, 71(2), ii-vii. World Health Organization. (1998). Obesity: Preventing and managing the world epidemic. Geneva: Author. Yelin, E. (1992). The cumulative impact of a common chronic condition. Arthritis Rheum, 33, 7 5 0 - 7 5 5 .

CHAPTER

10

Stress and Health FRANK L . COLLINS, J R . , KRISTEN H . SOROCCO, KIMBERLY R . HAALA, BRIAN I. MILLER, AND WILLIAM R . LOVALLO

A

lthough stress may not cause disease, it has been established that stress m a y be a risk factor for the develop-

ment o f disease, may aggravate an existing disease, and may reduce a compliance and treatment success. As a result, many health professionals frequently refer clients to clinical health psychologists for help in dealing with stress-related issues. Clients referred in this manner frequently have a basic understanding that emotional and psychological factors influence health (often seen as the mind influencing the body); however, they frequently do n o t understand the mechanisms involved in this process. Likewise, clinical

health

psychologists

may

have

an

in-depth understanding o f effective treatment methods for reducing stress while having only an elementary understanding o f the physiological foundations that can help to guide a m o r e sophisticated conceptualization

W H A T E X A C T L Y IS S T R E S S ? T o understand the complexities of the construct we call stress, it is important to have a basic understanding o f how the body is organized. T h e body is a complex machine that functions in a hierarchical manner. At the most basic level, individual organs and tissues have selfregulating properties that allow the body to maintain normal function (homeostasis) when external conditions are constant. However, individual organs and tissues are not able to respond to rapid changes (challenges) in the environment or coordinate their responses with other bodily systems. Therefore, higher levels in the nervous system modulate the self-regulation of tissues and organs when homeostasis is threatened. Modulation in self-regulatory functioning is achieved through the receipt o f sensory inputs, integrated control over target tissues, endocrine outflow, and autonomic function. This process is discussed in further detail later in this chapter.

and treatment for these disorders. T h e major

In its simplest form, stress involves a stres-

goals o f this chapter are to (a) provide health

sor and stress response that challenge the

professionals

with

body's ability to maintain homeostasis. A

clients, (b) review the literature on models o f

with

a model t o use

stressor is any physical or mental challenge to

coping, and (c) provide information assess-

the body that threatens homeostasis. Physical

ment and treatment strategies.

stressors are events that challenge the body to

170

BEHAVIORS THAT C O M P R O M I S E HEALTH function beyond normal capacity ( M c E w e n , 2 0 0 0 ) . Examples o f physical stressors include

Physiology of the Psychological Stress Response

bodily injury, physical exertion, noise, overcrowding, and excessive heat or cold. Physical stressors

are

generated

through

internal

After any external event occurs, sensory information related to the event is processed

mechanisms and are a bottom-up process.

within the corticolimbic system (Figure 1 0 . 1 ) .

Alternatively, psychological stressors are top-

In general, the corticolimbic system is respon-

down processes that challenge an individual's

sible for threat appraisals and the processing

mental

capacity.

Psychological

stressors

of emotions. T h e corticolimbic system is

time-pressured

composed o f multiple brain structures, includ-

tasks, speech tasks, mental arithmetic, inter-

ing the thalamus, sensory cortex, prefrontal

personal

isolation,

cortex, memory system, and amygdala. As an

and traumatic life events. Therefore, both a

individual experiences an external event in the

include challenges such as

conflict, overcrowding,

physical stressor, such as being trapped out-

environment, sensory information is relayed

side in below-freezing temperatures, and a

from the thalamus to the sensory cortex. From

psychological stressor, such as participating in

the sensory cortex, the information is relayed

a public speaking task, can challenge the

to the prefrontal cortex, which is responsible

homeostasis o f the body.

for decision making and planning. Interest-

A stress response may consist of both a

ingly, the prefrontal

cortex is tied to the

physiological

person's memory system, so incoming infor-

response. A behavioral response is any action

mation is evaluated based on his or her prior

taken on the environment, such as quickly

memories. T h e appraisal process is completed

leaving a dangerous situation or implementing

in the prefrontal cortex, which communicates

a coping skill, whereas a physiological response

with the amygdala, the region in the brain

is an alteration in physiological functioning

where emotions are processed.

behavioral

response

and

that serves to restore an imbalance in homeo-

O n e o f the main functions o f the cortico-

static functioning. Examples o f physiological

limbic system during the stress response is the

responses include an increase in blood pres-

appraisal o f potential threats in the environ-

sure, elevated heart rate, impaired memory and

ment. Lazarus and Folkman's ( 1 9 8 4 ) model o f

decision-making abilities, and altered metabo-

coping distinguishes between two types of

lism.

Both

behavioral

and

physiological

appraisals that occur during a stress response.

responses to a stressor may be associated with

A primary appraisal is responsible for deter-

a negative affective state for the individual.

mining the magnitude of the threat such as

M o s t individuals can identify stressors they

immediate danger. If a threat appraisal is

experience in their daily lives as well as how

made, secondary appraisals help an individual

they experience the negative effects o f stress.

to evaluate ways in which to cope with the

However, what goes on between the stressor

stressor. For example, if a threat

and the stress response in terms o f physiology

indicates immediate danger, the corticolimbic

is less clearly understood by clients with

system immediately activates the peripheral

w h o m health professionals come into contact.

nervous system to signal the body to engage in

By educating clients on the psychological and

behaviors that initiate movement.

physiological mechanisms o f stress, health

After primary and secondary been made

appraisal

appraisals

professionals can teach clients the adaptive

have

indicating a threat,

role o f the stress response to episodic stressors

corticolimbic system also sends a message to

the

and the detrimental physical and psychologi-

the hypothalamus in addition to the message

cal effects caused by chronic long-term stress.

that was sent to the peripheral nervous system

Stress and

Health

Cortico-Limbic Threat Appraisals

External Event

Hypothalamus

Brain Stem

Behaviors

ANS

Endocrine

r

ι

Target Tissues

Figure 10.1

Physiology of the Psychological Stress Response

NOTE: ANS = autonomic nervous system.

signaling the body to move. T h e hypothalamus

system in the stress response is to prepare the

is responsible for coordinating the nervous

body to respond to the stressor.

system and controls the autonomic nervous

The hypothalamus, as a coordinator between

system via the brain stem. T h e autonomic

systems, also communicates with the endocrine

nervous system is divided into three main

system during a stress response. There are two

branches: the sympathetic nervous system, the

main endocrine functions

parasympathetic

the

response: the adrenocortical response and the

entric nervous system. For the purposes o f this

adrenomedullary response. The adrenocortical

nervous

system, and

during a stress

chapter, only the sympathetic and parasympa-

response releases Cortisol into the body during a

thetic nervous systems are discussed. Both the

stress response. Cortisol is released through mul-

sympathetic and parasympathetic nervous sys-

tiple steps. First, the paraventricular nucleus of

tems are involved in maintaining homeostasis.

the

hypothalamus

releases

corticotropin-

The sympathetic nervous system is usually

releasing factor (CRF), which travels to the

responsible for increasing the activation of

pituitary gland. C R F causes the secretion of

bodily systems (flight-fight response), whereas

adrenocorticotropin in the anterior pituitary

the parasympathetic nervous system is respon-

gland and the secretion of Cortisol in the adrenal

sible for feeding, energy storage, and repro-

cortex. Cortisol is then released from

duction. T h e brain stem itself can initiate

adrenal cortex. Cortisol as a hormone is always

changes in the autonomic nervous system in

present in the body, indicating its importance in

single organs and tissues but is not efficient

normal functioning, but the levels vary due to

at coordinating across organs or between

both time of day (diurnal pattern) and current

systems. T h e role o f the autonomic nervous

stressors. Cortisol is responsible for increasing

the

BEHAVIORS THAT C O M P R O M I S E HEALTH sympathetic nervous system function, releasing

response, which cannot be easily eliminated by

stored glucose and fats for energy, and suppress-

behavioral and psychological mechanisms. If we reexamine the physiology of the stress

ing immune function. Another stress hormone that is important

response, some o f the negative consequences

also

of chronic stress become evident. T o begin

adrenomedullary

with, Cortisol and epinephrine, the hormones

response releases epinephrine into general cir-

released during the stress response, have detri-

culation in response to the increase in sympa-

mental effects when they are released continu-

to the stress response is epinephrine, known as adrenaline. T h e

thetic nervous system activity caused by the

ously. For example, one o f the roles o f Cortisol

release of Cortisol. Epinephrine increases rela-

is to suppress the immune function, which

tive to the stress response and assists in coor-

episodically is fine but which over a long

dinating

both

period of time leaves an individual susceptible

behavioral and metabolic changes necessary

to illness (Lovallo, 1 9 9 7 ) . Chronic stress also

bodily

systems

to

make

to deal with the stressor. M o r e specifically,

increases the amount o f time it takes for a

epinephrine stimulates heart muscles, increas-

wound to heal. For example, Kiecolt-Glaser,

ing heart rate and oxygen levels to prepare the

Marucha, Malarkey, M e r c a d o , and Glaser ( 1 9 9 5 ) examined the length of time it took for

body to respond to the stressor. After the first three components o f a stress

punch biopsy wounds to heal in individuals

response occur, regulation of the autonomic

caring for a relative with Alzheimer's disease

nervous system and endocrine system is main-

and found that wounds took significantly

tained by negative feedback. Information on

longer to heal in caregivers under chronic

Cortisol and epinephrine output is sent from

stress in comparison with control participants.

tissues and organs to the brain stem, hypotha-

The continuous release of Cortisol also might

lamus, and corticolimbic system, where the

be related to the sleep problems commonly

decision to continue production o f Cortisol

reported

among

individuals

experiencing

and epinephrine is made. If production o f

chronic stressors. As was mentioned earlier,

these hormones is no longer needed, messages

Cortisol is released diurnally two times per

are sent to the pituitary and adrenal glands to

day: once during the morning and then again

discontinue output.

after lunch. Researchers have found that the continuous release o f Cortisol decreases rapid eye movement ( R E M ) sleep, which is essential

Negative Physiological Impacts of Chronic Stress

to normal sleep cycles (Vgontzas, Bixler, & Kales, 2 0 0 0 ) .

Walter Cannon, a physiologist who first introduced

the term

stress,

distinguished

In addition, the release o f epinephrine during the stress response can put

individuals

between short-term and long-term stressors

experiencing chronic stress at risk for cardio-

(Carlson, 1 9 9 9 ) . H e discussed the fact that

vascular disease (Pollard, 2 0 0 0 ) . Epinephrine

physiologically we were built to deal with

stimulates cardiac muscles, resulting in an

episodic stressors rather than chronic stressors.

increased heart rate and potentially hyperten-

The stress response is designed to deal effi-

sion. Epinephrine also is involved in increasing

ciently with episodic stressors; however, there

blood platelet adhesiveness and in reducing

are negative physiological and psychological

clotting time, both of which are risk factors for

consequences when an individual is under

myocardial infarctions and

chronic stress. T h e negative physiological con-

accidents (Markovitz &c Matthews, 1 9 9 1 ) .

sequences resulting from chronic stress are due to the prolonged

activation o f the

stress

cerebrovascular

Chronic stressors also can negatively affect individuals

psychologically.

As

discussed

Stress and

Health

previously, the second stage in the stress

and how these models are translated

response after experiencing a stressor is the

treatment options.

into

appraisal process. During the appraisal process, emotions are generated, and emotions in turn influence an individual's mood. Chronic stress

Stimulus Models

can lead to a negative mood state such as depres-

Stimulus models focus on environmental

sion or anxiety. Negative mood states can influ-

events that produce demand on the organism.

ence how a person appraises situations by

Early research in this area (cf. Brown

serving as a filter through which he or she inter-

Harris, 1 9 7 8 ; Holmes & R a h e , 1 9 6 7 ) led to

prets information from the environment. H o w

a focus on negative life events as a major

&

the person appraises environmental events influ-

source o f stress. Intervention efforts focused

ences the duration of the stress response because

on learning to deal more effectively with these

it can be considered the highest level o f control

demands (coping) or on learning to predict

over homeostatic functioning (Lovallo, 1 9 9 7 ) .

and (where appropriate) minimize exposure

Although the human body is designed to

to negative life events. Cassidy ( 1 9 9 9 ) argued

deal with episodic stressors, chronic stress can

that these models primarily served a classifi-

negatively affect both the physiological and

cation role, providing researchers and clini-

psychological functioning o f an

individual.

cians with necessary tools for identification o f

However, individual differences resulting from

individuals experiencing stress. Intervention,

both genetics and life experiences influence

particularly stress management strategies, has

how individuals respond to stressors. In fact,

moved beyond stimulus models.

two individuals who experience the same traumatic event might react to the stressor completely differently depending on each

Response Models

individual's access to coping resources. By

Stress is frequently identified by the pres-

studying how individuals respond to stress,

ence o f specific symptoms that include overt

researchers have been able to develop coping

behavioral,

models for stress and to identify effective treat-

symptoms. These symptoms are the natural

p h y s i o l o g i c a l , and

cognitive

ment interventions designed to help individuals

consequences o f demand, and although one

develop coping skills.

cannot separate stress responses from stressors, focus on response models has played a major role in the development o f treatment strategies typically labeled "stress manage-

MODELS O F STRESS

m e n t " (cf. Lehrer &c W o o l f o l k , 1 9 9 3 ) . As noted previously, at the most basic level,

These models use a bottom-up explanation

stress involves two processes: an environmen-

rather

tal

physiological

appraisal models. M u c h o f the theory behind

response (stress response). Over the years,

these models comes out o f biofeedback and

models of stress have differentially focused on

relaxation research as well as from Eastern

these two components, with most contempo-

philosophy. T h e basic premise o f these models

event

(stressor)

and

a

than a top-down basis as in

the

rary models focusing on stress as a transactional

is that stress can be influenced by a person's

process (Cassidy, 1 9 9 9 ) . A comprehensive

level o f autonomic arousal. In other words, if

review o f the strengths and weaknesses of each

a person is experiencing high levels of arousal,

model is beyond the scope o f this chapter;

the person will feel as though he or she is

however, clinical health psychologists need to

under more stress. I f the arousal is reduced,

have familiarity with these major approaches

the person will subjectively experience lower

174

BEHAVIORS T H A T C O M P R O M I S E HEALTH amounts o f stress. This may occur even if the

event can be perceived as stressful or benign.

demands on the person have not been reduced

Stress appraisals, whether positive or negative,

or changed.

lead to autonomic arousal.

In relation t o this, it is believed that the

Lazarus proposed

three types o f stress

perception o f controllability o f arousal may

appraisals: harm/loss, threat, and challenge.

also influence stress levels. People w h o expe-

Harm/loss appraisals occur in cases where

rience high levels o f arousal and do not feel

damage has already occurred. For instance, a

as though they can control that arousal may

harm/loss appraisal would occur when a per-

report more stress than do people w h o expe-

son has become ill or injured, lost a loved one,

rience the same levels o f arousal but feel as

or suffered a blow to his or her self-esteem.

though they have control over their arousal.

Threat appraisals occur when harm or loss can be anticipated but has not yet occurred. These are different from harm/loss appraisals

Appraisal Models

mainly in that threat appraisals allow the per-

Appraisal models view psychological stress

son to plan and adapt to minimize or alleviate

as a process whereby an individual interprets

some o f the harm before it occurs. T h e third

or views environmental events and perceived

type o f stress appraisal is challenge. Challenge

coping ability that in turn shapes his or her

appraisals are more positive in that the focus

emotional,

physiological

is on opportunity to achieve growth or to gain

responses to events. Appraisal theories suggest

something from the event. These categories

that the person "appraises" an event in an

are not necessarily exclusive. There may be,

behavioral,

and

attempt to discern its meaning in the context of

and often are, situations in which threat and

his or her experiences. These appraisals lead

challenge appraisals are experienced from the

to decisions regarding whether or not the

same event.

event is viewed as threatening or harmful and

Once primary appraisal determines that an

what actions would be appropriate under the

event is stressful, a person must choose what he

circumstances.

or she is going to do about the situation. This is

Appraisal models are a natural outgrowth

where secondary appraisals come in. Secondary

of stimulus and response models. Appraisal o f

appraisals

an event by definition requires that an event

options for coping with a stressful event and the

evaluate the person's

available

occur. Thus, it should be no surprise that many

possible consequences of those actions. These

events that would be labeled as stressors are in

appraisals take into account personal resources

fact appraised as high demand. Likewise, when

and the limitations of the environment.

a person appraises an event as high demand,

Appraisals rarely occur in this linear fash-

the natural consequence o f such an appraisal is

ion. Rather, primary and secondary appraisals

behaviors, emotions, and/or cognitions that fit

may occur almost simultaneously, and changes

the definition of a stress response. Lazarus's model

in the event, new information, and/or changes

(Lazarus, 1 9 6 6 , 1 9 9 9 ;

in the level o f perceived threat may alter a

Lazarus & Folkman, 1 9 8 4 ) is the most widely

person's appraisals. Lazarus referred to these

accepted stress model. As noted previously,

new appraisals as reappraisals. A person reap-

Lazarus divided the appraisal process into two

praises an event when there are changes that

distinct

parts:

primary

and

secondary.

Primary appraisals are intended to determine the threat value of an event. They take into

may affect the stressfulness of the event or his or her ability to cope with it. Coping responses are generated from the

consideration the familiarity of the event, the

appraisal process. According to Lazarus, cop-

beliefs o f the person, and commitments. An

ing refers to constantly changing cognitive and

Stress and Health

175

behavioral efforts to manage specific external

whereas

and/or internal demands that are appraised

troubling to patients. Stress can lead to emo-

others can be quite severe

and

as taxing or exceeding the resources of the

tional impairments

person. Coping can be divided into two types

crying, nervousness, edginess, anger, and irri-

of responses: problem focused and emotion

tability. In addition, patients experiencing

focused. Problem-focused responses operate

chronic stress may feel overwhelmed, power-

directly on the situation itself and may include

less, and isolated. They may report general feel-

behaviors

personal

ings o f unhappiness and dissatisfaction. They

resources, altering the event, and/or generat-

may report feeling that life has no meaning any-

ing alternative solutions. Emotion-focused

more. Some patients may appear cynical or

coping is directed at lessening the emotional

apathetic. They may report that they feel empty

aimed

at

increasing

such as

inappropriate

distress caused by the event. Little or no effort

or directionless, and they may have a strong

is devoted to changing the event that caused

urge to try to prove themselves.

the distress. This type o f coping includes

People experiencing chronic stress often

strategies such as avoidance, reappraising the

exhibit cognitive problems such as foggy think-

situation, distancing, and selective attention.

ing, distractibility, and forgetfulness. They often

As with the division between types of appraisals,

say that they cannot stop worrying. Some

the

problem-focused

patients report that they cannot seem to be cre-

coping and emotion-focused coping is some-

ative anymore or have no sense of humor.

what blurred. People often engage in a coping

Chronic stress can also lead to behavioral prob-

strategy that serves both purposes or use more

lems and trouble in relationships. Stressed

than one strategy at the same time to serve

people may be bossy and critical o f others and

both purposes.

themselves. They may take up alcoholism or

boundary

between

Problem-focused strategies can be costly

smoking, or they may begin to eat or chew gum

early on because o f the energy and time that

compulsively. Spouses or partners of stressed

they require. However, they can lead to alter-

individuals often report that their significant

ations in the event that lessen its stress value

others grind their teeth in their sleep, have a

and so lessen the amount o f coping that con-

lowered sex drive, and have "clammed up."

tinues to be needed. Emotion-focused strate-

Stressed people may also seem resentful or

gies are not as costly early on, but if the

intolerant of others and may isolate themselves.

situation

remains

stressful,

these

coping

In addition to these impairments in a wide

responses can lead to a continued drain on

range o f functioning, people experiencing

resources. O n c e a coping response has been

chronic stress may experience a number o f

used, the situation is reappraised taking into

physical

account changes a person has made to the sit-

report headaches, fatigue, restlessness, and

uation or his or her response to it. In this way,

sleep disturbances. Patients also report unex-

the appraisal process is circular and recurrent.

plained backaches, painful muscle tension,

symptoms.

Patients

commonly

and gastrointestinal discomfort such as stomachaches and indigestion. Patients may also

SYMPTOMS OF CHRONIC STRESS

have an increased heart rate and increased blood pressure.

Chronic exposure to stress can lead to a variety of impairments in many domains. People who are under chronic stress report a number of symptoms. Some o f these symptoms are vague and do not greatly affect their functioning,

Effects of Stress on Health As noted earlier, stress increases the risk of disease. This can occur via the

numerous

176

BEHAVIORS T H A T COMPROMISE HEALTH symptoms just described or through the effects

disorders such as irritable bowel syndrome,

of stress on the immune system. In addition,

Chron's disease, and general gastric discomfort.

stress can exacerbate already existing disease states or can impede recovery from an illness.

As listed previously, some

Sleep Disorders.

Although the effects of stress on health have

of the symptoms o f stress include nervousness

been widely studied, there has been little con-

and constant worrying. These symptoms, as

clusive evidence on the mechanism by which

well as other stress effects, can lead to inter-

these effects occur.

ruptions in sleep patterns. Stress often leads to insomnia and frequent nighttime waking. T h e immune function is

Sleep efficiency is usually lowered, and people

very complex, involving many different anti-

may report feeling tired and worn out even

bodies and activities. One of the acute effects

after receiving a full night's sleep.

Immune

Function.

of stress is to suppress immune functioning and thereby increase infection susceptibility. Stress leads to increased adrenaline secretion,

Anxiety

and Depression.

As can be seen

from the list o f symptoms earlier, stress often

which suppresses the production o f some anti-

leads to feelings o f anxiety and depression, and

bodies, decreases macrophage activity, and

this can become a problem in itself for some

decreases interleukin production.

Reduced

patients.

immune

person's

function

can increase a

chances o f viral and bacterial infection, which

Substance

Abuse.

Some substances have a

may lead to illnesses such as the c o m m o n cold

stress-relieving effect, and some patients may

and mononucleosis. F o r instance,

resort to substance abuse as a way o f coping

Cohen,

Tyrrell, and Smith ( 1 9 9 1 ) placed a cold virus

with their high stress levels.

in the nasal passages o f participants. They found that participants who had reported high levels of stress within the past year were much

ASSESSMENT OF STRESS AND

more likely to become infected than were

T R E A T M E N T O F STRESS

those who reported low levels o f stress.

T h e exclusion o f "stress disorders" from the Cardiovascular

Disease.

Stress may also

exacerbate or lead to cardiovascular disease.

D S M - I V (Diagnostic of Mental

Disorders,

and Statistical

Manual

fourth edition [American

and

Psychiatric Association, 1 9 9 4 ] ) as a distinct

serum cholesterol levels. In addition, some evi-

category has led to a wide variety o f methods

Chronic stress elevates blood pressure

dence suggests that chronic central nervous

used in the measurement o f stress. F r o m the

system hyperactivity reduces the body's sensi-

clinical health psychologist's perspective, the

tivity to insulin, and this also increases blood

most important criterion for diagnosing a

pressure.

given complaint as a clinical stress problem is the judgment that it is amenable to improve-

Gastrointestinal

Disorders.

Stress

also

ment by changing the way in which the per-

affects the gastrointestinal tract. It can increase

son

colonic contractions or can lead to spasms in

transactions with

perceives

or

manages

his

the immediate

or

her

environ-

the colon. There may also be increased muscle

ment. Therefore, the diagnosis o f a clinical

tension in the abdominal area as well as

stress problem has less to do with the etiol-

throughout the body. Stress may also increase

ogy or severity o f the problem itself than

pain sensitivity. Consequently, people

with the prediction o f its responsiveness to

who

experience chronic stress may be seen for

the teaching o f coping skills.

Stress and Health

Assessment

177

interview format called the Bedford College Interview for Life Events and Difficulties, which

O n e o f the primary ways in which the

has been found to be both reliable and poten-

physician assesses preliminary signs o f stress

tially more useful because it allows trained

is the patient's self-report via questionnaires

raters to evaluate contextual factors surround-

and/or a clinical interview. Self-report ques-

ing specific life events. For example, someone

tionnaires typically allow the patient to rate

who lost a parent following a prolonged illness

whether a symptom is present or absent as

that preceded the death may view the "loss of a

well as the severity o f the symptom. Clinical

parent" event quite differently from someone

interviews are often designed to allow the

who lost a parent in an unexpected accident.

physician to use a checklist format for quick and efficient diagnoses.

Symptoms o f stress can be measured using common

emotional

scales, including

the

T w o o f the more frequently used scales to

Spielberger anxiety (Spielberger, Gorsuch,

assess stressors are the Life Events Survey

Lushene, Vagg, & J a c o b s , 1 9 8 3 ) and anger

(Sarason, Johnson, & Siegel, 1 9 7 8 ) and the

(Spielberger, 1 9 9 6 ) scales (for a review, see

Daily Hassles and Uplifts Scale (Kanner,

Spielberger,

Coyne, Schaefer, & Lazarus, 1 9 8 1 ) . T h e Life

1 9 9 9 ) , the Beck inventories (Beck Depression

Events Survey consists o f 5 7 items, and the

Inventory-II [Beck, Steer, &c Brown, 1 9 9 6 ] and

client checks each event that has ever hap-

Beck Anxiety Inventory [Beck, 1 9 9 0 ] ) , and

pened to him or her. T h e n the client rates each

broad-based measures such as the Symptom

of these items positively or negatively in terms

Checklist 90-Revised (Derogatis, 1 9 7 5 ) .

Sydeman, O w e n ,

&

Marsh,

of desirability and impact at the time the event occurred. Each item is rated on a 7-point scale from - 3 to + 3 , with the sum indicating the

Treatment

client's life events experience. Sarason and col-

T h e treatment o f stress disorders often falls

leagues ( 1 9 7 8 ) noted that negative scores are

into one o f two types: treatments aimed at

the best predictor o f health problems.

reducing central nervous system activation

The Daily Hassles and Uplifts Scale was

and treatments designed to address problems

developed to address more minor events in a

in appraisal or coping skills. Treatment tech-

person's life. This 143-item survey has gener-

niques that involve the alteration o f appraisals

ated enormous numbers of research studies

often incorporate cognitive strategies to alter

focusing on the types o f stressors found for

and improve the

competitiveness-readiness

individuals with various disease states (e.g.,

level, whereas central nervous system activa-

VanHoudenhove et al., 2 0 0 2 ) as well as on

tion reduction techniques focus on lowering

differences in stressful experiences of particu-

or controlling physiological arousal, anxiety,

lar high-risk populations

(e.g., M c C a l l u m ,

and muscular tension. It should be noted that is typically used

Arnold, & Bolland, 2 0 0 2 ) . In addition, psycho-

the term stress management

metric research evaluating the questionnaire

to describe a number o f treatment techniques

indicates that for some populations, the order

designed to reduce stress rather than referring

in which items are presented influences ratings.

to any one specific method. Lehrer

Specifically, events are rated as less uplifting

Woolfolk provided detailed chapters on the

when they follow hassle items than when they

methods and approaches that fit this broad

precede hassle items (Mayberry et al., 2 0 0 2 ) .

and

category o f "stress management" (Lehrer &

Life events can also be measured as part of a

Woolfolk, 1 9 9 3 ; W o o l f o l k & Lehrer, 1 9 8 4 ) .

structured or unstructured interview. Brown

In the current chapter, several o f the most

and Harris ( 1 9 7 8 ) developed a

common

structured

methods

are

merely

outlined.

178

BEHAVIORS T H A T COMPROMISE HEALTH Training in these individual techniques should

between tension and relaxation. T o first

be done under close supervision as part o f a

become familiar with the sensation o f tension,

formal training program.

the learner is instructed to lie on his or her back with arms at the sides and to bend the

Treatments Nervous

That System

Focus

on

Central

Reduction

Relaxation methods encompass a range o f

wrist up at a 90-degree angle. T h e learner perceives tension in the forearm. N e x t the learner performs much o f the same task except that this time the wrist is bent at a 45-degree

techniques, each with unique properties; how-

angle, producing less tension. This method is

ever, all share the goal o f creating a relaxation

repeated again at increasingly smaller angles.

response. This response is designed to activate

Using this method of diminishing tensions

the parasympathetic nervous system, resulting

teaches the learner to detect not only high ten-

in a decrease in oxygen consumption, heart

sion but even the most minute tension.

rate, respiration, and skeletal muscle activity

Relaxation

begins with

the

instructor

along with an increase in skin resistance and

explaining the basic physiology o f neuromus-

alpha brain waves. Four factors have been

cular circuits and the nature o f tension and

identified as important for eliciting a relax-

relaxation. T h e learning environment can be

ation response: a mental device (a word, a

quite varied; classrooms, gymnasiums, and

phrase, or an object to shift attention inward),

conference rooms all provide learners with

a passive attitude, decreased muscle tonus,

something soft to lie on such as mats, blan-

and a quiet environment. T h e ultimate goal of

kets, or thick carpets. In clinical treatment,

relaxation training is to evoke the relaxation

individual rooms with cots, pillows, and blan-

response to counter situational stress.

kets are often provided. It should be noted that complete elimination of external distrac-

Progressive

Relaxation.

Modern progres-

tion is not desired because the normal envi-

sive relaxation techniques were derived from

ronment

Edmond Jacobson's work during the early part

relaxing can be quite noisy. Relaxation starts

in which the individual will be

of the 2 0 t h century. T h e main premise of his

with the muscles o f the left arm and proceeds

approach was that it is impossible to be ner-

to the right arm, left and right legs, abdomen,

vous or tense when skeletal muscles are com-

back, chest, and shoulder muscles and then

pletely relaxed. Jacobson noted that relaxation

concludes with the neck and face muscles. T h e

is a fundamental physiological occurrence that

starting position is with the learner lying on

consists of systematically learning to elongate

his or her back, with the arms by the sides.

muscle fibers. For this reason, the use o f sug-

Only one position is practiced each hour. T h e

gestion by the progressive relaxation instructor

control signal, which for the position with

should be abandoned given that the perception

the hand bent back is the vague sensation in

of relaxation is not so important as actual

the upper surface of the forearm, is observed

physiological relaxation (McGuigan, 1 9 9 3 ) .

three times during each period. This is the

Jacobson's full progressive relaxation pro-

critical signal that the individual is to learn

cedure involves systematically tensing and

and recognize. T h e tensed position is held for

relaxing specific muscle groups in a predeter-

a minute or so, and then the "power goes off"

mined order and was described in great

(relaxing the signal away) for a few minutes.

detail by M c G u i g a n ( 1 9 9 3 ) . T h e individual is

During this initial session, the learner will

instructed to tense a muscle before relaxing it

make a few c o m m o n mistakes, and it is the

to help him or her recognize the difference

instructor's crucial j o b to catch and correct

Stress and Health these mistakes. These include misidentifying

Autogenic

Training.

Autogenic

179

training

a control signal as a strain and making an

was developed by Johannes Heinrich Schultz

effort to relax by working the hand down to

following his own observations o f individuals

a "resting" position, which is merely adding

under hypnosis and Oskar Vogt's observa-

m o r e tension, instead o f allowing the hand to

tions in brain research (Linden, 1 9 9 3 ) . Schultz

simply collapse.

noticed that hypnotized patients would report

The amount o f time required to learn pro-

a heaviness o f the limbs and a warmth sensa-

gressive relaxation may seem excessive from a

tion. Hypnosis was believed to be something

naive learner's point of view. Attempts to shorten

that patients allowed to happen to themselves,

the process have not yielded satisfactory results.

not something that the therapist did to them.

Jacobson explained that a body that has been

The objective o f autogenic training is to per-

practicing overtension for decades will not be

mit self-regulation in either direction (deep

able to reverse the process in brief sessions.

relaxation or augmentation o f a physiological

Children, however, have been shown to learn

activity) through

progressive relaxation quite rapidly, probably

also described as "self-hypnosis." Training

because they have not had as many years prac-

can be taught individually or in groups. T h e

ticing maladaptive tension habits.

ideal setting should be one at room temperature,

"passive

concentration,"

slighdy darkened, with a couch or exercise mats Abbreviated Training.

Progressive

Relaxation

and pillows.

Condensed versions o f progressive

relaxation have been linked to the w o r k o f

Biofeedback

Methods.

In general, biofeed-

W o l p e ( 1 9 5 8 ) , w h o developed a "short" ver-

back systems operate by detecting changes in

sion o f progressive relaxation for treating

the biological environment and conveying this

1993).

information to the client in the form o f visual

phobias

(Bernstein

Abbreviated

&

Carlson,

progressive

relaxation

was

and auditory signals (Stoyva &c Budzynski,

standardized and popularized by Bernstein

1 9 9 3 ) . T h e client then synthesizes this infor-

and Borkovec ( 1 9 7 3 ) in their classic text,

mation with a trial-and-error strategy to cause

and is the

the signals to change in the desired direction;

source citation for many clinical intervention

thus, the client learns how to control the bio-

studies using progressive relaxation (Hillenberg

logical response system. It is further intended

& Collins, 1 9 8 2 ) .

that the client will be gradually weaned away

Progressive

Relaxation

Training,

Bernstein and Carson ( 1 9 9 3 ) provided a detailed review of abbreviated which are summarized

procedures,

here. In the initial

from the biofeedback signal, allowing for the transfer o f control into everyday life. The most common form of biofeedback

training session, 1 6 muscle groups are the

used in stress management

focus of tension release procedures. T h e client

graphic ( E M G ) feedback. E M G feedback oper-

is electromyo-

is typically asked to recline during the intro-

ates

duction. T h e order in which the muscle groups

providing visual or auditory signals linked to

by

detecting

biological signals

and

are taught is standardized, and the therapist

this biological system via amplification of the

demonstrates the tensing methods and then

psychophysiological measures. This immediate

paces the client through the series o f tension

feedback is thought to facilitate learning to con-

release procedures. T h e client is encouraged to

trol or reduce arousal through trial-and-error

practice relaxation skills twice a day, 1 5 to 2 0

strategies designed to produce changes in the

minutes each time, with continued training in

signal in a desired

sessions paced by the therapist.

Budzynski, 1 9 9 3 ) .

direction

(Stoyva

&

180

BEHAVIORS THAT C O M P R O M I S E HEALTH E M G feedback offers a number o f specific

Meditation.

Although meditation is often

advantages as compared with traditional non-

viewed as a yoga-based technique, Carrington

biofeedback relaxation therapies in that it

(1978) introduced a "clinically standardized

provides a direct measure o f client learning

meditation procedure" that appears to be useful

through the monitoring o f muscular activity

for reducing stress symptoms in a range of

rather than depending on the client's verbal

health-related disorders (see also Carrington,

report

1993). Meditation can be divided into two dis-

o f relaxation. E M G data

quantify

physiological relationships and operationalize

tinct forms: concentrative and nonconcentrative.

the concept o f relaxation. Some drawbacks

The concentrative forms o f meditation

associated with biofeedback are that the client

simple to learn. The techniques are often prac-

may become dependent on the machine and

ticed in a quiet environment, with the object of

that it provides minimal training in coping

the meditator's attention being a mentally

strategies for reducing tension.

repeated sound, the meditator's breath, or some

are

other appropriate focal sound (e.g., running Yoga

water). If attention is found to be wandering, the

methods have had the most popularity in the

meditator is directed back to the attentional

Yoga-Based

Stress

Management.

treatment of hypertension (Patel, 1993). This

object in an unforceful manner. A nonconcen-

technique appears to reduce stress in part by

trative technique expands the meditator's atten-

helping the client to reframe the stressor in a

tional field to include as much of his or her

nonthreatening fashion. Yoga, which means

conscious mental activity as possible. In this

"union," is an Indian philosophy that presents

sense, the specific techniques of meditation are

various values, techniques, and disciplines to

secondary to the actual experience of meditation

teach ways of establishing harmony by develop-

in bringing about therapeutic change.

ing the mind among the various sides of life. The

In summary, there are many paths to the

sides of human life are both material (body) and

reduction

nonmaterial (mind and soul). Different tech-

activation, producing a shift toward lower

niques or combinations are used depending on

arousal characterized by

whether one's intellect, emotions, or actions dom-

nervous

inate. The main components of yoga include

stress response is characterized by a height-

14 breathing exercises (which facilitate regulation

ened sympathetic tone, shifting autonomic

o f sympathetic nervous

system

parasympathetic

system d o m i n a n c e . Because

the

of the mind and body), 2 0 0 balanced physical

dominance to the parasympathetic nervous

postures (which help to prevent musculoskeletal

system should be effective in

deterioration), and exercises for

awakening

stress and anxiety reactions regardless o f the

"kundalini" (the energy reservoir at the base of

methods used. Schwartz ( 1 9 9 3 ) pointed out

the spinal cord). Yoga is based on a belief that life

that although numerous methods are avail-

can be conceptualized as a gaseous exchange that

able for stress management, client character-

takes place between "inspired" (oxygenated) air

istics may lead the therapist to consider

and the blood circulating in the lungs. Deep

alternative

muscle relaxation, visualization, and meditation

clients' life histories and experiences and

strategies that

moderating

might

best fit

all are components of yoga-based therapies,

that might be more appealing to clients.

further illustrating yoga's emphasis ranging from

Therapists w h o develop skills in multiple

the physical to the spiritual in nature. For a more

methods will be in a better position to pro-

in-depth review of yoga methods, the reader

vide clients with methods that

is referred to Patel (1993), who provides a

evidence based and philosophically consistent

detailed summary of these methods.

with client expectations.

are

both

Stress and Health

|

COGNITIVE

cardiovascular, gastrointestinal). Therefore,

APPROACHES T O STRESS

the ultimate goal o f therapy is to reduce the dominance o f the controlling constellation o f

Cognitive approaches

conceptualize

stress

as the result o f an active cognitive set that includes successive appraisals of environmen-

cognitions and to allow the protective buffers' adaptive functions to take over. An

initial

treatment

approach

often

tal demands and the risks, costs, and gains of

includes directly reducing the exposure o f the

specific coping responses. W h e n an individual's

stressful stimuli to the individual. This serves

vital interests appear to be challenged, cognitive

to reduce the intensity o f the cognitive con-

processes provide a selective conceptualization

stellations, reduce the mobilization o f the

of what is occurring. Beck ( 1 9 9 3 ) provided an

neuromuscular endocrine system, and increase

in-depth review o f cognitive approaches

perspective and objectivity. This sets the stage

to

stress management that are summarized in the

for the individual to n o w reflect on his or her

current chapter.

reactions, test other options, and adopt a

T h e initial appraisal o f an event can be

broader and more realistic view o f the situa-

considered a quick scan to determine whether

tion. T h e specific terms for the previously

it is pleasant, neutral, or noxious. W h e n the

described treatment are as follows: identifying

vital interests (harm or enhancement) o f an

automatic thoughts

individual (egocentric view) are assessed to be

n o w ? " ) , recognizing and correcting cognitive

( " W h a t am I thinking

affected, a critical response ensues. An emer-

distortions ("It does not have to mean this; it

gency critical response is activated when the

is probably that"), and identifying the broad

individual perceives a threat to his or her sur-

beliefs and assumptions

vival, domain, individuality, or status. This

hyperactive constellations ("I'm a bad person

response is critical to the development o f stress

and I don't deserve good things"). T h e process

reactions. At the same time the situation is

described previously

evaluated as a threat, the individual is assess-

known as cognitive restructuring or the A B C

ing his or her resources for dealing with the

approach. T h e premise is that the antecedent

ensuing problem. This assessment is labeled

or event leads to thoughts and feelings that

"secondary appraisal" (Lazarus,

1966).

that underlie

outlines the

the

process

ultimately drive the individual's behavior. By

T h e basic rationale behind the treatment o f stress from a cognitive perspective is that cer-

changing the way in which the

individual

thinks about the events, the person will be able

tain idiosyncratic cognitive patterns become

to change his or her behavior. In respect to this

hyperactive and lead to the overmobilization

chapter, the individual will be able to reduce

of the voluntary nervous system and auto-

the stress response by "seeing the problem in

nomic nervous system. W h e n this occurs, the

another light" using this systematic approach.

protective buffers and adaptive functions (e.g., objectivity, perspective, reality testing)

are

rendered ineffective against the cognitive constellation that has been triggered. This overmobilization

directly

results

in

reactive

Stress Inoculation Training Stress inoculation training is based on the premise that bolstering (inoculating) an indi-

syndromes (e.g., anxiety, hostility) or psycho-

vidual's repertoire o f coping responses

somatic syndromes. In the long term, these

milder stressors can serve to defuse responses

to

physical effects can lead to dysfunction o f spe-

to major life stressors (for a more extensive

cific systems or organs (e.g., musculoskeletal,

review, see M e i c h e n b a u m , 1 9 9 3 ) . This is

182

BEHAVIORS T H A T C O M P R O M I S E HEALTH accomplished with the use o f an overlapping

cascade o f behavioral and biological processes

three-phase intervention approach. The goal of

that include autonomic nervous system arousal

the initial phase is to establish a relationship

and endocrine activation. Through the modifi-

between the trainer and the client to help the

cation o f appraisal processes, an

client better understand the nature of stress and

is able t o minimize threat

its effects on emotions and behavior. Similarly to

thereby reducing levels o f the stress response.

the cognitive approach, this initial phase focuses

Treatments that focus on central

on getting the client to appreciate how he or she

system reduction directly can be conceptualized

and

individual demand, nervous

appraises both events and on his or her ability to

as "bottom-up" methods that directly influence

cope with the events. In addition, alternative

behavioral and biological processes. In addi-

explanations and alternatives are explored. At

tion, some central nervous system reduction

the end of the initial phase, a reconceptualiza-

methods have been shown to directly influence

tion of the client's problems is made.

cognitive processes that show up as enhanced

T h e second phase focuses on coping skills acquisition

and

rehearsal

o f these skills.

coping and reduced perception of demand based on the individual's "knowing" that he or

Attention is paid to removing factors that

she now has the skill to reduce arousal directly.

may interfere with adequate coping such as

T h e following case study illustrates this point.

maladaptive beliefs and feelings o f low selfefficacy. T h e skills are practiced initially in the training setting, with gradual

introduc-

CONCLUSIONS

tion in vivo. The final phase of stress inoculation training

This chapter has provided an overview of the

calls for the client to apply the variety of learned

biological and psychosocial factors related to

coping skills across increasing levels ("inocula-

stress. A great deal o f attention was given to the

tion") of stressors on a graduated basis. This is

biological mechanisms involved in the stress

behavioral

response because this is an aspect o f training

rehearsal, modeling, role-playing, and graded in

that is often lacking. As the case study illus-

vivo exposure. Attention is also allocated to

trates, assessment and treatment may at times

relapse prevention. The client is taught how to

focus on behavioral and cognitive factors; how-

handle a lapse and not allow for it to become a

ever, knowledge of the biology of stress may

relapse. In summary, stress inoculation training

help clients to accept psychological treatment.

accomplished

by imagery and

combines client self-monitoring,

cognitive

T h e treatment methods presented in this

restructuring, problem solving, self-instructional

chapter were, by necessity, merely summarized.

and relaxation training, behavioral and imag-

Therapists who have not used relaxation or

ined rehearsal, and environmental change, with

other anxiety reduction methods should seek

the goal of enabling the client to be flexible in

out supervised experiences before using these

his or her coping repertoire and to have the

with clients. W h a t at times seems very easy to

confidence to cope resourcefully.

do can in fact be much more complicated than it appears. As should be noted from both the case study and the early work of Jacobson, it

Summary

takes a great deal of therapist time to success-

As this brief review illustrates, there are many

approaches

to

stress

management.

fully train relaxation skills. Merely sending clients home with a taped session is not suffi-

Cognitive approaches focus on a "top-down"

cient. Likewise, the cognitive

method, with the primary goal being the reduc-

require systematic training and should not be

tion o f cognitions that, if unchecked, begin a

attempted without supervised experiences.

interventions

Stress and

Health

CASE S T U D Y "Jane M . " was referred by her physician for treatment o f stress that was thought to be linked to her frequent headaches. J a n e had recently been promoted to a managerial position with her company, and the new position required that she visit regional offices in nearby states on a frequent basis. She was on the road several days each week, and for the past 6 months she reported constant fatigue and frequent headaches. While fatigued and tired, she found it difficult to relax at night while on the road. Baseline

assessment

included

the

D a i l y Hassles

and

Uplifts

Scale,

the

Spielberger State-Trait Anger Inventory, the Beck Depression Inventory-II, and a clinical interview. Results indicated mild levels o f depression and moderate to severe levels o f anger. T h e anger appeared to be most linked to J a n e ' s dissatisfaction with the staff at m a n y o f the hotels where she stayed and her inability to be "treated with the respect that she deserved" when problems arose. T h e r e were few life events rated as positive, with m a n y m i n o r annoyances receiving very negative ratings. Although it seemed clear that J a n e ' s stress levels were at times generated by her perceptions o f events and expectations that she " s h o u l d " be treated more respectfully, it was also obvious from early sessions that she was physiologically very tense and quite concerned that her physician believed her problems were all "mental." T h e therapist spent a great deal o f time discussing h o w negative events start a chain of physiological processes that lead to heightened arousal that for some people result in headaches or other physical problems. F o r some clients, merely learning to reduce this arousal can be useful. J a n e showed a strong interest in learning h o w to reduce physical arousal, and a treatment plan was developed that initially focused on learning relaxation skills. T h e relaxation method used was a form o f abbreviated progressive relaxation training developed by Charles R . Carlson (Carlson, Collins, Nitz, Sturgis, & Rogers, 1 9 9 0 ; Carlson, Ventralla, & Sturgis, 1 9 8 7 ; K a y & Carlson, 1 9 9 2 ) called stretch-based relaxation. Stretch-based relaxation focuses on stretching o f muscles, facilitating a differentiation o f muscle sensations that contributes to a recognition of muscle tension and fosters relaxation o f the muscles. Training was conducted over an 8-week period, with in-session relaxation training taking between 3 0 and 4 0 minutes o f each session. T h e remaining time was spent discussing the application o f stretch-based relaxation to J a n e ' s daily routine and fine-tuning home practice. H e r initial response was that she could not produce the levels o f relaxation at h o m e that she experienced in sessions, and these concerns and expectations were addressed with a reminder that she would improve with continued practice. At Session 5 , she reported feeling much more effective at home, and in-session training switched from being therapist-led training to client-paced training with the therapist observing J a n e ' s performance.

184

BEHAVIORS T H A T C O M P R O M I S E HEALTH

At Session 6 , J a n e reported a critical incident where she was checking into a hotel and the night clerk could not find her reservation. It t o o k some time for the clerk t o c o m e up with a suitable r o o m , and in the past she would have become physically tense and extremely angry and would have developed a headache that would keep her from sleeping well. She remembered thinking t o herself that if she got tense from this "incompetent c l e r k , " she would just use her relaxation skills to c a l m d o w n once she was in her r o o m and could avoid getting a headache. N o t only did she not get a headache that evening, she did not even feel tense while waiting. Discussion with her therapist indicated that the knowledge that she " k n e w what to do if she got t e n s e " seemed to ward off feelings o f tension. She began to entertain the idea that it was n o t merely the situation that " g o t her tense"; rather, it was her reaction to the situation (including the expectancy that a headache would ensue) that contributed to her tension. Sessions 7 and 8 involved a minor review o f stretch-based relaxation, with a great deal o f the sessions devoted to discussion o f h o w J a n e planned to implement this new skill in her life t o keep herself more relaxed. Readministration o f the Daily Hassles and Uplifts Scale indicated that the number o f situations did not change but that the perception o f the situations as negative was greatly improved. Headaches had dropped off significantly with more relaxed sleep and energy. J a n e was encouraged to continue formally practicing relaxation on at least a weekly basis.

REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beck, A. T . (1990). Manual for the Beck Anxiety Inventory. San Antonio, T X : Psychological Corporation. Beck, A. T. (1993). Cognitive approaches to stress. In P. M . Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 3 3 3 - 3 7 2 ) . New York: Guilford. Beck, A. T., Steer, R. Α., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-11. San Antonio, T X : Psychological Corporation. Bernstein, D. Α., & Borkovec, T . D. (1973). Progressive relaxation training: A manual for the helping professions. Champaign, IL: Research Press. Bernstein, D. Α., & Carlson, C. R. (1993). Progressive relaxation: Abbreviated methods. In P. M . Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 5 3 - 8 8 ) . New York: Guilford. Brown, G. W., & Harris, T . O. (1978). Social origins of depression: A study of psychiatric disorder in women. London: Tavistock.

Stress and Health Carlson, C. R., Collins, F. L., Nitz, A. J . , Sturgis, E. T., & Rogers, J . L. (1990). Muscle stretching as an alternative relaxation training procedure. Journal of Behavior Therapy and Experimental Psychiatry, 21, 2 9 - 3 8 . Carlson, C. R., Ventralla, Μ . Α., Sc Sturgis, Ε. T. (1987). Relaxation training through muscle stretching procedures: A pilot case. Journal of Behavior Therapy and Experimental Psychiatry, 18, 1 2 1 - 1 2 6 . Carlson, N. R. (1999). Foundations of physiological psychology (4th ed.). Boston: Allyn & Bacon. Carrington, P. (1978). Clinically standardized meditation (CSM) instructor's kit. Kendall Park, NJ: Pace Educational Systems. Carrington, P. (1993). Modern forms of meditation. In P. M. Lehrer Se R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 139-168). New York: Guilford. Cassidy, T. (1999). Stress, cognition, and health. New York: Routledge. Cohen, S., Tyrrell, D. A. J . , Sc Smith, A. P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325, 6 0 6 - 6 1 2 . Derogatis, L. R. (1975). The Symptom Checklist 90-Revised. Minneapolis, M N : NCS Assessments. Hillenberg, J . B., & Collins, F. L. (1982). A procedural analysis and review of relaxation training research. Behaviour Research and Therapy, 20, 2 5 1 - 2 6 0 . Holmes, T. H., Sc Rahe, R. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research, 14, 2 1 3 - 2 1 8 . Kanner, A. D., Coyne, J . C , Schaefer, C , Sc Lazarus, R. S. (1981). Comparison of two modes of stress measurement: Daily hassles and uplifts versus major life events. Journal of Behavioral Medicine, 4, 1-39. Kay, J . Α., Sc Carlson, C. R. (1992). The role of stretch-based relaxation in the treatment of chronic neck tension. Behavior Therapy, 23, 423—431. Kiecolt-Glaser, J . K., Marucha, P. T., Malarkey, W. B., Mercado, A. M., & Glaser, R. (1995). Slowing of wound healing by psychological stress. Lancet, 346, 1194-1196. Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill. Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York: Springer. Lazarus, R. S., Sc Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lehrer, P. M., Sc Woolfolk, R. L. (1993). Principles and practice of stress management (2nd ed.). New York: Guilford. Linden, W. (1993). The autogenic training method of J . H. Schultz. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 2 0 5 - 2 3 0 ) . New York: Guilford. Lovallo, W. R. (1997). Stress and health: Biological and psychological interactions. Thousand Oaks, CA: Sage. Markovitz, J . H., Sc Matthews, K. A. (1991). Platelets and coronary heart disease: Potential psychophysiologic mechanisms. Psychosomatic Medicine, 53, 643-668. Mayberry, D., Mayberry, M., Bresnan, R., Croft, B . , Graham, R., Macaulay, J . , McQualter, S., Mitchell, E., Sherwell, K., Sc Szakacs, E. (2002). Responding to daily event questionnaires: The influence of the order of hassle and uplift scales. Stress and Health: Journal of the International Society of the Investigation of Stress, 18, 1 9 - 2 6 . McCallum, D. M., Arnold, S. E., Sc Bolland, J . M . (2002) Low-income AfricanAmerican women talk about stress. Journal of Social Distress and the Homeless, 11, 2 4 9 - 2 6 3 . McEwen, B. S. (2000). Stress, definitions and concepts of. In G. Fink (Ed.), The encyclopedia of stress (Vol. 3, pp. 5 0 8 - 5 0 9 ) . San Diego: Academic Press.

185

186

BEHAVIORS T H A T C O M P R O M I S E HEALTH McGuigan, F. J . (1993). Progressive relaxation: Origins, principles, and clinical applications. In P. M . Lehrer &C R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 1 7 - 5 2 ) . New York: Guilford. Meichenbaum, D. (1993). Stress inoculation training: A 20-year update. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 3 7 3 - 4 0 6 ) . New York: Guilford. Patel, C. (1993). Yoga-based therapy. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 8 9 - 1 3 8 ) . New York: Guilford. Pollard, T. M . (2000). Adrenaline. In G. Fink (Ed.), The encyclopedia of stress (Vol. 3, pp. 5 2 - 5 8 ) . San Diego: Academic Press. Sarason, I. G., Johnson, J . H., &C Siegel, J . M. (1978). Assessing the impact of life changes: Development of the Life Experiences Survey. Journal of Consulting and Clinical Psychology, 46, 9 3 2 - 9 4 6 . Schwartz, G. E. (1993). Foreword: Biofeedback is not relaxation is not hypnosis. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. vii-viii). New York: Guilford. Spielberger, C. D. (1996). Manual for the State-Trait Anger Expression Scale. Odessa, FL: Psychological Assessment Resources. Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., Sc Jacobs, G. A. (1983). The State-Trait Anxiety Inventory. Palo Alto, CA: Mind Garden. Spielberger, C. D., Sydeman, S. J . , Owen, A. E., & Marsh, B . J . (1999). The StateTrait Anxiety Inventory (STAI) and State-Trait Anger Expression Inventory (STAXI). In M. E. Marush (Ed.), The use of psychological tests for treatment planning and outcome assessment (2nd ed., pp. 9 9 3 - 1 0 2 1 ) . Mahwah, NJ: Lawrence Erlbaum. Stoyva, J . M., Si Budzynski, T. H. (1993). Biofeedback methods in the treatment of anxiety and stress disorders. In P. M . Lehrer 8c R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 2 6 3 - 3 0 0 ) . New York: Guilford. VanHoudenhove, B . , Neerincky, E., Onghene, P., Vingerhoets, Α., Roeland, L., Sc Vertommen, H. (2002). Daily hassles reported by chronic fatigue syndrome and fibromyalgia patients in tertiary care: A controlled quantitative and qualitative study. Psychotherapy and Psychosomatics, 71, 2 0 7 - 2 1 3 . Vgontzas, A. N., Bixler, E. O., 8c Kales, A. (2000). Sleep, sleep disorders, and stress. In G. Fink (Ed.), The encyclopedia of stress (Vol. 3, pp. 4 4 9 - 4 5 7 ) . San Diego: Academic Press. Wolpe, J . (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Woolfolk, R. L., 8c Lehrer, P. M. (1984). Principles and practice of stress management. New York: Guilford.

CHAPTER

11

Management of Inappropriate Medication-Seeking Behavior SUZY BIRD GULLIVER, BARBARA A . W O L F S D O R F , AND ALEXANDER

P

MlCHAS

erhaps one o f the largest occupational

challenges

faced

by

clinical

health

medication seeking in a patient or in a group of

patients,

or the psychologist may

be

psychologists is that o f addressing the

required to intervene with a provider or a group

unhealthy and/or inappropriate use o f medi-

of providers whose prescribing practices are

cations. T h e problem o f medication seeking is

suspect. Regardless of how the medication-

made all the more c o m p l e x because medica-

seeking behavior is identified,

tion-seeking behavior is not solely the respon-

sional assessment and treatment plans are the

multidimen-

sibility o f the patient w h o is actively engaged

keys to successful amelioration o f the difficulty.

in the behavior. T h e prescribing providers,

This chapter defines the problem o f medication

the health care system in which the patient

seeking, proposes

seeks treatment, cyber-community

a conceptual

framework

(most recently)

the

for understanding medication seeking, and

for pharmaceuticals

all

describes assessment plans as well as treatment

and

constitute potentially active participants in

development

this high-risk, maladaptive behavior.

descriptive case study is also presented to illus-

to address

this behavior.

A

Clinical health psychologists are frequently

trate these ideas. Finally, the chapter concludes

called on to intervene not only with patients

with a synopsis of what is known and what

but also with providers and the system to effec-

still needs to be explored to meet the field's

tively extinguish the problem behavior. Indeed,

overarching objective o f optimal clinical care.

referral sources for evaluation and treatment of medication-seeking behavior are nearly as c o m m o n as the types o f drugs that patients

DEFINITIONS AND DESCRIPTION

seek. For example, a clinical health psycholo-

OF MEDICATION-SEEKING

gist may become aware of medication seeking

BEHAVIOR

in a patient being treated for another disorder, the psychologist may receive consult requests

Definitions o f medication-seeking

from

(also known as drug-seeking behavior) are often

care providers

who

have

identified

behavior

188

BEHAVIORS T H A T C O M P R O M I S E HEALTH incomplete, vague, or lacking in the literature

target psychologists, case managers, nurses,

addressing the phenomenon. For the purposes

pharmacists, and other providers

of this chapter, the term

medication-seeking

"gatekeepers" to prescribing physicians. For

is used to highlight the pursuit of

instance, within the chapter authors' outpatient

behavior

legal prescription medications rather

than

seen as

mental health clinic, the psychiatric Walk-In

illicit "drugs." Medication-seeking behavior is

Clinic (WIC) operates each afternoon of the

defined as a pervasive pattern o f requesting

business week. The W I C is staffed by psychol-

medications that have either little or no thera-

ogy and social work trainees, licensed mental

peutic efficacy for the presenting

problem

health care providers, and supervising clinical

and/or in dosages exceeding therapeutic limits.

health psychologists. Medication evaluations

This definition is consistent with that offered

(with the possibility o f immediate prescriptions)

by Pankratz, Hickam, and Toth ( 1 9 8 9 ) , who

are provided 3 days a week for 1 hour by nurse

defined drug-seeking behavior as "any attempt

practitioners and psychiatrists. O n e of the prin-

to influence a physician to prescribe excessive

cipal tasks in the W I C is to identify medication

medication or to obtain abusable medications

seeking and make appropriate treatment plans.

through illegal activities" (p. 1 1 5 ) .

The multidisciplinary team is ideally suited for

Notably, medication-seeking behavior may

this task, as is described in greater detail later.

occur within several contexts. For example,

The health psychologist, as a senior supervisor,

this maladaptive

manifest

must be aware of the different contexts within

within a somatoform disorder in which the

which medication-seeking behavior may occur

behavior m a y

patient has a genuine conviction of his or her

and must be prepared to work with a multitude

illness and requests medication "appropriate"

of

different

professionals relative to

this

for the believed illness (Singh, 1 9 9 8 ) . Alter-

issue. Although much discussion within this

natively, medication seeking may occur within

chapter centers on the prescribing physician,

the presence of an addiction that began with

the issues raised are equally important for all

appropriate treatment o f a valid medical or

health care providers who come in contact with

psychological illness, in which case the behav-

medication-seeking patients.

ior represents an attempt to prevent with-

The

pervasiveness of medication-seeking

drawal symptoms or loss o f functioning and

behavior, as defined here, is as yet unknown.

may or may not be sincerely driven. Finally,

Very little clean data exist that would yield

this behavior may be largely manipulative in

meaningful conclusions regarding its incidence

nature and be motivated by the desire for a

and prevalence. However, in addition to the

"high," for thrill seeking, or for the street

clinical lore that most practicing health psy-

value and concomitant financial rewards o f

chologists will endorse, some national statistics

possessing desirable medications. Clearly,

are useful. For instance, the American Medical

these contexts for medication-seeking behav-

Association (ΑΜΑ) stated, " T h e abuse of pre-

ior are not mutually exclusive.

scription drugs results in more injuries and

Furthermore, a number o f distinct health

deaths to Americans than all illegal drugs com-

care professionals may be affected by medica-

bined. Prescription drugs are involved in more

tion-seeking patients and subsequently may call

than 6 0 % of all drug-related emergency room

on health psychologists to intervene. Physicians

visits and 7 0 % o f all drug-related

deaths"

are likely the most frequently targeted group

(Weiss &c Greenfield, 1 9 8 6 , cited in Lewis &

(although this assertion has yet to be evaluated

Gaule, 1 9 9 9 , p. 8 3 8 ) . T h e National Institute

empirically), but patients may also look to

on Drug Abuse (NIDA, 2 0 0 1 ) reported that

nurse

to

approximately 9 million Americans over age

obtain medications. In addition, patients may

12 years used prescription medications for

practitioners

in

their

attempts

Inappropriate

Medication-Seeking

Behavior are

\

nonmedical reasons in 1 9 9 9 , and the incidence

addiction). Pain syndromes

of prescription drug abuse seems to be increas-

maintained, at least in part, by the negative

frequently

ing. For example, according to the 1 9 9 9

reinforcement achieved through narcotic medi-

National Household Survey on Drug Abuse,

cations. Although some data argue persuasively

increased

that a cycle of overuse cannot be instated when

for nearly all medication classes from 1 9 9 0

patients are faced with scheduled dosing for a

nonmedical use o f prescriptions

initiation

pain syndrome, certain subgroups of patients

increased by 1 8 1 % , tranquilizer use increased

are at increased risk for negative sequelae from

by 1 3 2 % , sedative use increased by 9 0 % , and

as-needed dosing (Poling 8c Byrne, 2 0 0 0 ) . That

to

1 9 9 8 . Pain relief medication

stimulant use increased by 1 6 5 % . In fact, the

is, patients who have a known history o f prior

street value o f abused (but prescribed) medica-

addictions

tions was second only to cocaine sales between

tobacco use disorder) are more likely to be

1 9 8 7 and 1 9 9 7 ( Α Μ Α , 1 9 8 8 ) .

noncompliant with a fixed dosing schedule and

(perhaps with the exception o f

addressing

are at increased risk for a craving response and

medication seeking are not clear and distinct,

possible relapse to the drug o f choice while on

indirect measures o f the scope and intensity o f

a fixed dosing schedule.

Although the published

data

the problem can be divided into the following categories: challenges for the

patient,

The final negative consequences o f medication-seeking behavior to patients are societal.

challenges for the physician, challenges for the

Patients who become labeled as

medical system, and challenges for the culture.

seeking

medication

suffer the slings and arrows o f social

disapproval,

often inspiring dislike

among

care providers. As described previously, many

Challenges for the Patient

patients began the cycle o f medication seeking

Multiple negative medical consequences

while under care for documented medical or

may result from medication seeking on the

psychological illnesses; therefore, they are in

part o f the patient. First, there is the risk o f

part correct in their assertions that they are ill

medication complications, such as overdose,

and in need o f medication. Y e t the attitude o f

and the ongoing concern o f polypharmacy.

hostility and dislike toward these patients, and

Second, when

physiological

the subsequent conflictual relationships with

addictions are unable to meet their medica-

health care providers, may result in increased

patients with

and/or

increased likeli-

tion needs, the possibility o f triggering an

"doctor shopping"

acute withdrawal

syndrome exists. Third,

hood o f the acquisition o f prescriptions from

patients w h o chronically medicate might not

providers motivated to avoid conflict (e.g.,

observe or report symptoms that need assess-

Longo, Parran, Johnson, & Kinsey, 2 0 0 0 ) .

ment and additional treatment.

These possible consequences in turn decrease

In addition, patients who attain the medica-

the likelihood o f appropriate patient care and

tions of choice begin a cycle of negative rein-

are largely iatrogenic because these patients

forcement that is ultimately likely to increase

are likely in need o f more—not less—clinical

the symptoms for which the medications are

management.

prescribed. For instance, Silberstein

(1992)

noted that medication abuse can result in increased headaches in patients who previously

Challenges for the Physician

had intermittent headaches. T h e tremendous

The drug-seeking patient presents multiple

power o f the negative reinforcement cycle is

challenges for the physician. First, the patient's

well documented in problems that are primarily

behavior places the patient's life in danger,

psychogenic in nature (e.g., anxiety disorders,

and this places attendant liability on

the

189

290

BEHAVIORS T H A T C O M P R O M I S E HEALTH physician. Patients suspected o f medication

medication. For instance, much o f the focus o f

seeking are difficult to assess and even more

changing physician prescribing practices has

challenging to treat. In addition, the assess-

been in the area o f decreasing the prescription

ment o f such patients treads very closely to

of "drugs of abuse." However, Parran ( 1 9 9 7 )

accusing them o f dishonesty, and this violates

stated that the systematic undertreatment of

the basic premise o f the physician-patient rela-

acute pain and undertreatment of malignant

tionship. Patients facing an evaluation o f

pain is pervasive and unnecessary. Also of

medication-seeking behavior frequently become

note is the fact that medications with exceed-

hostile and angry. This response is generally

ingly low abuse liability (e.g., antibiotics) are

experienced as punishing to the care provider,

overprescribed, and this creates a new cate-

and it decreases the chances that the provider

gory o f abuse. W i t h the advent o f antibiotic-

will confront similar patients in the future.

resistant bacteria, overprescription of other

Second, in most instances, the physician has

medications has also been called into question.

been trained in a " c u r e " model. Therefore, when a disease that cannot be cured (e.g., chronic pain syndrome) presents at a clinic, the appropriate response within this model o f

Challenges for the System Perhaps the most pervasive systemic prob-

training is to attempt to increase the dose or

lem with medication seeking is the amount of

intensity o f the treatment so as t o better help

time and resources that is consumed by medi-

the patient. I f the patient does not respond to

cation misuse, both in terms o f treating these

the increased care, the physician's confidence

patients

in the mode o f treatment declines, and the

and in terms o f attempting to intervene in

physician is left t o either "blame the healer or

these complex behavioral interactions. Systems

blame the patient."

must

Third, the physician's behavior is shaped by

appropriately

and

establish mechanisms

identify offending

patients

inappropriately

by which and

to

physicians.

the patient's response, and this presents two

They must track both groups for a sufficient

difficulties. T h e patient, w h o may immediately

duration to establish patterns o f behavior and

at

legitimacy o f claims, and they must create a

reinforces

remediation plan. These are costly measures in

become more pleasant and manageable the sight o f a prescription pad, providing

medication.

In

contrast,

the

terms o f both fiscal implications and systemic

unhappy patient can create a rather large dis-

morale. T h a t is, health care providers working

turbance in the course o f a busy schedule. T h e

within systems plagued by medication seeking

physician learns quickly that the provision o f

are likely unhappy with the position of "med-

medication will allow him or her to return to

ication police" and face additional scrutiny by

other patients who are less aversive, so an addi-

a community that may perceive differential

tional negative reinforcement loop emerges.

"fault." Furthermore, reports o f medication

T h e controversy over medication-seeking

mismanagement in the media are likely to

behavior and the concomitant responses o f

send more patients to alternative sources o f

physicians is not complete without acknowl-

health care, and this taxes the system in new

edgment that practices o f overprescribing are

ways (e.g., decreased revenues, increased acute

only half of the story. Inadequate pharmaco-

illness o f unknown etiology due to patient

logical treatment o f legitimate medical and

having nontraditional care that may have only

psychological illnesses presents

placebo effects or even be iatrogenic). Finally,

an

equally

problematic (although less widely discussed)

systems are aware o f bona fide medication

issue. In keeping with the medical code o f

prescriptions for dependents being used by

ethics, it is at least as problematic t o under-

medication-seeking caregivers (e.g.,

prescribe medication as it is to overprescribe

using their children's Ritalin, adult children o f

parents

Inappropriate terminally ill patients using parental

pain

medications to the detriment o f genuine pain management o f the ill parents).

Challenges for the Culture T h e problem o f medication seeking also has implications for the culture. Specifically, problems o f increased mortality o f patients, decreased confidence and hope in medicine (thereby driving health care providers away from patient care), and increased costs to the system all c o m b i n e to create significant threats to public safety. Determining appropriate interventions requires further consideration o f the legal implications for liability, responsibility, and potential prosecution. In sum, the problem o f medication seeking is large and complex and has the potential for widespread harm that far exceeds the dynamics of a small number o f individual patients who greatly t a x a small number o f physicians. A handful o f scientists and practitioners have started to explore a number o f intervention tactics for this problem. This literature is described next.

Medication-Seeking

Behavior

reference sections of the articles mentioned previously. Thus, an extensive review of 2 9 years of published, peer-reviewed literature yielded 5 2 available articles that were directly or peripherally related to this issue (a rate of less than 2 pertinent publications per year). These literature search results are consistent with the one published evaluation that could be located addressing the methodology o f the existing literature (Nichol, Venturini, & Sung, 1 9 9 9 ) . Nichol and colleagues ( 1 9 9 9 ) surveyed a computerized Medline

search from

1 9 8 0 to 1 9 9 6 using "patient compliance" as a major term and "drug therapy" as a subheading term. O f the random subset o f the 7 1 9 identified articles, the majority o f research articles on medication compliance (a behavioral neighbor o f drug seeking) were descriptive in nature ( 6 3 . 9 % of the articles reviewed). M o s t ( 4 1 . 7 % ) used a sample o f convenience, and the overall quality o f the

published

research was evaluated as very poor. Thus, the amount o f empirical literature available to inform this section is quite limited. With that cautionary note, there are three areas in which published data exist: (a) epidemiological data on prescription drug abuse, (b) content and case reviews of physicians, and (c) evaluation reports regarding the usefulness

O V E R V I E W O F RESEARCH IN

of systemic interventions to change the rein-

MEDICATION SEEKING

forcement o f medication seeking by decreasing

Very little empirical work on medication seeking is available in the literature today. A literature search using the Psycblit databases, including publications between 1 9 7 2 and 2 0 0 2 and using the terms "medication seeking" and "drug seeking," yielded 3 8 citations, o f which only 6 were directly relevant to this chapter. A similar Medline search using the same terms and years o f literature yielded 19 citations, o f which only 4 were relevant to this chapter. W h e n the search was expanded to include "prescription drug abuse" and "medication noncompliance" for the same time frame, an additional 4 relevant citations were found using Psych lit and an additional 1 2 relevant citations were found using Medline. Finally, 2 6 additional articles were identified from the

prescriptions, particularly among medications with higher abuse potential. O n e published evaluation o f methods to alter physician skill levels in assessing and responding to medication seeking was available but showed no significant gains as a result o f training (Taverner, Dodding, & White, 2 0 0 0 ) . N o data beyond a handful o f case descriptions were available on the nonmedical treatment o f medication seekers in an individual or group setting.

Epidemiological Data As noted previously, few data from epidemiological studies tracking the use and misuse o f prescription medications are available.

192

BEHAVIORS T H A T C O M P R O M I S E HEALTH T h e most recent National Household Survey on Drug Abuse (NIDA, 2 0 0 1 ) indicates that drugs other than caffeine, alcohol, nicotine,

Content and Case Reviews of Physicians

cannabis, stimulants, and heroin were used by

According t o Kofoed, B l o o m , Williams,

about 8 % of the general population during

Rhyne, and Resnick ( 1 9 8 9 ) , the problem o f

the month immediately preceding the trial.

inappropriate prescribing is the largest single

Given the sampling biases o f the National

category o f complaints filed against physi-

Household Survey (e.g., homeless individuals,

cians. Interestingly, only a small percentage

itinerant workers, and school truants are not

of physicians are responsible for most inap-

captured in the sample), actual drug use may

propriate prescriptions. F o r example, results

be greater in the population at large.

from M a r o n d e , Seibert, and Katzoff ( 1 9 7 2 )

Among drugs that are coded as Schedule Π

suggest t h a t

less t h a n

5%

o f the

(high abuse potential with severe dependence

accounted for 5 0 % o f the

liability [e.g., narcotics]) or Schedule ΙΠ (less

prescriptions written in one hospital.

staff

inappropriate

abuse potential than Schedule I and Schedule II

Kofoed and colleagues ( 1 9 8 9 ) reviewed

but containing small amounts of certain narcotic

the cases o f reported inappropriate prescrib-

agents [e.g., acetaminophen with codeine]), no

ing that were deemed substantive and pur-

published estimates of use or abuse could be

sued t o some degree by the O r e g o n B o a r d o f

found. Schedule I V medications (less abuse

Medical Examiners between 1 9 8 1 and 1 9 8 6 .

potential than Schedule ΠΙ medications, includ-

Results indicated that m o r e than half ( 5 1 % )

ing drugs such as benzodiazepines) do have

of the complaints resulting in informal inter-

drug-specific use figures. Specifically, the Task

views with the investigative committee o f the

Force on Benzodiazepine Dependency o f the

board

American Psychiatric Association reported that

writing. (This is in contrast t o the second

involved inappropriate

prescription

1 0 % to 1 2 % of the population use benzodi-

most frequent category o f complaints, habit-

azepines each year but that only 1 % to 2 % of

ual or excessive use o f intoxicants, which

the population take these drugs on a long-term

accounted for only 1 3 % o f such investiga-

basis (Gold, Miller, Stennie, &c Populla-Vardi,

tions.) Furthermore, complaints o f inappro-

1 9 9 5 ; Salzman, 1 9 9 0 ) .

priate prescribing involved an average o f

Perhaps

the most instructive data

drawn from

populations

are

o f hospitalized

approximately

2

drugs,

most

frequently

including opiates and/or benzodiazepines. In

patients. These data demonstrate that addic-

fact, 9 o f the 1 0 most frequently cited inap-

tions affect up to 5 0 % o f this population. In

propriately prescribed medications belonged

addition, 1 5 % t o 3 0 % o f patients seen in

t o one o f these two categories o f drugs.

primary care settings meet criteria for addic-

In addition to the identification of specific

tion (Longo et al., 2 0 0 0 ) . A m o n g psychiatric

types of medications that may be inappropri-

patients, estimates o f c o m o r b i d addictions

ately prescribed, Kofoed and colleagues (1989)

are even higher. Given that

identified types of patients w h o may be pre-

most

abuse

(upward o f 8 0 % in the example o f benzodi-

scribed medications inappropriately.

azepine abuse) o f Schedule I V drugs occurs

8 0 % of patients identified in complaints of

Nearly

within the context o f polysubstance abuse or

inappropriate prescribing were pain patients

dependence (Longo et al., 2 0 0 0 ) , the prob-

( 5 5 % ) or drug-seeking patients ( 2 4 % ) . In addi-

lem o f drug abuse is likely t o be a significant

tion, slightly more than half of the physicians

red flag for identification o f populations at

under investigation for any reason between

increased risk for medication seeking.

1 9 8 1 and 1 9 8 6 had a history of at least one

Inappropriate of

medication-seeking behavior by the disruption

for inappropriate prescription writing.

of

diversion

may

indirectly

\

other investigation during the previous 4 to 9

drug

methods

Behavior

years; of those previous complaints, 7 0 % were Perhaps most important is the assertion by

these

Medication-Seeking

affect

(Cooper, Czechowicz,

Molinari, & Petersen, 1 9 9 3 ) . T h e Automated

Kofoed and colleagues ( 1 9 8 9 ) that inappropri-

Reports and

ate prescribing is unlikely to be a problem o f

( A R C O S ) , Drug Investigational Units (DIU),

intentional deceit. In fact, less than 5 % of

Electronic Point o f Sale Systems ( E P O S ) ,

physicians under investigation appeared to be

Medicaid Fraud and Abuse System (MFAS),

clearly dishonest. Rather, the large propor-

and

tion o f physicians under investigation were

(MCPP) all are available to decrease medication

guilty o f possessing inadequate pharmacological

diversion. An expert panel at N I D A evaluated

knowledge or o f being

"pseudobenevolent

the clinical utility o f these systems and pub-

overprescribers." These last-mentioned over-

lished its findings in 1 9 9 3 . It was found that

prescribers are characterized by a strong need to

although each system had its own advantages

help their patients, grandiose thoughts about

and disadvantages, the differences in applica-

their own importance in treating particular

tions of each method made an empirical evalu-

patients, an orientation toward

immediate

symptom relief rather than long-term

out-

comes, and an inability to handle their own emotions

if the

medication

is

withheld.

Consolidated Orders System

Multiple C o p y Prescription

Program

ation of all systems impossible. Nonetheless, each system did have some impact. M a c L e o d and Swanson ( 1 9 9 6 ) described the systemic intervention made in the emer-

Unfortunately, the phenomena o f inadequate

gency departments o f four Canadian hospitals

knowledge and pseudobenevolent

to better manage chronic pain without inap-

overpre-

scribing may co-occur.

propriate prescribing practices or the reinforce-

With only a general sense o f the categories o f

ment of medication-seeking behavior. These

patients who may be using prescription medi-

hospitals operationally define medication seek-

cations inappropriately, and a similarly general

ing as any patient coming in to any department

idea regarding the health care professionals who

1 0 or more times during the previous 12-month

provide such prescriptions, intervention may

period and requesting opiods for a chronic pain

seem to be a daunting task. O f particular

problem. Once a patient is identified in this

importance is the choice of targets for interven-

manner, treatment is refused unless the patient

tion. Should the target be the patient, the pre-

is registered in the chronic pain registry, where

scriber, the system, or some combination

he or she undergoes a systematic evaluation for

thereof? These options are discussed in greater

pain syndrome and treatment planning. Once

detail within the context o f a biopsychosocial

on the registry, the patient receives only one

model for understanding medication-seeking

care provider. This primary care physician

behavior. However, it may be useful to first

becomes the only recognized prescriber. In

review interventions (all systemic in nature) that

addition, the patient is allowed to visit only one

have been described in the literature.

emergency

department

(to

further

limit

attempts to doctor shop or the "splitting" of

Descriptions of Systemic Interventions According to N I D A, five types o f systemic

treatment providers). Primary care providers see the patient once every 9 weeks for evaluation o f the home care prescribed by the consulting physician. This thoughtfully designed

interventions have been developed to address

system has not yet been evaluated empirically.

medication misuse on a systemic level. Each

T h e results of such an investigation would be

193

194

BEHAVIORS T H A T C O M P R O M I S E HEALTH particularly useful to other systems attempting

use of patients in the sole provider program is

to change maladaptive prescribing practices

monitored on an ongoing basis, with decreas-

and medication-seeking behavior as well as to

ing frequency over time. Formal and widely

improve patient care.

accessible computerized files are established

Another example o f an innovative systemic

and continually updated t o reflect any and all

intervention for the problem o f medication

attempts on the part o f these patients to pro-

seeking can be found in the Tripler Army

cure prescriptions (both successful appropriate

Medical

program

attempts and those conceptualized as mal-

Center's

sole provider

(Lewis & Gaule, 1 9 9 9 ) . Similar to the inter-

adaptive medication seeking). This facilitates

vention described by M a c L e o d and Swanson

prescription monitoring and communication

( 1 9 9 6 ) , the sole provider program focuses on

among the health care providers. Hence, when

the systemic monitoring o f prescriptions for

a patient presents to a provider, all potential

controlled substances and access to, as well as

prescribers are armed with the knowledge of

communication among, health care providers

the individual's prescription history and poten-

as important means by which to reduce medi-

tial difficulties associated with that history.

cation-seeking behavior. In this system, a

As in the previous example, such a system

patient can be enrolled in the sole provider

integrates patient care, facilitates easy and

program either through

a referral from a

efficient communication among health care

health care professional or through identifica-

providers, and improves delivery o f service t o

tion during twice-annual reviews o f all pre-

the patient.

scriptions for controlled substances. In the

supports the success o f this program, it also

Although

anecdotal evidence

latter case, a multidisciplinary sole provider

awaits empirical evaluation. W i t h

subcommittee reviews prescriptions for con-

examples in mind, a biopsychosocial model

these

trolled substances written to patients within

of

the Tripler Army Medical Center. Patients

offered next. Based on this model, additional

w h o are identified as having suspicious pat-

targets for intervention may be elucidated.

understanding

medication

seeking is

terns o f prescriptions (e.g., unusual numbers, large quantities, or multiple providers o f prescriptions) are reviewed closely by the sub-

UNDERSTANDING MEDICATION-

committee. If no legitimate explanation for a

SEEKING BEHAVIOR AND

patient's prescriptions can be identified, the

IDENTIFYING TARGETS FOR

patient is provided with one physician (usually

INTERVENTION: A

his or her primary care manager), w h o acts as

BIOPSYCHOSOCIAL MODEL

the patient's point of contact for all prescriptions. T h e patient is also provided with an

Although the paucity o f empirical literature

alternative provider (usually the head o f the

precludes the development o f a data-driven

group within which the sole provider works)

model for understanding and intervening with

for situations in which the sole provider is not

medication-seeking behavior, the existing the-

available.

oretical and clinical literature provides a start-

All providers who have previously written prescriptions

for

identified

patients

are

ing point for the development o f such a model. Specifically,

biological, psychological, and

informed o f these patients' entry into the pro-

social (including environmental) variables all

gram via written communication (i.e., confi-

play important roles in the development and

dential, closed-loop e-mail and letter). Patients

maintenance of medication seeking (e.g., the

are encouraged to address any questions or

biopsychosocial model of behavior [Engel,

concerns to their sole provider. The prescription

1 9 7 7 ] ) . As seen in Figure 1 1 . 1 , these variables

Inappropriate

Medication-Seeking

Behavior

Relevant Factors (Possible Targets for Intervention)

Source of Intervention

r

Biological Factors (-)

x

Physiological addiction Withdrawal symptoms

Health Psychologist

Figure 11.1

Ϋ

Psychological Factors

^

Coping skills Distress (-) Thrill seeking (+) History of substance use disorders Antisocial personality traits Tendencies toward somatization (+)

>v

/

Social/Environmental Factors

\ ] / / V

\

Street value of medications (+) History of drug dealing

/

\ / /

Medication-Seeking Behavior: A Framework for Understanding and Intervention

NOTE: D E A = Drug Enforcement Agency. Minus sign (-) indicates negatively reinforced factors. Plus sign (+) indicates positively reinforced factors.

may be interrelated and form both positive

associated with medication misuse, reversal o f

and negative reinforcement loops for medica-

withdrawal symptoms associated with medica-

tion-seeking behavior.

tion misuse, and/or financial gains associated

Of

greatest

relevance

to

the

health

with black market prescription

medication

psychologist are the psychological factors

sales), and a tendency to manifest psychologi-

associated with (and often reinforced by) the

cal distress as physical symptoms (as in the case

medication-seeking behavior as well as the

of somatoform disorders or subclinical somati-

role o f the prescriber (usually a physician but

zation [Longo et al., 2 0 0 0 ] ) . Interestingly, no

alternatively a nurse practitioner or another

studies that

used psychometrically

sound

prescribing health care professional) in the

assessments of patients characterized as medi-

cycle o f medication seeking.

cation seeking were discovered in the current review o f the literature. Research measures of illicit drug use, abuse, and dependence are

Patient Targets

likely too unwieldy to be clinically useful. be

Future research is needed to establish efficient,

characterized by a number o f psychological

valid, and reliable means o f assessing medica-

characteristics, including ineffective

and/or

tion-seeking behavior. Ideally, such measure-

self-

ment development will allow comparisons to

T h e medication-seeking patient may

maladaptive

coping skills (of which

medication may be just one), high levels o f

be made between baseline measures o f medica-

distress, a tendency toward thrill seeking, a

tion seeking and postintervention assessment

predisposition to addiction based on a history

of such maladaptive behaviors. Currently, the

of substance use disorders, antisocial personal-

description

ity traits (i.e., tendencies toward manipulation

be based on descriptive reports and clinical

o f patient

characteristics

must

for the patient's own gain such as pleasure

experience.

\

195

196

BEHAVIORS T H A T C O M P R O M I S E HEALTH Patients m a y different

engage in a number

medication-seeking

of

behaviors.

Specifically, Parran ( 1 9 9 7 ) identified 1 1 such behaviors, including overreporting facturing

symptoms

These

A final patient behavior that is particularly

manu-

difficult to assess and to intervene with is the phenomenon o f "doctor shopping." Patients

or vague

vague

pads and forging prescriptions.

to procure prescription

medication and endorsing complaints

written by physicians or stealing prescription

or

somatic

doctor shop when they use a minimum of two

complaints.

(but often many more) physicians, medical

multiple

somatic

exaggerated

reports

often

centers, or multidisciplinary

clinics, either

include descriptions o f pain (with n o organic

professing dissatisfaction with the previous

origin), anxiety, and/or insomnia. In addition,

prescriber or claiming to have no other care

because the street value o f certain medica-

providers. Patients quickly become aware o f

tions is higher (e.g., Percocet and drugs with

which facilities, as well as which physicians,

known intoxicating effects are worth more

are less likely to identify doctor shopping.

than non-narcotic medications), and because

These psychological factors and forms o f

brand-name medications carry a higher street

medication-seeking behavior suggest numer-

value than do generic medications (perhaps

ous interventions on the part of the health psy-

because brand names are easily verified as

chologist and physician (or other prescribing

such

medication-seeking

clinician). In the chapter authors' own clinical

or

environment, health psychologists often act as

by

the

buyer),

patients may insist on specific refuse

a generic

equivalent.

cation-seeking behaviors arguments demands tions

about

medications

Additional medi-

"gatekeepers" to psychiatric medication man-

include

making

agement. Therefore, they interact

making

with medication-seeking patients and have the

medica-

opportunity to intervene relative to psycho-

pharmacology,

for multiple

prescription

(i.e., polypharmacy) or demands

controlled making tolerance

directly

for

logical factors before the patients even reach

and

the potential prescribers. In instances where

high

the patient is an ongoing patient o f the health

for the medication (and therefore

psychologist, beliefs about prescription medi-

substances assertions

on a first

that patients

visit,

have

a

need a higher or more frequent dosage). Particularly uncomfortable for the health

cation use and misuse can be identified, examined, and challenged. In addition, alternative

medication-seeking

coping strategies can be taught and practiced,

behaviors that involve excessive manipula-

relapse prevention approaches can be imple-

tion and/or dishonesty. Examples o f such

mented,

behaviors include patients w h o seek medica-

placed in the context o f existing distress.

care professional

tion via veiled

are

threats

to the prescriber, clinic

staff, or hospital and those w h o seek medication via excessive

flattery

preceding a pre-

and

somatic complaints c a n

be

Furthermore, with a therapeutic alliance in place,

the

equipped

health

psychologist

is

better

to challenge antisocial behaviors

scription request (Parran, 1 9 9 7 ) . In addition,

(e.g., manipulation) and to set clear limits

Parran and colleagues (Longo et al., 2 0 0 0 ;

regarding appropriate use o f prescribed medi-

Parran,

cation. Finally, and perhaps most important,

1 9 9 7 ) described

typical

scams

prescriptions.

in an ongoing therapeutic relationship, the

Examples o f these scams include claims that

health psychologist can (and should) be suffi-

patients spilled a bottle o f medication or that

ciently familiar with the genuine symptoms

the bottle was somehow lost or stolen. At its

and illnesses o f the patient so that the psycho-

used by patients to procure

most extreme, medication-seeking behavior

logist can identify the appropriate

may take the form o f altering prescriptions

medication in their treatment. Any appropriate

role o f

Inappropriate

Medication-Seeking

Behavior

\

pharmacological intervention may then be

addition, prescribers are encouraged to be

delivered within the context o f psychosocial

meticulous in their prescription-writing practices,

treatment (as recommended in the " B R E N D A "

taking extreme care with legibility so as to

approach, which combines medication and

decrease the likelihood o f a medicine dosage or

psychosocial treatments within the context o f

amount

addiction

adhere to rational and systematic prescribing

treatment

[Volpicelli, Pettinati,

being altered. Prescribers should

practices. In particular, caution with medicines

McLellan & O'Brien, 2 0 0 1 ] ) .

of greater abuse liability should be evident and reflected behaviorally through shorter duration

Prescriber Targets

of prescribing and more careful monitoring of

In instances where the health psychologist

use. Finally, firm limits to prescription pad

has only a brief interaction with the medica-

access must be established (Finch, 1 9 9 3 ; Longo

tion-seeking patient and/or where the health

et al., 2 0 0 0 ) .

psychologist acts as a consultant to the pre-

Early work in the health care field by the

scribing physician, educating the prescriber

Α Μ Α (1990) led to development of a descriptive

about psychological illness and the influences

taxonomy o f the "problem prescriber" known

of psychological factors on physical illness is

as the " 4 D ' s " (Longo et al., 2 0 0 0 ; Parran,

critical to a successful outcome. In addition,

1 9 9 7 ; Wesson &c Smith, 1 9 9 0 ) . According to

the health psychologist will play an important

this view, problem prescribers fall into four cat-

role in working with prescribers to more com-

egories: dated, duped, dishonest, and disabled.

fortably set limits and process conflicts related

In the chapter authors' opinion, the importance

to medication seeking with their patients as

of this system is largely historic. Since the

well as in establishing and coordinating systemic

paradigm shift brought about by Miller and

interventions to reduce medication-seeking

Rollnick's (1991) seminal work on motivational

behavior.

interviewing, the iatrogenic nature o f pejorative

A number o f suggestions for physicians that

labeling processes is understood. T h e qualities

have been published by the medical commu-

subsumed under the 4 D's can be described

nity (Council on Scientific Affairs, 1 9 8 2 ) are

more effectively as barriers to physician success

useful to the health psychologist and

can

in the management of medication seeking. For

easily extend to other prescribing targets. T o

those physicians who have fallen behind the cur-

facilitate the prevention and management o f

rent knowledge base on prescribing practices,

medication-seeking behavior, prescribing care

state-mandated continuing education can facili-

providers must first identify potential mal-

tate change. In response to those individuals

adaptive medication seeking. As noted

by

whose wish to trust their patients sometimes

Parran ( 1 9 9 7 ) , physicians can learn to recog-

overwhelms indications of potential medication

nize c o m m o n scams, including those described

misuse, introduction to and instruction in the

earlier such as the following: " I dropped my

techniques of motivational enhancement will

medicine off the sink and into the toilet. I had

provide the care provider with an empathie

plenty left. I don't know how I can afford to

stance while addressing behaviors that do not

have it refilled, but it's the only thing that

help the patient to receive optimal care. Truly

helps." Prescribers can be empowered to effec-

dishonest care providers with prescription privi-

tively confront the medication seeker, perhaps

leges are atypical based on reviews of state

tech-

registries, and legal interventions with these indi-

niques. Parran described "turning the tables on

viduals appear to be effective (e.g., Kofoed et al.,

the scammer" as an effective intervention. In

1 9 8 9 ) . Disabled prescribers must be assessed

through

motivational

enhancement

197

198

BEHAVIORS T H A T C O M P R O M I S E HEALTH and treated as mandated by the ethical codes o f

Gaule, 1 9 9 9 ; M a c L e o d & Swanson, 1 9 9 6 ) .

the governing body. Thus, three interventions

Although outcome data are as yet unavailable,

for problem prescribers are (a) education,

several examples of hospital systems' efforts to

(b) training and feedback in effective interven-

implement these steps to reduce medication-

tions, and (c) support and reinforcement for

seeking behavior have been described in the

adaptive prescribing practices.

literature, and

o u t c o m e measures

should

become available in the future.

Systemwide Interventions Systemwide interventions

actually roll

outward from the individual prescriber to the office setting, where clear procedures are mandated, adhered to, and monitored by objective means. F o r instance, Finch ( 1 9 9 3 )

ASSESSMENT AND T R E A T M E N T S OF MEDICATION-SEEKING BEHAVIOR

Assessment

suggested three office-based policies, namely

In the chapter authors' opinion, the most

that (a) refills should be available through

pressing diagnostic issue is the lack of a system-

only one prescriber, (b) no refills should ever

atic means o f assessment for medication-seeking

be allowed during off-hours, and (c) a rapid

patients. Across what is available in the litera-

accurate method for tracking refills must be

ture, a number of medical and psychological

instated and maintained (Finch, 1 9 9 3 ) .

conditions exist that might prompt careful

Approximately 2 0 years ago, the Florida

assessment of the potential for medication

Medical Association and several county medi-

seeking. Just a few of the conditions with

cal societies took steps to reduce medication-

demonstrated relationships to adaptive and mal-

seeking behavior. These efforts included an

adaptive medication seeking are chronic pain

absence o f certain controlled substances being

disorders, addiction, diabetes, cancer, seizure

routinely stocked in pharmacies and a delay in

disorders, posttraumatic stress disorder, stress,

their delivery (amphetamines or methaqualones),

anxiety disorders, endometriosis, and premen-

personal verification of all prescriptions o f these

strual syndrome. Certainly, a new patient pre-

controlled substances by phone between phar-

senting with any of these concerns should be

macists and prescribers, reminders to physi-

screened for medication seeking. In addition,

cians to safeguard their prescription

patients for whom medications o f choice have

pads

(including avoiding having Drug Enforcement

significant abuse liability should be monitored

Agency numbers printed on the prescription

carefully to guard against dependence.

pads), and assistance by both pharmacy and

Given that a well-developed, psychometri-

law enforcement agencies in these efforts

cally sound assessment o f medication seeking is

(Council on Scientific Affairs, 1 9 8 2 ) .

not available, we suggest that standard clinical

Hospital-based programs are thought to be

interviews

be

augmented

by

self-report

most effective when (a) there is only one pre-

measures and biochemical validation when-

scriber per patient, (b) a systematic yet private

ever possible. First, a mini-mental status exam

marking system for charts is in place to alert

should be conducted. Patients should be asked

other health care providers to the potential for

to list all medicines they take, including over-

medication noncompliance, and (c) communi-

the-counter preparations, herbal supplements,

cation between care providers is fostered by

and teas. Alcohol use, tobacco use, and caffeine

staff meetings and scheduled team supervision

use should also be queried. Information regard-

(Council on Scientific Affairs, 1 9 8 2 ; Lewis &c

ing past use o f medications and medication

Inappropriate

Medication-Seeking

Behavior

\

reactions should be gathered. Illegal drug use,

outcome literature will likely generalize to

abuse, and dependence can be measured by the

the care of the medication-seeking patient. T h e

Drug Abuse Screening Test (Skinner, 1 9 8 2 ) .

compelling data regarding brief interventions

Risky alcohol use can be measured quickly via

delivered in motivational enhancement therapy

the Alcohol Use Disorders Identification Test

( M E T ) (e.g., Miller & Rollnick, 1 9 9 1 ) argue

(Reinert & Allen, 2 0 0 2 ) or even more quickly

persuasively for the use o f M E T both at the

via the C A G E (cut down, annoyed, guilty, eye

time o f the identification and assessment o f the

opener) questionnaire (Buchsbaum, Buchanan,

problem and during the initial feedback stages.

Centor, Schnoll, & Lawton, 1 9 9 1 ) . If possible,

T h e second active component in the treat-

physiological data, such as liver function tests,

ment o f medication-seeking behavior involves

could be gathered for later use in a motivational

education about the cycle o f negative rein-

enhancement session with medication-seeking

forcement, where the patient is encouraged to

patients. All assessment can be conducted under

identify misuse o f medication as allowing

the umbrella o f ensuring an accurate and thor-

escape or avoidance from unpleasant physio-

ough understanding of the patient.

logical or affective states. T h e patient can then

Such assessment procedures are commonly

be taught to see how escape or avoidance rein-

used in the W I C and frequently inform the

forces the initial state and will likely increase

development of the treatment plan. In addi-

the occurrence of the presenting symptom.

tion, this assessment procedure gathers specific

The next phase of treatment is usually aided

data to be used in the context o f the interven-

by a functional analysis of the antecedents and

tion to the patient as well as in informing the

consequences of the drug-seeking

social support network, the prescribing health

Functional analysis is presented as a means of

care provider, and the health care system.

helping the patient to identify his or her own

behavior.

"choice points for change," in keeping with both M E T and the principles of functional anal-

Treatment

ysis. T h e patient is then encouraged to make a

There are four primary goals for treatment.

plan for change that may, depending on the level

The first goal is to extinguish medication seek-

of physiological dependence to the medications

ing, as defined previously, in patients presenting

in question, involve a supervised taper and/or

for treatment. The second goal is to ensure that

medical detoxification. The patient may also

the bona fide wellness concerns of medication

accept a referral to appropriate individual and/or

seekers are adequately managed as medically

group support at this time.

indicated. The third goal is to ameliorate the

In sum, the treatment provided to the

problems of physicians whose prescribing voli-

medication-seeking patient is truly a brief inter-

tionally or involuntarily contributes to the prob-

vention that may be elaborated or pared back

lem of medication seeking. Finally, interventions

depending on the setting in which the patient

should result in sustained systemic support of

is encountered. Creative application of these

the identification and management of medica-

techniques is easily construed across settings.

tion seeking, as described earlier in the Tripler Army system (Lewis & Gaule, 1 9 9 9 ) . Strategies Strategies

for

Patients

for

Physicians

T h e overarching strategies o f behavior change are perhaps equally effective in conduct-

The chapter authors believe that the most

ing an intervention to aid physicians treating

effective treatments from the addictive behaviors

medication-seeking patients. An M E T approach (Text continues

on page

205)

199

200

BEHAVIORS T H A T C O M P R O M I S E HEALTH

CASE S T U D Y "Geoffrey V a n S n e w t " was a busy, 48-year-old, married businessman. H e initially presented to a clinical health psychologist with his wife o f 2 5 years, w h o was having some menopausal difficulties. T h e couple had three children, the oldest o f w h o m was in college. T h e two younger children were in boarding schools two states away from the family h o m e . B o t h parents reported that the children were within normal limits psychosocially and were o f no inordinate concern to the parents. Neither M r . nor M r s . V a n Snewt had living parents. Both reported that the marriage had been solid, without any threats to the longevity o f the relationship. Financial difficulties were absent. T h e husband and wife owned their h o m e and could afford the tuition for all three o f their children's private educations. M r s . V a n Snewt did not w o r k outside the h o m e but volunteered in the community. Aside from the menopausal symptoms and recent depressive symptoms, neither partner complained o f health difficulties, although M r . V a n Snewt mentioned that he was not able to bounce b a c k from athletic injuries as easily and quickly as he had been able to do in the past. Both adults were active and nonsedentary. Neither partner reported smoking cigarettes, and M r . V a n Snewt denied alcohol use beyond the rare social drink while on business. M r s . V a n Snewt reported daily drinking in amounts that were uncomfortable to her and "out o f character." She was not drinking to intoxication but was concerned because she had not been a regular drinker before menopause began. M r s . V a n Snewt presented as the primary patient, although both

parties

reported extreme distress around the perceived changes in her affect and behavior. Specifically, M r s . V a n Snewt reported symptoms o f depression, including loss o f interest in shared activities, decreased libido, and increased alcohol use. T h e couple was advised to seek individual therapy for M r s . V a n Snewt while continuing the conjoint sessions with the clinical health psychologist to increase communication and decrease distress in the relationship. T h e treating clinical health psychologist made a referral for M r s . V a n Snewt to obtain individual treatment and requested and received permission to speak with M r s . V a n Snewt's gynecologist and primary care physician regarding the time course o f her complaints. A brief course o f psychoeducation regarding menopause as well as communication skillsoriented marital therapy followed, with good resolution. After five sessions, the couple felt more able t o cope with fluctuations in M r s . V a n Snewt's m o o d and activity levels, and both partners reported that their communication skills had improved. M r s . V a n Snewt continued with individual therapy and reported that it was going well. N o additional couples treatment was deemed necessary. A b o u t 3 months after treatment concluded, M r s . V a n Snewt called the clinical health psychologist and stated that she thought her spouse was "in trouble" with his pain medication. She stated that he was unwilling t o call for an appointment himself but that he would return t o the clinic if the psychologist agreed to see both parties similar t o the w o r k done when M r s . V a n Snewt had " h e r " difficulties. T h e clinical health psychologist subsequently offered the couple a conjoint assessment

Inappropriate

Medication-Seeking

Behavior

session and asked both parties to bring a list o f all current medications kept in the h o m e as well as a list o f all physicians (including their contact information). W h e n the couple arrived for their session, M r . V a n Snewt exuded

self-

confidence. H e t o o k his seat in the therapist's office and charmingly thanked the therapist for meeting with the couple so quickly. M r . V a n Snewt said, I feel such relief now that it is out on the table. I started on Percocet about a year and a half ago for the plantar fasciitis I developed from running and tennis. As being on the tennis court is imperative for business, I need the medication to keep me on the courts. I'm sure I can get back on track. I've already asked Dr. Galtry to give me a referral to a podiatrist to make me some new orthotics. Runners magazine said they are a sure cure for the problem. I came in today because when Sara found those bottles in my gear, she flew off the handle. She was better for a time, but now she's making a mountain out of a molehill. I just had prescriptions from around the country because of my hectic travel schedule. I know that Sara benefited from individual work, but she really got better when we did it together. She didn't keep seeing her psychologist after our work together stopped, and I don't see why I should have to go to individual therapy either. My plan is to have just one person give me medication, only when I really need it. M r s . V a n Snewt produced lists o f the medications that were currently in the couple's home, most o f which were unremarkable. T h e only medication with significant abuse potential was Percocet. Unfortunately, M r s . V a n Snewt had located more than 1 5 bottles o f the narcotic medication, all prescribed to M r . V a n Snewt over the past 1 8 months. M o s t bottles were empty; however, M r s . V a n Snewt was concerned because these medications came from seven different walk-in centers in the couple's county. In addition to those seven centers, one bottle (with refills) came from the family physician, and the others c a m e from drop-in clinics from cities M r . V a n Snewt had visited while on business. There was also a large bottle from M e x i c o that still contained a number o f pills. M r s . V a n Snewt said,

Geoffrey is so smooth, he can talk a hungry dog off a meat truck. Although he says he knows that this isn't normal, I'm having trouble trusting his plan. He hid this from me all this time, and I thought we had no secrets. I guess I was just too wrapped up in my own problems. I think he needs to see someone, but he is afraid that it will damage his career. I tell him that bringing drugs into the country from Mexico would damage his career more than being unable to play tennis, but he just winks and says it will be okay.

Case Conceptualization M r . V a n Snewt had developed a dependence to Percocet that was maintained by powerful, short-term, positive consequences and a fixed belief that the short-term

202

BEHAVIORS T H A T C O M P R O M I S E HEALTH

consequences outweighed any possible long-term negative consequences. T h a t is, he had multiple rapid reinforcers for continued prescription drug use and abuse, including (a) the powerful pain relief offered to him by the narcotic, (b) the immediate success o f "scoring" new prescriptions, (c) the euphoric m o o d associated with narcotic intoxication that aided him during high-intensity business meetings and social interactions, and (d) the avoidance o f loss o f business "meetings" on the tennis courts. In contrast, he believed that stopping Percocet use would (a) decrease his business success, (b) deprive him o f pleasurable activities, and (c) create a perception within his marriage that he had a " p r o b l e m . " A natural strength motivating M r . V a n Snewt toward change was the potential disruption to the marital relationship. Although he did not see this as an overt mediator in his medication-seeking behaviors, the therapist contemplated the utility o f incorporating the marital relationship as a strength to be drawn on in motivating behavioral change. In addition, M r . V a n Snewt valued his status in the business world and had a strong wish to be admired by his children. T h e potential threat to his status inherent in his high-risk, medication-seeking behaviors (e.g., possessing multiple prescriptions from different prescribers, importing large quantities o f medications) was a potential place to build on the discrepancies between the patient's belief that he was not in any danger and the reality that he was. Given M r . V a n Snewt's dedication to athletic pursuits, the health psychologist thought that education about maintenance o f physical integrity might also aid in motivating M r . V a n Snewt to see the genuine potential for long-term physical damage that misusing pain medications might cause. Clearly, the system in which M r . V a n Snewt achieved successful medication procurement needed attention as well. T h e family physician, w h o appeared to be very well meaning but not well informed about the pervasiveness o f M r . V a n Snewt's use, needed t o be involved in the intervention. If necessary, the health maintenance organization ( H M O ) through which M r . V a n Snewt received his care could be called on to assist. T h e therapist completed the model in Figure 1 1 . 2 for the conceptualization o f the case and prepared "pros and c o n s " worksheets for M r . V a n Snewt to complete.

Treatments Used At the outset o f treatment, the clinical health psychologist determined that strategies o f motivational enhancement would be useful. T h e overall therapeutic framework from which the clinical health psychologist worked was similar to that described by Miller and Rollnick ( 1 9 9 1 ) , wherein therapists approach treatment as a collaborative effort with the patient. M r . V a n Snewt's ambivalence regarding changing his Percocet use was to be respected and addressed in an empathie nonjudgmental emphasized.

style. His responsibility and freedom to choose change was

Inappropriate

Medication-Seeking

Behavior

Relevant Factors (Possible Targets for Intervention)

Source of Intervention

Family Physician & Other Prescribers

7

Health Psychologist

Psychological Factors

^ \

/

Beliefs about consequences o f stopping \ P e r c o c e t use Value on athleticism ( + ) Coping skills Euphoria ( + ) Distress ( - ) Pleasure o f "scoring" prescriptions ( + ) Thrill seeking {+ ) History' of substance use disorders ν Antisocial personality traits . ^^Tendencies toward somatization (+

DEA

Figure 11.2

Case Conceptualization of Mr. Van Snewt's Medication-Seeking Behavior

N O T E : D E A = Drug Enforcement Agency; H M O = health maintenance organization. Minus sign (-) indicates negatively reinforced factors. Plus sign (+) indicates positively reinforced factors. Relevant aspects of the model are denoted in roman type and black. Aspects of the model inapplicable to this conceptualization are in italic type and gray.

T h e first session was framed as an assessment session, during which the clinical health psychologist led the couple through a series o f questions regarding perceived use, reviewed the medications listed, and gathered contact information for prescribers. W h i l e the patient and his wife were present, the clinical health psychologist contacted the primary care physician, w h o confirmed that M r . V a n Snewt had told him he was having foot problems, had received one prescription for Percocet (refilled twice), and had recently requested a referral for an assessment with a podiatrist. T h e clinical health psychologist advised the physician that the patient and his wife were present in her office and had given consent for the psychologist to disclose that the patient was overusing his prescription and had received prescriptions from multiple sources. T h e physician then stated that it was likely that the patient could manage a slow taper off the medication and that he would see the patient to begin the taper that afternoon. T h e patient was offered an appointment

but

declined, citing other commitments. T h e physician was thanked and was assured that communication between treatment providers would continue, with the full consent o f M r . V a n Snewt.

204

BEHAVIORS THAT C O M P R O M I S E HEALTH

At the close o f the assessment session, the conceptual model was presented to M r . and M r s . V a n Snewt, with the therapist highlighting the particular choice points for change, including assessment o f actual use, biochemical validation (random and scheduled), continued contact and contracting with the clinical health psychologist, and setting up o f a variety o f contingency contracts designed to encourage change. T h e couple was encouraged to contemplate the feedback delivered regarding its medication-seeking patterns and health status and was encouraged to m a k e decisions from an informed perspective. T h e menu o f alternative change methods from which the V a n Snewts could choose was offered. T h e V a n Snewts were also provided with information about medically supervised inpatient detoxification in case it proved to be necessary. In keeping with M E T and M r . V a n Snewt's stated goals, the therapist's task was to reflect those goals back to the patient by way o f recapitulation, reality test their likelihood, and begin to identify the things that would have t o change for success to occur. The V a n Snewts accepted another appointment within one business week but canceled the appointment several days later, stating that an unexpected visit from one o f their children would preclude their attendance. At the time o f cancellation, M r s . V a n Snewt scheduled a new appointment for the following week. M r s . V a n Snewt attended the rescheduled appointment, reportedly expecting t o meet her husband at the clinical health psychologist's office. M r . V a n Snewt telephoned his wife on her mobile phone 1 0 minutes after the appointment was scheduled to begin, explaining that he was running late at w o r k and that she should "go a h e a d " without him. Because M r . and M r s . V a n Snewt were seeing the clinical health psychologist as a couple, the session was ended at that time. Before leaving the office, M r s . V a n Snewt and the clinical health psychologist scheduled an additional appointment for the couple. T h e morning o f the appointment, M r s . V a n Snewt called the clinical health psychologist, explaining in a voice mail message that the problem had been "solved" and that the couple would no longer need to see her. She continued to say that the family physician had tapered M r . V a n Snewt off the Percocet and had refused to provide any additional prescriptions. M r s . V a n Snewt explained that she was pleased with this outcome and was certain that M r . V a n Snewt was "cured." M r . V a n Snewt did not contact the clinical health psychologist again.

Problems Encountered As can be ascertained from this case example, a substantial systemic challenge exists when treating patients w h o seek and use prescribed controlled substances inappropriately. Although such patients may exist within a relatively integrated system o f care (e.g., a large veterans hospital or other medical center), such individuals often have multiple, relatively disconnected health care providers. W h e n the

Inappropriate

Medication-Seeking

Behavior

j

possibility o f cyber-prescriptions is entered into the equation, systemic intervention becomes even more challenging. In this situation, it is essentially impossible to create a treatment team united in the prevention o f medication seeking and prescription drug abuse. In additional to issues at a m a c r o level, m o r e personal factors often play a significant role in the treatment o f medication-seeking patients. In this case, M r . V a n Snewt's ambivalence regarding the extent to which his use o f Percocet was problematic, as well as M r s . V a n Snewt's investment in believing her husband and avoiding conflict in the marital relationship, intersected in a way that ultimately precluded intervention with the couple directly. Although ambivalence regarding change is a normative characteristic o f most patients early in treatment and could have been managed optimally using an M E T approach, the couple's presence was obviously a prerequisite for this to occur. Finally, individual and systemic challenges intersect in this case, where M r . V a n Snewt's considerable financial and w o r k success, high status in the community, and personal charm disarmed potential prescribers. In thinking o f "medication-seeking patients," M r . V a n Snewt is unlikely to fit the image conjured up by such professionals. Therefore, these prescribers were likely caught off-guard and were easily convinced o f sincere physical pain and the "appropriateness" o f providing prescriptions for controlled substances to this "upstanding responsible" man.

will ensure that the physician does not perceive

controlled drug prescription,

the health psychologist as critical. Education

careful documentation with a firm diagnosis and

teaching

in

about the pattern of negative reinforcement for

the ruling out of chemical dependency,

both the patient and the physician can be con-

practice. This training should be supervised

and

ducted. Specifically, a functional analysis of the

and have ample role-playing

conditions in which prescribers are effective ver-

Physicians are also encouraged to enlist the sup-

opportunities.

sus when they are ineffective will help to clarify

port of all the pharmacists given that pharma-

the behavior for the physician, both in terms o f

cists are liable for filling controlled prescriptions

the patient process of negative reinforcement

along with the physicians who wrote them.

and in terms of the physician process of negative reinforcement. Finally, the physician needs to have easily accessible information

regarding

treatment referrals at his or her disposal. The

Α Μ Α encourages physicians

who

Systemic The

Interventions

systemic interventions, as change.

outlined

are treating medication seekers to have addi-

here, are likely to effect

tional training. Such training should include

research is needed to address the particular

Future

the acquisition and use o f chemical depen-

effects o f each program as well as the effects

dence screening skills, practice in early and

o f the individual components that make up

firm limit setting regarding indications for

each program.

205

206

BEHAVIORS THAT C O M P R O M I S E HEALTH CONCLUSIONS

Biochemical validation o f current use should be considered in the development of such mea-

The most compelling conclusion to be drawn

sures. M a n y interesting questions regarding

from the existing literature and the chapter

this project are possible. Specifically, can med-

authors' clinical experience with the problem

ication seeking be operationally defined and

of medication seeking is that the knowledge

accurately diagnosed in an efficient and effec-

base is extremely

tive manner? Is there a means o f taking the

limited. Indeed, health care

professionals have no true sense o f the prevalence and incidence o f medication seeking

guesswork out o f it? Second, psychometrically sound assess-

itself. Neither are they currently equipped to

ments o f prescribing practices should

describe the financial, physical, and emotional

developed and implemented. W i t h national

be

costs o f this behavior. Health care profession-

databases o f prescription medications easily

als can follow good clinical practice, but they

within the purview o f the established medical

have no means o f establishing the utility o f

community and the experience o f existing

programs designed to deal with this problem.

systems designed to track such measures, this

The state o f the current literature is that they

possibility should not be difficult.

must begin anew. T o that end, this chapter concludes with the following suggestions. First, psychometrically sound assessments of medication seeking need to be developed.

Finally, educational programs to assist in the identification o f inappropriate seeking, as well as inappropriate prescribing, need to be evaluated systematically.

REFERENCES American Medical Association. (1988). Balancing the response to prescription drug abuse: Proceedings from the Second White House ΑΜΑ Symposium on preChicago: American Medical Association, scribing controlled substances. Department of Substance Abuse. American Medical Association. (1990). Balancing the response to prescription drug abuse: Report of a national symposium on medicine and public policy. Chicago: American Medical Association, Department of Substance Abuse. Buchsbaum, D. G., Buchanan, R. G., Centor, R. M., Schnoll, S. H., & Lawton, M. J . (1991). Screening for alcohol use using CAGE scores and likelihood ratios. Annals of Internal Medicine, 115, 7 7 4 - 7 7 7 . Cooper, J . R., Czechowicz, D. J . , Molinari, S. P., & Petersen, R. C. (Eds.). (1993). Impact of prescription drug diversion control systems on medical practice and patient care (NIDA Research Monograph No. 131). Bethesda, M D : National Institute on Drug Abuse. Council on Scientific Affairs. (1982). Drug abuse related to prescribing practices. Journal of the American Medical Association, 247, 8 6 4 - 8 6 6 . Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 1 2 9 - 1 3 6 . Finch, J . (1993). Prescription drug abuse. Primary Care, 20, 2 3 1 - 2 3 9 . Gold, M . S., Miller, N. S., Stennie, K., & Populla-Vardi, C. (1995). Epidemiology of benzodiazepine use and dependence. Psychiatric Annals, 25, 1 4 6 - 1 4 8 . Kofoed, L., Bloom, J . D., Williams, M. H., Rhyne, C , & Resnick, M . (1989). Physicians investigated for inappropriate prescribing by the Oregon Board of Medical Examiners. Western Journal of Medicine, 150, 5 9 7 - 6 0 1 .

Inappropriate

Medication-Seeking

Lewis, P., 8c Gaule, D. (1999). Dealing with drug-seeking patients: The Tripler Army Medical Center experience. Military Medicine, 164, 8 3 8 - 8 4 0 . Longo, J . P., Parran, T., Johnson, B . , & Kinsey, W. (2000). Addiction: II. Identification and management of the drug-seeking patients. American Family Physician, 61, 2 4 0 1 - 2 4 0 8 . MacLeod, B. D., & Swanson, R. (1996). A new approach to chronic pain in the ED. American Journal of Emergency Medicine, 14, 3 2 3 - 3 2 6 . Maronde, R. F., Seibert, S., &c Katzoff, J . (1972). Prescription data processing: Its role in the control of drug abuse. California Medicine, 117, 2 2 - 2 8 . Miller, W. R., & Rollnick, S. (1991). Motivational interviewing. New York: Guilford. National Institute on Drug Abuse. (2001). Prescription drugs: Abuse and addiction (Research Report Series, NIH Publication No. 0 1 - 4 8 8 1 ) . Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Nichol, M . B., Venturini, F., & Sung, J . C. (1999). A critical evaluation of the methodology of the literature on medication compliance. Annals of Pharmacotherapy, 33, 5 3 1 - 5 3 5 . Pankratz, L., Hickam, D. H., & Toth, S. (1989). The identification and management of drug-seeking behavior in a medical center. Drug and Alcohol Dependence, 24, 1 1 5 - 1 1 8 . Parran, T. P. (1997). Prescription drug abuse: A question of balance. Medical Clinics of North America, 81, 9 6 7 - 9 7 8 . Poling, Α., & Byrne, T. (2000). Introduction to behavioral pharmacology. Reno, NV: Context Press. Reinert, D. F., Sc Allen, J . P. (2002). The Alcohol Use Disorders Identification Test (AUDIT): A review of recent research. Alcoholism: Clinical and Experimental Research, 23, 2 7 2 - 2 7 9 . Salzman, C. (1990). Benzodiazepine dependence, toxicity, and abuse: A task force report of the American Psychiatric Association (Task Force on Benzodiazepine Dependency). Washington, DC: American Psychiatric Association. Silberstein, S. D. (1992). Evaluation and emergency treatment of headache. Headache, 32, 3 9 6 - 4 0 7 . Singh, B . S. (1998). Managing somatoform disorders. Medical Journal of Australia, 168, 5 7 2 - 5 7 7 . Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7, 363-371. Taverner, D., Dodding, C. J . , &C White, J . M. (2000). Comparison of methods for teaching clinical skills in assessing and managing drug-seeking patients. Medical Education, 34, 2 8 5 - 2 9 1 . Volpicelli, J . R., Pettinati, H. M., McLellan, A. T., & O'Brien, C. P. (2001). The BRENDA method: Combining medication and psychosocial treatments for addiction treatment. New York: Guilford. Weiss, R. D., &c Greenfield, D. P. (1986). Prescription drug abuse. Psychiatric Clinics of North America, 9, 4 7 5 - 4 9 0 . Wesson, D. R., & Smith, D. E. (1990). Prescription drug abuse: Patient, physician, and cultural responsibilities. Western Journal of Medicine, 152, 6 1 3 - 6 1 6 .

Behavior

12 10

CHAPTER

Adherence to Medical Recommendations NICOLE E . BERLANT AND SHERI D . PRUITT

T

he

failure

to

adhere

to

medical

adherence

appear

to

be

insurmountable.

recommendations is a significant and

Fortunately, behavioral science offers valuable

multifaceted

principles, theories, and models that address

health

care

problem.

Estimates are that 3 0 % to 7 0 % o f patients

the determinants

do not fully adhere to the medical advice o f

providers, and organizations (Pruitt, 2 0 0 1 ) .

o f behaviors of patients,

their physicians (National Heart, Lung, and

These same principles, theories, and models

Blood Institute, 1 9 9 8 ) . M o r e o v e r , up to 8 0 %

from behavioral science provide a conceptual

o f patients are unsuccessful in following rec-

framework for organizing current knowledge,

ommendations for behavioral changes such

testing future

as smoking cessation and dietary restrictions.

multilevel interventions for improving patients'

Adherence is a complex behavioral process

hypotheses, and

developing

adherence to medical recommendations.

that is determined largely by environmental influences on the patient. However, the patient's

DEFINITIONS AND

environment is broad, extending beyond his or

DESCRIPTION OF ADHERENCE

her immediate surroundings to encompass associated health care providers and the health care

208

Although adherence has been defined as the

organization in which the patient receives ser-

extent to which patient behavior corresponds

vices. Nonadherence is far more than a patient

with recommendations from a health care

problem, and efforts that focus solely on the

provider (Rand, 1 9 9 3 ; Vitolins, R a n d , Rapp,

patient impede the ability to make meaningful

Ribisl, &c Sevick, 2 0 0 0 ) , this broad definition

advances in the adherence arena.

belies the complexity of the issue. Adherence

The expansion of the conceptualization o f

is better conceptualized as an acceptable fre-

adherence to include multiple levels (i.e., patients,

quency, intensity, and/or accuracy o f specific

providers, and health care organizations), and

behaviors, given a specific circumstance, that

the realization that there are multiple influences

is associated with

on a patient's behavior within each o f these

comes. Adherence is a process—a behavioral

improved

clinical

out-

levels, could make the challenge of improving

means to the end point o f better health status.

Adherence T h e process of adherence is influenced by multiple determinants. These include a variety of factors at the patient, provider, and health

to Medical

Recommendations

209

patients are asked to follow some degree of recommendations for all medical conditions. W i t h the possible exception o f psychiatric

care organization levels. Factors at the patient

disorders,

level consist of a person's knowledge and beliefs

particular condition o r condition regimen

adherence is not specific to a

about illness, degree o f motivation and self-

(Haynes, 1 9 7 9 ) . Basic behavioral principles

efficacy related to illness management behav-

and models o f behavior change cut across all

iors, and expectancies related to the outcomes

medical conditions, rendering a review o f

of adherence or nonadherence. In addition,

each specific condition less important than

disease- and treatment-specific issues influence

a grasp o f the c o m m o n themes. M o r e o v e r ,

adherence at the patient level. These include

increasing the effectiveness o f

(a) the social, physical, psychological, and

interventions may have a far greater impact

adherence

occupational disabilities resulting from symp-

on the health o f the population than would

toms and treatments; (b) the cultural mean-

any improvements in specific medical treat-

ings o f diseases and treatments; (c) the disease

ments (Haynes et al., 2 0 0 2 ) .

severity and prognosis; and (d) the complexity, timing, and

degree o f beneficial and

detrimental effects o f treatments.

Although adherence traditionally is discussed as a patient problem (e.g., " T h e patient is nonadherent"), the time has c o m e to con-

Influential factors at the provider level

sider the adherence issue within the larger

encompass the knowledge, skills, and attitudes

health care organization context. Adherence is

of health care providers as well as the quality

a multifaceted construct that spans patients'

of the patient-provider relationship. Health

medical problems, but providers

care organization factors involve characteris-

health care organization must be considered

tics o f the organization such as access to diag-

as similarly responsible for improving adher-

nostic and treatment services, education to

ence rates. Clarifying our conceptualization o f

manage health problems, coordination and

the construct could serve to forward interven-

and

the

integration o f care, and organizational links to

tion efforts. Better interventions are impera-

community support services (World Health

tive because if significant improvements in

Organization, 2 0 0 1 ) .

adherence are not made, many medical treat-

The need for a clear conceptualization o f the adherence construct becomes even more

ments and providers' therapeutic efforts will continue to be inefficient.

evident when measurement and intervention strategies are taken into consideration. For example, provider recommendations

range

from advice that requires relatively simple and

THE ROLE OF BEHAVIORAL S C I E N C E ΓΝ A D H E R E N C E

familiar behaviors (e.g., requests for patients to return for follow-up appointments or to obtain

T h e influence of behavior on health has never

inoculations) to recommendations that patients

been as apparent as it is today. M o s t people

participate in complex and novel regimens (e.g.,

living in this century will die from "lifestyle

daily alterations in diet, smoking cessation,

illnesses" or medical conditions resulting from

increase in physical activity). Measurement and

daily habits such as diet, exercise, alcohol con-

intervention strategies obviously differ accord-

sumption, tobacco use, and/or health risk

ing to the circumstances and/or intensity of the

behaviors (Kaplan, Sallis, & Patterson, 1 9 9 3 ) .

recommendations. Nevertheless, it is important

In fact, current estimates indicate that daily

to note that adherence is fundamental

for

behavior contributes as much as 5 0 % to an

successful management of health problems, and

individual's overall health status (Institute for

210

BEHAVIORS THAT C O M P R O M I S E HEALTH the Future, 2 0 0 0 ) . Decades o f behavioral

F r o m a theoretical standpoint, it would be

research provide proven strategies for chang-

possible to "control" behavior of patients,

ing behavior. Integrating

providers, and health care organizations if the

this

knowledge

within the medical arena can help patients to

events preceding

and

following a specific

alter their daily patterns and reduce the risks

behavior could be controlled. F r o m a practical

associated with the development o f health

standpoint, behavioral principles can be used

problems and/or negative consequences o f

to design interventions that have the potential

preestablished conditions. Moreover, behavior

to shape behavior at each incremental level o f

change strategies can be applied across diverse

influence (patient, provider, and health care

medical conditions (Dunbar-Jacob, Burke, &

organization) to address adherence problems.

Pyczynski, 1 9 9 5 ; Nessman,

Carnahan,

&

Nugent, 1 9 8 0 ) . In addition, the same learning

Behavioral interventions

based on

the

basic principles o f learning (i.e., antecedents

principles that are effective in changing patient

and

behavior are effective in altering the behavior

changing behavior. N e w behaviors can be

of health care providers ( O x m a n , Thomson,

learned, and established behaviors can be

Davis, & Haynes, 1 9 9 5 ) and health care orga-

increased or decreased using these concepts.

nizations (DeBusk et al., 1 9 9 4 ) .

In fact, a variety o f health behaviors have

c o n s e q u e n c e s ) are

quite

potent

for

Behavioral science is the application of

been altered successfully using some varia-

experimental methods to learn about, predict,

tion o f operant-based techniques (Brownell

and explain the observable actions of humans,

&

including not only observable behaviors but

1 9 7 4 ) . In general, behavioral change strate-

also verbal statements about subjective experi-

gies that focus on what occurs before and

ences and symptoms. M u c h o f human behav-

after targeted behaviors have been substan-

ior has been well understood for decades. T h e

tially more effective than other approaches.

most basic yet most powerful principle is the

Cohen,

1 9 9 5 ; Janis,

1 9 8 3 ; Mahoney,

The most effective methods for changing

influence o f antecedents and consequences on

behavior are those that teach individuals how

behavior, that is, operant learning (Skinner,

to integrate the basic principles o f learning into

1 9 3 8 , 1 9 5 3 ) . Antecedents, or preceding events,

their daily lives (Bandura 8c Simon, 1 9 7 7 ;

are internal (thoughts) or external (environ-

Matarazzo,

1 9 8 0 ) . This practice is called

mental cues) circumstances that elicit a behav-

"self-management,"

ior. Consequences, or expected consequences,

change," or "self-regulation." Specific tech-

"self-directed

behavior

that can be conceptualized as rewards or pun-

niques for changing and maintaining one's

ishments also influence behavior. These princi-

health behavior include self-monitoring, goal

ples translate into the ability to predict the

setting, stimulus control, self-reinforcement,

probability o f a patient, provider, or health

behavioral rehearsal, arranging social support,

care organization initiating or continuing a

behavioral contracting, and relapse prevention.

behavior because such behaviors

partially

The use of behavioral principles in the area of

depend on what happens before and after the

relapse prevention has been particularly well

specific behavior occurs. Although

learning

studied in response to the ubiquitously high

theory historically has been criticized for

rates o f relapse after health behavior changes

explaining behavior in overly simplistic "stim-

such as smoking cessation, reduction in alco-

ulus-response"

relationships,

contemporary

hol consumption, and weight loss. Research in

learning theory integrates environmental cues

relapse prevention has demonstrated the signif-

and contexts, memory, expectancies, and neu-

icance of contextual cues (e.g., physical envi-

rological processes related to learning (Institute

ronment, time of day, emotional status) in the

of Medicine, 2 0 0 1 ) .

maintenance or extinction o f health behaviors.

Adherence Although the fundamental

to Medical

Recommendations

principles o f

behavioral changes are predicated on the belief

learning and behavior change appear to be

that a person can successfully complete a

simple, they are deceptively so. Behavior change

desired behavior. This belief is necessary even

and maintenance continues to be an enigma,

when all other predictors o f behavior would

and even the best behavioral techniques are not

suggest that a person is ready to engage in a

invariably effective. Nevertheless, a century o f

particular behavior. For example, a person can

behavioral science remains the strongest foun-

feel vulnerable to a disease, understand how

dation to guide current efforts in changing

to change his or her behavior to be healthier,

behavior to improve health.

believe that the new behavior will decrease the behavioral

likelihood o f illness, and feel supported by the

science into physical health was recognized

social environment. However, if the person

The

obligation to integrate

2 5 years ago when the interdisciplinary field of

lacks conviction in his or her ability to change,

behavioral medicine was formally

the social cognitive theory predicts that the per-

defined

(Schwartz &c Weiss, 1 9 7 7 ) . T h e adherence

son is unlikely to be successful.

problem is ideally attacked from this interdisci-

The construct regarding a person's belief

plinary perspective. In fact, researchers in the

about ability to change is called "perceived

behavioral medicine arena have

developed

self-efficacy" and is modified by four sources

sophisticated models that envelop the basic

of information: (a) performance attainment or

principles o f learning and apply them to com-

success with previous tasks, (b) vicarious expe-

plex health behaviors.

rience or watching others perform a task, (c) verbal persuasion, and (d) physiological states such as anxiety and relaxation. T h e social

MODELS FOR

cognitive theory predicts that

UNDERSTANDING

influences adherence by mediating behaviors in

self-efficacy

multiple ways, including immediate behavior

ADHERENCE BEHAVIOR

choices, effort expenditure, thoughts, emoTheories and models provide a conceptual

tional reactions, and behavior performance.

framework

about

There is empirical support for the theory as it

adherence and other health behaviors. Over the

relates to adherence and the maintenance of

for organizing thoughts

past 1 0 0 years, numerous theories about behav-

behavior change, but Bandura's theory is

ior have been proposed. This section briefly

limited by the complexity o f quantifying the

reviews some of the more influential models: the

conceptual elements in the model.

social cognitive theory (Bandura & Simon, 1 9 7 7 ) , the theory of reasoned action (Ajzen & Fishbein,

1980),

the

health

belief

model

(Rosenstock, 1 9 7 4 ) , the theory o f interpersonal

Theory of Reasoned Action The

theory

of

reasoned

action

was

behavior (Triandis, 1 9 7 7 ) , the transtheoretical

introduced in an attempt to explain the rela-

model (Prochaska & DiClemente, 1 9 8 2 ) , and

tionships among beliefs (normative and behav-

the information-motivation-behavioral skills

ioral), attitudes, intentions, and

(1MB) model (Fisher & Fisher, 1 9 9 2 ; Fisher,

According to this theory, an individual's intent

Fisher, Miscovich, Kimble, & Malloy, 1 9 9 6 ) .

to adopt a behavior is determined by his or her

behaviors.

attitude about performing the behavior and

Social Cognitive Theory

social factors such as the perception o f attitudes about the behavior held by significant

Bandura's social cognitive theory (Bandura,

others (Ajzen &c Fishbein, 1 9 8 0 ) . Ajzen and

1 9 8 2 ; Bandura & Simon, 1 9 7 7 ) suggests that

Fishbein ( 1 9 8 0 ) suggested that attitude toward

212

BEHAVIORS T H A T C O M P R O M I S E HEALTH a behavior is a much better predictor o f that

and cons o f adopting a behavior, an affective

behavior than is attitude toward the disease

analysis o f previous positive and

that is associated with the behavior. F o r

experiences, the social influence o f normative

example,

attitude t o w a r d

negative

mammography

and role beliefs, and personal beliefs about

should be a better predictor o f screening

responsibility for one's health. Habit influ-

behavior than is attitude toward breast cancer.

ences the likelihood o f behavior when regular

Personality and sociocultural variables influ-

behaviors become automatic, at which point

ence the likelihood of adopting a behavior by

the role o f intention is reduced.

mediating the attitudes of the individual and of his or her significant others. Both the degree of influence imposed by the person's attitude and his or her perception o f other's beliefs vary with each behavior.

Transtheoretical Model T h e transtheoretical model (Prochaska & DiClemente, 1 9 8 2 ) proposes the "stages of change" framework as a comprehensive model of behavioral change in both the positive and

Health Belief Model

negative directions (e.g., the acquisition of a 8c

health behavior such as exercise, the reduction

M a i m a n , 1 9 7 5 ; Rosenstock, 1 9 7 4 ) integrates

or cessation o f a risk behavior such as smok-

The

health

belief

model

(Becker

behavioral and cognitive theories to explain

ing). Originally developed as a smoking cessa-

why people fail to adhere to health behaviors

tion tool, the transtheoretical model has been

by considering the impact o f the consequences

applied to psychotherapy and a variety o f

and expectations related to the behaviors.

health behaviors as a way o f matching individ-

Specifically, the probability that a person will

uals to their stage o f preparedness for behavior

adopt or maintain a behavior to prevent or

change. Cross-sectional studies have supported

control a disease depends on four things: (a)

the existence of five stages (precontemplation,

perceived susceptibility, (b) perceived threat,

contemplation, preparation, action, and main-

(c) perceived benefits, and (d) perceived barri-

tenance), but some longitudinal studies have

ers. Perceived susceptibility describes the

not identified these discrete stages. In addition,

perception o f risk to personal health, whereas

a recent investigation has reported the stages to

perceived threat describes the proportion of

be w e a k predictors o f smoking cessation

negative consequences o f disease. Perceived

(Institute of Medicine, 2 0 0 1 ) . Nevertheless, the

benefits and barriers describe the beliefs about

finding that many people have low levels of

the outcomes of recommended behaviors in

motivation for behavior change has led to

reducing the perceived threat. It should be

interventions specifically intended to increase

noted that the health belief model highlights

motivation

the fact that adherence to health behaviors

( 2 0 0 2 ) motivational interviewing strategies.

such as Miller and

Rollnick's

often requires people to act to prevent illness

(A more detailed discussion of motivational

even while they are still healthy.

interviewing was provided in Chapter 4.)

Theory of Interpersonal Behavior

Information-MotivationBehavioral Skills Model

The

theory

o f interpersonal

behavior

(Triandis, 1 9 7 7 ) interrelates a person's inten-

Each o f the theories just discussed has advan-

tion to perform a behavior, facilitating condi-

tages and disadvantages, yet none of them read-

tions, and habit. In this model, intention is

ily translates into a comprehensive intervention

mediated by a cognitive analysis o f the pros

for changing health behavior. The recently

Adherence

to Medical

Recommendations

213

information-motivation-behavioral

support for such behavior, and the patient's

skills model (Fisher 8c Fisher, 1 9 9 2 ; Fisher et al.,

subjective norm or perception o f how others

1996) borrows elements from the earlier theo-

with this medical condition might behave.

developed

ries to construct a conceptually based, generaliz-

"Behavioral skills" includes ensuring that the

able, and parsimonious model to guide thinking

patient has the specific behavioral tools or

about complex health behaviors. Subjected

strategies necessary to perform the adherence

to rigorous empirical investigation, interven-

behavior such as enlisting social support and

tions based on this model have demonstrable

other self-regulation strategies. Finally, infor-

efficacy in effecting behavioral change across

mation, motivation, and behavioral skills must

a

pertain directly to the desired behavioral out-

variety o f clinical applications

(Carey,

Kalichman, Forsyth, Wright, & Johnson, 1 9 9 7 ;

come; that is, they must be specific.

Fisher & Fisher, 1 9 9 2 ; Fisher et al., 1 9 9 6 ) . In

M u c h o f the adherence research and inter-

both prospective and correlational studies, the

ventions applies individual components of the

information, motivation, and behavioral skills

1MB model despite evidence that all three

constructs have accounted for an average of

elements are necessary for complex behavior

3 3 % of the variance in behavior change (Fisher

change. T h e failure to explicitly implement

et al., 1 9 9 6 ) .

information, motivation, and behavioral skills

The 1MB model, similar to what has been

may be partially attributed to the commonsen-

reported previously, demonstrates that infor-

sical nature o f the model. Health care providers

mation is a prerequisite but that information

often assume that they provide information to

in itself is insufficient to alter behavior (see

patients and motivate them, and providers also

Mazzuca, 1 9 8 2 ) . It provides evidence that

recognize the importance of behavioral skills in

motivation and behavioral skills are critical

improving health. However, there is evidence

determinants that are independent of behavior

that providers typically give limited informa-

change (Fisher 8c Fisher, 1 9 9 2 ; Fisher etal.,

tion (Waitzkin 8c Stoeckle, 1 9 7 6 ) , lack motiva-

1 9 9 6 ) . Information

enhancement

abilities

(Botelho

8c

and motivation

work

tional

largely through behavioral skills to

affect

Skinner, 1 9 9 5 ) , and lack the knowledge (often

behavior. However, when the behavioral skills

leading to frustration)

are familiar or uncomplicated, information and

behavioral skills (Alto, 1 9 9 5 ) .

motivation can have direct effects on behavior.

The

expense

of

in teaching patients intensively

educating

In this case, a patient might fill a prescription (a

physicians to improve their information dis-

simple familiar behavior) based on information

semination, motivational interviewing,

given by the provider. T h e relationship between

behavioral skills training may be prohibitive

the information and motivation constructs is

when

weak. In practical terms, a highly motivated

strategies for improving patient

person may have little information, or a highly

However, creative education strategies, such

informed person may have low motivation.

as distance learning techniques, have been

However, in the 1MB model, the presence o f

used successfully to train physicians in basic

both information and motivation increases the

behavioral concepts to influence adherence

likelihood o f complex behavior change.

considering

(Casebeer, K l a p o w ,

efficient

Centor,

and

and

effective adherence.

Stafford, 8c

T o this point, each o f the components of the

Skrinar, 1 9 9 9 ) . Training less expensive or

1MB model has been described. "Information"

more readily available providers in the applica-

consists of basic knowledge about a medical

tion of the 1 M B model may be a more viable

condition and effective strategies for managing

option. Pharmacists, case managers, health

it. "Motivation" encompasses personal atti-

educators, and any persons involved in patient

tudes toward the behavior, perceived social

care should be exposed to these basic concepts.

2U

BEHAVIORS T H A T C O M P R O M I S E HEALTH Nonphysician providers have an incredibly

most efficacious patient-focused interventions do

important role and opportunity to improve sig-

not yield substantial effects for adherence behav-

nificantly the health of their patients by specif-

ior over the long term (Haynes, McKibbon, &c

ically targeting patient adherence issues.

Kanani, 1 9 9 6 ) , and few randomized controlled

M o r e structured, thoughtful, and sophisticated provider-patient interactions are essential

trials targeting patient adherence behavior exist (Haynes et al., 2 0 0 2 ) .

if improvements in adherence are to be realized.

A recent review o f the long-term manage-

The generalizable 1MB model can be applied to

ment of obesity (Perri, 1 9 9 8 ) described many

providers to meet this goal. As this empirically

of these techniques by examining the status of

based model predicts, when providers have

research concerning adherence and relapse

adequate information, motivation, and behav-

prevention in weight management. A number

ioral skills, they will integrate new behaviors

of strategies to increase adherence to weight

into their practices. Adapted to an organiza-

control behaviors have been investigated,

tional level, the same 1MB framework can be

including continuing therapist contact, formal

used to change the behavior of decision makers

relapse prevention training, monetary incen-

and administrators toward improved health

tives, low-calorie food provision, and peer

care organization functioning.

support. Intensive behavioral therapist contact (beyond

6 months)

has

been

repeatedly

demonstrated to prolong the maintenance o f STATE-OF-THE-ART

weight loss, although contact does not result

INTERVENTIONS FOR

in greater weight loss (Perri, 1 9 9 8 ) .

IMPROVING ADHERENCE

Relapse prevention training has been used

Adherence intervention research has focused largely on patient behavior and medication regimens as opposed to targeting provider and health care organization variables. According to several published adherence reviews, no single intervention targeting patient behavior is effective, and the most promising methods o f improving adherence behavior use a combination of the following strategies

(Houston-

Miller, Hill, Kottke, & Ockene, 1 9 9 7 ; Haynes et al., 2 0 0 2 ; Roter et al., 1 9 9 8 ) : • • • • •

Patient education (Morisky et a l , 1983) Behavioral skills (Oldridge & Jones, 1983; Swain & Steckel, 1981) Self-rewards (Mahoney, Moura, & Wade, 1973) Social support (Daltroy & Godin, 1989) Telephone follow-up (Taylor, HoustonMiller, Killen, & DeBusk, 1990)

successfully as part of a multicomponent maintenance program

(Perri, Shapiro, Ludwig,

Twentyman, & M c A d o o , 1 9 8 4 ) . Marlatt and Gordon's

(1985)

"relapse prevention"

is

defined as a set of techniques designed to keep people from relapsing to prior health habits after initial successful behavior modification, including training and coping skills for highrisk relapse situations and lifestyle rebalancing (Taylor, 1 9 9 5 ) . In addition, peer support meetings have been associated with greater weight loss maintenance over time. However, neither of these components has been shown to lead to greater behavioral adherence (Perri et al., 1 9 8 7 ) . Multicomponent maintenance programs lead to greater sustained weight loss than does standard care, but within these programs continued therapist contact appears to be the key component. Perri (1998) hypothesized that the improved outcomes seen in extended treatment programs are due to the maintained

Various combinations of these techniques

adherence to behavior changes. This extended

have been shown to increase adherence behavior

adherence is likely secondary to the ongoing

and treatment outcomes. However, even the

effects o f the social pressure o f groups, repeated

Adherence

to Medical

Recommendations

215

eating and exercise,

associations with patient health outcomes have

continued therapist reinforcement and problem

been demonstrated. In a review of randomized

cues for "appropriate"

solving, and sustained motivation and morale

controlled trials, Stewart (1996) reported that

from continued therapeutic support.

providers who share information, build partnerships, and provide emotional support to their patients have better outcomes than do providers

Adherence Interventions at the Patient Level

who do not interact with patients in this manner. Correlational studies reveal a direct

M o s t people have difficulty in adhering

relationship between patient adherence

and

to medical recommendations, especially when

provider communication styles that include pro-

the

care.

viding information, engaging in "positive talk,"

Consequently, patient characteristics have

and asking patients specific questions about

advice entails self-administered

been the focus o f numerous adherence investi-

adherence (Hall, Roter, & Katz, 1 9 8 8 ) . Patient

gations. Efforts to identify stable personality

satisfaction also plays a role in that those who

traits of the "nonadherent patient" have been

are satisfied with their providers and medical

futile. However, mental health problems have

regimens adhere to recommendations more

been examined in recent reports, and there

diligently (Whitcher-Alagna, 1 9 8 3 ) . Finally,

is evidence that depression and anxiety are

patients who view themselves as partners

predictive of adherence to medical recommen-

engaged in their treatment plans have better

dations

adherence

(Chesney, Chrisman,

Luftey, &c

Pescosolido, 1 9 9 9 ; D i M a t t e o , Lepper, Croghan, Ziegelstein

2000; et

Lustman al.,

2000).

et

&

behavior

and

health

outcomes

(Schulman, 1 9 7 9 ) .

al., 1 9 9 5 ;

O n e example of the potential for providers

Interestingly,

to affect health behavior change is the use of

providers historically have attributed

adher-

"minimal contact" interventions in primary

ence problems to patients' personalities (Davis,

care to help patients quit smoking. Advice or

1 9 6 6 ) or attitudes (Stone, 1 9 7 9 ) . It may be that

counseling alone produces increased 6- and 1 2 -

providers are detecting mental health prob-

month quit rates in biochemically validated

lems, such as depression, but are inaccurately

studies (e.g., Ockene et al., 2 0 0 0 ) . T h e most

labeling these problems as "attitudinal"

or

effective primary care interventions include

"personality" faults in their patients. Such mis-

several core elements such as a strong provider-

attribution leads to a failure to treat possible

delivered "quit smoking" message; self-help

underlying mental health disorders that, if

materials covering motivational, behavioral,

treated, can improve patient adherence.

and relapse prevention strategies; a prescription for nicotine replacement therapy; brief

Adherence Interventions at the Provider Level

counseling that includes setting a quit date; and follow-up support (Glasgow & Orleans, 1 9 9 7 ) . T h e American Medical Association has

Because providers play a significant role in

recognized the important influence o f health

adherence, designing interventions to affect their

care providers in reducing smoking rates and

performance seems to be a reasonable strategy,

during the early 1 9 9 0 s created guidelines for

but investigations in this area are few. Providers

the treatment of nicotine addiction (American

prescribe the medical regimen, interpret it, mon-

Medical Association, 1 9 9 3 ) . T h e guidelines

itor clinical outcomes, and provide feedback to

recommend that providers do the following:

patients (Center for the Advancement o f Health, 1 9 9 9 ) . Accordingly, provider communication has been widely examined, and importantly,

• •

Ask about smoking at every opportunity. Advise all smokers to quit.

216

BEHAVIORS T H A T C O M P R O M I S E HEALTH •

•

and pharmacies to share information regarding

Assist smokers to quit through the use of self-help materials and nicotine replacement whenever appropriate.

patients' behavior around prescription refills

Arrange follow-up contacts.

possible because the information allows health

has the potential to improve adherence. This is care providers to track patients' use o f medi-

The

ask-advise-assist-arrange model has

cation as a proxy of medication adherence.

been used successfully for inpatient and outpa-

Patients can be contacted if they are using med-

tient settings and has resulted in quit rates sig-

ications at a rate that is too fast or too slow. In

nificantly higher than usual-care approaches

addition, organizations determine the level of

(Glasgow & Orleans, 1 9 9 7 ) .

communication with patients. Ongoing communication efforts (e.g., phone contacts) that help to keep patients engaged in their health

Adherence Interventions at the Health Care Organization Level

care may be the most simple and cost-effective strategy for improving

Health care organizations have the potential to influence patient adherence behavior as

adherence

(Haynes

et al., 1 9 9 6 ) . The

"state-of-the-art"

interventions

in

well given that they control access to care. For

adherence target each level o f the adherence

example,

problem

organizations

direct

providers'

mentioned

previously

(patient,

schedules, appointment lengths, allocation of

provider, and health care organization). Several

resources,

programs

fee

structures,

communication/

have demonstrated

good

results

information systems, and organizational priori-

using a multilevel team approach

(Hyper-

ties. As such, health care organizations ulti-

tension Detection and Follow-up

Program

mately influence patients' behavior in many

Cooperative

ways. Organizations set parameters of care

Factor Intervention Trial Research Group,

(e.g.,

leading

1 9 8 2 ; S H E P Cooperative Research Group,

providers to report that their schedules do not

1 9 9 1 ) . In fact, adequate evidence exists to sup-

allow enough time to address adherence behav-

port the effectiveness o f innovative, modified

ior adequately (Ammerman et al., 1 9 9 3 ) . Fee

health care teams over traditional, independent

structures are determined

physician practice and minimally

appointment

length),

often

by organizations,

Group,

1 9 7 9 ; Multiple

Risk

structured

and many systems (e.g., fee-for-service) lack

organizations (DeBusk et al., 1 9 9 4 ; Peters,

financial reimbursement for patient counseling

Davidson, & Ossorio, 1 9 9 5 ) .

and

education,

substantially

threatening

adherence-focused interventions. T h e allocation o f resources within an organization may

STATE-OF-THE-ART

result in high stress and increased demands

MEASUREMENT OF

on providers that in turn have been associated

ADHERENCE BEHAVIOR

with decreased patient adherence

behavior

(DiMatteo & DiNicola, 1 9 8 2 ) .

Accurate assessment o f adherence behavior is

Furthermore, organizations determine continuity of care. Patients demonstrate

better

necessary for effective and efficient treatment planning and for ensuring that changes in

adherence behavior when they receive care

health outcomes can be attributed

to the

from the same health care provider over time

recommended regimen. In addition, decisions

and when patient information is communi-

to change recommendations,

cated with other providers (Meichenbaum &

and/or communication style so as to invoke

T u r k , 1 9 8 7 ) . For example, the ability o f clinics

patient participation depend

medications, on valid

and

Adherence

to Medical

Recommendations

217

reliable measurement of the adherence construct.

objective strategies may initially appear to be an

Indisputably, there is no "gold standard" for

improvement over subjective approaches, both

measuring adherence behavior (Farmer, 1 9 9 9 ;

approaches have their drawbacks. For example,

Vitolins et al., 2 0 0 0 ) . However, a variety of

remaining dosage units (e.g., tablets) can be counted at clinic visits, but counting inaccura-

strategies have been reported in the literature.

cies are common and typically result in overestimations of adherence behavior (Matsui et al.,

Subjective Measures of Adherence Behavior O n e measurement

1 9 9 4 ) . In addition, important information, such as the timing of dosages and the patterns of

approach

is to

ask

providers and patients to provide their subjec-

missed dosages, is not captured

using this

strategy. Recently, electronic monitoring devices,

tive ratings of adherence behavior. W h e n

such as the Medication Event Monitoring

providers rate the degree to which patients

System ( M E M S ) , have been used to record the

follow their recommendations, providers over-

time and date that a medication container was

estimate adherence behavior (DiMatteo

&

opened, thereby giving a better description of

DiNicola, 1 9 8 2 ; Norell, 1 9 8 1 ) . T h e validity of

the manner in which patients take their medica-

patients' subjective reports has been problem-

tions (Cramer & Mattson, 1 9 9 1 ) . Unfortu-

atic as well. Patients who reveal that they have

nately, the expense o f these devices precludes

not followed advice tend to describe their

their widespread use. Pharmacy databases can

behavior accurately (Cramer &

also be used to check when prescriptions are

Mattson,

1 9 9 1 ) , whereas patients who deny their failure

filled initially, refilled over time, and/or discon-

to follow recommendations tend to report their

tinued prematurely. However, one problem

behavior inaccurately (Spector et al., 1 9 8 6 ) .

with this approach is that complete information

Other subjective rating indicators include stan-

is difficult to obtain given that patients may use

dardized, patient-administered

more than one pharmacy or data might not be

questionnaires

(e.g., Morisky, Green, & Levine, 1 9 8 6 ) . These

routinely captured.

questionnaires have typically been used to assess global patient characteristics or "personality" traits that have proved to be poor predictors o f adherence behavior (Farmer, 1 9 9 9 ) . There are no stable (i.e., trait) factors that reliably predict adherence. However, questionnaires that assess specific behaviors that relate to specific medical recommendations, such as food frequency questionnaires (Freudenheim, 1 9 9 3 ) used for measuring eating behavior to improve management o f obesity, may be reasonable predictors o f adherence

behaviors

(Sumartojo, 1 9 9 3 ) .

Biochemical Measures of Adherence Behavior Biochemical

measurement

is

a

third

approach for assessing adherence behavior. N o n t o x i c biological markers can be added to medications, and their presence in blood or urine c a n provide evidence that a patient recently received a dose o f the medication under examination. This assessment strategy is far from perfect given that findings can be misleading and influenced by a variety o f individual factors, including diet, absorption,

Objective Measures of Adherence Behavior

and rate o f excretion (Vitolins, 2 0 0 0 ) . In sum, adherence measurement provides useful information that outcome monitoring alone

Another approach in assessing adherence

cannot provide, but it remains only an estima-

behaviors is using objective measures. Although

tion of a patient's actual behavior. Several of the

218

BEHAVIORS T H A T C O M P R O M I S E HEALTH

CASE S T U D Y Kaiser Permanente, a large health maintenance organization, is addressing the problem o f adherence at the patient, provider, and health care organization levels. M o s t recently, chronic conditions have been the target o f organizational efforts directed toward improving adherence. Specific factors at each level k n o w n t o influence patients' ability to adhere to medical recommendations are addressed, with the ultimate goal o f improving health outcomes in patients with chronic problems. O n e strategy for improving adherence rates is to offer a variety o f appointment formats and time frames (e.g., individual, group, interdisciplinary team led, telephone) so as to increase the amount o f c o n t a c t between patients and providers. Offering a range o f services maximizes opportunities for providers and patients to attend t o adherence issues and incorporates professionals other than physicians into clinical contacts. Clinical health educators, registered dieticians, pharmacists, care managers, and clinical health psychologists are examples o f nonphysician providers at Kaiser Permanente w h o augment patient care and serve to increase the frequency o f patient contacts within the health care organization. Nonphysician providers have different areas o f expertise and different approaches to the adherence problem. M o r e o v e r , they can extend physicians' time and influence by supporting physicians' recommendations through additional education, motivation, coordination, and self-management support. Another strategy for improving adherence at Kaiser Permanente is t o ensure the quality o f the patient-provider relationship. Patients are assigned a consistent primary care provider (PCP) w h o oversees and coordinates all medical care. T h e PCP establishes an ongoing and open relationship with the patient to maintain continuity o f care over time and to enhance two-way communication and shared responsibility for chronic condition

management.

M o s t Kaiser

Permanente

PCPs

participate in group appointments during which adherence issues are routinely addressed. Patients learn about their conditions, undergo motivational enhancement to initiate and maintain new behaviors, and learn new behavioral skills to implement for the daily management o f their health problems. Sophisticated information systems also help to identify patients having difficulty in adhering to recommendations. Kaiser Permanente's electronic systems facilitate communication among primary care, specialty care, inpatient care, and pharmacy services. PCPs and specialists are able to monitor pharmacy data on prescription refills and use this information as a proxy o f adherence to medication regimens. Laboratory results are also readily available to PCPs, and patients' attendance at group appointments or educational classes can be monitored. Treatment protocols specific to different chronic conditions allow for the ongoing monitoring o f a number of biological indexes and o f adherence to screening and prevention activities. Finally, there are special efforts to promote continuity and contact with the organization to maximize patients' adherence behavior and to minimize or delay

Adherence

expensive disease complications. Care is planned;

to Medical

follow-up

Recommendations

|

appointments,

laboratory tests, and health education group appointments are scheduled. W h e n patients do not adhere to the care protocols, they are contacted through a variety o f outreach strategies. These strategies include regular patient newsletters, individualized reminder letters from their PCPs, and telephone calls from care managers. Patient-centered

outcomes continue to improve. Biological indexes

have

improved across conditions such as heart disease, asthma, and diabetes. Screening and prevention activities have increased, and hospital admissions for patients with chronic conditions have declined.

measurement strategies are extremely costly

(Malahey, 1 9 6 6 ; Marlatt & Gordon, 1 9 8 5 ;

(e.g., M E M S ) or depend on information tech-

Zola, 1 9 8 1 ) . Effective strategies that consis-

nology (e.g., pharmacy databases) that is not

tently change and maintain complex behaviors

available in many organizations. Determining

across

the "best" measurement strategy to get an

However, substantial evidence exists in the

time

might

never

be

discovered.

approximation o f adherence behavior requires

behavioral science arena identifying the most

taking all considerations into account. M o s t

effective strategies for changing behavior. This

important, the strategies employed must meet

abundant body o f research should guide future

basic psychometric standards o f acceptable

intervention efforts. Behavioral science also

reliability and validity (Nunnally & Bernstein,

provides fundamental principles o f behavior

1994).

and empirically evaluated models that can

Additional

meeting

the

goals

considerations of

the

include

provider

or

researcher, the accuracy requirements associated with the regimen, the available resources,

serve as a framework for organizing the conceptualization o f the adherence problem. The

fundamental

concepts from behav-

the response burden on the patient, and how

ioral science apply to behavior in general,

the results will be used. Finally, because no

including all medical conditions and the rec-

solitary

measurement

strategy

been

ommendations for their management, health

approach

care provider behavior, and the behavior o f

that combines feasible self-report and reason-

health care organizations. T h e conceptual

able objective measures is the current state o f

models (e.g., 1 M B model) provide a frame-

the art in the measurement

w o r k for these behavioral principles. Given

deemed optimal, a multimethod

has

o f adherence

behavior.

this knowledge, efforts for improving adherence behaviors c a n be focused and intensified. M o r e o v e r , although complete control is

CONCLUSIONS

impossible, consistent consideration o f the significance o f events that precede and follow

Adherence is behavior. Changing it becomes

behavior at the patient, provider, and health

increasingly more difficult as patients are asked

care organization levels will advance adher-

to learn new behaviors, alter their daily rou-

ence e n h a n c e m e n t

tines, and maintain the changes over time

affect health outcomes.

efforts

and

ultimately

219

220

BEHAVIORS T H A T C O M P R O M I S E HEALTH

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BEHAVIORS T H A T C O M P R O M I S E HEALTH World Health Organization. (2001). Adherence to long-term therapies: Policy for action (WHO Adherence Project: Toward Policies for Action). Geneva: Author. Ziegelstein, R. C , Fauerback, J . Α., Stevens, S. S., Romanelli, J . , Richter, D. P., &c Bush, D. E. (2000). Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Archives of Internal Medicine, 160, 1 8 1 8 - 1 8 2 3 . Zola, I. K. (1981). Structural constraints on the doctor-patient relationship: The case of non-compliance. In L. Eisenberg 8c A. Kleinman (Eds.), The relevance of social science for medicine (pp. 2 4 1 - 2 5 2 ) . New York: D. Reidel.

Part III BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Introduction

T Λ.

to Part III

he next nine chapters epitomize the critical role that psychologists play within health treatment teams across the globe. W h e r e a s Part II focused on unhealthy behaviors that deteriorate health status, this section targets the unhealthy out-

comes o f certain behaviors and explores adaptive behavioral approaches that improve, prevent, and/or alleviate such deleterious medical conditions. M o r e o v e r , the chapters in this section also focus on understanding and addressing psychological problems, such as depression, that result from these medical conditions. In Chapter 1 3 , B o o t h b y , Kuhajda, and T h o r n explore the role o f individual difference variables (e.g., biological states, personality), cognitive appraisal, and coping skills in relation t o an individual's adjustment to pain. T h e y address these issues within a biopsychosocial framework and note that chronic pain can have a significant impact on h o w an individual experiences day-to-day life. T h e y also note h o w chronic pain c a n create psychological problems that complicate adequate adjustment to their condition. Clinicians working with this population are encouraged to w o r k as valued members o f multidisciplinary teams and to positively influence the lives o f such patients via cognitive-behavioral techniques. In Chapter 1 4 , al'Absi and Hoffman define hypertension, discuss the etiological factors that contribute t o this health concern, and highlight h o w t o assess and treat this problem. Their underlying message is that hypertension is a silent killer that can be easily overlooked by medical professionals because there are n o specific symptoms. As such, body weight, alcohol consumption, low levels o f physical activity, and the

226

THE HEALTH P S Y C H O L O G Y HANDBOOK experience o f chronic stress are targeted as factors that may independently

and

conjointly contribute t o hypertension. Clinicians are encouraged t o intervene using cognitive-behavioral approaches designed to control weight, reduce or eliminate alcohol consumption, teach more effective ways in which to cope with stress, and foster adherence to medical and psychological treatments. In Chapter 1 5 , Schwartz and Ketterer provide a practical set o f recommendations for working clinically with patients suffering from heart disease. T h e y conceptualize coronary heart disease within a cognitive-behavioral framework and point out the importance o f a comprehensive assessment. T h e y note that the assessment and treatment o f patients' health risk behaviors, such as smoking, obesity, and lack o f exercise, are essential to secondary prevention efforts and are critical for optimal recovery o f function and general health. Given the significant influence o f negative emotions on the development o f heart disease, clinical health psychologists play a vital role in the treatment o f such patients by employing cognitive-behavioral interventions with and without pharmacotherapy. In Chapter 1 6 , H o f f and her colleagues present issues and behavioral strategies associated with the management o f type 2 diabetes as well as assessment and treatment recommendations. T h e y describe and discuss etiological factors, including a host of psychological consequences that co-occur with this health problem. T h e y note that clinical health psychologists intervene with diabetic patients in a variety o f ways, including making patients more aware o f their health-compromising behaviors via self-monitoring and encouraging behavioral changes that lead to a healthier lifestyle. In addition, clinical health psychologists are in a unique position to address the psychological issues that may arise as a result o f this chronic condition. In Chapter 1 7 , Kreitler takes o n the awesome task o f reviewing the significant body of research examining etiological, assessment, and treatment issues related to cancer. She addresses the psychological phenomena

that undermine

annual

preventive

measures, such as screening for cancer, among high-risk groups. She also explores psychological factors that interfere with the adjustment, coping, and preparation o f patients at various stages o f cancer progression. In addition, Kreitler discusses the assessment o f psychological problems that arise from the impact o f cancer on a person's life and the subsequent treatment options for such issues. T h r o u g h o u t the chapter, she highlights the impact o f cancer n o t only on the patient but also on family members and health care providers. In Chapter 1 8 , G a r o s discusses sexual dysfunctions that may arise due to multiple factors. T h e chapter begins with a section reviewing the human sexual response, followed by a discussion about the psychological and medical conditions that may initiate or exacerbate sexual dysfunction. Given that males and females suffer from different types o f sexual dysfunction, Garos opens with an overall approach to treatment and then breaks down the ensuing assessment and treatment section into various male and female sexual problems. In this section o f the chapter, the reader will find prevalence rates and contributing factors for each dysfunction as well as idiosyncratic treatment approaches to each disorder. In Chapter 1 9 , Blalock and Campos present a thought-provoking piece on human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). T h e y describe the various expressions o f H I V and the stages at which H I V develops into AIDS.

Behavioral

Aspects of Medical

Next, they highlight the importance o f primary prevention and offer

Problems

prevention

strategies for health psychologists and medical personnel. T h e chapter also includes detailed descriptions o f various assessment tools and recommended

treatment

approaches for psychosocial issues that reduce patients' quality o f life. Both psychological and pharmacological treatments for coexisting psychological disorders are presented. In Chapter 2 0 , Lackner notes the high prevalence o f irritable bowel syndrome (IBS) and describes the clinical and diagnostic features associated with this disorder. N e x t , he points out that this syndrome has historically been viewed as a physical manifestation o f a variety o f psychiatric conditions. As such, he uses a biopsychosocial model to illustrate the interplay between psychological functioning and I B S . Lackner also emphasizes the importance o f comprehensive psychodiagnostic assessments before discussing treatment approaches for patients suffering from I B S . T r e a t m e n t recommendations explore the contribution o f conjunctive therapy that uses pharmacotherapy, cognitive-behavioral, and motivational enhancement approaches. Finally, in Chapter 2 1 , Wolfe and Pruitt discuss the impact that insomnia and the other sleep disorders have on human functioning and the overall quality o f life. T h e y start by describing the basic elements o f sleep before delving into the etiology o f a variety o f sleep disorders. N e x t , they break down assessment and treatment recommendations by type o f sleep disorder. Given the high prevalence and pervasive negative impact o f insomnia, much o f the treatment section in this chapter focuses on this disorder. Clinical health psychologists are urged not to underestimate sleep problems when patients present with such disorders.

227

CHAPTER

13 10

Diagnostic and Treatment Considerations in Chronic Pain JENNIFER L . BOOTHBY, MELISSA C . KUHAJDA, AND BEVERLY E . THORN

P

experience that

site o f the pain problem. LeResche and V o n

includes sensory and emotional compo-

Korff ( 1 9 9 9 ) reviewed prevalence rates for

ain is a perceptual

nents associated with actual or threat-

back

pain

across

several

studies.

They

(Merskey & Bogdale,

reported that approximately 1 1 % to 4 5 % o f

1 9 9 4 ) . Virtually everyone experiences pain at

individuals are affected by persistent back

some time in his or her life, but for most

pain. Other researchers found that 1 7 % o f

ened tissue damage

individuals the pain experience is time limited

men and 2 0 % o f women in Australia reported

and does not warrant clinical intervention.

experiencing a chronic pain problem during

However, for some individuals, the pain prob-

the previous 6 months (Blyth et al., 2 0 0 1 ) .

lem persists and significantly disrupts daily

Approximately 5 0 % o f a sample o f U.S. vet-

functioning. Pain that persists for longer than

erans seeking medical treatment

6 months is referred to as "chronic pain"

suffering from at least one chronic pain com-

reported

(Keefe, 1 9 8 2 ) , and chronic pain is often associ-

plaint

ated with feelings of "demoralization, helpless-

migraine headaches have been reported to

ness, hopelessness, and outright depression"

range from 3 . 4 % to 1 7 . 6 % (Breslau, Davis, &

(Clark, 2 0 0 2 ) . Prevalence rates for

(Turk, 1 9 9 6 , p. 3 ) . T h e experience o f chronic

Andreski, 1 9 9 1 ) ,

pain can be far-reaching, affecting numerous

mandibular joint pain were found to range

and

rates o f t e m p o r o -

areas o f an individual's life. F o r example,

from 3 % to 1 5 % (LeResche & V o n Korff,

limited

1 9 9 9 ) . Overall, w o m e n appear to suffer from

physical functioning, inability or reduced abil-

higher rates o f chronic pain problems than do

ity to work, financial concerns related to their

men, and prevalence rates for many pain com-

work situations and medical costs, frequent

plaints increase with age (LeResche & V o n

medical visits, emotional distress, and/or dis-

Korff, 1 9 9 9 ) .

chronic pain

patients

often

face

rupted interpersonal relationships.

Pain is one o f the most c o m m o n reasons vary

for seeking medical care, and for many med-

depending on the population studied and the

ical disorders pain is a primary complaint.

Prevalence rates for chronic pain

229

230

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS For

example, rheumatological

disorders,

options). T h e cognitive appraisal

processes

cancer, dental problems, gastrointestinal dis-

influence one's emotional, cognitive, behav-

orders, AIDS, and neurological conditions all

ioral, and physiological response to the pain

share pain as a presenting complaint. In addi-

experience. Those responses that

tion, many individuals w h o sustain injuries

attempts to mitigate the pain experience are

represent

experience substantial pain, and for some the

called coping attempts. T h e efficacy of the cop-

pain persists for years. M o r e o v e r , pain is not

ing attempt is not what gives it the label of

entirely a physiological experience. Decades

"coping"; rather, it is the effortful intention to

o f research have shown that pain has sen-

manage the stressful pain experience. Coping

sory, affective, and evaluative components

responses ultimately influence important adap-

(Melzack & Wall, 1 9 6 5 ) . Thus, understand-

tational outcomes such as social and occupa-

ing pain and understanding its treatment are

tional functioning, morale and mood,

important areas in which health psychologists

somatic health. Finally, it is crucial to note that

and

should become involved. In fact, a health psy-

the process of appraisal, coping, and adapta-

chologist would be hard-pressed to work in a

tion is fluid rather than static;

medical setting and not confront patients with

itself changes the nature of the pain experience,

pain problems on a relatively frequent basis.

which affects cognitive appraisal processes,

adaptation

thereby influencing coping and adaptation. T h e transactional model as adapted for pain is not limited to appraisal of, and coping with,

BACKGROUND AND ETIOLOGY

the pain stimulus. Obviously, there are many related aspects o f chronic pain such as feelings

Biopsychosocial Model of Pain

of dependency, dealing with marital strain or

Our current understanding of pain percep-

divorce, and losing one's j o b and income. Each

tion is consistent with the biopsychosocial

of these environmental challenges contributes

model. A useful conceptual heuristic for the

to the "stress" o f a person with chronic pain.

biopsychosocial model

been

T h e multifaceted nature of stressors related to

adapted from Lazarus and Folkman's ( 1 9 8 4 )

pain, and the patient's evolving response to

transactional stress and coping theory (Thorn,

them, is particularly important in the context

Rich, & Boothby, 1 9 9 9 ) and is expanded in

of coping with chronic pain.

o f pain

has

Figure 1 3 . 1 . In the expanded model, the influ-

T h e model just conceptualized is useful

ence of individual variables, cognitive appraisal

from a theoretical perspective but does not

processes, and coping interact to influence

offer a format for treatment conceptualiza-

ongoing adjustment to the pain experience.

tion. T o this end, the chapter authors have

Individual variables include biological state

adopted a cognitive conceptualization through

(e.g., disease process), dispositional factors (e.g.,

which cognitive-behavioral treatment can be

personality), and stable social roles (e.g., pri-

delivered. A cognitive formulation fits well

mary relationship issues). Cognitive appraisal

with a transactional model o f pain because it

processes include both primary appraisal mech-

not only emphasizes the importance o f cogni-

anisms (whether a pain-related experience is

tions but also presumes that cognitive factors

judged to be stressful or benign, and if it is

precede and determine the nature o f coping

stressful, whether it is judged to be a threat, a

attempts. A cognitive formulation also pre-

loss, or a challenge) and secondary appraisal

sumes that

processes (cognitions and beliefs about

results in changes in his or her emotional,

the

altering a person's

cognitions

pain, cognitions and beliefs about the self, and

behavioral, cognitive, and physiological cop-

expectations about the utility of certain coping

ing processes. Put another way, the cognitive

Individual Characteristics : \ biological state personality I \. social roles /

/ /

Primary \ Appraisals:

/

Secondary ^ Appraisals:

Coping: emotion cognition behavior physical

cognitive errors beliefs

threat, harm/loss y challenge

Adaptation: function mood health Figure 13.1

Transactional Model of Adjustment to Chronic Pain

formulation assumes that cognitions are the

important

mechanisms through which certain variables

than to increase coping (Geisser, Robinson, &

have their impact on outcome (i.e., cognitions

Riley,

serve as mediators for adaptive change). Although it is far from established that

to reduce negativistic cognitions

1 9 9 9 ; Newton &

Barbaree, 1 9 8 7 ;

T u r k & Rudy, 1 9 9 2 ) . Thorn, Boothby, and Sullivan ( 2 0 0 2 ) suggested that, especially for

cognitive mechanisms are the mediators for

those individuals w h o engage in catastrophic

adaptive change in pain management, several

thinking about pain and pain-related stressors,

models

it may be important t o target treatment toward

of

cognitive-affective

functioning

ascribe antecedent status to cognitive factors in

reducing cognitive errors prior to attempting to

the development

increase coping skills. These and other authors

o f emotional

dysfunction

( B e c k & Emery, 1 9 8 5 ; Riskind & Williams,

(Chaves & Brown, 1 9 8 7 ) hypothesized that

1 9 9 9 ; Vasey & Burkovec, 1 9 9 2 ) . Vlaeyen and

the change mechanism involved in pain man-

Linton ( 2 0 0 0 ) adopted a cognitive framework

agement is the reduction o f maladaptive think-

to account for pain-related disability, suggest-

ing. There are examples in the literature that

ing that catastrophic thinking might represent

provide support for this formulation.

the cognitive precursor t o pain-related behav-

Pain-related

catastrophizing

is a

well-

ioral avoidance. Several psychosocial pain

researched cognitive factor that is a remarkably

researchers have suggested that it may be more

robust predictor

o f pain

responsivity

and

232

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS adjustment

to

chronic

painful

states.

tendency toward maladaptive cognitions could

Catastrophizing is consistently related to higher

moderate levels o f catastrophic and other nega-

levels of self-reported pain as well as to other

tive pain-related thinking. Negative

measures o f pain maladjustment

(Geisser,

related thoughts could also result from primary

1 9 9 4 ; Jacobsen &

threat and loss/harm appraisals, thereby serving

Butler, 1 9 9 6 ; Robinson et a l , 1 9 9 7 ; Sullivan &

as secondary appraisal processes (Thorn et al.,

Robinson, &

Henson,

pain-

Neish, 1 9 9 8 ; Sullivan, Rouse, Bishop, Sc

1 9 9 9 ) . Finally, there has been some suggestion

Johnston, 1 9 9 7 ) .

that catastrophic responses could represent a

Clearly, individuals

who

catastrophize about their pain are less func-

means of seeking support through emotional

tional than persons who do not catastrophize.

disclosure (Sullivan et al., 2 0 0 0 ) . Because social

M o r e important to the cognitive formulation

support is often used as a means o f coping, it

described previously, catastrophizing has been

might be that negative cognitive, emotional,

shown to mediate certain relations between

and behavioral expressions o f pain and its

individual differences (e.g., sex differences) and

potential consequences may be used to gain

pain responsivity (Sullivan, Tripp, Sc Santor,

social proximity, attention, and/or

2 0 0 0 ) . Relatedly, other negative cognitions

from others. Although the primary goal o f the

empathy

associated with pain have been shown to medi-

communal coper may be to gain empathy and

ate the relation between beliefs about pain and

support, and not necessarily to reduce pain, the

certain outcome measures (Stroud, Thorn,

ultimate outcome o f such coping behavior

Jensen, & Boothby, 2 0 0 0 ) . In a recent path

might be maladaptive in that such negative

analysis of multiple potential predictors o f pain,

thought processes, emotions, and behaviors

catastrophizing predicted pain over and above

may contribute to heightened pain experiences

measures of fear o f pain, trait anxiety, and state

(Sullivan et al., 2 0 0 1 ) .

anxiety (Sullivan, Stanish, Sullivan, Sc Tripp, 2 0 0 2 ) , suggesting that although catastrophizing is related to other variables (in this case emotion), catastrophizing is a separate construct and is more predictive of adjustment to pain debate

regarding whether catastrophic thinking and other maladaptive cognitions are a manifestation o f a personality type (Sullivan et al., 2 0 0 1 ) , an appraisal process (Thorn et al., 1 9 9 9 ) , or a coping strategy (Keefe, Lefebvre, &

Clinical

Description

" M a r y ' s " story, a description o f which

than are these other variables. Although there has been some

Diagnostic and Etiological Issues

Smith,

1 9 9 9 ) , using the transactional model described previously, catastrophizing and other negative thoughts could be accommodated at several locations within the model. For example, the trait-like tendencies toward negative affectivity, neuroticism, and emotional vulnerability all have been associated with catastrophic thinking (Affleck, Tennen, Urrows, Sc Higgins, 1 9 9 2 ; Crombez, Eccleston, V a n den Broek, V a n Doudenhove, & Goubert, 2 0 0 2 ; Ward, Thorn, Sc Clements, 2 0 0 2 ) . Thus, the dispositional

follows and which is actually a compilation o f the stories o f many patients who present for pain management treatment in practice, is not at all dissimilar to what health psychologists see in pain clinics across the United States and abroad. M a r y walked slowly and gingerly, in a self-protective manner, from the waiting r o o m into the therapy office and grimaced as she carefully sat in the chair. She said, No hard feelings intended, but I really don't want to be here today. My doctor, after having sent me to six different specialists who were unable to help, told me yesterday that there is nothing else he can do for me and that I've just got to learn to live with this pain. He suggested that I come to you, but I don't think I need a shrink! I mean, my pain

Chronic Pain is real. I'm not just making it up. I actually had to quit a job I dearly loved, one that I had spent years searching for, but as my pain grew worse, I began to feel fatigued more and more often. I also started having trouble remembering things and would get halfway through a story and forget what it was I was even talking about. It became embarrassing and depressing to think that I might endanger the lives of the people I work with, so I first took a leave of absence but eventually quit. I know I'm depressed, but I wouldn't be if I didn't have this pain.

feel depressed, anxious, and hopeless. These feelings lead to increased muscle tension and the production o f harmful stress hormones, which in turn lead to an increase in pain intensity. Negative and exaggerated thoughts and feelings also influence decisions about activity levels. Inactivity leads to muscle deconditioning, so that when patients attempt activity at a future time, it will be uncomfortable or may be excruciatingly painful, thereby influencing their decision to stay in bed. W h e n patients present for pain treatment, they often have been completely sedentary or perhaps even bedridden for

M a r y also described feelings o f despair and hopelessness. She explained that

6 months prior to their first visit.

her

husband, w h o originally was understanding and supportive, had begun to question the veracity o f her condition by saying things

Diagnostic

Considerations

Historically, the health psychologist has

such as the following: "Everybody gets pain,

looked to the D S M (Diagnostic

especially as they age. Y o u ' r e going to need

Manual

of Mental

and

Statistical

for guidance in

Disorders)

to toughen up and learn to live with it."

accurately diagnosing patients with chronic

M a r y was tearful and angry. N o t only was

pain

her pain negatively affecting her relationship

Psychiatric Association, 1 9 6 8 ) provided no

with her husband, but she had noticed that

specific

some o f her friends had stopped calling—

Therefore, pain patients o f this era were

"probably because I had refused many invi-

typically given a D S M - I I diagnosis o f "psycho-

conditions. T h e D S M - I I diagnosis

pertaining

(American to

pain.

tations to go shopping and to go to the gym

physiological

like I did all the time before this pain."

emotional factors were thought to influence

disorder,"

especially

when

The first several sessions with a health

their painful condition. Psychogenic pain dis-

psychologist are primarily devoted to rapport

order appeared under the rubric o f somato-

building, ensuring pain patients that the psy-

form disorders in the DSM-III (American

chologist believes their pain is real, helping

Psychiatric Association, 1 9 8 0 ) . Three major

patients to understand that feeling depressed

criteria were required for a diagnosis o f psy-

about their pain is actually a normal response

chogenic pain disorder: severe and prolonged

to an abnormal situation, and beginning the

pain, no known organic pathology, and psy-

process of educating patients about the impor-

chological factors (e.g., pain onset is positively

tant body-mind connection. When patients'

correlated with psychological conflict) that are

bodies hurt and they have been diagnosed with

etiologically involved in the pain.

controversial

illnesses (e.g.,

fibromyalgia,

In the DSM-III-R (American Psychiatric

chronic fatigue syndrome), they strive to make

Association, 1 9 8 7 ) , psychogenic pain disorder

sense of this experience. They soon may begin

was

to have exaggerated and distorted

because demonstrating

thoughts

about their current condition, and the follow-

renamed

somatoform that

pain pain

disorder is psy-

chogenic proved to be nearly impossible. T w o

ing may be a common comment: " I ' m never

major criteria were required for a diagnosis of

going to feel better. M y pain is ruining my life."

somatoform pain disorder:

Having catastrophic thoughts leads patients to

with pain" for at least 6 months and no known

"preoccupation

233

234

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS organic pathology (or when organic pathology

100%

is found, the complaint of pain and functional

comorbid depression, according to the studies

[e.g., social, occupational] impairment is not

they reviewed. Fishbain, Goldberg, Meagher,

commensurate with physical findings

o f patients with chronic pain have

but

Steele, and Rosomoff ( 1 9 8 6 ) found depression

rather is grossly exaggerated). T h e D S M - I V

and chronic pain to coexist approximately

subcommittee on pain disorders found that the

5 0 % o f the time. Panic disorder is diagnosed

D S M - M - R somatoform pain disorder diagno-

in 1 6 % to 2 5 % o f patients presenting to

sis was rarely used because there appeared to

emergency rooms with chest pain (Beitman

be no consensus on what "preoccupation with

et al., 1 9 9 1 ; Carney, Freedland, Ludbrook,

pain" meant. In addition, there was difficulty

Saunders,

in determining whether the patient's response

Feinmann, and Harris ( 1 9 9 2 ) reported that

&

Jaffe,

1990).

Aghabeigi,

to pain was being grossly exaggerated. There

2 1 % of fibromyalgia patients in their clinic

was also disagreement on the appropriateness

carried a dual diagnosis o f pain disorder and

of this diagnosis for individuals with disabling

posttraumatic stress disorder. Other studies

pain due to known medical conditions.

purport that anywhere from 5 0 % to 1 0 0 % of

In the D S M - I V

(American Psychiatric

pain patients entering clinical treatment for

Association, 1 9 9 4 ) , somatoform pain disorder

pain management have comorbid posttrau-

was renamed as pain disorder. Diagnostic cri-

matic

teria included pain in at least one specific area

Bertrand, & Maciewicz, 2 0 0 0 ) . It appears to

stress

disorder

(Kulich,

Mencher,

of the body significant enough to warrant clin-

be the case, then, that the D S M - I V pain disor-

ical attention, pain that causes distress or func-

der diagnosis, like its D S M predecessors

tional (e.g., social, occupational) impairment,

(somatoform pain disorder and psychogenic

psychological issues that are thought to play a

pain disorder), remains a diagnosis o f exclu-

significant part in important components o f

sion with ambiguous inclusion criteria.

the pain (onset, frequency, duration, severity, exacerbation, or maintenance), pain that is not intentionally produced or feigned (as in

CO-OCCURRING

factitious disorder or malingering), and pain

PSYCHOLOGICAL DISORDERS

that is not better accounted for by a mood, anxiety, or psychotic disorder and does not

As indicated previously, chronic pain patients

meet criteria for dyspareunia.

often have symptoms consistent with a mood

T h e D S M - I V pain disorder diagnosis has

disorder, namely depression. It is common for

been criticized for a number o f reasons. First,

these patients to argue that depression is their

no guidelines are provided for determining

reaction to the limitations placed on them via

when psychological factors significantly affect

their chronic pain condition. In other words, if

pain or are sufficient to warrant

they did not have chronic pain, they would not

separate

D S M - I V diagnoses in addition to pain disor-

be depressed. Whether or not this is true is of

der. There is a high prevalence of depression

little actual consequence in terms of treatment

and anxiety disorders among chronic pain

considerations. W h a t health psychologists do

patients, yet under the D S M - I V criteria, these

know is that alleviating depressive symptoms in

patients who seemingly would be most appro-

chronic pain patients, regardless of the depres-

priate for this diagnostic category could con-

sive etiology, not only makes their pain more

ceivably be excluded due to the criterion that

tolerable but also lifts their mood, both of

"pain is not better accounted for by a M o o d ,

which serve to improve the quality o f their lives.

Anxiety, . . . Disorder." R o m a n o and Turner

O n the other hand, chronic pain patients may

( 1 9 8 5 ) reported that anywhere from 1 0 % to

view a diagnosis of depression (or anxiety) as a

Chronic Pain

235

sign that their pain is not real—a common

or representative o f a deficit or incapacity.

concern for pain patients. They may perceive

Others believe pain to be the most common

mood and anxiety disorder diagnoses as dis-

conversion symptom

counting their pain and may be prone to ask

Myer, 1 9 6 0 ) . Sullivan ( 2 0 0 1 ) purported that

(Ziegler, Imboden,

&

questions such as the following: "Since I have

although there may be some components of

depression, does that mean that my pain is all in

conversion disorder present in chronic pain

my head?" T h e pain specialist/health profes-

patients (secondary gain), classifying these

sional can typically remedy this misunder-

patients with a conversion disorder is generally

standing by assuring these patients that their

not useful.

depressive or anxious characteristics are actually a normal response to abnormal circumstances.

Although the diagnosis o f somatization disorder is rarely used, it warrants a few brief

Substance-induced mood disorder can also

statements. Several specific criteria are required

occur in chronic pain patients. Due to these

for this diagnosis, and these are detailed in the

patients' compromised health conditions, dif-

D S M - I V (American Psychiatric Association,

ferent physicians frequently prescribe numer-

1 9 9 4 ) under somatoform disorders. Prevalence

ous medications. For this reason, it is a good

estimates for somatization disorder range from

idea to recommend that pain patients main-

0 . 1 3 % to 0 . 4 0 % in the community (Smith,

tain a list o f all current medications, indicating

1 9 9 1 ) , from 0 . 2 % to 5 . 0 % in primary care set-

specific dosages and frequencies with which

tings (Sullivan, 2 0 0 1 ) , and from 8 % to 1 2 % in

they take each o f them, and to make a point

pain clinics (Kouyanou, Pither, Rabe-Hesketh,

of

&

providing

each

o f their

health

care

Wessely, 1 9 9 8 ) . Sullivan ( 2 0 0 1 )

stated,

providers with this list. Medications known

"Somatization as a process, meaning the somatic

to evoke m o o d symptoms include, but are not

experience

limited to, steroids, anticonvulsants, antihy-

Somatization disorder is a rare, chronic, and

pertensives, anti-Parkinsonian

medications,

treatment-resistant condition that characterizes

antiulcer medications, cardiac medications, oral

the most severely and chronically distressed

of

distress,

is

ubiquitous. . . .

individuals" (p. 2 8 4 ) . Thus, although many

contraceptives, and muscle relaxants. Anxiety disorders, such as panic disorder

chronic pain patients might initially appear to

fre-

be highly focused and preoccupied on somatic

quently associated with chronic pain disorders.

functioning, meeting full criteria for a diagnosis

In addition to the studies cited earlier, Stewart,

of somatization disorder is relatively rare.

and posttraumatic

stress disorder, are

Breslau, and Keck (1994) reported that migraine

It is imperative for the health psychologist to

headaches are more strongly correlated with

have at least a basic understanding of common

panic attacks than are any other types of

chronic pain conditions (where pain is the pri-

headache. In a community assessment o f

mary symptom) and other related health condi-

1 0 , 0 0 0 individuals who presented to their pri-

tions (where pain is an associated symptom but

mary care physicians with complaints o f

not the primary one) when patients present for

headache, 1 5 % of females and 1 3 % of males

clinical pain management.

had a history of panic disorder (Sullivan, 2 0 0 1 ).

chronic pain conditions include, but are not

Whether or not pain disorders should be

limited to, fibromyalgia, headache, chronic low

Some c o m m o n

classified as conversion disorders has been, and

back pain, and complex regional pain syn-

continues to be, a point of contention among

drome. Other related health conditions include

health care professionals. Some do not support

chronic fatigue syndrome, multiple chemical

the notion that pain conditions can be classified

sensitivities, and lupus. By and large, the etiol-

as conversion disorder symptoms because most

ogy, nature, and treatment o f these conditions

pain conditions are not neurological in nature

are considered controversial among health care

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

236

professionals. Before describing specific aspects

approximately 2 % of the population

of each, it may be useful to look at common

fibromyalgia.

challenges that nearly all chronic pain patients

has

According to the International Headache

face regardless o f etiology. Taylor, Friedberg,

Society's

and Jason (2001) identified the following seven

Criteria for Headache Disorders, Cranial

challenges. First, these patients' symptoms and

Neuralgias, and

"Classification

and

Facial P a i n "

Diagnostic (Headache

degree of impairment vary significantly across

Classification Committee o f the International

individuals and chronic pain conditions (e.g.,

Headache

one fibromyalgia patient may be working full-

tension-type headaches are the most com-

time, whereas another is bedridden). Second,

monly diagnosed chronic headache disorders.

treatments (e.g., pharmacological, psychologi-

Pain characteristics o f tension-type headaches

Society,

1988),

migraine

and

cal, physical) for chronic pain conditions are

(previously called tension, muscle contraction,

ameliorative in nature and typically do not cure

stress, or ordinary headaches) include a press-

these disorders. Third, these chronic pain con-

ing and/or tightening sensation o f a mild to

ditions are much more prevalent

among

moderate intensity occurring bilaterally, with

women than among men (e.g., women com-

minimal aggravation by routine physical activ-

prise approximately 7 0 % of chronic fatigue

ity (Rapoport & Sheftell, 1 9 9 6 ) . Typical pain

patients, 9 0 % of fibromyalgia patients, and

characteristics for migraine headaches include

7 5 % o f multiple chemical sensitivities patients).

a throbbing and/or pulsating sensation o f

Fourth, there is high comorbidity

among

moderate to severe intensity occurring unilat-

chronic pain conditions (e.g., many fibromyal-

erally, with aggravation by routine physical

gia patients have chronic fatigue as well). Fifth,

activity. T h e presence o f nausea and/or vomit-

recovery rates are minimal (and that is why

ing along with photophobia and phonophobia

they are referred to as chronic conditions).

is usually characteristic o f migraineurs exclu-

Sixth, patients incur multiple losses of an eco-

sively, although

nomic and social nature (e.g., disability and

experienced to a lesser degree by tension-type

social isolation). Seventh, there is a high level o f

headache sufferers

these symptoms (Rapoport &

may

be

Sheftell,

psychiatric comorbidity (e.g., many patients

1 9 9 6 ) . Although the exact cause o f headache

with fibromyalgia also have depression and

pain remains a mystery, several theories have

anxiety disorders).

been generated. F o r migraine

In 1 9 9 0 , the American College o f Rheumatology officially recognized fibromyalgia as an illness with the following classification criteria: (a)

history o f widespread

muscular

pain

and (b) tenderness in 1 1 of 18 "tender points" located in specific areas o f the body (Wolfe etal., 1 9 9 0 ) . Fatigue, disrupted sleep, headache, irritable bowel, and irritable bladder are also characteristic symptoms o f this disease. The etiology o f fibromyalgia is unknown, but many affected individuals and their health care professionals report that symptoms

often

appear following surgery, following an injury of a traumatic nature, or following an acute

headaches,

Rapoport and Sheftell ( 1 9 9 6 ) reported three major theories, namely that (a) changes occur in cerebral blood flow and electrical cortical activity; (b) neurogenic inflammation, produced by the release o f Substance Ρ and other neurotransmitters, impinges on the site where trigeminal nerve endings meet durai arteries; and (c) the size o f peripheral blood vessels is altered (e.g., constricted, dilated) in response to some unknown noradrenergic and serotonergic disruption. T h e etiology of some tensiontype

increase

in

pericranial muscle activity ( R a p o p o r t

headaches

involves

an

&

Sheftell, 1 9 9 6 ) .

medical illness (Waylonis & Perkins, 1 9 9 4 ) .

The lifetime prevalence of low back pain

Wolfe and colleagues ( 1 9 9 0 ) estimated that

is estimated to be 7 0 % for individuals in

Chronic

Pain

developed countries. Approximately 1 6 % of all

and colleagues ( 1 9 9 4 ) described the current

workmen's compensation claims are low back

U.S. diagnostic criteria as (a) prolonged (at

pain related, and the estimated cost o f lost

least 6 months) overwhelming fatigue that is

productivity is enormous (Amundson, 2 0 0 2 ) .

not ameliorated with rest, where (b) during the

There are many causes o f chronic low back

same 6-month period o f chronic fatigue, the

pain, including muscle spasm and tightness,

individual experiences at least four o f eight

whiplash, osteoarthritis (or spondylosis, a

minor symptoms (sore throat, cognitive dys-

degenerative process affecting the normal func-

function [short-term memory or concentration

tion and structure o f the spine), osteoporosis

problems], cervical or axillary lymph node ten-

(degeneration o f bone mass), herniated disc,

derness, muscle pain, joint pain, development

sciatica (pain [lower back, buttocks, radiating

of new type o f headache, sleep disturbance, or

down the thighs and sometimes into the feet]

malaise) for at least 2 4 hours. T h e etiology o f

that follows the sciatic nerve), compression

chronic

fracture (vertebral body that is crushed by

although medical researchers have speculated

external force to the spine), spinal stenosis (nar-

for years that viruses such as Epstein-Barr,

rowing of small nerve passageway called fora-

cytomegalovirus, and herpes simplex virus

fatigue

syndrome

is

unknown,

men, causing nerve compression, swelling, and

(Types I and II), or an overactive immune sys-

pain), and osteomyelitis (infection in the spine).

tem, may have a role in causing the syndrome.

It is not unusual for individuals with low back pain to have no structural abnormalities that can

be detected on physical examinations,

Multiple chemical sensitivities, a recognized

disorder

by

the

American

Lung

Association, the American Medical Associa-

X rays, or magnetic resonance imaging proce-

tion,

dures (MRIs). In addition, patients who have

Agency, and the U.S. Consumer

undergone repeated back surgeries may have

Safety Commission, remains a controversial

pain from scar tissue that is pressing on nerves.

health condition among many health care

Complex regional pain syndrome, type 1,

professionals. Taylor and colleagues ( 2 0 0 1 )

also known as reflex sympathetic dystrophy,

referred to it as " a chronic condition o f

Sudeck's dystrophy, or hand/shoulder

syn-

irritation or inflammation o f sensory organs,

drome, is a condition that can develop after

gastrointestinal distress, fatigue, and c o m -

traumatic injury to the extremities (Caudill,

promised neurological function,

2 0 0 2 ) but has also been known to develop

learning and memory deficits, hypersensitivity

Harden,

to unpleasant smells, tingling o f nerves, and

2 0 0 1 ) . A primary symptom is autonomic

sensory discomfort" (p. 5 ) . These symptoms

spontaneously

(Bruehl, Steger, &

nervous system dysfunction

that

includes

the

U . S . Environmental

Protection Product

including

appear to be triggered by exposure to certain

swelling, increased sweating, blood vessel

chemical

constriction or dilation, and severe pain in the

reported to be primarily pesticides, detergent

agents,

which

Donnay

(1998)

involved extremity. T h e diagnosis o f complex

residues, and perfumes. In California and

regional pain syndrome with specific criteria

N e w M e x i c o , public health department sur-

agreed on by the International Association for

veys reveal prevalence rates to be anywhere

the Study o f Pain was developed in 1 9 9 4 .

from 2 % to 6 % (Taylor et al., 2 0 0 1 ) .

Chronic fatigue syndrome, a significant

Lupus, or systemic lupus erythematosus, is

public health concern, lowers the quality of all

thought to be an autoimmune disorder that

aspects o f life (e.g., social, occupational, inter-

affects multiple organ systems and that is char-

personal) for approximately 0 . 4 2 % o f the U.S.

acterized by skin lesions (butterfly rash) on sun

population or 8 0 0 , 0 0 0 individuals (Anderson

exposure, arthritis and pain in multiple joints,

& Ferrans, 1 9 9 7 ; Jason et al., 1 9 9 9 ) . Fukuda

chronic kidney infection, and blood vessel

237

238

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS inflammation (causing peripheral neuropathy

related to ease o f use and ability o f patients

in hands and feet or causing pain, ulceration,

to conceptualize their pain in the manner

and infection in lungs, heart, and intestines).

requested (Williams, 1 9 9 6 ) .

T h e etiology may be due at least partially to a genetic defect in Β lymphocytes, which produce autoantibodies that attack cells (F. A.

Pain

Experience.

Although assessing pain

intensity is an important aspect of any pain eval-

Davis, 1 9 9 7 ) . Although some individuals die

uation, other aspects o f the pain experience are

from this disease (i.e., with multiple organ

also critical in fully understanding the patient's

system involvement), medical researchers are

perspective. Measures such as the McGill

helping lupus patients to live much longer

Pain Questionnaire (Melzack, 1987), the West

and higher quality lives than ever before

Haven-Yale Multidimensional Pain Inventory

(Lahita, 2 0 0 1 ) .

(Kerns, Turk, & Rudy, 1 9 8 5 ) , and the Sickness Impact Profile (Roland & Morris, 1 9 8 3 ) provide information regarding sensory and emo-

ASSESSMENT AND TREATMENT

tional components o f pain, physical activity level, spouse responses to pain, and overall psychosocial functioning. Pain behaviors can also

Pain Assessment

be included under the rubric of overall pain

T o effectively treat chronic pain, the health

experience and can be assessed through self-

psychologist must fully assess the individual's

report or observation of the patient. Pain behav-

pain experience and also explore variables

iors include grimacing, moaning, limping, lying

known to affect treatment response. A general

down, and consuming pain medications. Many

strategy for pain assessment is presented here,

pain behaviors are often reinforcing and lead

with specific examples of assessment instru-

to higher levels of disability. For example, if

ments and information about h o w individual

the spouse of a chronic pain patient attempts to

variables affect treatment outcome. Evaluation

comfort the patient whenever he or she appears

strategies for specific pain problems or medical

to be hurting, the patient may learn that certain

disorders are not discussed.

pain behaviors result in attention and sympathy. Keefe and Hill (1985) developed a methodology

Pain Intensity.

Self-reported pain intensity

for

assessing pain

behavior that

requires

is believed to be a good measure o f overall

videotaping, whereas other clinicians have

pain and suffering. Several methods exist for

developed checklists to evaluate behavioral

obtaining this information from patients. For

responses

example, numerical rating

to

pain

(Waddell, M c C u l l o c h ,

scales require

Kummel, & Venner, 1 9 8 0 ) . Pain assessments

patients to rate the intensity o f their pain

that address the broader pain experience have

using a number, for example, from 0 to 1 0 .

the potential of offering more detailed treatment

Verbal rating scales ask patients to describe

recommendations and of providing a standard

their pain with an adjective chosen from a list

of comparison for patients'

that can then be quantified. Visual analog

functioning.

posttreatment

scales are straight lines with verbal intensity descriptors on the end points and require patients to rate their pain by placing a m a r k on the line. Clinicians must then use a ruler to measure where the mark occurs so as to quantify the rating. Each o f these methods has its strengths and weaknesses, primarily

Pain

Beliefs

and

Cognitions.

Cognitive

factors, such as beliefs, appraisals, and cognitive distortions, play an important role in adjustment to pain and the development o f disability ( D e G o o d & Shutty, 1 9 9 2 ) . F o r example, the critical role o f catastrophizing

Chronic Pain in altering the pain experience was highlighted

assessment o f cognitions that are more illness

earlier in this chapter. In addition to catas-

specific.

trophizing, research has shown other negative cognitions to be associated with poorer functioning a m o n g chronic pain patients. For example,

DeGood

and

Shutty

(1992)

Pain Coping.

Coping consists o f cognitive

and behavioral efforts undertaken to manage stressful

situations.

How

chronic

pain

described the importance o f low self-efficacy

patients cope with the pain experience is

and beliefs that pain is mysterious or out o f

related to their physical and psychosocial

the individual's control in predicting poor

functioning. Coping attempts that are pas-

pain treatment response. Fear o f pain and

sive, such as hoping or praying for an end to

reinjury is also associated with poor pain

the pain, are often associated with higher

outcomes, and recent research has revealed

levels o f physical disability and psychological

that

dysfunction than are more active strategies

anxiety sensitivity exacerbates pain-

related

fear

and

leads to

physical activity (Asmundson,

avoidance of

for

1996). Fear o f

Jensen,

pain is associated with selective attentional bias for pain-related Ellery, Hunt,

information (Keogh,

8c Hannent, 2001), potentially

coping

(Boothby, Thorn,

Stroud, &

1999). Catastrophizing is sometimes

conceptualized as a coping strategy, and as described previously, catastrophizing is consistently related to p o o r

pain

outcomes

resulting in more negative pain experiences

(Sullivan et al., 2001). Although active coping

for individuals with elevated fears o f pain.

strategies, such as distraction techniques and

Finally, several studies

that

using positive coping self-statements, are not

(e.g., overgeneralization,

generally associated with negative pain out-

selective abstraction) are related to depressive

comes, they are also not consistently corre-

symptoms in chronic pain patients (Lefebvre,

lated with positive outcomes (Boothby et al.,

cognitive errors

have found

Smith, Christensen, Peck, 8c W a r d ,

1999). As a result, some pain researchers

1994) and that pain treatment that addresses

have suggested that it is more important to

cognitive factors (e.g., cognitive errors) is

decrease passive coping or negative coping

1981;

effective at alleviating depression in this pop-

attempts rather than to only teach more

ulation ( M o r e n o , Cunningham, Gatchel, &

adaptive,

Mayer,

1991). Pain research has also

revealed that changes in negative cognitions and beliefs m o r e generally are also associated with

improvement

following

multidisci-

plinary pain treatment (Jensen, Turner, 8c Romano,

2001).

et al.,

active coping strategies (Geisser

1999; N e w t o n 8c Barbaree, 1987).

Several measures exist for the assessment o f pain coping. T h e Coping Strategies Questionnaire (Rosenstiel 8c Keefe, 1983) was specifically developed to assess coping among pain patients, and it is the most frequently used

M a n y instruments exist for the measure-

instrument o f its kind. T h e Cognitive Coping

ment o f pain-related beliefs and cognitive

Strategies

factors. A few o f these measures include

Beaulieu, Schwebel, & Thorn, 1989) and the

Inventory

the Pain Beliefs and Perceptions Inventory

Vanderbilt

Pain

(Butler,

Management

Damarin, Inventory

1989), the Inventory o f

(Brown 8c Nicassio, 1987) are also inventories

Negative Thoughts in Response to Pain (Gil,

specific to pain coping assessment. Numerous

1990), the Pain

instruments exist for the evaluation o f coping

Scale (Sullivan, Bishop, 8t

strategies more generally. However, it is rec-

1995), and the Pain Anxiety Symptoms 8t Gross, 1992).

ommended that a pain-specific instrument be

(Williams & T h o r n ,

Williams, Keefe, & B e c k h a m , Catastrophizing Pivik,

Scale ( M c C r a c k e n , Zayfert,

used whenever possible because coping is

A variety o f similar instruments exist for the

often

conceptualized as situation specific

239

240

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS (Lazarus, 1 9 9 3 ) and patients might cope with

had higher pretreatment levels o f depression,

chronic pain

anxiety, psychoticism, and overall distress than

differently

from

how

they

approach other stressors.

did patients who returned to work. Gatchel, Polatin, and M a y e r ( 1 9 9 5 ) evaluated a large Individuals with

sample o f acute low back patients and found

chronic pain often have associated emotional

higher levels of self-reported pain and disabil-

difficulties.

ity as well as higher scores on Scale 3 (hysteria)

Emotional

Functioning.

E m o t i o n a l reactions, such

as

depression and anxiety, are c o m m o n respon-

of the M M P I to be associated with a lack o f

ses to persistent pain and can serve to c o m -

return to work after 1 year. Thus, evaluating

pound the original pain problem and lead to

patients for the presence o f these symptoms

more

and disorders is an important piece in poten-

severe

impairment

and

disability.

Research has demonstrated consistently that

tially preventing

certain types o f psychopathology are associ-

planning effective treatment. T h e assessment o f

severe disability and

in

ated with poorer adjustment to chronic pain

psychological symptoms and disorders can be

and poorer treatment response (Block, 1 9 9 6 ;

undertaken using self-report measures that are

Brennan, Barrett, & Garretson, 1 9 8 6 ; Gaskin,

common to clinicians in other areas of psy-

Greene, Robinson, & Geisser, 1 9 9 2 ) .

chological practice (e.g., M M P I ,

Rates o f depression, anxiety, and anger have been shown to be higher among chronic pain patients than in community

Checklist-90-Revised,

Beck

Symptom Depression

Inventory).

samples

(Banks &c Kerns, 1 9 9 6 ; Fernandez & Turk, 1 9 9 5 ; Gaskin et al., 1 9 9 2 ) . Research using the

Acute Pain Management

Minnesota Multiphasic Personality Inventory

Health psychologists are involved in the

( M M P I ) has demonstrated that patients with

management o f acute pain less frequently than

chronic pain tend to have higher elevations on

they are in the management of chronic pain.

scales measuring preoccupation with somatic

Because acute pain is by definition time limited,

complaints, depression, and the development

it is managed primarily with pharmacological

of physical symptoms in response to stressful

agents. However, research has shown

situations (Etscheidt, Steger, & Braverman,

health psychologists can make

1 9 9 5 ) . Personality disorders are also quite

contributions to acute pain

that

important

management.

prevalent among chronic pain patients, with

Chapman and Turner ( 1 9 8 6 ) proposed three

one study finding avoidant, dependent, and

goals for interventions with patients undergo-

obsessive-compulsive personality disorders to

ing painful medical procedures: (a) increasing

be particularly c o m m o n (Elliott, J a c k s o n ,

the patients' knowledge about the procedure,

Layfield, & Kendall, 1 9 9 6 ) . Other researchers

(b) enhancing a sense of control over the proce-

reported that more than 5 0 % of chronic low

dure and the pain experience, and (c) improv-

back pain patients involved in a functional

ing the patients' ability to diminish emotional

restoration program met criteria for a person-

responses to pain that increase stress responses.

ality disorder, with paranoid personality dis-

Research has shown

that

information-

order being the most c o m m o n (Gatchel,

based strategies can be effective at reducing

Polatin, Mayer, & Garcy, 1 9 9 4 ) .

fear and anxiety associated with medical pro-

Higher

levels o f psychopathology

are

cedures as well as at decreasing pain intensity

treatment

during the procedure (Suis & W a n , 1 9 8 9 ) .

response and continued disability. Robbins,

Instructing patients in the use o f relaxation

M o o d y , Hahn, and Weaver ( 1 9 9 6 ) found that

techniques serves to decrease sympathetic

chronic pain patients who did not return to

nervous system arousal and also provides a

work following multidisciplinary

means of enhancing personal control over the

commonly associated with poor

treatment

Chronic Vain

241

pain experience. Relaxation techniques consist

Nedeljkovic, & Katz, 1 9 9 8 ; Moulin e t a l . ,

of deep breathing exercises, progressive mus-

1 9 9 6 ) . Researchers have also suggested that

cle relaxation, guided imagery, biofeedback,

using narcotic analgesics as the sole treatment

and hypnosis. T o date, n o one specific relax-

program without incorporating psychosocial

ation technique has been shown to be signifi-

interventions can undermine overall rehabilita-

cantly more effective than any other for acute

tion and functional restoration

(Turk

&

pain management (Williams, 1 9 9 9 ) . Several

Meichenbaum, 1 9 9 4 ) . Thus, opioids are often

studies have shown that patients who receive

combined with other medical and behavioral

psychological interventions, such as training

treatments to manage chronic pain most effec-

in relaxation methods, prior to painful medi-

tively. Despite strong concerns on the part o f

cal procedures report less pain, use less opioid

medical

analgesics, report less anxiety, and recover

regarding the potential for addiction to opioid

professionals

and

patients

alike

more quickly than do patients who receive

medications, there is a relatively low risk of

standard medical management (Gil, 1 9 8 4 ;

addiction in patients without a history o f sub-

Schultheis, Peterson, & Selby, 1 9 8 7 ) .

stance abuse if the drug is administered orally (Merskey &

Moulin, 1 9 9 9 ) . Nevertheless,

chronic administration o f any drug, particu-

Chronic Pain Management

larly multiple analgesic agents, does

not

Pharmaco-

enhance function and possibly contributes to

logical agents are the first line o f treatment for

pain-related disabilities. It is estimated that 3 %

Pharmacological

Interventions.

acute pain, and these agents are often used

to 1 8 % o f patients seeking treatment

aggressively in an effort to bring rapid relief

chronic pain have substance abuse problems

for

from pain. Centrally acting analgesics are com-

(Fishbain, Rosomoff, 8c Rosomoff, 1 9 9 2 ) .

monly used in the treatment o f acute pain. However, the treatment o f chronic pain tends

Surgical

and Other

Medical

Interventions.

to be more complex, with the use of a wider

A variety o f medical interventions exist for the

variety of pharmacological agents and with the

management o f chronic pain, ranging from

goal of managing the pain condition for a

more radical procedures, such as surgery, to

longer duration. Examples of pharmacological

more benign types o f interventions, such as

agents used to treat chronic pain include nar-

stimulation therapies. Surgery for chronic pain

cotic analgesics (e.g., Lortab, Percodan), non-

conditions is most appropriate when nonsur-

narcotic analgesics (e.g., Ibuprofen, Tylenol),

gical methods have failed to provide pain relief

muscle relaxants (e.g., Flexeril, Robaxin), topi-

and when an individual is severely disabled

cal analgesics (e.g., Z o v a x ) , anticonvulsants

due to the pain. A psychological evaluation is

(e.g., Neurontin,

Tegretol), antidepressants

often a useful precursor to invasive procedures

(e.g., Paxil, Prozac), and antianxiety medica-

given that studies have found a number o f

tions (e.g., Librium, Ativan).

psychosocial risk factors, such as negative

Although narcotic analgesics are commonly

affect, certain personality types, catastrophiz-

used in the treatment of chronic pain, there are

ing, and a history o f medicolegal problems,

mixed findings regarding their utility. Some

to be predictive o f poor surgical outcome

studies have found the long-term use o f opioids

(Block, 1 9 9 6 ) .

to provide significant pain relief (Portenoy &

Stimulation therapies, such as transcuta-

Foley, 1 9 8 6 ) and to increase functional status

neous electrical nerve stimulation ( T E N S ) , are

(Zenz, Strumpf, & Tryba, 1 9 9 2 ) , whereas

another medical intervention for the treatment

others have found opioids to provide only

of pain. Stimulation therapies are based on the

minor pain relief without improvements in

concept o f counter-irritation, in which large-

activity levels (Jamison, Raymond, Slawsby,

diameter afferent fibers are stimulated and

242

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS serve to temper pain transmission by "closing

sensations. One goal of C B T is to reduce

the gate" on the transmission o f pain signals

muscle tension through the use o f one or more

(Melzack, 1 9 7 5 ) . T E N S has been shown to be

relaxation strategies. Biofeedback, progressive

an effective intervention for individuals with

muscle relaxation, and guided imagery all have

low back pain, peripheral nerve damage, and

been shown to be effective at reducing muscle

degenerative musculoskeletal disease, among

tension. Studies that have attempted to com-

other conditions (Melzack, 1 9 7 5 ; Meyler, de

pare the effectiveness of these relaxation tech-

Jongste, & Rolf, 1 9 9 4 ) . However, patients

niques have found no significant differences

who report high levels of psychological dis-

(Holroyd &c Penzien, 1 9 8 5 ; Spence, Sharpe,

tress do not respond as favorably to T E N S

Newton-John, &

(Meyler et al., 1 9 9 4 ) .

choice of which strategy to use with a specific

Champion,

1995).

The

patient will depend largely on patient characBecause

teristics such as age, personality, and overall

chronic pain reflects more than just physical

motivation. For example, the physical tensing

Cognitive-Behavioral

Interventions.

symptomatology, psychosocial treatments are

and releasing of tension called for in progressive

useful in addressing the psychological and

muscle relaxation might fatigue some elderly

environmental difficulties common to pain

individuals. Other individuals might believe

patients. Although cognitive-behavioral ther-

that the active participation and physical exer-

apy (CBT) for pain is a multifaceted approach

tion required by this strategy are required to see

with many goals and objectives, a primary goal

success, and they have difficulty in grasping the

of this treatment approach is to assist chronic

idea that passive interventions, such as guided

pain patients in understanding that pain is

imagery, will result in improvement. Still other

manageable and that disability and depression

patients will be convinced of a treatment's

are not inevitable consequences o f living with

worth only if the strategy appears to be more

a pain condition. Additional treatment goals

"medical" and so will buy into the usefulness of

often focus on developing more adaptive meth-

biofeedback as a treatment approach. W h a t

ods of thinking, feeling, and behaving that will

appears to be more important than

result in increased physical activity, improved

relaxation strategy is incorporated into treat-

interpersonal relationships, and decreased psy-

ment is how patients perceive the intervention

chological distress.

and whether they believe in its utility.

which

W h a t constitutes a C B T program for pain

Another behavioral approach common in

varies from clinician to clinician. Because

the treatment o f pain is operant conditioning

C B T is comprised o f many techniques and

for the reduction of pain behaviors. Operant

interventions, clinicians often pick and choose

conditioning relies on extinction paradigms to

from among those techniques that seem most

reduce overt pain behaviors and uses rein-

fitting for individual clients. For example,

forcement strategies to increase well behaviors.

cognitive and behavioral interventions are

For example, to increase a patient's overall

often quite distinct in their focus but are

activity level, uptime and exercise are gradually

commonly used in conjunction with

one

increased and the patient is reinforced for this

another to treat pain. Frequently used C B T

activity. Similarly, to decrease a patient's ver-

approaches for chronic pain treatment are

bal complaints o f pain, treatment providers

discussed in what follows, but the reader

ignore such instances and instead reinforce the

should bear in mind that many alternative

patient for the absence o f overt pain behaviors.

approaches exist.

The cooperation of a patient's spouse or family

Muscle tension is a c o m m o n

problem

often is enlisted to apply the operant condi-

and

tioning methods within the home. Operant

tensing are often automatic responses to pain

methods have been shown to be particularly

among pain patients because guarding

Chronic Pain

243

effective at increasing chronic pain patients'

coping skills training programs is often to arm

physical functioning and thereby increasing

patients with an arsenal of skills for decreasing

return to work (Fordyce, 1 9 8 8 ) .

pain, increasing functioning, and

Cognitive interventions for pain management

include cognitive restructuring

improving

their overall quality o f life. As mentioned previ-

and

ously, some pain researchers believe that reduc-

cognitive coping skills training. Cognitive

ing maladaptive coping attempts is more critical

restructuring is commonly used in the treat-

to treatment success than is increasing more

ment o f depression and anxiety, and

this

positive coping strategies (Geisser etal., 1 9 9 9 ;

approach can be adapted to address cognitive

Newton & Barbaree, 1 9 8 7 ) . However, research

errors accompanying chronic pain. T h e ratio-

has not been conducted to evaluate this issue

nale o f cognitive interventions for pain is that

specifically. Moreover, even if reducing passive

changing a person's cognitions results in emo-

or negative coping strategies is critical for

tional, behavioral, and physiological changes,

patient improvement, most patients

would

and there is evidence that cognitive mecha-

likely benefit to some degree from also learning

nisms are involved in improvement in adap-

more active and positive methods for coping

tive functioning among chronic pain patients.

with pain.

T h o r n and colleagues ( 2 0 0 2 ) proposed a cognitive treatment framework for specifically

Multidisciplinary

Treatment.

Given that

reducing catastrophizing, a c o m m o n cognitive

the experience o f pain is best understood in a

distortion among pain patients. This treat-

biopsychosocial framework, it follows that

ment approach is based in part on cognitive

pain treatment should also address each o f

therapy for depression (Beck, 1 9 9 5 ) , and it

these areas—the physical, the psychological,

assists patients in first identifying maladaptive

and the environmental. Multidisciplinary pain

thinking patterns and then challenging and

clinics have been established to provide such

replacing those dysfunctional thoughts with

comprehensive treatment and are typically

m o r e adaptive

staffed

thinking

styles.

Although

by health care professionals

from

T h o r n and colleagues focused specifically on

many disciplines, including physicians, nurses,

catastrophizing,

physical therapists, occupational therapists,

other

maladaptive

pain

beliefs and attitudes, such as those described

and psychologists (Turk &c Stacey,

earlier in the chapter, can easily be a focus o f

T h e first pain clinic was established at the

the intervention. In addition, T h o r n and col-

University of Washington in 1 9 6 1 , and it is

leagues expanded their treatment approach to

estimated that more than

address other factors that might

maintain

plinary pain centers exist in the United States

catastrophic thinking. For example, patients

today (Okifuji, Turk, & Kalauokalani, 1 9 9 9 ) .

are introduced to assertiveness skills training as a means o f meeting interpersonal needs rather than relying on catastrophizing as a strategy for garnering social support.

1997).

3 5 0 multidisci-

Although multidisciplinary programs vary in their treatment approaches, most include an assessment process that attempts to identify the specific needs o f a patient so that treatment can

Cognitive coping skills training for pain

be customized to match the patient's needs

focuses on developing new coping skills to better

(Turk & Stacey, 1 9 9 7 ) . T h e objectives o f most

manage pain. Coping skills training

often

pain clinics include reduction o f pain, elimina-

encompasses many strategies for pain manage-

tion (or significant reduction in the use) o f opi-

ment rather than instruction in any one specific

oid medications, reduction in the use o f overall

skill. These coping strategies might include dis-

medical services, improvement in physical

traction techniques, reinterpretation of pain sen-

functioning, and improvement in social sup-

sations, problem

port

solving, positive

coping

self-statements, and goal setting. T h e goal of

(Follick, Ahern, Attanasio, &

Riley,

1 9 8 5 ) . T h e ultimate goal is not to eliminate

the

244

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS pain but rather to rehabilitate patients and improve their quality o f life. T o achieve these ends, patients might be exposed to physical exercise and physical therapy modalities. They are often educated about the nature of pain and its cognitive, affective, and social correlates. They might participate in individual and group psychotherapy where cognitive and behavioral interventions are used for pain management.

Family members are

often

included in the treatment process to provide support and to assist with maintenance o f treatment gains on program completion. Drug

the experience of pain. Because pain has sensory, affective, and evaluative aspects, it is best understood and treated from a biopsychosocial perspective with input from health psychologists. Health psychologists have the training and expertise necessary to positively affect patients with chronic pain, helping them t o manage pain more effectively and to improve their overall quality o f life. Moreover, health psychologists, by nature o f their broadbased training in psychosocial complications of many medical conditions, are in the unique position of being able to offer pain management services in a variety o f medical contexts.

detoxification is sometimes necessary to assist

Multidisciplinary pain clinics are an obvious

patients in reducing their reliance on pain med-

site for health psychologists to be involved in

ications. Finally, work-related issues are often

the treatment of pain. However, other tertiary

addressed,

including

increasing

patients'

care settings, such as neurology clinics and can-

physical capacity to return to w o r k and remov-

cer treatment centers, provide ample opportu-

ing barriers to obtain employment.

nities for health psychologists to play a role in

Meta-analyses have shown that chronic pain

pain management. Although primary care set-

patients w h o participate in multidisciplinary

tings are becoming more popular locations for

pain treatment experience greater pain relief

collaborative treatment relationships between

than do patients who receive either no treat-

psychologists and physicians, they are still a

ment or standard, single-discipline pain treat-

largely untapped source for providing pain

ment (Cutler etal., 1 9 9 4 ; Flor, Fydrich, &

interventions. Because many individuals with

Turk, 1 9 9 2 ) . Multidisciplinary treatment was

pain complaints initially visit primary care

also found to result in significant improvements

providers for treatment, health psychologists in

in mood, activity levels, medication use, pain

these settings would have the opportunity to see

behaviors, return to work, and overall health

patients earlier in the pain experience and could

care use, and treatment gains persisted over an

potentially make important contributions to

extended period o f time. Research has also

preventing chronic pain and disability from

shown that multidisciplinary pain clinic treat-

developing. V o n Korff

ment costs less than standard medical interven-

specific treatment approach for primary care

tions for pain, with an estimated annual savings

patients presenting with pain problems. This

( 1 9 9 9 ) proposed a

of close to $ 2 8 0 million in medical and surgical

approach addresses common challenges to the

costs alone (Okifuji etal., 1 9 9 9 ) . Savings also

treatment o f pain in a primary care setting and

occur when the number of individuals requiring

delineates several foci of treatment that resem-

long-term disability payments is substantially

ble many of the treatment components pre-

reduced.

sented in this chapter. Other psychologists have proposed methods for developing relationships with primary care providers (Bray & Rogers,

CONCLUSIONS

1 9 9 5 ; Holloway, 1 9 9 5 ) , although not specifically for the management o f pain.

Chronic pain clearly affects the totality o f an individual's life experience and often creates additional burdens and stressors that exacerbate

Although our understanding o f the pain experience has grown tremendously during recent decades, research on pain continues

Chronic

Pain

CASE S T U D Y Earlier in the chapter, a case conceptualization o f a hypothetical patient, " M a r y , " was provided. Over a period of several years, M a r y had been diagnosed with fibromyalgia, migraine headaches, and irritable bowel and bladder syndromes. This 42-year-old woman was in her second marriage and had two grown children living out o f the house. Although M a r y had been gainfully employed as a nurse for 1 0 years, she was no longer working and had recently begun receiving disability benefits. She no longer drove because she was concerned that her pain level would cause her to lose control of her car. Thus, she was dependent on her husband for her frequent visits to health care providers. Mary's friendships and other social contacts had been slowly eroding as the amount o f time she spent in bed or on the couch increased. M a r y complained o f an inability to concentrate that had reached the point where she could no longer get enjoyment from reading. Although M a r y complained that her husband was growing weary of her chronic pain and disability, the chapter authors' observation was that her husband was very solicitous and that part of the partners' marital identity was their conjoint attendance to Mary's needs and visits to health care professionals. Mary's medication regimen included more than 1 0 daily prescription drugs, with additional prescribed medications as needed for pain and over-the-counter analgesics as she judged to be necessary. Multiple physicians prescribed the medications, and it was unclear at the time of evaluation whether there was sufficient communication among these physicians. M a r y was admitted into the chapter authors' cognitive-behavioral chronic stress and pain management group described elsewhere ( T h o r n et al., 2 0 0 2 ) . This 10-week group presents pain as a stress-related illness, formats treatment as a stress management approach, and focuses o n both cognitive and behavioral aspects o f increasing coping and function despite the pain. T h e authors believe that group

treatment

offers the advantage o f patient interaction and an opportunity for the patients to learn from one another in addition to modeling appropriate emotional expression and assertive requests regarding pain problems. M a r y successfully completed the group and continues to pursue individual therapy regarding underlying social stressors, including an unfulfilling marriage, which she n o w sees as exacerbating her pain experience and disability. She continues to struggle with issues o f assertive expression o f her needs rather than the aggressive emotional displays that drive away family members. Although she is still in daily pain and continues t o receive disability payments, she is taking fewer medications and her social interactions have improved. T h e next goal for M a r y is t o reduce her fears and anxieties regarding physical activity and to motivate her to engage in a gentle, daily exercise regimen.

and will undoubtedly result in greater refine-

with

ment o f current pain models. T h e role o f

and analyses, those factors m o s t critical for

more

psychosocial processes in the pain experi-

treatment

ence demands continued investigation, and

apparent.

sophisticated

research

designs

success will also b e c o m e

more

245

246

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

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fain

CHAPTER

14

Hypertension MUSTAFA AL'ABSI AND RICHARD G . HOFFMAN

H

ypertension is a major risk factor o f

Cultural and psychosocial factors, as well as

heart disease, the leading cause o f

responsiveness to interventions, may also con-

death in the United States. It con-

tribute to differences in hypertension preva-

tributes to stroke, the third leading cause of

lence (Horan & Mockrin, 1 9 9 2 ) .

death, and it also contributes to approximately

Increased risk for hypertension is directly

one fourth o f kidney failures. These devastating

associated with increased risk for premature

diseases exact a high toll in human suffering,

death due to cardiovascular diseases (Lie,

deteriorating quality o f life, and financial cost,

Mundal,

making a strong case for continuous effort to

Wentworth,

&

Erikssen, 1 9 8 5 ; N e a t o n

identify causes and develop means to control

Hypertension increases workload on the heart

hypertension. As is described in more detail

and contributes to myocardial cell enlargement

1 9 9 2 ; Stamler et al.,

left-ventricular

hypertrophy.

oc

1989).

later in this chapter, hypertension is one of the

and

risk factors that can be controlled by available

increases, the pumping action o f the heart

As BP

behavioral and pharmacological interventions.

requires more effort and energy. Under the

However, many challenges face clinicians in

condition of high BP, the arteries carry blood

their efforts to implement and ensure compli-

that

ance with regimens for this disorder.

is

moving

under

greater

pressure.

Chronically, this state eventually leads to vari-

is used to indicate

ous structural changes in the heart and blood

high blood pressure (BP). Although hyperten-

vessels, leading to the hardening o f arteries,

sion can occur at any age, it is more prevalent

and other organs may also get directly affected,

in adults over age 3 5 years. It is particularly

leading to the sequelae of hypertension, includ-

T h e term hypertension

prevalent among African Americans, middle-

ing stroke, congestive heart failure, kidney

aged and elderly people, obese individuals, and

failure, and heart attack. Another important

heavy drinkers ( M a c M a h o n , Cutler, Brittain,

risk for hypertension is that when it is present

Wentworth,

with other risk factors (e.g., high blood choles-

1 9 9 2 ; Stamler et al., 1 9 8 9 ; Whelton, 1 9 8 5 ) .

terol, smoking, diabetes, obesity), the danger

However, there is a high heterogeneity in

of major heart problems or a stroke increases

hypertension prevalence related to heterogene-

in a manner that exceeds the simple addition o f

ity in underlying pathophysiological processes.

the risk weight o f these risk factors.

&

Higgins, 1 9 8 7 ; Neaton &

Hypertension

j

O n e in four adults has high BP, and

systolic 1 4 0 to 1 5 9 m m Hg or diastolic 9 0 to

approximately 3 2 % of those with hypertension

9 9 m m Hg. Fifth, Stage 2 (moderate) hyperten-

are not aware that they have it. Approximately

sion is systolic 1 6 0 to 1 7 9 m m H g or diastolic

1 5 % of those with hypertension are not on any

1 0 0 to 1 0 9 m m Hg. Finally, Stage 3 (higher)

therapeutic regimen, and about 2 6 % are inade-

hypertension is systolic 1 8 0 or higher m m H g

quately treated. Furthermore,

or diastolic 1 1 0 m m H g or higher.

hypertension

affects about one in three African Americans (Burt et al., 1 9 9 5 ) . Hypertension develops earlier in life, and is usually more severe, in blacks

Etiological Issues

than in whites. T h e longer hypertension is left

Hypertension is a highly heterogeneous dis-

untreated, the more serious its complications

order with multiple pathogenic mechanisms.

can become, and this possibly contributes to

T h e causes for 9 0 % to 9 5 % o f hypertension

the prevalence o f the different levels of cardiac

cases (called "essential hypertension") are not

adaptation processes and the greater sequelae

known. T h e remaining 5 % to 1 0 % o f hyper-

seen in African Americans with high BP (Burt

tension (called "secondary hypertension") may

et al., 1 9 9 5 ; Koren, Mensah, Blake, Laragh, &

be caused by other diseases such as kidney

Devereux, 1 9 9 3 ) .

abnormalities, congenital abnormalities in major blood vessels in the body, and abnormalities associated with vasoconstriction of

BACKGROUND AND ETIOLOGY

arteries. Despite no clear identification o f the pathophysiology o f essential hypertension, the role

Diagnosis

of psychological variables in hypertension has

When BP is measured, it is defined as two

occupied a prominent position within the field

numbers: systolic and diastolic. Systolic BP rep-

of behavioral medicine (Alexander, 1 9 3 9 ) . In

resents the force at which blood flows when the

particular, recent evidence suggests that stress

heart beats. Diastolic BP, on the other hand, is

may contribute to the pathophysiology o f

an estimate o f the force o f blood flow when the

hypertension (Henry et al., 1 9 9 3 ) . Researchers

heart relaxes (in between heartbeats). Together,

propose

these numbers (written as the value o f systolic

responses to frequent

that

exaggerated

cardiovascular

and persistent stress

BP divided by the value of diastolic BP, recor-

episodes may be a risk factor and/or a marker

ded in millimeters o f mercury

[mm Hg])

for cardiovascular disease (Everson et al.,

compose a person's BP and are used to deter-

1 9 9 7 ; Light et al., 1 9 9 9 ) . For example, expo-

mine whether or not the pressures are in a

sure to stress has been found to accelerate

healthy range. T h e Joint National Committee

hypertension development in spontaneously

on Detection, Evaluation, and

Treatment

hypertensive rats, whereas unstressed rats had

of High Blood Pressure ( J N C , 1 9 9 7 ) and the

a delayed development and milder hyperten-

American Heart Association have put forth rec-

sion (Henry et al., 1 9 9 3 ; Y a m o r i , Matsumoto,

ommendations on the classification o f BP levels.

Y a m a b e , &c O k a m o t o , 1 9 6 9 ) . Research has

T h e recommendations are as follows. First,

also shown that responses to laboratory stress-

optimal BP is systolic less than 1 2 0 m m H g and

ors predict future BP elevations (Matthews,

diastolic less than 8 0 m m Hg. Second, normal

Woodall, & Allen, 1 9 9 3 ; Menkes et al., 1 9 8 9 ;

BP is systolic less than 1 3 0 m m H g and diastolic

Treiber et al., 1 9 9 6 ) . Individuals who are at

less than 8 5 m m Hg. Third, high normal BP is

high risk for hypertension or who have chron-

systolic 1 3 0 to 1 3 9 m m Hg or diastolic 8 5 to 8 9

ically elevated BP tend to show exaggerated BP

mm Hg. Fourth, Stage 1 (mild) hypertension is

responses to behavioral stressors (al'Absi,

253

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

254

Buchanan, 8c Lovallo, 1996; al'Absi, Lovallo, M c K e y , & Pincomb, 1994; Everson, Kaplan,

1996). These elevated

Goldberg, & Salonen,

responses, combined with the high baseline BP,

cardiovascular activation on the heart and blood vessels. Thus, they may play a role in the development of hypertension. The relationship among stress, Cortisol, and hypertension development bears some parallel

contribute to a high workload on the heart. in

in humans. Patients with high levels o f Cortisol

Chapter 10, the primary peripheral hormone

due to Cushing's syndrome show about 80%

As

was

discussed

more thoroughly

1990).

produced by the adrenal cortex, Cortisol, is

prevalence o f hypertension (Kaplan,

considered to be the central component o f the

This is often corrected using glucocorticoid

stress response (Kaplan, that

1998). It is proposed

antagonists, which

also reduce BP (Fallo,

stressful

events

Paoletta, T o n a , Boscaro, & Sonino,

one mechanism through

Cortisol response

to

1993).

which

Furthermore, normotensives w h o are at high

hypothesized

risk for hypertension and borderline hyperten-

pathogenic effects on hypertension (Litchfield

sives show enhanced adrenocortical activity

represents prolonged

stress

exerts

its

1998; W a t t et al., 1992). In short, Corti-

(e.g., elevated Cortisol) in response to a variety

sol is essential to the maintenance o f normal

of psychological stressors (al'Absi 8c Arnett,

et a l ,

vascular tone. It has effects on responses to

2000). For example, prior research has evalu-

catecholamines and other vasoactive agents

ated

such as angiotensin II and vasopressin (Vander,

high risk for hypertension during rest and in

8c Luciano, 1994). T h e physical

response to acute stressors. W h e n at rest in a

Sherman,

adrenocortical activity in persons

at

nature o f cardiac output and the resistance o f

novel experimental environment,

the blood vessels to this blood flow determine

hypertensives showed enhanced adrenocorti-

BP. T h e control o f these activities is mediated

cal activation relative to low-risk controls

by

(al'Absi 8c Lovallo, 1993)

neurohumoral

activity, including

nor-

epinephrine, epinephrine, acetylcholine, and

borderline

and had larger

responses during work on mental arithmetic

1994).

their receptors, and these agents are modu-

and psychomotor stress (al'Absi et al.,

lated by Cortisol. Cortisol has ready access to

These tendencies are exaggerated in the pres-

the central nervous system, affecting areas o f

ence o f psychostimulants such as caffeine.

the brain that are involved in the control o f BP

Relative to low-risk controls, caffeine can

(e.g., hypothalamus, limbic system) (Wilson

differentially

8c Foster, 1992). In addition,

unmediated, mildly hypertensive men (al'Absi,

Cortisol

increase Cortisol secretion in

8c Wilson, 1995). This suggests

enhances sympathetic nervous system activity

Lovallo, Sung,

by increasing adrenergic receptor sensitivity to

that early stages o f hypertension

neurotransmitter

especially sensitive to caffeine's

Lefkowitz,

activation

(Davies

8c

1984). T h e bolstering of sympa-

thetic nervous system activity is believed to

adrenocortical effects when under

may

be

pituitarystressful

conditions.

enhance circulating fluid volume by causing

Prior research has also obtained similar

fluid to shift from intracellular to extracellular

results in normotensive persons at high risk

compartments in the kidney (Kaplan,

1990).

for hypertension, defined as having a positive

This results in improved venous return to the

parental history or having mildly elevated B P

heart and increased cardiac output. Cortisol

but not yet medicated (al'Absi, Everson, 8c

also inhibits the production o f prostaglandin

Lovallo,

and arachidonic acid, bradykinin, serotonin,

vated adrenocorticotropin and Cortisol con-

1995). These individuals showed ele-

8c Foster, 1992), lead-

centrations after caffeine ingestion relative to

ing to vasoconstrictive effects. These proper-

placebo. They also showed an additive effect

ties

on adrenocorticotropin and Cortisol increases

and histamine (Wilson of

Cortisol

increase

the

effects

of

Hypertension to the acute stress and caffeine. T h e high-risk

\

ASSESSMENT AND T R E A T M E N T

group showed earlier and more persistent rises throughout the tasks than did the low-risk group (al'Absi et al., 1 9 9 8 ) . Neither

behavioral stress nor caffeine alone produced Cortisol responses

in normotensive

Measurement

the Hypertension is usually called the silent

men,

killer because it has no specific symptoms.

although significant elevations occurred in

Patients may have hypertension for many years

the low-risk men after the tasks in the presence

without knowing it because there is no specific

of caffeine. This line o f work suggests that

perceived sensory information associated with

the previously observed increased activation

high BP. T h e only way in which to determine

of the autonomic nervous system (Julius &c

whether a person has hypertension is by mea-

Nesbitt, 1 9 9 6 ) and the cardiovascular control

suring BP. Measurement o f BP is a quick and

centers o f the hypothalamus and medulla may

a reliable way in which to determine levels

be paralleled by enhanced responses o f the

of risk for hypertension. A screening measure-

adrenocortical system to behavioral stress and

ment can be conducted in a hospital clinic,

to stimulant agents such as caffeine.

doctor's office, nurse's office, company clinic,

T h e increased Cortisol levels and responses

or school or at a health fair. If screening sug-

in hypertension-prone persons may represent

gests high BP, a physician may ask for more

an altered stress response, characterized by

detailed BP measurement, including ambula-

heightened hypothalamic-adrenocortical acti-

tory monitoring over a 24-hour period. This

vation. T h e development o f hypertension is

more detailed assessment is important to have

accompanied by enhanced activation o f the

a reliable conclusion o f BP levels.

cardiovascular control centers o f the hypothalamus and medulla (Bunag &

Takeda,

In a clinical setting, BP is measured using an instrument called a sphygmomanometer.

1 9 7 9 ; Jin & Rockhold, 1 9 9 1 ) as well as by

During this measurement, a rubber cuff is

increased sympathetic nervous system function

wrapped around the patient's upper arm. T h e

and adrenergic activity (Julius &

Nesbitt,

cuff is then inflated, causing the cuff to com-

1 9 9 6 ) . Such activation would predict greater

press a large artery in the arm, thereby stopping

levels of adrenocortical activity, possibly initi-

blood flow in the arm. T h e pressure is then

ated at the hypothalamic level above in the

reduced by releasing the air from the cuff. With

central nervous system. As illustrated in Figure

the reduced cuff pressure, blood starts to pulse

1 4 . 1 , adrenocortical activation may contribute

through the artery, making a sound, while the

independently and in combination with other

clinician listens with a stethoscope. This pulsing

risk factors to increase BP. Genetic vulnerabil-

sound continues until the pressure in the artery

ity may enhance adrenocortical activation both

is higher than the pressure in the cuff. T h e clin-

centrally and peripherally. This adrenocortical

ician records BP using a gauge connected to the

activation may also be caused by other risk

cuff. T w o BPs are recorded. T h e first is when

factors known to increase Cortisol such as

the first sound is heard. This reflects the systolic

obesity

alcohol intake (Keltikangas-

BP and indicates pressure related to the blood

Jarvinen, Raikkonen, Hautanen, & Adlercreutz,

flow when the heart beats. T h e second is when

1 9 9 6 ; Raikkonen, Hautanen, & Keltikangas-

the final sound is heard. This reflects the dia-

Jarvinen, 1 9 9 6 ) . Therefore, it is appealing to

stolic pressure

propose that adrenocortical dysregulation, in

between heartbeats. T h e unit for the assessment

combination with environmental factors such

of BP is millimeters of mercury.

and

as high salt intake and smoking, may represent enhanced risk.

and indicates the

pressure

There are several factors that might introduce error variance into measurement of BP,

255

256

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

Stress

CRH τ

(")

ACTH&

β-endorphin

ÎCortisol

Τ Vascular resistance

Î Cardiac output

Τ Blood Pressure Figure 14.1

Potential Pathways Among Stress, Cortisol, and Hypertension Risk

N O T E : C R H = corticotropin-releasing hormone; A C T H = adrenocorticotropic hormone.

including behavioral and environmental factors.

hypertension." This occurs when BP mea-

health

sured in the clinic or in the physician's office is

status, prior smoking, consumption o f caffeine-

high enough to warrant diagnosis for hyper-

containing beverages, and time since last meal

tension, but measurement in the field outside

all are factors that could artificially affect accu-

the clinic (e.g., at home) shows a normoten-

For example, prevailing temperature,

racy of BP measurement. Prior to measurement,

sive range of BP (Pickering, Coats, Mallion,

the patient should sit in a comfortable chair with

M a n c i a , & Verdecchia, 1 9 9 9 ; Pickering et al.,

his or her feet on the floor for approximately 5

1 9 8 8 ) . It is estimated that 2 0 % o f hyperten-

minutes. The patient should have emptied his or

sives have white coat hypertension (Pickering

her bladder and should not be engaged in con-

et al., 1 9 9 9 ) . It is still not clear what the clini-

versation during the assessment. Measurement

cal significance o f this discrepancy is or how

should be conducted multiple times to obtain an

to address this phenomenon in treatment.

average, and intervals between measurement

Nevertheless, it should be noted that about

should be more than 1 minute.

one in four of those w h o are considered for antihypertensive

Assessment in Clinical Settings: The "White Coat" Effect

medication may

have white c o a t hypertension

actually

(Myers

Reeves, 1 9 9 1 ; Selenta, Hogan, &

&

Linden,

2 0 0 0 ) . Persons with white coat hypertension

important issue to consider during

differ from true normotensives on several

diagnosis is a phenomenon called "white coat

demographic and lifestyle variables. They tend

One

Hypertension

\

to be male, past smokers, and older and also

strategies that have been used in the control o f

tend to consume more alcohol.

hypertension are described and evaluated.

Some investigators argue that the white c o a t hypertension

is a benign

(Gosse, P r o m a x , Durandet,

&

condition Clementy,

1 9 9 3 ; Julius et al., 1 9 9 0 ; Verdecchia, Schillaci,

Weight Loss,

Control, and Blood

Weight Pressure

Borgioni, Ciucci, & Porcellati, 1 9 9 7 ) . Others argue that it has clinical significance, including increased cardiovascular risk

(Kuwajima,

Suzuki, Fujisawa, & Kuramoto, 1 9 9 3 ; W e b e r , Neutel, Smith, & Graettinger, 1 9 9 4 ) . Because this condition is not associated with sustained BP elevation, it is possible that the harmful effect o f this condition is due to high BP variability across settings (Lantelme, M i l o n , Gharib, Gayet, & Fortrat, 1 9 9 8 ) . An exaggerated BP lability may contribute to greater organ

damage

in

hypertensives

(Parati,

The Role of Weight Control in Primary Prevention. A clear direct relationship exists between body weight and B P . Overweight individuals (body mass index greater than 2 7 . 8 for men and greater than 2 7 . 3 for women) have an increased incidence o f hypertension (Oparil, 2 0 0 0 ) , and this relationship between obesity and hypertension appears to be strongest for younger adults (Stone & Kushner, 2 0 0 0 ) . T h e pathogenesis o f obesity-induced hypertension is not well characterized but is likely

Pomidossi, Albini, Malaspina, &c M a n c i a ,

related to hemodynamic

1 9 8 7 ) and in individuals with white coat hyper-

dysfunction, and an increase in sympathetic

tension (Cavallini et al., 1 9 9 5 ) . Individuals

nervous system activity that may be related to

with white coat hypertension may represent a

insulin resistance (Hall, 1 9 9 7 ) . T h e hemody-

subgroup o f hypertensives w h o require a tar-

namic changes are likely due to increases in

alterations, renal

geted intervention to manage the situational

adipose tissue and expansion o f extracellular

reactivity they exhibit. This is significant in

water and total blood volume, resulting in

light o f the observed negative cardiac abnor-

an augmented stroke volume and increased

malities that have been observed in those with

cardiac output proportional

white coat hypertension (Cardillo, D e Felice,

Abnormal renal sodium and water handling

to body size.

Campia, & Folli, 1 9 9 3 ) . Finally, it has been

(pressure natriuresis) causes the initiation o f

shown that the white coat effect may have a

hypertension

negative prognostic

Ultimately, eccentric left ventricular hyper-

impact, even in

the

(Stone &c Kushner,

2000).

absence o f sustained hypertension (Kuwajima

trophy may develop as an adaptation

et al., 1 9 9 3 ; W e b e r et al., 1 9 9 4 ) .

increased vessel wall stress that results from expanded

intravascular

volumes,

to

venous

return, and left ventricular preload increase

Intervention Strategies to Control Hypertension

(Messerli, 1 9 8 2 ) . Echocardiography studies have demonstrated that a positive correlation

The treatment o f hypertension is a long-term

exists between percentage overweight

and

effort that puts a burden on patients and their

both left ventricular wall thickness and inter-

health care providers. M a n y patients

with

nal dimension, even in the absence o f hyper-

behavioral

tension (Stone & Kushner, 2 0 0 0 ) . Among the

reducing

severely obese, duration o f obesity is associ-

weight, eating properly, and getting the right

ated with higher left ventricular mass, poorer

amount o f exercise. Pharmacotherapy is also

left ventricular systolic function, and greater

hypertension may benefit from modification techniques such as

widely used for treatment o f hypertension. In

impairment o f left ventricular diastolic filling,

the following subsections, specific intervention

and this ultimately may lead to concentric

257

258

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS left

ventricular

hypertrophy

(Alpert

Sc

a direct relationship between weight loss and BP reduction in normotensive individuals, sug-

Hashimi, 1 9 9 3 ) . multiple

gesting that clinically significant long-term

echocardiographic studies suggests that weight

reductions in BP and reduced risk for hyper-

reduction reduces left ventricular mass in both

tension can be achieved with even modest

obese hypertensive and normotensive patients,

weight loss.

The

available evidence from

resulting in a direct hemodynamic effect as a result o f the reductions in blood volume, sys-

The Effect

of Weight

Control

and

Dieting

temic BP, venous return, cardiac output,

on Blood

stroke volume, and

T h e sixth report of the J N C ( 1 9 9 7 ) recom-

oxygen

consumption

Pressure

in Hypertensive

Patients.

(Himeno, Nishino, Nakashima, Kuroiwa, Sc

mended

Ikeda,

hypertension who are above their ideal weight

1 9 9 6 ; Stone Sc Kushner,

2000).

the following: "All patients

with

Because o f findings such as these, prevention

should be prescribed an individualized, moni-

efforts have focused on weight loss. Data from

tored weight reduction program

such efforts demonstrate that weight loss

caloric restriction and increased physical activ-

reduces BP in people at risk for developing

ity" (p. 2 4 2 2 ) . Available guidelines suggest

involving

(Appel et al., 1 9 9 7 ; Stamler

that a target weight loss goal of 1 0 % o f body

et al., 1 9 8 9 ; Stevens et al., 1 9 9 3 , 2 0 0 1 ) . For

weight over 6 months o f therapy is appropri-

example, individuals who were placed on a

ate, with combinatory treatment o f dietary

low-saturated fat diet rich in fruits, vegetables,

therapy, physical activity, and behavior ther-

and low-fat dairy foods showed substantial

apy. Following N H L B I guidelines, treatment

reductions in BP o f 5.5 m m H g relative to

should be initiated with 3 0 to 4 5 minutes o f

control participants (Appel et al., 1 9 9 7 ) .

moderate physical activity 3 to 5 days per

hypertension

As delineated by Stevens and colleagues

week in addition to a low-calorie diet that pro-

( 1 9 9 3 , 2 0 0 1 ) , prevention efforts include group

duces a 5 0 0 - to 1,000-calorie-per-day deficit

and individual counseling focused on dietary

(Stone 8c Kushner, 2 0 0 0 ) . A review o f the

change, physical activity, and social support.

voluminous literature in the behavioral treat-

Dietary interventions target fat, sugar, and alco-

ment o f obesity is beyond the scope of this

hol consumption. Graded increases in physical

chapter, but obvious strategies for weight loss

activity are also planned

monitored.

with this population would include self-moni-

Eventually, physical activity should reflect brisk

toring strategies, weight loss problem solving,

walking at the level of 4 0 % to 5 5 % of heart

urge control, stimulus control interventions,

rate reserve for 3 5 to 4 5 minutes per day, 4

and stress management approaches related to

and

to 5 days per week. Interventions also include

dieting (Bonato Sc Boland, 1 9 8 6 ; Simkin-

weekly group meetings used to facilitate social

Silverman, Wing, Boraz, Meilan, Sc Kuller,

support and enhance nutritional education as

1998;

well as to motivate behavior change. Specific

2 0 0 0 ; Wadden,

behavior change techniques include setting

Wisniewski, Sc Steinberg, 2 0 0 1 ) .

explicit short-term goals and developing spe-

The

Rapoport,

available

Clark,

Sc

Wardle,

Berkowitz, Sarwer, Prusliterature

from

several

cific action plans to achieve goals, developing

weight loss studies that have enrolled hyper-

alternative strategies for situations that trigger

tensive patients suggests that weight reduc-

problem eating, and engaging in self-monitor-

tions o f 3 % to 9 % o f body weight, with

ing via food diaries and graphing of daily

antihypertensive drug regimens held constant,

physical exercise.

are likely to yield reductions in systolic BP in

Evidence from three large-scale clinical

the range o f 3.0 to 6.8 m m H g and reductions

weight loss and dieting trials has demonstrated

in diastolic BP in the range o f 2 . 9 to 5.7 mm Hg

Hypertension

\

(Brand et al., 1 9 9 8 ; Corrigan, Raczynski,

W h i t m o r e , Leenen, &c Larochelle, 1 9 9 9 ) .

Swencionis, &

Jennings, 1 9 9 1 ; Langford

Instead, weight reduction is viewed as a more

et al., 1 9 8 5 ; Reisin et al., 1 9 8 3 ; Stamler et al.,

desirable target for primary prevention efforts.

1 9 8 9 ) . Trials that allowed adjustment o f antihypertensive drug regimens generally found

The

Effect

of Salt

Restriction

on

Blood

that lower doses and/or a fewer number o f

Pressure

antihypertensive drugs were required by suc-

guidelines recommend restrictions o f dietary

in Hypertensive

Current

Patients.

cessful participants in weight reduction pro-

sodium to a range o f 9 0 to 1 3 0 millimoles per

grams versus controls, suggesting that weight

day in hypertensive patients over the age of

loss may enhance the efficacy o f antihyper-

4 4 years (Fodor et al., 1 9 9 9 ) . This corresponds

tensive drugs (Oparil, 2 0 0 0 ) .

to about 3 to 7 grams o f salt per day. Patients should be counseled to avoid foods high in

Sodium

Intake

and Blood

salt (e.g., prepared foods) and to choose foods

Fressure

low in salt (e.g., fresh fruits and vegetables).

Sensitivity.

Combined salt restriction and diet modifica-

Epidemiological literature suggests a direct

tion trials have demonstrated a great deal o f

Primary

Prevention

and Salt

BPs and

promise (Sacks et al., 2 0 0 1 ; Vollmer et al.,

sodium intake, typically expressed as the

2 0 0 1 ) . Such trials report decreases in BP o f

relationship between population

effect o f dietary salt intake (Elliott, 1 9 9 1 ;

between 7 and 1 2 m m Hg in systolic BP and at

Stamler, 1 9 9 7 ) . There is also some support in

least 5 m m H g in diastolic pressure for hyper-

the literature to suggest that the effect o f

tensive patients who were on both a salt

dietary salt intake may vary a m o n g subpop-

restricted diet and the Dietary Approaches to

ulations and that the relationship between

Stop Hypertension

dietary sodium and BP may be pronounced

etal., 2001).

in these subgroups. There have been several studies that suggest that older adults

(DASH) diet (Vollmer

Although there is evidence that salt restric-

and

tion, either alone or in combination with

African Americans may be "salt sensitive"

dietary intervention, is effective in lowering BP

and have a greater BP response to dietary

in short-term clinical trials, there is a clear

sodium intake ( e.g., Ishibashi et al., 1 9 9 4 ;

need for an increased role o f behavioral inter-

Weinberger, 1 9 9 6 ) , and there is at least one

vention in the long-term maintenance o f this

report that suggests an increased salt sensi-

benefit.

tivity in w o m e n (Kojima et al., 1 9 9 2 ) .

reported very little change in BPs at 9 - to 1 8 -

Brunner

and

colleagues

(1997)

a

month follow-up o f hypertensive patients after

restriction in salt intake would have an effect

dietary advice to reduce salt intake was given

on the incidence o f hypertension, even within

by nutritionists or specially trained counselors,

salt-sensitive subpopulations.

and a similar finding was reported by Ebrahim

To

date, it remains unclear whether

Because evi-

dence suggests that the association o f sodium

and Davey ( 1 9 9 8 ) at 6-month

intake with cardiovascular mortality and mor-

although a 2 . 1 - m m H g decrease in diastolic

follow-up,

bidity varies by overweight status (He e t a l . ,

pressure was maintained.

1 9 9 9 ) and that advice to restrict salt intake is less effective in preventing hypertension in overweight people than is advice on weight reduction (He, Whelton, Appel, Charleston,

Alcohol Primary

Intake

and Blood

Prevention

Pressure and

Alcohol.

&C Klag, 2 0 0 0 ) , most current health risk guide-

Epidemiological data indicate a direct rela-

lines do not support a restriction o f salt intake

tionship between excess alcohol consumption

in the

and risk o f hypertension, with several studies

normotensive

population

(Fodor,

259

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

260

suggesting a linear dose-response relationship

suggest a relatively modest effect on BP (Xin

starting with an alcohol consumption thresh-

et al., 2 0 0 1 ) . For example, high normal to

old o f three drinks per day (roughly 3 0 grams

slightly hypertensive heavy drinkers

of ethanol); more than 2 ounces o f alcohol per

than 2 1 drinks per week), who showed an

day significantly increases the risk o f becom-

average decrease in alcohol consumption o f

(e.g., Klatsky, Friedman,

1.3 drinks per day, reduced their BP by only

ing hypertensive

(more

Siegelaub, & Gerard, 1 9 7 7 ; Treadway, 2 0 0 0 ) ,

1.2/0.7 m m H g following a cognitive-behav-

whereas a daily alcohol intake o f less than 1

ioral outpatient alcohol reduction program

in BP

(Cushman et al., 1 9 9 8 ) . Moreover, meta-

(Gilman, C o o k , Evans,

analytic data from 1 5 alcohol reduction trials

ounce may result in a modest decrease for

m o s t people

Rosner,

&

Hennekens,

1995)

except

involving 2 , 2 3 4 total patients demonstrated

African American males (Fuchs, Chambless,

an overall reduction in BP attributable to alco-

Whelton, Nieto, & Heiss, 2 0 0 1 ) . Recent data

hol reduction of only 3 . 3 1 m m H g systolic

(Thadhani et al., 2 0 0 2 ; Witteman et al., 1 9 9 0 )

and 2 . 0 4 m m H g diastolic ( X i n et al., 2 0 0 1 ) .

also suggests that regular consumption o f

Although these effects are modest, a dose-

more than one and a half drinks per day,

response relationship was observed between

regardless o f the type o f alcoholic beverage

mean percentage o f alcohol reduction and

consumed, substantially increases the risk o f

mean BP reduction. Regardless o f the modest

hypertension for women.

reductions in BP with concomitant alcohol

The mechanism o f alcohol-induced hyper-

reduction, available guidelines suggest that

tension is not clearly delineated. Alcohol is

hypertensive nondrinkers should continue to

hypothesized to affect the renin-angiotensin-

abstain from consuming alcohol. For hyper-

aldosterone axis and Cortisol secretion in

tensive alcohol drinkers, alcohol intake should

addition to contributing to heart rate variabil-

be limited to no more than 1 ounce o f alcohol

system

(2 ounces o f 1 0 0 - p r o o f whiskey, 8 ounces o f

discharge, and affecting insulin sensitivity

wine, or 2 4 ounces o f beer) per day in most

(Oparil, 2 0 0 0 ; Potter & Beevers, 1 9 8 4 ) . As

men and half that amount in women and

such, available guidelines suggest that

smaller men (Oparil, 2 0 0 0 ) .

ity, disrupting

adrenergic nervous

to

reduce the relative risk o f developing hypertension, those healthy adults who choose to drink should limit alcohol consumption to no more than 2 standard drinks per day, with consumption

not

exceeding 1 4

standard

drinks per week for men and 9

Exercise Primary

and Blood Prevention

Pressure and Exercise.

In 1 9 9 5 ,

the Centers for Disease Control and Prevention

standard

and the American College o f Sports Medicine

(Campbell,

jointly issued a recommendation regarding the

Ashley, Carruthers, Lacourciere, & M c K a y ,

primary prevention o f cardiovascular disease,

drinks

per week for w o m e n

1 9 9 9 ) . A standard drink is defined as approx-

stating that "every U.S. adult should accumu-

imately a 12-ounce glass o f beer, a 5-ounce

late 3 0 minutes or more of moderate-intensity

glass o f table wine, or a 1.5-ounce glass o f dis-

physical activity on most, preferably all, days

tilled spirits (Cushman et al., 1 9 9 8 ) .

of the week," with moderate physical activity defined as equivalent to brisk walking at 3 to 4

The Effect

of Alcohol

on Blood

Pressure

in

miles per hour for healthy adults (Pate et al.,

Even though the evi-

1 9 9 5 ) . Current recommendations were based

dence is fairly clear in implicating alcohol con-

on findings that moderate- to high-intensity

sumption as a risk factor for hypertension, the

exercise, if sustained, leads to a lowering o f BP

available data related to the effect o f reducing

in normotensive individuals and an apparent

alcohol consumption in hypertensive patients

reduction in the relative risk o f developing

Hypertensive

Patients.

Hypertension hypertension

(Braith, Pollock, Lowenthal,

(Hagberg, Ferrell, Dengel, & Wilund, 1 9 9 9 ) .

Limacher, 1 9 9 4 ; Paffenbarger,

This may account for some o f the variation in

Jung, Leung, & Hyde, 1 9 9 1 ) . For example,

BP responses to exercise, including the 2 5 % or

regularly scheduled moderate physical activity,

so o f hypertensive patients who show very

such as swimming or brisk walking for 3 0 min-

little response to exercise (Blumenthal, Siegel,

utes, has been reported to decrease both sys-

& Appelbaum, 1 9 9 1 ; Cooper, 2 0 0 0 ) . Although

Graves, &

tolic and diastolic BP from 4 to 8 m m Hg, with

most o f the work in this area has examined the

an average reduction of 6 to 7 m m Hg (Arrol

effect o f moderate-intensity exercise, there is

& Beaglehole, 1 9 9 2 ; Fagard, 1 9 9 5 ) , and this

some evidence to suggest a possible beneficial

level of activity may be more effective in low-

role o f light aerobic exercise in the reduction of

ering BP than more vigorous activity such as

BP in older patients. Young, Appel, Jee, and

jogging (Jennings, 1 9 9 7 ) .

Miller (1999) reported decreases of 7.0 m m Hg systolic BP and 2 . 4 m m H g diastolic BP in a

The Effect

of Exercise

on Blood

Pressure

in

sample of 6 2 sedentary older adults with high

T h e available evidence

normal or Stage 1 hypertension who had com-

suggests that regular rhythmic physical exer-

pleted a 12-week program of t'ai chi, an Eastern

cise of the lower extremities by hypertensive

form of relaxation and exercise.

Hypertensive

Patients.

individuals decreases both systolic and dia-

The sixth report o f the J N C ( 1 9 9 7 ) recom-

stolic BP (in about 7 5 % o f such individuals)

mended that hypertensive patients follow the

by as much as 11 m m H g and 8 m m Hg,

physical activity guidelines outlined in the sur-

respectively, independent

o f weight loss,

geon general's report for lowering resting BP,

alcohol intake, and sodium intake (Hagberg,

which consists o f moderately intense aerobic

Montain, Martin, & Ehsani, 1 9 8 9 ; Kelly &

exercise at 4 0 % to 6 0 % o f m a x i m u m oxygen

McClellan,

&

c o n s u m p t i o n . T h i s c a n be achieved, for

Cushman, 1 9 9 0 ) . Although the mechanism o f

example, by 3 0 to 4 5 minutes o f brisk walk-

1 9 9 4 ; Martin,

Dubbert,

action is not well understood in all cases, there

ing several times per week. T h e most recent

is some evidence that exercise training may

recommendations o f the Canadian Medical

result in regression o f pathological left ventric-

Association are consistent with these guide-

ular hypertrophy in at least some hypertensive

lines, specifically recommending that individu-

patients (Hagberg, Park, & Brown, 2 0 0 0 ) . In

als with mild hypertension should engage in

some cases, a consistent exercise regimen may

5 0 to 6 0 minutes o f moderate rhythmic exer-

also obviate the need for medication in mildly

cise o f the lower limbs, such as brisk walking

hypertensive

or

patients

(Kelemen,

Effron,

Valenti, & Stewart, 1 9 9 0 ) .

cycling, three to four times per week

(Cleroux, Feldman, & Petrella, 1 9 9 9 ) . T h e

The effect o f exercise in this population

Canadian Medical Association guidelines also

appears to be more pronounced in women

suggest that exercise should be prescribed as

than in men, and middle-aged people may

adjunctive therapy for individuals who require

derive more benefit than either younger or

pharmacotherapy for hypertension, especially

older people. Exercise reduces BP more consis-

those who are not receiving beta blockers.

tently in Asian and Pacific Islander patients than in Caucasian patients, especially when systolic BP is examined (Hagberg et al., 2 0 0 0 ) . There is some evidence to suggest that apoE, A C E , and LPL genotypes may identify hyper-

Stress and

Management Blood

Primary

Pressure Prevention

and

Stress

Manage-

tensive patients who are most likely to improve

ment. There is very little evidence in the litera-

BP, lipoprotein lipids, and

cardiovascular

ture to date to suggest that successful stress

disease risk the most with exercise training

management prevents hypertension despite the

262

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS implication that chronic psychosocial stress

Linden, Ramsden, &

may play a role in the etiology o f hypertension

particular, it has been suggested that a stress

Taenzer, 1 9 9 9 ) . In

(e.g., Anderson, Myers, & Pickering, 1 9 8 9 ;

management intervention should include some

Lucini, Norbiato, Clerici, & Pagani, 2 0 0 2 ) . For

or all o f the following components: skills train-

example, Phase 1 of the Trials of Hypertension

ing in adaptive mood management, communi-

Prevention project (Trials o f Hypertension

cation,

Prevention Collaborative Research Group,

reduction of sympathetic arousal as well as

problem

solving, and

relaxation/

1992) examined the effect of a multimodality

training in the réévaluation of negative life

stress management program, which included

events and increased awareness o f stressors

progressive relaxation, on the BP of 5 6 2 indi-

and stress responses.

viduals in the general population with normal

Linden and Chambers ( 1 9 9 4 ) compared

to high normal BP and found no statistically or

the effect sizes o f single-method relaxation,

clinically significant changes in BP following

multimethod relaxation, and

this intervention relative to matched controls

cognitive-behavioral treatment therapies

(Batey et al., 2 0 0 0 ) . However, further investi-

reduce BP. They reported

individualized, to

observed mean

gation in this area is needed to investigate the

decreases o f 9.7 m m Hg in systolic BP and 7.2

efficacy of highly individualized stress manage-

m m H g in diastolic BP with such interven-

ment programs as a preventive measure in

tions. Individualized,

at-risk target populations of normotensive indi-

treatment therapies were found to reduce BP

cognitive-behavioral

viduals with high levels o f chronic psychosocial

at a level comparable in effect size to BP med-

stress.

ications and weight reduction/physical exercise, with observed mean decreases o f 1 5 . 2

The Effect Fressure

of Stress Management

in Hypertensive

Patients.

Blood

m m Hg in systolic BP and 9.2 m m H g in

A variety o f

diastolic BP. T h e individualized, cognitive-

on

meta-analyses have been conducted to test the

behavioral

hypothesis that stress management interven-

studies focusing on marital communication

tions effectively reduce BP among hypertensive patients

(Eisenberg et

al.,

1993; Jacob,

treatment

therapies

included

training for hypertensive patients

(Ewart,

Taylor, Kraemer, & Agras, 1 9 8 4 ) , cognitive

Chesney, Williams, Ding, & Shapiro, 1 9 9 1 ;

restructuring and behavioral intervention pro-

Kaufman et al., 1 9 8 8 ; Linden & Chambers,

grams (Bosley & Allen, 1 9 8 9 ; Chesney, Black,

1 9 9 4 ) . A conservative interpretation o f such

Swan, & W a r d , 1 9 8 7 ; Jorgensen, Houston, &

meta-analytic findings is that individualized,

Zurawski, 1 9 8 1 ) , anger management inter-

multicomponent stress management treatment

ventions (Achmon, Granek, G o l o m b , & Hart,

appears to be more effective in lowering BP

1 9 8 9 ) , and individualized stress management

than do single-component, standardized relax-

that included the recognition of somatic cues

ation

for stress (Richter-Heinrich et al.,

interventions

(Johnston,

Gold,

&

very

encouraging

results

1981).

Kentish, 1 9 9 3 ; Linden & Chambers, 1 9 9 4 ;

Similar,

Ward, Swan, & Chesney, 1 9 8 7 ) . In fact, the

reported by Schneider and colleagues ( 1 9 9 5 )

were

results were negligible in most cases when a

and Linden, Lenz, and Con ( 2 0 0 1 ) .

single stress management technique was used. Therefore, the Canadian Medical Association has tentatively recommended that if stress

Pharmacological Interventions

is viewed as a prominent contributor to a

Hypertension is treated pharmacologically

patient's high BP, an individualized stress man-

by several categories o f medications called

agement intervention that uses multiple com-

antihypertension

ponents should be considered (Spence, Barnett,

Although details into the specific pharmacology

medications (Table

14.1).

Hypertension Table 14.1

Class of

Examples of Categories of Medications Used in the Treatment of High Blood Pressure

Medications

Generic Name Examples

Brand Name

Examples

Captopril Fosinopril sodium Moexipril Ramipril

Capoten Monopril Univasc Altace

Doxazosin mesylate Prazosin hydrochloride Terazosin hydrochloride

Cardura Minipress Hytrin

Candesartan Irbesartan Losartan potassium Valsartan

Candesartan Irbesartan Losartan potassium Valsartan

Acebutolol Atenolol Betaxolol Bisoprolol fumarate Carteolol hydrochloride Metoprolol tartrate Metoprolol succinate Nadolol Penbutolol sulfate Pindolol Propranolol hydrochloride Timolol maleate

Sectral Tenormin Kerlone Zebeta Cartrol Lopressor Toprol-XL Corgard Levatol Visken Inderal Blocadren

Amlodipine besylate Diltiazem hydrochloride

Norvasc Cardizem, Dilacor-XR, Tiazac Plendil DynaCirc Cardene Adalat, Procardia Sular Calan, Covera-HS, Isoptin, Verelan

ACE inhibitors

Alpha blockers

Angiotensin II receptor blockers

Beta blockers

Calcium channel blockers

Felodipine Isradipine Nicardipine Nifedipine Nisoldipine Verapamil hydrochloride Central agonists Alpha methyldopa Clonidine hydrochloride Guanabenz acetate Guanfacine hydrochloride

Aldomet Catapres Wytensin Tenex (Continued)

|

263

264

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Table 14.1 Class of

(Continued)

Medications

Generic Name

Examples

Brand Name

Examples

Diuretics Chlorthalidone Chlorthalidone Furosemide Hydrochlorothiazide Indapamide Metolazone

of these categories of medications are beyond

Hygroton Hygroton Lasix Esidrix, hydroDIURIL, microzide Lozol Mykrox, Zaroxolyn

Pharmacological interventions

introduce

the scope of this chapter, familiarity with these

another complication, namely side effects.

classes and specific generic and brand names

Clinicians can help to reduce the negative

may be helpful for psychologists who work in

effects o f side effects on compliance by edu-

primary medical care settings. Furthermore,

cating their patients about these side effects,

information about side effects of these medica-

helping them to learn ways in which to min-

tions should enhance the expertise o f behav-

imize side effects or to adjust medication

ioral therapists in their efforts to help other

dosages in coordination with their prescribers

medical professionals and patients, drawing

after achieving normal B P .

better outcomes from pharmacotherapy and increasing compliance. O n e class o f medication that is used to treat

Multicomponent Approach

hypertension is diuretics. These medications

As noted earlier, there are well-docu-

work by helping the body remove excess flu-

mented lifestyle modifications with proven

ids and sodium salt. Beta blockers work by

efficacy (e.g., weight control, diet, exercise,

reducing the heart rate and thereby reducing

alcohol control, sodium restriction, at least

the volume o f blood ejected by the heart (car-

some stress management interventions). A

diac output). Because the sympathetic nervous

significant proportion o f all available health

system innervates the heart, arteries, and other

care resources are expended for the treatment

parts o f the body, activation o f this system can

of hypertension. Hypertension accounts for

increase heart work or constrict arteries, lead-

about 3 0 million physician visits per year in

ing to increased BP. Therefore, a class o f med-

the United States alone and is the second most

ications called sympathetic nerve inhibitors

c o m m o n reason for outpatient

works by inhibiting sympathetic nerves on

visits in the country (Knight et al., 2 0 0 1 ) .

blood vessels. Vasodilators work by causing

Despite this staggering number o f physician

blood vessel walls and muscles to relax, lead-

visits, and despite the impressive array o f

physician

ing to dilation o f the vessels and reducing their

pharmacological and

pressure. T h e angiotensin-converting enzyme

interventions that are available for the man-

nonpharmacological

(ACE) inhibitors work by interfering with

agement o f hypertension,

the production o f angiotensin. Angiotensin

(Berlowitz et a l , 1 9 9 8 ; H y m a n & Pavlik,

it is estimated

is a vasoconstricting chemical. T h e angio-

2 0 0 1 ; M u l r o w , 1 9 9 8 ) that fewer than one

tensin II receptor blockers block the effects o f

third o f U.S. patients with hypertension have

angiotensin. T h e calcium antagonists (calcium

controlled BP (less than 1 4 0 / 9 0 m m Hg). In

channel blockers) reduce BP by reducing heart

one large sample o f 1 , 3 9 4 N e w Y o r k City

rate and relaxing blood vessels.

health care workers, only 1 2 % o f those

Hypertension

\

patients w h o were treated for hypertension

of the American Society o f Hypertension

had BP controlled at less than 1 4 0 / 9 0 m m H g

Ad H o c Panel (Pickering, 1 9 9 5 ) describe the

despite having comprehensive medical insur-

role o f patient self-monitoring o f BP both in

ance and full access to health care (Stockwell,

assessing the response to

Madhaven,

medications more accurately and in poten-

Cohen, Gibson, &

Alerman,

1 9 9 4 ) . O f equal or greater concern, a recent

tially improving

patient

antihypertensive compliance

and

study that employed electronic monitoring o f

involvement in patients' own health care. In a

patients with long-standing serious hyperten-

similar fashion, Gonzalez-Fernandez, Rivera,

sion suggested that fully 6 1 % o f these patients

Torres, Quiles, and J a c k s o n ( 1 9 9 0 ) reported

failed to take their antihypertensive medica-

a 6 0 % increase in compliance and decreases

tion as prescribed (Lee et al., 1 9 9 6 ) .

of 1 4 / 1 1 m m H g systolic/diastolic BP at 8-

Multiple factors have been implicated as

week follow-up after a brief, four-session,

contributing to poor BP control, including the

inpatient educational program administered

lack o f primary care physicians in some pop-

to a sample o f 5 7 middle-aged to elderly

ulations

(Shea, M i s r a , Ehrlich, Field,

&

hypertensive patients.

Francis, 1 9 9 2 ) , the cost o f antihypertensive

There are additional intervention strategies

medication (Ahluwalia, M c N a g n y , & R a s k ,

that may be useful to consider in an effort to

1 9 9 7 ) , medication side effects, presence or

maximize patient compliance and minimize

absence o f comorbid illness, age o f the patient,

adherence problems. T h e use o f reminders

severity o f the disease, health habits, intensity

and prompts, including medication reminder

of care, physician compliance with estab-

calendars or alerts, specialized medication

lished guidelines (Oliveria et al., 2 0 0 2 ) , c o m -

dispensers,

plexity o f the medication regimen, patient

physician or clinic appointments, is very useful

and

reminder

calls

regarding

knowledge base and understanding o f the

for many patients. Behavioral contracting has

seriousness o f uncontrolled hypertension, and

a clear role in the management o f hypertensive

patient behavior related to compliance and

patients, particularly in maintaining adherence

adherence (Knight et al., 2 0 0 1 ; Oliveria et al.,

to nonpharmacological interventions. Stepwise

2 0 0 2 ) . T h e remainder o f this section focuses

introduction of antihypertensive interventions

on the role o f educational

is recommended, that is, using a graduated

interventions,

multicomponent behavioral programs,

and

approach o f introducing more easily attainable

interventions

and

goals early in treatment so as to shape subse-

related

to c o m p l i a n c e

adherence for hypertensive patients given that

quent adherence behavior. Similarly, interven-

patient adherence has been identified as one

tions designed to enhance the medical office

o f the main reasons why BP therapy fails

visit experience have been documented

(Miller, Hill, Kottke, & O c k e n e , 1 9 9 7 ) .

increase adherence. These include using a

to

General guidelines for physicians related to

scheduling system that minimizes waiting time

improving patients' adherence to antihyper-

for patients, providing adequate opportunity

tensive therapy have been published by the

for

JNC

care personnel

(1997)

and

elaborated

by

Kaplan

patients to communicate with

health

(including liberal call-in or

( 1 9 9 8 ) . T a b l e 1 4 . 2 represents a compilation

on-call with clinic staff), and other interven-

of the recommendations from both o f these

tions designed to provide a

sources. M o s t o f these

patient experience in a physically attractive

recommendations

rest on solid behavioral principles from the

personalized

and positive medical office environment.

behavioral medicine adherence literature. For

A recent meta-analysis of the medical adher-

example, self-monitoring is a cornerstone o f

ence literature completed by Roter and col-

assessing adherence, and the recent guidelines

leagues (1998) o f 1 5 3 intervention strategies

265

266

[

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

Table 14.2

General Guidelines to Improve Patient Adherence to Antihypertensive Therapy

1. Be aware of signs of patient nonadherence to antihypertensive therapy. 2. Establish the goal of therapy: to reduce blood pressure to nonhypertensive levels with minimal or no adverse side effects. 3. Educate patients about the disease, and involve them and their families in its treatment, a. Have patients measure blood pressure at home. 4. Maintain contact with patients, a. Consider telecommunications. 5. Keep care inexpensive and simple. a. Integrate pill taking into routine activities of daily living. 6. Encourage lifestyle modifications. 7. Prescribe medications according to pharmacological principles, favoring long-acting formulations. a. Continue to add effective and tolerated drugs, stepwise, in sufficient doses to achieve the goals of therapy. b. Be willing to stop unsuccessful therapy and to try a different approach. c. Anticipate side effects, and adjust therapy to ameliorate side effects that do not disappear spontaneously. 8. Encourage a positive attitude about achieving therapeutic goals. 9. Consider using nurse case management. S O U R C E : Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1997). N O T E : Cortisol response is initiated by the release of corticotropin releasing factors (CRF) from neuronal cell bodies of the paraventricular nucleus (PVN). C R F acts on the corticotrope cells of the anterior pituitary, stimulating synthesis of proopiomelanocortin ( P O M S ) , and leading to the subsequent release of A C T H and β - e n d o r p h i n into the systemic circulation. U p o n reaching the adrenal cortex, A C T H leads to the synthesis and release of Cortisol. Cortisol, through direct and indirect cardiovascular mechanisms, contributes to increased blood pressure. These effects, as discussed in the text, seem to be stronger in hypertension-prone individuals.

designed to promote patient adherence

to

that educational interventions plus counseling

medical regimens suggests that adherence strate-

interventions achieved a higher level of hyper-

gies that combine educational, behavioral, and

tension control than did either intervention

affective components may be more effective

alone. T h e best method to increase compliance

than single-focus interventions. For example,

and adherence is likely to involve highly individ-

Clifford, Tan, and Gorsuch (1991) reported sig-

ualized

nificant improvements in weight, percentage

example, patients who characteristically have

body fat, exercise adherence, and systolic and

active styles of coping with illness and treat-

approaches

to

each

patient.

For

diastolic BP in middle-aged overweight patients

ment-related

who were given social support and

control-based strategies such as self-monitoring,

taught

several cognitive-behavioral techniques

issues may benefit from

self-

that

self-evaluation, and self-reinforcement of adher-

applied to exercise adherence, weight reduction/

ence behaviors (Haynes et a l , 1 9 7 6 ) . Patients

maintenance, and stress management relative to

with more passive styles may benefit from more

an assessment-only control group.

structured

adherence interventions such as

Similarly, Boulware and colleagues' (2001)

behavioral contracting, direct instruction by

meta-analysis of 15 behavioral interventions for

health care providers, and external inducements

hypertension involving 4 , 0 7 2 patients noted

or rewards (Christensen & Johnson, 2 0 0 2 ) .

Hypertension

CASE S T U D Y T h e patient, "George R i c h a r d s , " is a 42-year-old married Caucasian male w h o works as a certified public accountant in Minneapolis, M i n n e s o t a . H e had received episodic medical care over the course o f the past 1 5 years, although he has had excellent health benefits through his company. H e had seldom been sick and had not seen any reason to visit a doctor. H e was last seen medically 4 years ago, at age 3 8 years, when he visited his family physician for a physical examination prior to scheduled surgery for repair o f a hernia that he had sustained while helping a friend move some furniture. This had been George's only surgery, and up to that point he had experienced no chronic illnesses o f any sort. At that time, he was 5 feet 7 inches tall and weighed 1 7 0 pounds. H e was a nonsmoker and social drinker, averaging four to six glasses o f wine per week. H e had few hobbies and was a self-professed " w o r k a h o l i c " w h o typically worked 6 0 hours or more per week in a very stressful w o r k environment. At that doctor visit, George's BP was 1 4 5 / 9 5 . H e had n o k n o w n family history o f either hypertension or cardiovascular disease. His cholesterol was within or below the average range at 1 7 2 , and his lipid profile was within normal limits. N o electrocardiogram ( E C G ) was done. H e was told by the family physician to lose 1 0 pounds and to try to get into some sort o f exercise program. H e was also advised to try to do something for relaxation and to cut b a c k his hours at w o r k . H e was advised that his BP would be checked on each subsequent visit back to see the doctor. After George was fully recovered from his noneventful

hernia surgery, he

bought an exercise bicycle but found that he seldom had time to use it and also found this to be a relatively boring activity for him. H e began walking with his wife when he could fit it into his w o r k schedule, which typically was one time per week or less and usually was a mile or so at a time unless the couple was interrupted by a call on George's cell phone. H e tried to watch his weight initially, but he frequently ate in restaurants with business clients and eventually went b a c k to a traditional "meat and potatoes" diet. His alcohol intake increased to t w o to three drinks per day, usually in an attempt to " u n w i n d " after a long day at the office. H e had been promoted to a supervisory position in his office, and this increased his workload and job-related stress; however, with t w o children in college, he felt that he had no other option than to w o r k longer and longer hours. H e developed some occasional sleep onset insomnia but otherwise convinced himself that he "felt just fine" and saw no reason to see his physician. Because o f changes in his company's health maintenance organization insurance plan, George was recently assigned to a different medical practice with a new physician, and an initial physical was recommended

by that medical

plan.

Although he saw no reason to see this new physician either, George reluctantly made an appointment for a physical e x a m . H e had recently become a partner in his firm and had considerable difficulty in fitting a visit to the physician into his busy

267

268

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

schedule. At this initial visit, George's B P averaged 1 7 5 / 1 0 5 over three separate readings. His weight was 1 8 5 pounds. An E C G done in the office showed a normal rate and rhythm but revealed an axis deviation consistent with mild left ventricular hypertrophy. George was informed that his B P was in the range o f Stage 2 hypertension, which required initial nonpharmacological intervention and BP monitoring every 2 weeks by the clinic nursing staff. A " n o added salt" diet (3 to 4 grams per day) was prescribed that was low in saturated fat and rich in fruits, vegetables, and low-fat dairy products. H e was advised to limit his alcohol intake t o 1 ounce per day. Because his office building had a health club, he was encouraged to purchase a membership and schedule time for exercise at least three times per week. H e was told that if his BP did not normalize within 2 t o 3 months, a full dose o f a first-line antihypertensive medication would be necessary. Subsequent to this office visit, George's BPs averaged 1 6 5 / 1 0 0 in clinic B P checks over the course o f the next 6 weeks. George had lost about 4 pounds but was having difficulty in sticking to his diet. Although he did purchase a health club membership, he found exercising there t o be as boring as it had been using the exercise bicycle, and he had used his membership on only two brief occasions. H e did cut back his alcohol intake to one to two drinks per day but discovered that he had trouble unwinding and had significant problems with insomnia when he had fewer drinks than that. W h e n George saw his physician at 6-week follow-up, the decision was made to refer him t o a local behavioral medicine clinic to attempt to bolster the nonpharmacological interventions prescribed to that point. A psychologist at the behavioral medicine clinic saw George 2 weeks later. At the request o f this psychologist, George was seen with his wife. An individualized exercise plan was crafted for him, including daily walking with his wife or walking on a treadmill placed in front o f the family's large-screen television at increasing rates and distances that he would self-monitor and report b a c k on subsequent weekly visits. George and his wife were given copies o f a modified version o f the D A S H diet that would fit their lifestyle and were asked t o keep dietary intake records. At a subsequent visit 2 weeks later, a behavioral intervention program for George's insomnia was devised. George was enrolled in a stress management course that included relaxation tapes that he could use to help with his sleep onset problems as well as training in life management skills that he could apply in his place o f business. George was seen again by his family physician after attending six weekly sessions at the behavioral medicine clinic. His weight was n o w 1 7 4 pounds, and his BP was 1 5 0 / 9 5 . H e was walking 1 to 2 miles an average o f five times per week, and his alcohol consumption was down to one to two glasses o f wine per week. His physician started him on a low dose o f an A C E inhibitor (Lisinopril, 5 milligrams per day) as an adjunct to the behavioral interventions. At 1 month follow-up, George's BP had stabilized at 1 3 0 / 8 5 , his total cholesterol was 1 9 1 , his weight had stabilized at 1 7 0 pounds, and he was continuing in monthly maintenance sessions at the behavioral medicine clinic.

Hypertension

behavioral medicine research has contributed

CONCLUSIONS

significantly Hypertension is a major risk factor for many devastating

\

illnesses, including

coronary

heart disease, stroke, and kidney

toward

expanding

available

intervention methods. Because o f the longterm

nature o f interventions,

behavioral

failure.

researchers have focused their efforts on devel-

Efforts to develop effective means for diag-

oping diverse behavioral modification tech-

nosing and treating hypertension have been

niques, targeting factors such as weight, eating

in the forefront o f public health research.

habits, physical activity, and substance use. In

These efforts have led to greater recognition

addition to behavioral and psychosocial meth-

o f the importance o f frequent screening o f BP

ods, advancement has been made in available

and for implementing reliable means

pharmacological treatment options.

for

measuring B P , including the use o f ambulatory monitoring for diagnosing this disorder. A strong movement toward promoting pre-

Although advancement has been made in developing effective control strategies, many challenges in implementing them

remain.

ventive efforts has also characterized public

These include compliance with regimens and

health work over the past two decades. T h e

consistency in applying interventions over a

greater awareness o f hypertension has also led

long period o f time. Behavioral medicine

to a more comprehensive view o f the etiologi-

scientists and clinicians are in the forefront

cal

of trying to maximize patients' cooperation

factors o f this disorder,

consequently

leading to a greater emphasis on a menu o f

and

strategies targeting BP control. T o that end,

hypertension.

c h a n c e s for

success in

controlling

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CHAPTER

Coronary Heart

10 15

Disease

Behavioral Cardiology in Clinical Practice STEVEN M . SCHWARTZ AND MARK W . KETTERER

H

eart disease continues to number

be the

o n e killer o f m e n

and

w o m e n in the United States, where

myocardial infarctions ( M i s ) occur at a rate

(e.g., depression, anger, anxiety) is essential to secondary prevention efforts and is critical for optimal recovery o f function and general health.

o f about 1.5 million per year. F o r about 3 0 %

T h e modern evolution o f behavioral cardi-

of these patients, death is sudden and the

ology arguably began during the m i d - 1 9 7 0 s

first "symptom" they experience. Ischemic

with the work o f Friedman and R o s e n m a n

heart disease or coronary heart disease ( C H D )

( 1 9 7 4 ) on " T y p e A behavior." Since that

is predicted to remain the leading cause o f

time, behavioral scientists and clinicians in

death

collaboration with medical colleagues have

worldwide

through

2020.

Despite

these compelling statistics, the survival rate

considerably

from

to

understanding o f the relationship among psy-

improve, and more than 1 million people

chological, emotional, psychophysiological,

survive acute c o r o n a r y events annually in the

and behavioral factors in the development,

United

maintenance, and

acute c o r o n a r y events continues

States. T h u s , issues pertaining

to

psychological functioning, behavioral risk,

expanded

and

refined

our

exacerbation of C H D .

Given the increasing clinical role o f behav-

and quality o f life are increasingly relevant as

ioral clinicians in managing heart patients,

heart patients face m o r e favorable prospects

this chapter provides (a) a brief review o f

for recovery and

the etiology o f heart disease, (b) a cognitive-

rehabilitation. Assessing

and treating these patients' health risk behav-

behavioral case conceptualization o f C H D ,

iors, such as smoking, obesity, fatty diet, lack

and (c) a pragmatic presentation o f the clini-

of exercise, nonadherence to medical regi-

cal issues for assessing and treating patients

men, social isolation, and emotional status

with coronary artery disease.

279

280

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

PSYCHOPHYSIOLOGICAL AND BIOMEDICAL ASPECTS OF THE CHD PATIENT

much higher prevalence o f "small" lesions

Atherosclerosis

M i s (absolute number) actually occur at sites

trunk. Also o f note, although large blockages are more likely to produce an infarct, the (less than 5 0 % occlusion) means that most with low-level occlusion.

Atherosclerosis is defined as the buildup o f plaques

Atherosclerosis will follow a "stuttering"

(e.g., "blockages," "stenoses,"

course marked by periods o f growth, stasis,

"lesions," "occlusions") typically composed o f

and (sometimes) regression. Plaques may be

lipids, complex carbohydrates,

and

blood

fibrous and stable, or they may be unstable,

products along artery walls. T h e development

containing a pool o f dead cells and lipids cov-

and

ered by a thin membrane or cap and eccentric

progressive unless the condition is vigorously

o f atherosclerosis is multidetermined

in shape. W h e n this cap ruptures, the contents

treated. By the time a cohort reaches middle

of the pool are thought to provoke thrombus

age, half or more will have some amount o f

formation (i.e., clot), sometimes self-resolving

atherosclerosis. However, some people reach

(but perhaps provoking angina) and some-

advanced ages of 8 0 years or more with little

times evolving into a full blockage o f the

or no clinically significant atherosclerosis.

artery ( M I ) . Fully 8 5 % to 9 0 % o f infarctions

Therefore, although a number of etiological

are believed to be caused by this sequence. T h e

risk factors have been identified, our under-

cause of plaque instability is thought to be

standing o f the etiology remains incomplete.

chronic recurring inflammation, perhaps with

However, most o f the currently accepted risk

some causal contribution from genetic factors

factors (aside from family history, sex, and

and/or infection with Chlamydia

age) are modifiable by medication, changes in

(Ridker, Hennekens, Buring, & Rifai, 2 0 0 0 ;

lifestyle, or both.

Ross, 1 9 9 9 ) .

pneumoniae

W h e n patients have lesions at one site

Precisely what triggers a rupture remains a

(e.g., coronary arteries), it is highly probable

matter o f debate (Allen & Scheldt, 1 9 9 6 ) ,

that they will have lesions at other sites (e.g.,

although it has been hypothesized that elevated

carotid, femoral, or renal arteries). Blockages

emotional states may be one triggering mecha-

that

are large enough

blood

nism secondary to emotion-aggravated con-

supply, and thus to threaten oxygen flow to

tractility of the heart, blood pressure changes,

critical areas (e.g., heart, brain, kidney, legs),

increased blood viscosity, vasoconstriction,

produce

transient

to threaten

ischemia (i.e., reversible

and/or localized vasospasm. Thrombogenesis

oxygen supply/demand deficit) or permanent

is certainly encouraged by various psychobio-

damage secondary to infarction (i.e., tissue

chemicophysical events, including via stress

death due to cessation o f blood

supply).

reactivity pathways. For example, elevated cir-

Large plaques ( 5 0 % or greater blockage) are

culating catecholamines and platelet aggrega-

associated with a higher risk o f infarction.

tion are associated with states o f acute fear

Interestingly, although

large plaques

may

or anger (Markovitz, 1 9 9 8 ) . Heart rates and

threaten adequate blood flow locally, chronic

diastolic and systolic blood pressures rise,

deprivation o f an adequate blood supply to

sometimes precipitously, in response to even

the heart can provoke the development o f col-

mild transient and contrived stressors in the

lateral arteries around the occluded sites as a

laboratory (Goldberg et al., 1 9 9 6 ; Ketterer,

remarkable biological compensatory strategy.

Freedland, et al., 2 0 0 0 ) . Daily life stress is typi-

These collateral arteries then provide natural

cally more meaningful and chronic, provoking

bypasses in the event o f infarction of the main

more intense and prolonged emotional burden

Coronary

Heart

Disease

on patients. This has been measured with in

"discomfort" (e.g., pain, pressure, fullness,

vivo monitoring studies (e.g., Polk, Kamarck,

squeezing), angina sometimes manifests as

& Shiffman, 2 0 0 2 ) .

arm

N o t e that even when accounting for all o f the factors in epidemiological studies, only

pain,

jaw

pain,

lower

back

headache, nausea/vomiting/upset

pain,

stomach,

cognitive confusion, dyspnea (i.e., shortness o f

about half o f cases o f ischemic heart disease

breath), dizziness,

can be explained (Farmer & G o t t o , 1 9 9 7 ) .

and/or

Although most infarctions are probably the

delineated triggers (typically physical exertion

syncope/near

syncope,

weakness. Stable angina has well-

result o f unstable plaque rupture, 2 % to

and sometimes stress) and responds well to

1 0 % o f all infarctions in the human heart

nitrates. Unstable angina is far less predictable

occur in the absence o f any atherosclerosis,

and is often accompanied by severe and pro-

and another 5 % to 1 0 % occur in a part o f

longed pain. T h e presence o f unstable angina

the coronary vascular tree without plaque.

is clinically considered an acute

T h u s , acute thrombus formation can occur

event requiring emergent care because it may

independent

o f plaque rupture. It is n o w

be caused by plaque rupture.

believed that the occurrence o f a M I requires something beyond atherosclerosis.

coronary

Angina is generally presumed

to

result

from ischemia, but this "causal" relationship

Depending on location (which détermines

is less than perfect (e.g., Krantz et al., 1 9 9 4 ) .

the amount o f heart muscle affected by cessa-

Importantly,

tion o f blood flow) and the presence o f collat-

shared by a wide range o f other conditions,

eral circulation and/or anatomical variants in

including acute emotional states, psychiatric

the symptoms

o f angina

are

the coronary vascular tree, the size and signifi-

disorders, and other medical conditions, mak-

cance o f an infarction can vary widely. M i s

ing differential diagnosis difficult at times

considered large will generally decrease the

(Richter, 1 9 9 2 ; Schwartz, Trask, & Ketterer,

heart's pumping function (i.e., ejection fraction

1 9 9 9 ) . M o s t episodes o f ischemia captured

[EF]). A normal E F (i.e., the proportion o f

on Holter monitoring in both laboratory test-

blood ejected from the left ventricle during

ing and in vivo settings are not associated with

systole) will average about 6 6 % in the heart o f

chest pain/pressure or other symptoms, typi-

a healthy adult but includes values above 5 0 % .

cally referred to as silent myocardial ischemia.

strenuous

(A Holter monitor is a small portable device

physical activity, EFs above 4 0 % may be unde-

Unless the

patient

engages

in

that collects electrocardiogram [ECG] data on

tectable by the patient. EFs below 4 0 % define

a continuous basis during daily life.) Further-

heart failure, and this generally affects routine

more, most episodes o f chest pain are not

physical function (i.e., dyspnea, fatigue, and/or

associated with ischemia as measured by sur-

dependent edema). W i t h EFs below 2 0 % , the

face E C G ("atypical" or "noncardiac" chest

patient may be considered for a transplant.

pain). In fact, recurrent emergency r o o m visits by cardiac patients for chest discomfort without evidence o f ischemia/infarction are quite

Angina

common.

Angina pectoris refers to transient chest

Angina is strongly associated with depression/

pain or discomfort resulting from ischemia o f

anxiety, and cognitive-behavioral treatment of

occurs sec-

emotional distress has been found to reduce

ondary to an oxygen supply/demand deficit.

episodes o f angina and ischemia (Blumenthal

Hence,

et al., 1 9 9 7 ; Ketterer, Fitzgerald, et al., 2 0 0 0 ;

heart muscle. T h e discomfort strenuous

physical

activity

that

increases the heart's workload is a c o m m o n

Lewin, 1 9 9 7 ) . Pain intolerance

trigger. M o s t commonly experienced as chest

to

depression/anxiety,

or

secondary

ischemia/angina

282

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS provocation secondary to fear/anger, increases

ventricular

chest discomfort (Ketterer, Fitzgerald, et al.,

fibrillation,

2000;

sudden cardiac death. Note that the ventricular

Ketterer

etal.,

1998;

Schwartz

tachycardia the presumed

and

ventricular

causal culprits in

et al., 1 9 9 9 ) , and chest discomfort provokes

portion of the heart is the primary pumping

treatment seeking and aggressive diagnostic/

chamber for the brain and general body. There

treatment decisions by physicians. Thus, if

are a number of factors (e.g., drugs, disease,

not directly affecting disease

progression,

infarction, emotional distress) that can produce

emotional distress will still affect quality o f life,

abnormal rhythms, many o f which can be seri-

illness behavior, and disease management in

ous or even life threatening. In severe instances,

adverse ways.

blood flow may slow sufficiently to cause acute

Because angina is the major driving force

brain failure (syncope). When the heart has been

behind medical system use, treatment of emo-

thrown into inefficient sequencing o f its con-

tional distress may reduce this use (Black,

tractions, cardioversion (transthoracic electrical

Allison, Williams, Rummans, 8c Gau, 1 9 9 8 ;

shock) is used to achieve a normal sinus rhythm.

Davidson, 2 0 0 0 ; Frasure-Smith & Lesperance, 1 9 9 8 ) . Recently, Schwartz and

colleagues

Patients at high risk for future life-threatening arrhythmias will likely receive antiar-

( 1 9 9 9 ) proposed a spectrum approach to chest

rhythmic medications that regulate heartbeat,

pain management (e.g., pain and palpitations)

pacemakers, and (in severe cases) implantable

that

cardioverter defibrillators. This latter device,

includes presentations

consistent

with

pain/anxiety, Syndrome X/nonischemic chest

like the pacemaker, is placed inside the body

pain, Prinzmetal's angina, and angina pectoris.

and can function as an " o n b o a r d " crash cart

Because psychological and behavioral prob-

that greatly improves both sudden cardiac

lems are similar in angina and other forms of

death and

chest discomfort regardless o f the underlying

medication management alone (Gilkson &

cause, disease management strategies should

Friedman, 2 0 0 1 ) . However, there is growing

all-cause mortality relative

to

be multidisciplinary. T h e rise of "chest pain"

evidence that the device itself can produce

clinics for nonemergent chest pain attests to

problems o f behavioral or psychological mal-

greater recognition of this overlapping

and

complex problem.

adjustment

in a significant subgroup o f

patients (for an excellent review, see Sears, T o d a r o , Lewis, Sotile, & Conti, 1 9 9 9 ) . Behavioral clinicians are particularly famil-

Arrhythmias

iar with the sinus tachycardias

The heart contracts and relaxes in a highly

most character-

istic o f panic attacks and other acute anxiety

orchestrated fashion or rhythm to efficiently

and mood states. Importantly, clinicians must

move blood from the venous

compartment

be aware that patients can and do develop anx-

(deoxygenated blood) to the arterial compart-

ious presentations from more dangerous heart

ment (oxygenated blood). This is a two-phase

rhythms as well (Schwartz et al., 2 0 0 2 ) . Also,

process in which the heart fills during the

there is considerable evidence that the subjec-

relaxation phase (diastole) and then the heart

tive symptom of palpitation correlates poorly

forcefully empties during the contraction phase

with underlying cardiac rhythm (Barsky, 2 0 0 1 ;

(systole). This orchestration is electrochemical in

Barsky, Cleary, Barnett, Christiansen,

nature and is maintained by a specialized cluster

Ruskin, 1 9 9 4 ) , as was described previously for

8c

of cells collectively called the sinoatrial node or

chest pain. Although it is generally acknowl-

natural pacemaker. Disruption o f this sequenc-

edged that panic spectrum disorders can and

ing is referred to as an arrhythmia. Arrhythmias

do masquerade

can range from

reverse is also true. T o illustrate the complexity

benign to malignant. O f

particular clinical significance are

sustained

among

as cardiac problems,

anxiety, palpitations,

and

the

cardiac

Coronary rhythm,

Lessmeier and colleagues

(1997)

permanent

tissue

Heart Disease

death

|

("infarction").

found that 6 7 % o f patients presenting for

Likewise, certain patterns on the E C G (ST seg-

treatment

ment

o f paroxysmal

supraventricular

depression)

reflect ischemia or infarc-

tachycardia (PSVT) met criteria for panic and

tion. Table 1 5 . 1 presents some o f the c o m m o n

that P S V T went unrecognized in 5 5 % o f the

cardiac diagnostic and treatment procedures.

patients even after an initial medical evaluation. Equally striking, 8 6 % of patients displayed resolution o f anxiety symptoms with antiarrhythmic therapy.

Cognitive-Behavioral Case Conceptualization of CHD Understanding the factors that contribute

Hemodynamics

to both acute and chronic aspects o f C H D

This chapter has already alluded to the

would be incomplete without consideration o f

notion that the heart can develop compen-

the psychological, emotional, and behavioral

satory strategies in the presence o f heart

characteristics o f the patient or the patient

dysfunction/disease

(e.g., development

of

population. T h e clinical study o f these unique

bypass).

risk factors and their modification is at the

Hemodynamics is the study o f the forces

very "heart" o f behavioral cardiology. Given

involved in the movement of blood through

what is currently supported by the evidentiary

collateral

arteries

as

a

natural

the circulatory system. It is through the study

literature, a general cognitive-behavioral con-

of these processes that one can understand the

ceptualization o f cardiovascular disease devel-

physical and functional changes that occur in

opment and rehabilitation can be constructed

the diseased heart as it attempts to maintain

on the following assumptions:

homeostasis in the body. A simplified version of the process is as follows. As the E F o f the heart declines in heart failure, or with infarctrelated heart muscle damage, the heart begins to struggle to push blood out into the body, creating a variety o f physical changes in the heart's structure

over time. This process,

referred to as remodeling,

can be characterized

by heart enlargement, thickening o f the heart walls, and leaking heart valves that regurgitate blood as the heart becomes more inefficient. This inefficiency is manifest in wall motion abnormalities. W a l l m o t i o n

abnormalities

can be visualized by blood pool radionuclide imaging (technetium sestamibi) or on echocardiogram. Localized perfusion defects can be visualized by uptake o f radioactively labeled glucose (technetium pyrophosphate

or thal-

lium). This type o f diagnostic testing is thought to reflect impairment o f blood flow to an area of heart muscle. This impairment reversible when

the patient

is not

can be being

stressed, or it is "fixed" (present when the patient is both at rest and stressed), implying

1. Many of the biological processes that underlie cardiovascular disease develop over time out of health risk behaviors and lifestyles. These risk factors for CHD are relevant to disease development, maintenance, and exacerbation and also contribute to related and complicating conditions such as emphysema, type 2 diabetes, pulmonary hypertension, and heart failure. 2. Lifestyle and behavioral risks are generally immediately and highly gratifying. The powerful reward value of these risk behaviors causes them to become habitualized as a consequence of frequent and persistent practice, thereby making them particularly resistant to intervention. For example, a pack-a-day smoker receives 7 0 , 0 0 0 infusions of nicotine during the course of a year; that is a number of "hits" unparalleled by any other recreational drug. 3. The negative, debilitating health consequences of these behaviors typically develop slowly over time, allowing the person to accommodate to many of the

283

284

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS Table 15.1

Common Cardiac Diagnostic and Treatment Procedures

ECG:

Monitors the electrical activity in the heart to past or present heart attack, the location of the heart affected, and the rhythm of the heart; can be used with or without exercise (treadmill testing) and in vivo with Holter monitoring (continuous monitoring) or event monitoring (event-specific recordings)

Echocardiogram:

Ultrasound evaluation of the heart allowing for an working heart to be captured, including chambers, muscle walls; can also be done in conjunction with medication (e.g., Dobutamine) that increases heart

Cardiac catheterization:

Invasive procedure that is performed by inserting a catheter (tube-like device) into an artery (typically in the groin) and advancing through the arterial system into the heart, with the catheter able to measure pressures inside the heart chambers and, when equipped with a camera, able to take video of the heart in action

Percutaneous transluminal coronary angioplasty (PTCA)/ directional coronary atherectomy (DCA):

Advancing a catheter up to a blockage in a critical artery and reducing the occlusion by expanding a small balloon or using a plaque-cutting device, with stents (stainless steel mesh tubes) sometimes being put into place to prevent re-occlusion

Coronary artery bypass graft:

Surgical procedure that takes blood vessels from another part of the body (typically in the legs or chest) and then stitches them around the blocked coronary artery

symptoms of physiological degradation and reduced function. 4. The individual's cognitive and emotional status mediates lifestyle risk factors and also contributes more directly to disease development, maintenance, and exacerbation through the autonomic nervous system's stress reactivity pathways associated with fight/flight and psychoneuroimmunological pathways. 5. The biological, psychological, and behavioral factors noted previously, as well as environmental factors, influence one another in a bidirectional or reciprocal fashion.

imaging of the valves, and heart exercise or use of a rate

requires the use o f an objective, psychometrically sound questionnaire to aid clinical staff in recognizing distress. There are a number o f well-validated self-report measures

for

assessing C H D patients, and most focus on emotional status, functionality, and/or quality o f life. T a b l e 1 5 . 2 lists some o f the c o m monly

used

tools

and

the

underlying

constructs they purport to measure. Any o f the psychometric instruments validated as prospective predictors o f cardiac outcomes could be used, but they are clearly redundant in terms o f their predictive utility (Ketterer et al., 2 0 0 2 ) . Because o f brevity, nonstigma-

ASSESSMENT OF T H E CHD PATIENT

Screening Identification and triaging o f emotionally distressed patients from cardiac settings often

tizing content, and ease o f administration and

scoring

(many

become frustrated

CHD

with

patients

lengthy

will

question-

naires or test batteries), the Hospital Anxiety and Depression Scale ( H A D S ) . with a cutoff o f 13 or greater, is recommended (Herrman, 1 9 9 7 ) . T h e chapter

authors

suspect

that

Coronary Table 15.2

Heart Disease

Self-Report Measures for the Cardiac Patient

Hospital Anxiety and Depression Scale Symptom Checklist-90-Revised (Brief Symptom Inventory) Beck Depression Inventory State-Trait Anxiety Inventory Crown-Crisp Cook-Medly Hostility Scale Ketterer Stress Symptom Frequency Checklist Millon Behavioral Health Inventory Toronto Alexithymia Scale SF36 Seattle Angina Questionnaire Minnesota Living With Heart Failure Questionnaire Cardiac Anxiety Questionnaire

screening will eventually require an instrument

model (Goldfried & Sprafkin, 1 9 7 6 ) is one o f

designed for completion by a significant

several c o m m o n models and is used here for

other so as to circumvent denial (Ketterer

illustration purposes.

et al., 1 9 9 6 , 1 9 9 8 , 2 0 0 2 ) , but this remains to be proven in prospective studies.

Clinical Interviewing (Functional Analysis) Evaluation should, as always, include a thorough psychosocial history, mental status e x a m , and review o f cardiovascular risk factors

(Table

1 5 . 3 lists the domains

to

consider in an initial evaluation). Importantly, this evaluation should include identification of barriers to change as well as cardiovascular risk factors. Behavioral assessment models have long been used in the functional analysis of problem behaviors (Barrios, 1 9 8 8 ) , including illness behavior (Schwartz, Gramling, & Mancini,

1994).

Because the

modifiable

risk factors for C H D are deeply embedded in the psychology and behavior o f the patient, approaching

The Stimulus (patient triggers or hot buttons). T h e stimulus portion o f the S O R C model refers to the triggers o r cues that evoke health risk behavior. Stimulus control variables relate to cardiovascular risk in a number o f ways. Overt behaviors such as s u b s t a n c e a b u s e (e.g., n i c o t i n e , a l c o h o l , cocaine), lack o f exercise, and acute emotional reactions can have a broad range o f environmental and cognitive triggers. F o r example, it is not unusual for the mere presence o f a critical supervisor to trigger acute autonomic arousal and c o n c o m i t a n t emotional distress (e.g., anxiety, anger, irritation, w o r r y ) , even when there is no current overt conflict. Therefore, it is imperative to identify the patient's triggers (or buttons), noting that patients m a y vary greatly in their understanding o f or insight into the functional relationships between triggers and emotional or behavioral responses.

the initial assessment o f the

patient can be greatly facilitated by using a

Organismic

Variables.

Organismic variables

functional-analytic framework. T h e Stimulus-

are the dispositional characteristics of the patient

Organismic-Response-Consequence ( S O R C )

(e.g., genetic, physiological, temperamental,

\

285

286

J BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Table 15.3

An Evaluation Checklist for CHD Patients

Frequency and triggers for chest pain Disease-specific worries (often grief over disease-imposed role changes or limitations) Disease-specific knowledge (what the patient knows about his or her condition and recovery) Physical activity level (including activities such as walking and gardening) Smoking (e.g., number of cigarettes per day, smoking history in years) Eating habits (e.g., high-risk foods with high fat content, salt, sugar; eating behaviors such as binging, rapid eating, stress/emotional eating) Alcohol intake (e.g., number of drinks per day/week, drinking history, CAGE questions) Interpersonal conflicts (particularly focusing on work and marital relationships) Job stress (e.g., deadlines, responsibilities) Sleep habits (e.g., apnea, insomnia, restless leg syndrome) Emotional status (e.g., depression, grief, anxiety, anger/hostility, alexithymia) Comorbid medical conditions (e.g., diabetes, heart failure, chronic obstructive pulmonary disease)

experiential) that are peculiar to the individual.

change. Understanding the ways in which these

The familial aspects of cardiovascular disease

behaviors are reinforced or maintained is criti-

reflect both genetic factors and early learning

cal to the secondary prevention process. Timing

experiences. O f particular interest may be the

is particularly important in health risk behav-

early modeling of cardiovascular risk behaviors

ior. As a general rule, temporal proximity of

such as smoking, angry acting out, and a mal-

behavior and consequence will wield greater

adaptive

and/or

influence over the behavior. As noted previ-

achievement at the expense of other important

ously, many risk behaviors provide immediate

aspects of development.

gratification. In particular, it is important to

emphasis on competition

view the C H D patient's actions as maintained The Response.

T h e response describes the

by relief from negative affective states.

target risk behavior itself (e.g., eating a fatty meal). T h e response can also be operationalized as a nonbehavior (i.e., failure to act) such

Emotional Status

as an inability or unwillingness to engage in

There are several emotional domains that

regular exercise. In addition, behavioral risk

have consistently proven themselves to have

includes not only overt acts or failures to

robust relationships to cardiac outcome and/or

act but also covert behaviors such as certain

are relevant to individual work with the C H D

cognitions. T a b l e 1 5 . 4 lists some o f the c o m -

patient (for an excellent review, see Rozanski,

mon maladaptive cognitions to assess in the

Blumenthal, &c Kaplan, 1 9 9 9 ) . Assessment of depression/dysphoria,

C H D patient.

anger/hostility, stress,

anxiety, and alexithymia is essential in a thorThere are several factors that

ough evaluation of the C H D patient. It is

affect the power o f a consequence to shape

important to note that many patients may pre-

behavior. M a n y of the risk behaviors seen

sent with subclinical levels o f emotional distress

Consequences.

in the C H D patient are highly overlearned,

(relative to cutoffs for traditional psychiatric

habitualized, and/or otherwise resistant

patients), and these levels may still be clinically

to

Coronary Table 15.4

Heart Disease

\

Common Cognitive Errors in CHD Patients

Chronic and excessive worry or anger about uncontrollable events (e.g., "catastrophizing" finances of retirement, allowing kids to sink or swim, confronting boss) is a chronic stressor for many patients. In many cases, patients have difficulty in discriminating the degree of control present in any stressful situation. Inaccurate understanding of "normal" is common, particularly among Type A or assertivenessimpaired patients. Unrealistic expectations regarding their own behavior or others' behavior can cause chronic aggravation or feelings of being unloved (commonly accompanied by the "shoulds" or a set of rigidly held obligations or responsibilities). "Anyone would react as I did" is probably a variant of the misunderstanding of "normal" and can be assessed using the "Rule of 1 0 0 " test." Malevolent attributions are present in many cases. Often, patients will make attributions regarding the motives and intentions of others as malevolent (e.g., a car cuts them off on the highway, thereby provoking rage because the other driver was "obviously" stupid, irresponsible, and/or dangerous). Surreptitious arrogance in interpersonal interactions is often characterized by overt politeness but dismissal of others' desires/opinions and devaluation of their feelings. Inability to trust is frequently present and may have its origins in malevolent attributions or deeper insecurities that patients might not acknowledge or even be aware of fully. Catastrophizing lateness!"unproductive" time is part of the time urgency characteristic of the Type A personality. Often, patients will have a profound intolerance for "downtime." Various forms of selfpacing exercises requiring the patient to go slower are helpful. Confusing "right" with "harmful" might also be called the "just world hypothesis," in which patients will get very angry over perceived injustices, slights, or inequities. They believe that if they can "prove" their case, the world would have to come into compliance. In fact, it often does not matter whether one is right or not, and anger will still kill. Is this worth dying for? Importance of "things" over persons, that is, what is regretted on deathbeds is time not spent with family/friends rather than time not spent at the office. a. The clinician should a s k himself or herself, "If 100 people were in this situation, what proportion would react in this w a y ? " Thus, the clinician's sense of normative behavior can be used to gauge how "normal" the patient's reaction is.

significant, related to important clinical out-

Obtaining two or three adjectives for affect,

comes, and worthy o f treatment even if they do

and then obtaining concrete examples where

not

and

these imply chronic conflict, for each significant

fourth

other (e.g., parent, sibling, spouse/lover, child,

meet

Statistical edition

formal Manual

DSM

of Mental

(Diagnostic Disorders,

[American Psychiatric Association,

boss) facilitates efforts toward mapping the

1 9 9 4 ] ) diagnostic criteria. In many cases,

patient's psychosocial stressors. This can also

patients will "somatize" their distress (i.e.,

provide some clues as to how the patient

report only the physical symptoms and deny or

construes and responds to others and as to the

minimize the affective/cognitive symptoms).

success o f these coping patterns. O f particular

Therefore, emphasizing the concrete benefits of

importance are overlearned/automatized coping

improved sleep or energy, or o f reduced chest

responses (which are presumably learned early

pain, can help the patient to accept treatment.

in life and are often outside the

patient's

287

288

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS awareness) and whether they succeed at merely

care regardless o f the impact on CHD-specific

reducing distress but not stress (maladaptive)

morbidity and mortality.

or at reducing both distress and stress (adaptive). Testing the patient's history against the

Anger.

The

work

of

Friedman

and

"Rule of Three" may be a useful exercise. If the

Rosenman ( 1 9 7 4 ) on the Type A personality

patient has made the same mistake three times

identified a number o f characteristics that

or more (e.g., getting fired, marrying an abusive

tended to cluster together and appeared to be

alcoholic), it is highly likely that this is a deeply

associated with cardiovascular

ingrained pattern that the patient does not

Apart

perceive regarding himself or herself. It should

constant effort, these characteristics include

become a goal o f treatment to raise the patient's

cynicism/mistrust,

from

ambition,

prognosis.

"busyness,"

and

stubbornness/opinionated,

awareness of this pattern, define a face-saving

perfectionism/demanding, alexithymia, control-

way o f construing the pattern, and then develop

ling/overcontrolled, impatient, and

more

obsessional. Importantly, not one of these

adaptive

alternative

responses.

For

worrier/

example, instead of framing the problem as

characteristics c a n

"I'm an angry guy," it may be more acceptable

gnomonic o f the syndrome, nor does any

be argued

as

patho-

and constructive to frame it as " I care too much

appear to have a direct effect on the genesis or

and have too high a set o f expectations, and

exacerbation o f C H D . Rather, these charac-

therefore I get frustrated a lot."

teristics are o f importance because they tend to foster a hostility complex or " A I A I " (aggra-

Depression.

There are now numerous pub-

vation, irritation, anger, and impatience).

lished reports linking depression and depres-

Although the literature has been marred by

sive symptoms to adverse cardiac outcomes

inconsistent operational definitions, psycho-

(e.g., B o o t h - K e w l e y &

metric problems with self-report measures,

Friedman, 1 9 8 7 ; Jaffe,

and a more complex relationship between the

1 9 9 5 ; Cassem & Hackett, 1 9 7 3 ; Frasure-

AIAI construct and C H D than was originally

Carney, Freedland, Eisen, Rich, &

Smith, Lesperance, & Talajic, 1 9 9 3 ) . Based on

conceived, it nevertheless remains prudent to

this evidence, depression should n o w be con-

assess the patient's ability to modulate anger.

sidered an established independent risk factor

AIAI has been proved to be a causal factor for

for C H D outcomes (Glassman & Shapiro,

C H D in a randomly assigned, controlled clin-

1 9 9 8 ) . Unfortunately, there are not yet any

ical trial o f cognitive/behavioral stress man-

randomized

agement that targeted AIAI and

controlled trials o f sufficient

reduced

methodological rigor to demonstrate a reduc-

death/Ml rates by 3 7 % relative to placebo

tion in C H D morbidity or mortality as a

controls (Dusseldorp, van Elderen, M a e s ,

result o f treating depression either psycho-

M e u l m a n , & Kraaij, 1 9 9 9 ; Friedman et al.,

therapeutically or psychopharmacologically.

1986, 1987).

However, S A D H A R T (Zoloft vs. placebo)

A related issue concerns

and E N R I C H D (stress management plus a

avoidance,

confrontation

where conflict with either family

selective serotonin reuptake inhibitor [SSRI]

members or coworkers often leads to "stew-

vs. standard care) are ongoing clinical trials

ing" (anger) or chronic anxiety. This has been

targeting depression in C H D . W h a t can be

conceptualized as the "anger in/anger out"

said with some certainty is that CHD/depres-

issue. This can occur for a variety o f reasons,

sion comorbidity does affect patient function-

including the Type A w h o despises but will

ality, compliance, and quality of life such that

not discuss conflicts with his or her boss and

assessment and aggressive treatment where

the Type A's spouse w h o is afraid o f express-

indicated is an essential part o f comprehensive

ing his or her disagreement over even trivial

Coronary

Heart Disease

\

matters due to the consequent verbal assault

from traditional psychological intervention,

(e.g., "that's so stupid") or cold shoulder.

although they are typically good at complying

O n e c o m m o n example seen is the cardiac

with behavioral assignments.

patient w h o has living with him or her a late adolescent w h o is not working, going to school, or contributing to the workload at home and who may be abusing drugs or even being verbally abusive with the parents.

Substance Use Assessment o f substance use, particularly tobacco products, is particularly important in any evaluation. Smoking is a powerful predic-

T h e data supporting a relationship

tor for many diseases, including C H D . If the

between anxiety and C H D is perhaps more

patient is an active or recent smoker, immedi-

Anxiety.

complex and less compelling than those sup-

ate referral for Zyban or an SSRI and possible

porting depression. As stated previously, acute

nicotine replacement should

anxiety might play an acute role in plaque rup-

(Edwards, Murphy, Downs, Ackerman,

tures,

Rosenthal, 1 9 8 9 ; Ketterer, Pickering, Stoever,

arrhythmias,

and

blood

pressure.

be facilitated &

Anxiety has been implicated as a major risk

& Wansley, 1 9 8 7 ; Murphy, Edwards, Downs,

factor for C H D in multiple prospective risk

Ackerman, &c Rosenthal, 1 9 9 0 ) . Smoking is

factor studies, particularly for death or sudden

such a potent predictor o f outcomes that hesi-

death (Kamarck &c Jennings, 1 9 9 1 ; Ketterer,

tation is not prudent unless the patient insists

&

on thinking it over. T h e patient should be

Sparrow, 1 9 9 8 ) . Unfortunately, no large-scale

taught techniques to avoid smoking cues (e.g.,

randomized control trials exist, nor are any

bars, sitting around after meals) and to disrupt

under way, to examine treatment in this popu-

smoking habits (e.g., smoke with the opposite

1999;

Kubzansky,

Kawachi,

Weiss,

lation and cardiac outcomes. It should be

hand, change brands, smoke menthol), and

noted that acute digoxin toxicity (e.g., tremor,

should be taught relaxation procedures to help

loss of appetite, confusion) may mimic anxiety.

control acute urges prior to setting a contracted quit date (preferably during a psy-

Alexitbymia.

Many

CHD

patients

are

c h o s o c i a l ^ quiescent period). Giving

the

found to display some degree o f alexithymia,

patient 24-hour-per-day access to the clinician

which refers to difficulty in identifying and/or

during the first month o f cessation is a privilege

labeling emotional states in self and others.

that will rarely be used or abused, and it seems

Patients with this disorder

to assist some patients in managing

will display

a

poverty o f vocabulary in reporting their feelings and describing other people's personalities, and

they will typically n o t

explore

their

impulses. Although not a common problem in this population, chemical dependency (e.g., cocaine,

psychosocial circumstances as possible causes

alcohol) should be ruled out. It is a futile exer-

of their problems. T h e y will present as emo-

cise to try to treat emotional distress in some-

tionally concrete (as opposed to metaphorical)

one whose central nervous system is under

in talking about what appear to be emotion-

assault by fluctuating levels o f psychoactive

ally charged situations. W h e n exploring their

substances. Detoxification may be necessary

psychosocial circumstances, it is necessary to

before further treatment can proceed. Note that

gently probe for concrete event/behavioral

prolonged alcohol abuse can result in car-

details because these patients rarely volunteer

diomyopathy.

Prevalence rates for cocaine

information spontaneously because they fre-

abuse in C H D do not exist, but it is clear that

quently view it as irrelevant. Alexithymia can

chronic cocaine use, particularly when smoking

make it difficult for many patients to benefit

is the route o f administration, can lead to early

289

290

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS heart disease. Because cocaine can provoke

early-stage,

coronary vasoconstriction, chest pain, and M I

manifesting on magnetic resonance imaging/

as well as depression, it is important to consider

computerized

this in the history of the patient. Cocaine use is

"periventricular leukomalacia" or "ischemic

probably the most common single factor pre-

white matter changes") is elevated. Although

cipitating M I in young people (e.g., under age

the patient may still be highly functional, irri-

4 0 years), so a drug screen may help to account

tability/frustration over subtle memory-related

for early C H D .

multi-infarct tomography

dementia

(often

[MRI/CT]

as

problems may be an aggravating factor if he or she externalizes causality. Ruling out alternative, potentially arrestable causes (e.g., a

Sleep Apnea Sleep apnea

thyroid-stimulating hormone for thyroid probis a periodic cessation o f

lems, a venereal disease research laboratory or

breathing during sleep that is an underappre-

a rapid plasma regain test for neurosyphilis) is

ciated comorbidity in C H D . Clinicians should

important, but such causes are only rarely

suspect sleep apnea when there are signs o f

found. Patients often fear a large cerebrovascu-

persistent nightly snoring, bed partner c o m -

lar accident more than they fear a heart attack.

plaints or descriptions o f choking/gasping/

Because prophylaxis o f cerebrovascular acci-

cessation o f breathing, and/or chronic fatigue

dents is the same as the regimen followed for

("excessive daytime

M i s , patients can be reassured that all reason-

sleepiness"). Patients

may also manifest subtle signs of cognitive

able steps are being taken, and their concern

dysfunction or m o o d symptoms. Suspected

can be used to further motivate "taking care of

apnea should result in referral for evaluation

themselves."

to a sleep center. It is not clear whether treatment

o f sleep apnea

lowers the risk o f

Ml/death, but this seems likely to be the case (Ketterer, Brymer, Rhoads, Kraft, & Kenyon,

The Importance of Collateral Clinical Data

1 9 9 4 ) . Because many apneics develop a reac-

Because o f the high rate o f denial/mini-

tive depression due to self-attributions regard-

mization/alexithymia present in this patient

ing their "laziness," treatment o f sleep apnea

population, the clinician should be somewhat

can improve m o o d (Dahlof, Ejnell, Hallstrom,

skeptical about the patient's version o f his or

& Hdner, 2 0 0 0 ) .

her life and circumstances. Although it is important

"holes" in narration (e.g., " G e e , I don't k n o w

O f particular importance in this population, particularly given advanced age, are consideration o f whether the patient displays any cogni(often subtle and

patient

attributes meaning to events, psychological

Cognitive Dysfunction

tive impairment

to understand h o w the

why she left m e " ) should be seen as important and indicative o f a chronic coping problem. Significant others should always be used as

in the

collateral sources of information when evaluat-

absence of waxing/waning arousal and atten-

ing a patient or tracking response to treatment.

tion). T h e use o f a cognitive screening tool or

Sometimes, this can be accomplished by simply

procedure

asking the patient,

(e.g., month,

year, three

items

immediate and delayed, counting backward) at

" H o w does your wife

[husband] think you are doing?" Other times, it

initial evaluation is important. Because of the

is necessary to obtain independent contact with

patient's vascular disease and/or arrhythmias

the significant other because o f the patient's

(particularly those patients w h o have atrial

denial/alexithymia or other lack of insight.

fibrillation), the likelihood of mild-moderate,

Often, it is necessary to obtain this data out of

Coronary

Heart

Disease

the patient's hearing range given that many

knows you well" to complete and return

spouses report "walking on eggshells" so as not

independently by mail before

discussions with

to provoke the patient's ire. One prudent tactic

the patients. Although not yet documented, it

is to simply tell the patient that "it's always

will be interesting to see whether this relation-

helpful to have another person's perspective on

ship holds true for female patient/male signifi-

how you're doing." At a later point in time, the

cant other dyads.

clinician can encourage the patient to use an appropriate significant other as a "monitor" under the mutual contract that the spouse should not be punished for providing accurate but unwelcome feedback. As an adjunct to interviewing significant others, the Spouse/Friend Ketterer Stress Symptom

Frequency

PRACTICE

Stress and Coping Framework

(KSSFC)

Stress is a concept that most people, includ-

(Ketterer et al., 1 9 9 6 , 1 9 9 8 , 2 0 0 2 ) is recom-

ing those with C H D , readily accept and for

mended for obtaining a significant other's

which they have some intuitive understanding.

assessments o f the patient's emotional status.

Framing any psychological or behavioral prob-

T h e K S S F C is unique in this feature o f allow-

lems within a diathesis stress model rather than

ing both patient self-ratings and ratings by sig-

using more traditional or formal psychiatric

nificant others. T h e spouse/friend K S S F C can

nomenclature (e.g., "crankiness" rather than

be administered by sending it home with min-

"anger," feeling "down" rather than feeling

imal written

Checklist

T R E A T M E N T AND CLINICAL

stamped

"depressed," "worried" or "stressed" rather

addressed envelope to "someone who knows

instructions and

a

than "anxious") will typically provoke the

you well." T h e patient and significant other

least resistance and help to facilitate a thera-

should be encouraged to not discuss the ques-

peutic alliance. Clinicians working within a

tionnaire until after it has been mailed back. If

traditional psychiatric context and looking to

the clinician is seeking direct input from a

develop cardiac referrals will face resistance

spouse/significant other on the patient's rou-

from patients even before their first visits.

tine emotional functioning, it is critical that

Ideally, treatment should be done as part o f a

the conversation occur without the patient

multidisciplinary cardiac team or consultation

being present. It has been demonstrated that

service rather than removed in a separate psy-

spouse/friend-reported

depression using the

chiatric setting to maximize destigmatization.

K S S F C is a stronger correlate of coronary

Table 1 5 . 5 summarizes some of the treatment

artery disease severity (by angiography) than

studies focusing on stress reduction.

is self-report and that denial of depression

Here the transactional model of Lazarus

(spouse/friend minus self-ratings) is an even

and Folkman ( 1 9 8 4 ) works nicely. In the most

1996).

general sense, coping efforts can be presented

stronger correlate (Ketterer et al.,

Furthermore, spouse/friend ratings (and not

to patients as taking one o f two tacks: prob-

self-ratings) of anxiety were the only predictor

lem-focused coping or emotion-focused cop-

of angina at 5-year follow-up, and it was

ing. For heuristic purposes, these two coping

shown that denial o f distress (particularly

efforts can be discussed as if they are separate,

AIAI) is a very strong predictor o f mortality

independent coping methods, whereas in vivo

(Ketterer et al., 1 9 9 8 ) . F o r this reason, the

they most often interact in dynamic fashion

chapter authors routinely send their male

and over time the patient will need to integrate

patients home with a questionnaire

about

them more effectively. Problem-focused cop-

themselves to be given to "someone who

ing, or efforts aimed at defining the problem,

292

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS Table 15.5

Benefits of Treating "Stress" in Ischemic Heart Disease

Proven (i.e., at least one intervention study published) Improved quality of life Decreased myocardial infarction and death Reduction of ambulatory ischemia Decreased smoking relapse Decreased chest pain/pressure

Dusseldorp et al. (1999) Dusseldorp et al. (1999); Ketterer (1993) Blumenthal et al. (1997); Dusseldorp et al. (1999); Blumenthal et al. (1997); Ketterer, Fitzgerald, et Dusseldorp et al. (1999); Chambers (1994)

Reduction of moderate-level hypertension Probable (i.e., demonstrated to correlate with stress) Greater compliance to medications Greater compliance to exercise recommendations Greater compliance to glucose control Decreased medical system use

Friedman et al. (1996) Hall et al. (1994, 1998) Gallacher et al. (1997); al. (2000); Lewin (1997) Linden and

Carney et al. (1995) Dusseldorp et al. (1999); Stetson et al. (1997) Cox and Gonder-Frederik (1992) Allison et al. (1995); Black et al. (1998); Frasure-Smith & Lesperance (1998)

Possible (i.e., mechanistically plausible) Decreased infection/ulcération/ destabilization of plaque by Chlamydia pneumoniae} Decreased need for revascularization secondary to decreased chest pain Decreased treatment-seeking delay Increased heart rate variability

its solution, and implementation o f instrumen-

tolerate "downtime," and substance use are

tal actions designed to bring about resolution,

indicative o f poor emotion-focused coping.

is often highly developed in C H D patients.

It is usually useful to teach some form of

skills,

relaxation to new patients. Acute reductions in

Despite their good problem-solving

C H D patients may display poor discrimination

heart rate and blood pressure, and the subjec-

skills in situations where problem solving is

tive benefits (e.g., calming, reduced

likely to be ineffective. Consequently, they may

reduced chest pain, reduced headache, easier

worry,

manifest an inability to profit from experience

sleep onset) that accompany these exercises,

(e.g., banging their heads against a brick wall)

provide an immediately perceived sense of con-

conse-

trol over previously "uncontrollable" events

quences. Repeated failures may lead to AIAI.

and so reinforce instructions regarding stress

in apparent defiance o f punishing Consequently, feeling trapped in

stressful

circumstances is a common experience. Reliance on problem-focused coping strate-

and C H D . T h e chapter authors use such a procedure prior to all group sessions because it also seems to foster psychological mindedness,

gies often comes at the expense o f good, con-

permitting possible alteration of pathogenic

structive, emotion-focused coping skills. Issues

cognitive attributions. Helping patients to mas-

such as poor self-pacing, inability to relax or

ter abbreviated relaxation methods, such as a

Coronary

Heart

Disease

"cleansing breath," is important in the transfer

patients, while readily labeling others, seem to

of relaxation skills to in vivo stressors.

have lived unexamined lives. This means that

The core goal o f stress management in coro-

the uniqueness (and maladaptiveness) of one's

nary artery disease patients is to reduce the

own personality often is not part of the way in

frequency/intensity/duration

(or "density") o f

which the patient attributes meaning to events.

emotional distress (or "stress"). T h e clinician

Once the clinician has a firm grasp on the

should consider whether the patient's psy-

patient's habitual ways o f thinking/responding,

stressful

it is critical to find a positive (or humorous) or

(i.e., triggers) and should identify one chronic

pragmatic way in which to frame this trait.

stressor (or a few) and use ongoing life events

Thus, an obsessional person can be described

to alter habitual cognitions/behaviors ("cop-

as "thorough" or "careful," or he or she can

chosocial environment is unusually

ing"). An alcoholic spouse, a demanding or

be described as "picky." T h e former will gen-

abusive boss, and kids w h o are abusing drugs

erally be received by the patient as a positive

and sponging off the patient all require a dif-

trait (perhaps carried too far at times), whereas

ferent nexus of the intervention. For example,

the latter will evoke defensiveness. Once rap-

the chapter authors have seen a half dozen

port is established, teasing/humor can be a

cases where getting an angry spouse on an

powerful tool for getting the patient to cast

SSRI resolved a patient's chest pain.

himself or herself in a new light and for diffus-

Frequently recurring stressors that lead to problematic emotions/behaviors

should

be

ing angry or resentful emotional responses. The locus of the problem then is no longer

identified and reviewed at each session to see

"out there" but at least partly "in here." Well-

whether the patient is attempting suggested

written readings (generally full o f stories/cases)

alternatives and whether the alternatives are

on topics such as Type A behavior (Friedman

"working" (i.e., reducing the density o f emo-

&

tional distress). By attacking the largest stres-

Emmons,

Ulmer, 1 9 8 4 ) , assertiveness (Alberti

sors first, the patient is most likely to succeed

1983),

1 9 7 5 ) , panic attacks and

nurturant

&

(Sheehan,

communication

at having a big effect quickly. T h e only excep-

(Gordon, 1 9 7 0 ) can be helpful in getting the

tion to this strategy is when the patient is

patient to think about his or her life, beliefs,

too overwhelmed (fearful) o f attempting an

and behavior. Without such rich biographical

alternative response or when response-specific

examples, the patient tends to restrict his or her

skills deficits are present and require time to

perspective (e.g., " I ' m right, dammit, and that

remediate. For example, the patient might not

S O B is going to admit it") so as to win the

k n o w h o w to behave assertively and/or might

battle while losing the war. T h e clinician who

not be able to appropriately

can bring a rich body of personal, historical, or

discriminate

between assertive and aggressive behaviors.

clinical vignettes to bear will teach the patient

For such a patient, time must be spent review-

more quickly than will the clinician who deals

ing events and teaching and even role-playing

only in abstractions (Friedman, 1 9 7 9 ) .

skills until the patient begins to perceive the

It is important to review weekly/monthly

unavoidability o f facing the "dragon" (usually

stressful events with the patient to ascertain

a boss, parent, child, or spouse) and

has

frequency o f stressors, the cognitive/behavioral

attained adequate skills. If such attempts are

response of the patient, whether a suggested

unsuccessful, consideration should be given

alternative response was tried, and the success/

to involving the dragon in treatment.

failure o f the response as well as to encourage

The clinician should assess and begin to

alteration o f future events. It is common for

("I'm/He's

patients to not recognize that a " n e w " event is

the kind o f person who . . . " ) . M a n y cardiac

in fact the same as, or at least similar to, a

challenge self/other perceptions

294

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS previous pattern. Thus, helping the patient to

acquired or focus narrowly, in a problem-solving

perceive the similarities is necessary before he

manner, on current stressors with which the

or she will experience familiarity and so the

patient is stuck. The therapy should also secon-

opportunity for a new choice. Some patients

darily serve to support and reinforce adherence

are deliberately evasive or seem to be truly

to secondary prevention efforts given that long-

unable to recall examples of stressful interac-

term adherence rates in cardiac rehabilitation

tions from their own lives. Some such patients

are generally poor (Burke, Dunbar-Jacobs, &

will offer relatively trivial or minor events,

Hill, 1 9 9 7 ) . This is an often neglected aspect of

avoiding discussion o f the major stressors. If a

the coaching role. It is critical to recognize,

patient is reluctant/unable to offer examples

accept, and work within the patient's cognitive,

from daily life, the clinician should use clinical

emotional, behavioral, intellectual, fiscal, and

stories or examples from his or her own life to

life structure limitations so as to help him or her

destigmatize/normalize and provide examples

reengineer a healthier lifestyle. One issue in par-

of situations that the clinician thinks are appli-

ticular pertains to helping the patient to distin-

cable to the patient's situation. T h e chapter

guish between a lapse (i.e., momentary slip in

authors have observed many such patients

behavior) and a relapse (return to baseline level

who, despite no discussion of the significant

of the problem behavior). It is not uncommon

stressors in their own lives, nonetheless bene-

for patients to have lapses, and these should be

fited from hearing the counselors' or others'

normalized for the patient. The intent here is to

stories in group sessions. Indirect feedback

circumvent the patient from allowing lapses to

(usually from a spouse) indicates that

the

evolve into relapses (e.g., "Well, I already

patient is attempting to alter his or her habitual

smoked two cigarettes, so I might as well smoke

way o f thinking/coping.

the whole pack").

Optimizing Self-Management: Using a Family Practice Model

Psychopharmacology Behavioral clinicians are often less familiar

The goal of the therapist is generally to make

with the types o f medications used in treating

himself or herself obsolete as soon as possible,

cardiac diseases. Thus, Table 1 5 . 6 provides a

although the idea of a "cure" in any psycho-

list of the classifications o f the most common

therapeutic relationship is untenable

(Hoyt,

medications along with a summary o f the func-

1 9 9 5 ) . The chapter authors find the family

tions associated with each medication type.

practice model (Hoyt, 1 9 9 5 ; Morrill, 1 9 7 8 )

Importantly, patients can develop tolerance to

attractive for the C H D patient. In this light, they

these drugs, rendering them less effective over

find it helpful

time with frequent use.

to think o f themselves as

"coaches" rather than as "doctors" or "thera-

The

advent

o f the newer

antianxiety/

pists" who serve as periodic resources for reality

antidepressive agents (mostly serotonin and

testing and problem solving. Although the initial

noradrenalin reuptake inhibitors but also atypi-

stages of therapy may follow a more traditional

cals such as Buspar and Wellbutrin) has revo-

pathway, the course of treatment is best con-

lutionized psychopharmacotherapy

ceived of as intermittent but longitudinal, with

patients. Although these new agents are no

in C H D

the ultimate treatment goal of assisting the

more effective at treating anxiety/depression

patient in fitting disease self-management into

than are the older agents, the older agents

the unique circumstances o f his or her own life. Treatment episodes evolve into "tune-up" or "booster" sessions that reinforce skills already

(tricyclic or heterocyclic antidepressants) have anticholinergic properties

(e.g., dry

mouth,

blurry vision, orthostatic hypotension)

that

Coronary Table 15.6

Heart Disease

Common Cardiac Medications Listed by Function

Nitrates (e.g., Sublingual nitroglycerin, Nitropatch, Isordil, Sorbitrate, Ismo, Imdur): Drugs that produce vasodilation, used particularly for the relief of angina ACE inhibitors (e.g., Capoten/Vasotec, Monopril, Destril, Prinivil, Altace, Accupril): Vasodilators that are used as antihypertensives Beta blockers (e.g., Inderal, Lopressor, Toprol, Corgard, Sectral): Drugs that serve as beta-division adrenergic blockers, thereby reducing heart rate, blood pressure, and strength of heart contraction used for hypertension and relief of angina Calcium channel blockers (e.g., Cardizem, Dilacor, Procardia, Norvasc, Isoptin): Central and peripheral vasodilators that serve as antihypertensives and anti-ischemics used to treat chest pain, hypertension, and irregular heartbeats Digoxin (e.g., Lanoxin, Digitoxin): Decreases the strength of heart contractions and allows the heart to keep beating regularly; used for arrhythmias Diuretics (e.g., Lasix, Dyazide, Esidrix): Medications to increase urinary output and decrease fluids in the body and cardiovascular system; particularly used in heart failure Anticoagulants (e.g., asprin, Coumadin, Ticlid, Persantine, Plavix, Lovenox, Ecotrin, Heparin): Change the blood's viscosity by acting as blood "thinners" Antilipidemics (e.g., Lipitor, Zocor, Mevacor, Lopid, Lescol, Niacin): Medications that affect blood lipids by reducing low-density lipoprotein (LDL, bad cholesterol) and total cholesterol and by increasing high-density lipoprotein (HDL, good cholesterol) Antiarrhythmics (e.g., Quinidine, Betapace, Amniodarone, Norpace, Rythmol): Help to prevent both atrial and ventricular arrhythmias

make

adherence

problematic.

In

CHD

and variable, the adage "start low, go slow" is

patients, these agents prolong the " Q R S "

advisable. M a n y patients will stop the medica-

interval that is thought to place some patients

tion if no change is observed during the first

at risk for possibly fatal arrhythmias. H o w -

few days unless the importance o f at least a

ever, in the only (nonrandomized) comparison

1-month trial is emphasized repeatedly. With

o f patients on tricyclic antidepressants (TCAs),

some SSRIs (e.g., Paxil, Remeron), there often

death rates were actually lower (Pratt et al.,

is an immediate soporific effect, and these

1996).

should initially be tried at night. Otherwise, the

T h e use o f SSRIs in the treatment o f stress

medications are taken in the morning to avoid

among C H D patients requires thorough initial

interfering with sleep and with food to mini-

instructions, careful monitoring of side effects,

mize gastrointestinal distress (i.e., abdominal

comparatively low dosing, and consideration

cramping or diarrhea). M o s t o f the improve-

of possible drug-drug complications. Doses

ments will "sneak up" on patients over 1 0 days

typically used in this population are at or

to 6 weeks. Indeed, it is common for patients

therapeutic

to say " I don't feel any different" but for

range in psychiatric patients. Thus, 1 0 to 2 0

below the generally recognized

family members and/or coworkers to notice a

milligrams of Celexa or 2 5 to 5 0 milligrams of

change in the patients. Prepping patients about

Zoloft is adequate for perhaps 9 0 % o f this

the subtle effects of these medications can go a

population. Because the delay in onset is slow

long way toward circumventing unrealistic

\

295

296

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS expectations and potential

nonadherence.

SSRI can result in lowered heart rate and

Tracking a symptom (e.g., chest pain, fatigue,

blood

sleep onset delay, nocturnal awakening) in an

complain o f worsened fatigue or tiredness,

empirical fashion c a n help to

document

pressure.

Clinically, patients

will

dizziness, or light-headedness. Because o f the

improvements. Patients may be inclined to

effects on the liver, hepatic

attribute improvements to other factors. It is

times result from use of an SSRI. This is most

critical that clinicians indicate their belief that

c o m m o n in patients with prior liver injury

the medication is probably the cause.

strain will some-

(e.g., history of alcohol abuse or hepatitis) or

C o m m o n side effects within 2 4 to 4 8 hours

in patients receiving other hepatically difficult

of starting therapy include diarrhea/ abdomi-

medications (e.g., lipid-lowering agents). In

nal cramping (about 1 0 % of patients). Half o f

severe enough cases, weakness, nausea, and

those

loss o f appetite will indicate low-level hepatic

experiencing

diarrhea/abdominal

cramping are only mildly affected, and it

failure and should result in immediate cessa-

should resolve within 1 0 days. T h e remainder

tion o f the drug until liver function tests can be

must be tried on other agents. Headache

obtained. Some SSRIs may be less likely to

occurs in about 3 % o f patients and generally

have this effect.

resolves within 1 0 days. In addition, intense

M a n y patients will resist referral to a psy-

anxiety occurs in about 1 % o f patients. Over

chiatrist but will accept these agents from a

several weeks, about one quarter of patients

cardiologist or a primary care physician. If one

develop loss of libido or erectile problems.

is attempting a first trial, working with the car-

Alternative agents, or referral to a psychiatrist

diologist/primary care physician may be ade-

for additional agents, should be considered.

quate. But if special circumstances occur (e.g.,

Some weight gain (7 to 1 0 pounds) may occur.

nonresponse, intolerance o f two agents, multi-

T h e chapter authors have observed several

ple or problematic side effects such as sexual

adverse effects of SSRIs that are unique to this

dysfunction,

need for larger doses, recent

population. Some patients, usually with a

history o f substance abuse, propensity for som-

history of prior atrial fibrillation, may develop

atization), referral to a psychiatrist should

worsened

atrial fibrillation on SSRIs. T h e

become a goal of psychological treatment.

authors believe that consultation with a psy-

Another option may be to use the herbal St.

chiatrist is necessary to select a safe and effec-

John's wort, which is widely used in Europe

tive agent (e.g., Buspar, Wellbutrin). Likewise,

for the treatment of depression. Several dozen

because o f the effect

on

randomized clinical trials on St. John's wort

cytochrome P 4 5 0 metabolic pathways in the

have demonstrated an effectiveness equivalent

liver, some drugs will be removed from the

to that of T C A s (and therefore presumably

bloodstream more slowly, thereby raising

SSRIs) but with fewer side effects than T C A s

bioavailability.

o f some SSRIs

Management

can

include

(Linde &

Mulrow, 1 9 9 9 ) , although

other

reduced dosing of the affected agent or use o f

reports have called these data into question.

another SSRI that is less likely to have this

Preparations by reputable manufacturers (e.g.,

effect. Celexa and Zoloft are minimally likely

Centrum, Quanterra) should be used because

to interfere with other medications and so are

smaller sources have not carefully standardized

generally first-choice agents. Among the med-

source or dose given that these supplements are

ications potentially affected in cardiac patients

not regulated by the U.S. Food and Drug

are digoxin and beta blockers. Digoxin

toxic-

Administration. Because St. John's wort is not

ity can result in confusion/cognitive impair-

viewed as "artificial" or a "psychiatric medica-

ment, loss o f appetite, and a resting tremor.

tion," patients will sometimes try it (or even

by use o f an

insist on it) rather than the better understood

Potentiation

of beta

blockers

Coronary

Heart

Disease

CASE S T U D Y T h e case o f "Harriet R . " is a useful one that illustrates many o f the psychological aspects of C H D . Harriet was a 46-year-old, white, married mother of three children who was referred for stress management by her cardiologist after she had experienced an M I 6 months earlier. N o risk factors were detected other than her constant stress. Harriet lived with constant tension over avoiding confronting her sometimes outspoken and opinionated husband. O n e o f the early examples o f tension was that her husband frequently "forgot" to do things he was supposed to do, and Harriet was resentful that she had to remind her husband to do things and was often criticized by him for her constant reminding (which he described as "nagging"). F o r example, she reported that she always had to remind him to take his hymnal to choir practice. N o t only did she feel angry over always having to remind him, but she frequently experienced chest pain when thinking about these interactions. Harriet's husband seemed quite concerned but was not able to empathize with her. Rather, he t o o would get angry when she reminded him to do things. Following suggestions from the therapist, Harriet agreed to "deliberately not remind" her husband for a week. H e "spontaneously" began remembering things himself, and it became apparent to Harriet that her worry/resentment was totally wasted energy. N o t only did it seem that she did not need to remind her husband so often, but the number o f negative interactions that the couple experienced went down and the frequency with which Harriet experienced angina was greatly reduced. At this point, discussions with Harriet's therapist shifted her concerns to the belief that her daughter might be gay and that her husband would ban the daughter from the family if he found out. Like her experiences with "reminding her husband," whenever she began to worry about her daughter's sexual orientation, Harriet experienced frequent angina. After reviewing why Harriet thought her daughter was gay, the therapist agreed that it was likely and encouraged her to discuss this with her daughter. Pointing out that Harriet had previously sold her husband short, the therapist coached the patient on h o w to approach the topic with her husband. H e responded with surprise and disappointment, but after pondering the possibility for a few days, he stated that he would still love her and want her in the family. These experiences helped Harriet learn that much o f her concern and worry were generated by her own expectations and that her perceived negative outcomes were not always as predictable as she had once believed. Over the course o f treatment, Harriet became better at recognizing the role o f her beliefs and expectations in her stress levels, and she was able to greatly reduce the frequency with which she became angry at others. This resulted in remarkable reductions in the frequency and severity o f her angina. Harriet reported to her therapist that when she would begin to feel any anger, she could quickly assess the potential "validity" o f what was making her angry, and most o f the time the anger went away immediately when she realized that the situation was not as negative as she had initially thought.

297

298

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS and tested SSRIs. Importantly, St. John's wort

all stripes, have played a significant role in

is known to decrease digoxin levels by about

moving this scientific literature forward. M o r e

2 5 % to 3 3 % .

recent trends have allowed for practitioners to

T h e chapter authors have not yet found it

play more central roles in clinical settings such

necessary to refer a patient for electroconvul-

as Phase II cardiac rehabilitation and consulta-

sive therapy ( E C T ) . But if a patient presents

tion services targeting cardiology patients.

an otherwise intractable depression, special

These trends are likely to continue, thereby

considerations are necessary. Heart failure,

allowing greater and more varied practice

aneurysm, and arrythmias

are considered

contraindications to E C T .

opportunities

with this patient

population.

This chapter has attempted to provide an experienced and practical set o f recommendations for working clinically with the C H D patient.

SUMMARY AND CONCLUSIONS

There is a continued need for more practicebased writing in this arena that combines evi-

There is mounting evidence that psychological

dence-based literature with clinical experience.

and behavioral factors play an independent and

In addition, novel methods o f integration into

critical role in the development, maintenance,

service delivery behavioral interventions must

and exacerbation o f C H D . T h e clinical behav-

be explored for all manner o f secondary pre-

ioral sciences, including health psychologists of

vention targets (Trask et al., 2 0 0 2 ) .

REFERENCES Alberti, R. E., & Emmons, M. L. (1975). Stand up, speak out, talk back! New York: Pocket Books. Allen, R., & Scheldt, S. (1996). Empirical basis of cardiac psychology. In R. Allen & S. Scheldt (Eds.), Heart and mind: The practice of cardiac psychology (pp. 6 3 - 1 2 3 ) . Washington, DC: American Psychological Association. Allison, T. G., Williams, D. E., Miller, T. D., Patten, C. Α., Bailey, K. R., Squires, R. W., & Gau, G. T. (1995). Medical and economic costs of psychologic distress in patients with coronary artery disease. Mayo Clinic Proceedings, 70, 7 3 4 - 7 4 2 . American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Barrios, B. (1988). On the changing nature of behavioral assessment. In M. Hersen &c A. S. Bellack (Eds.), Behavioral assessment: A practical handbook (pp. 3 - 4 1 ) . New York: Pergamon. Barsky, A. J . (2001). Palpitations, arrhythmias, and awareness of cardiac activity. Annals of Internal Medicine, 134, 8 3 2 - 8 3 7 . Barsky, A. J . , Cleary, P. D., Barnett, M . C , Christiansen, C. L., & Ruskin, J . N. (1994). The accuracy of symptom reporting by patients complaining of palpitations. American journal of Medicine, 97, 2 1 4 - 2 2 1 . Black, J . L., Allison, T. G., Williams, D. E., Rummans, Τ. Α., & Gau, G. T. (1998). Effect of intervention for psychological distress on rehospitalization rates in 39, 1 3 4 - 1 4 3 . cardiac rehabilitation patients. Psychosomatics, Blumenthal, J . Α., Jiang, W., Babyak, Μ. Α., Krantz, D. S., Frid, D. J . , Coleman, R. E., Waugh, R., Hanson, M., Appelbaum, M., O'Connor, C , & Morris, J . J . (1997). Stress management and exercise training in cardiac patients with myocardial ischemia. Archives of Internal Medicine, 157, 2 2 1 3 - 2 2 2 3 .

Coronary

Heart

Booth-Kewley, S., & Friedman, H. S. (1987). Psychological predictors of heart disease: A quantitative review. Psychological Bulletin, 101, 3 4 3 - 3 6 2 . Burke, L. E., Dunbar-Jacobs, J . M., & Hill, M . N. (1997). Compliance with cardiovascular disease prevention strategies: A review of the research. Annals of Behavioral Medicine, 19, 2 3 9 - 2 6 3 . Carney, R. M., Freedland, K. E., Eisen, S. Α., Rich, M. W., & Jaffe, A. S. (1995). Major depression and medication adherence in elderly patients with coronary artery disease. Health Psychology, 14, 8 8 - 9 0 . Cassem, N. H., & Hackett, T. P. (1973). Psychological rehabilitation of myocardial infarction patients in the acute phase. Heart & Lung, 2, 3 8 2 - 3 8 8 . Cox, D., & Gonder-Frederik, L. (1992). Major developments in behavioral diabetes research. Journal of Consulting and Clinical Psychology, 60, 6 2 8 - 6 3 8 . Dahlof, P., Ejnell, H., Hallstrom, T., & Hdner, J . (2000). Surgical treatment of the sleep apnea syndrome reduces associated major depression. International Journal of Behavioral Medicine, 7, 7 3 - 8 8 . Davidson, K. W. (2000). Dose-response relations between hostility reductions and cardiac-related hospitalizations. Psychosomatic Medicine, 62, 149 (Abstract 1430). Dusseldorp, E., van Elderen, T., Maes, S., Meulman, J . , & Kraaij, V. (1999). A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychology, 18, 5 0 6 - 5 1 9 . Edwards, Ν. B., Murphy, J . K., Downs, A. D., Ackerman, B. J . , & Rosenthal, T. L. (1989). Doxepin as an adjunct to smoking cessation: A double-blind pilot study. American Journal of Psychiatry, 146, 3 7 3 - 3 7 6 . Farmer, J . Α., & Gotto, A. M. (1997). Dyslipidemia and other risk factors for coronary artery disease. In E. Braunwald (Ed.), Heart disease: A textbook of cardiovascular medicine. Philadelphia: W. B . Saunders. Frasure-Smith, N., & Lesperance, F. (1998). Depression and anxiety increase physician costs during the first post-MI year. Psychosomatic Medicine, 60, 9 9 . Frasure-Smith, N., Lesperance, F., 8c Talajic, M. (1993). Depression following 270, myocardial infarction. Journal of the American Medical Association, 1819-1825. Friedman, M. (1979). Qualities of therapist required for successful modification of coronary-prone (Type A) behavior. Psychiatric Clinics of North America, 2, 243-248. Friedman, M., Breall, W. S., Goodwin, M . L., Sparagon, B. J . , Ghandour, G., & Fleischman, N. (1996). Effect of Type A behavioral counseling on frequency of episodes of silent myocardial ischemia in coronary patients. American Heart Journal, 132, 3 3 3 - 3 3 7 . Friedman, M., Powell, L. H., Thoreson, C. E., Ulmer, D., Price, V., Gill, J . J . , Thompson, L., Rabin, D. D., Brown, B . , Breall, W. S., Levy, R., & Bourg, Ε. (1987). Effect of discontinuance of Type A behavioral counseling on Type A behavior and cardiac recurrence rate of post myocardial infarction patients. American Heart Journal, 114, 4 8 3 - 4 9 0 . Friedman, M., & Rosenman, R. H. (1974). Type A behavior and your heart. New York: Alfred A. Knopf. Friedman, M., Thoreson, C. E., Gill, J . J . , Ulmer, D., Powell, L. H., Price, V. Α., Brown, B . , Thompson, L., Rabin, D. D., Breall, W.S., Bourg, Ε., Levy, R., & Dixon, T. (1986). Alteration of Type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: Summary results of the Recurrent Coronary Prevention Project. American Heart Journal, 112, 6 5 3 - 6 6 5 . Friedman, M., & Ulmer, D. (1984). Treating Type A behavior and your heart. New York: Alfred A. Knopf. Gallacher, J . E. J . , Hopkinson, C. Α., Bennett, P., Burr, M. L., & Elwood, P. C. (1997). Effect of stress management on angina. Psychology & Health, 12, 5 2 3 - 5 3 2 .

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positive angiograms: Importance of "denial" in assessing psychosocial risk factors. Journal of Psychosomatic Research, 44, 2 4 1 - 2 5 0 . Ketterer, M . W., Kenyon, L., Foley, Β. Α., Brymer, J . , Rhoads, K., Kraft, P., 8c Lovallo, W. R. (1996). Denial of depression as an independent correlate of coronary artery disease. Journal of Health Psychology, 1, 9 3 - 1 0 5 . Ketterer, M . W., Pickering, E., Stoever, W. W., 8c Wansley, R. A. (1987). Smoking prevention, cessation, and maintenance: A review for the primary care physician. Journal of the American Osteopathic Association, 87, 2 4 8 - 2 5 7 . Krantz, D. S., Hedges, S. M., Gabbay, F. H., Klein, J . , Falconer, J . J . , Merz, C. N., Gottdiener, J . S., Lutz, H., & Rozanski, A. (1994). Triggers of angina and st-segment depression in ambulatory patients with coronary artery disease: Evidence for an uncoupling of angina and ischemia. American Heart Journal, 128, 7 0 3 - 7 1 2 . Kubzansky, L. D., Kawachi, I., Weiss, S. T., 8c Sparrow, D. (1998). Anxiety and coronary heart disease: A synthesis of epidemiological, psychological, and experimental evidence. Annals of Behavioral Medicine, 20, 4 7 - 5 8 . Lazarus, R. S., 8c Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lessmeier, T. J . , Gamperling, D., Johnson-Liddon, V., Fromm, B. S., Steinman, R. T., Meissner, M . D., 8c Lehmann, M . H. (1997). Unrecognized paroxysmal supraventricular tachycardia: Potential for misdiagnosis of panic disorder. Archives of Internal Medicine, 157, 5 3 7 - 5 4 3 . Lewin, B. (1997). The psychological and behavioral management of angina. Journal of Psychosomatic Research, 43, 4 5 3 - 4 6 2 . Linde, K., 8c Mulrow, C. D. (1999). St. John's wort is more effective than placebo for treating depressive disorders. ACP Journal Club, 130, 6 0 - 8 0 . Linden, W., 8c Chambers, L. (1994). Clinical effectiveness of nondrug treatment of hypertension: A meta-analysis. Annals of Behavioral Medicine, 16, 3 5 - 4 5 . Markovitz, J . H. (1998). Hostility is associated with increased platelet activation in Medicine, 60, 5 8 6 - 5 9 1 . coronary heart disease. Psychosomatic Morrill, R. G. (1978). The future of mental health in primary health care programs. American Journal of Psychiatry, 135, 1 3 5 1 - 1 3 5 5 . Murphy, J . K., Edwards, Ν. B., Downs, A. D., Ackerman, B. J . , Sc Rosenthal, T. L. (1990). Effects of doxepin on withdrawal symptoms in smoking cessation. American Journal of Psychiatry, 147, 1 3 5 3 - 1 3 5 7 . Polk, D. E., Kamarck, T. W., 8c Shiffman, S. (2002). Hostility explains some of the discrepancy between daytime ambulatory and clinic blood pressure. Health Psychology, 21, 2 0 2 - 2 0 6 . Pratt, L. Α., Ford, D. E., Crum, R. M., Armenian, H. K., Gallo, J . J . , Sc Eaton, W. W. (1996). Depression, psychotropic medication, and risk of myocardial infarction: Prospective data from the Baltimore ECA follow-up. Circulation, 94, 3 1 2 3 - 3 1 2 9 . Richter, J . E. (1992). Overview of diagnostic testing for chest pain of unknown origin. Medical Clinics of North America, 92(Suppl. 5A), S 4 1 - S 4 5 . Ridker, P. M., Hennekens, C. H., Buring, J . E., Sc Rifai, N. (2000). C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. New England Journal of Medicine, 342, 8 3 6 - 8 4 3 . Ross, R. (1999). Atherosclerosis: An inflammatory disease. New England Journal of Medicine, 340, 1 1 5 - 1 2 6 . Rozanski, Α., Blumenthal, J . Α., Sc Kaplan, J . (1999). Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation, 99, 2 1 9 2 - 2 2 1 7 . Schwartz, S. M., Gramling, S. E., Sc Mancini, T. (1994). The influence of life stress, personality, and learning history on illness behavior. Journal of Behavior Therapy and Experimental Psychiatry, 25, 1 3 5 - 1 4 2 .

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BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Schwartz, S. M., Lipman, H., Glasburg, D., Pagano, C , Jones, D., Deaner, S. L., & Lehmann, M. H. (2002). Gender differences in symptom reporting in patients Medicine, 64, 1 3 5 . with palpitations. Psychosomatic Schwartz, S. M., Trask, P. C , & Ketterer, M. W. (1999). Understanding chest pain: What every psychologist should know. Journal of Clinical Psychology in Medical Settings, 6, 3 3 3 - 3 5 1 . Sears, S. F., Todaro, J . F., Lewis, T. S., Sotile, W., & Conti, J . B. (1999). Examining the psychosocial impact of implantable cardioverter defibrillators: A literature review. Clinical Cardiology, 22, 4 8 1 - 4 8 9 . Sheehan, D. V. (1983). The anxiety disease. New York: Scribner. Stetson, Β. Α., Rahn, J . M., Dubbert, P. M., Wilner, B. L, & Mecury, M. G. (1997). Prospective evaluation of the effects of stress on exercise adherence in community-residing women. Health Psychology, 16, 5 1 5 - 5 2 0 . Trask, P. C , Schwartz, S. M., Deaner, S. L., Paterson, A. G., Johnson, T., Rubenfire, M., & Pomerleau, O. P. (2002). Behavioral medicine: The challenge of integrating psychological and behavioral approaches into primary care. Effective Clinical Practice, 5(2), 7 5 - 8 3 .

CHAPTER

10 16

Behavioral Management of Type 2 Diabetes AHNA L . HOFF, JANELLE L . WAGNER, LARRY L . MULLINS, AND JOHN M . CHANEY

T

ype 2 diabetes (DM2)

is a chronic

(Anderson, Freeland, Clouse, &

Lustman,

illness characterized by a dysregulation

2001).

of glucose metabolism secondary to

impact o f diabetes is staggering; in 1997,

O n a more global scale, the economic the

an imbalance between insulin sensitivity and

direct and indirect costs associated with dia-

insulin secretion. An estimated 11 million

betes in the United States were an estimated

people in the United States were diagnosed

$98 billion (Ray, Thamer, Gardner, &c Chan,

1998).

2000 (Boyle approximately 90% o f

et al., those

betes in the United States represents a critical

individuals were diagnosed with DM2.

The

public health problem with respect to health

number o f individuals diagnosed with

DM2

care use and resources.

with diabetes in the year

2001),

and

has been rising at an alarming rate over the past several decades (Harris,

1998).

Thus, the increasing prevalence of dia-

Fortunately, DM2

is medically manage-

It has

able, and many o f the serious medical compli-

been estimated that this figure will increase by

cations that are associated with the illness are

165% to 29 million by the

preventable

year

2050, reflect-

through

adequate

control o f

ing a 7.2% prevalence rate. Such an increase

blood glucose levels. Therefore, the primary

is hypothesized to be the result o f changes in

treatment goal for individuals with DM2 is to

demographic composition o f the population,

maintain blood glucose levels within a normal

population growth, and increasing prevalence

range. This requires individuals with diabetes

2001).

rates (Boyle et al.,

to consistently maintain a complicated, life-

Personal and public health consequences

long treatment regimen with few immediate

For

tangible rewards for their efforts. For many,

example, individuals with diabetes experience

maintaining this complex treatment regimen is

associated with

DM2

are profound.

of health complications

difficult, and assistance with disease manage-

(Harris, 1998) and are at higher risk for depres-

ment is often warranted. As such, researchers

sion than are their medically well counterparts

and the medical community have recognized

a greater number

303

304

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS the critical role o f behavioral sciences in optimizing regimen adherence

and

health

ability to produce sufficient amounts o f insulin and so can no longer maintain euglycemia, that

outcomes among patients with D M 2 (Glasgow

is, near-normal

glucose levels (DeFronzo,

et al., 1 9 9 9 ; Wysocki & Buckloh, 2 0 0 2 ) .

Bonadonna, & Ferrannini, 1 9 9 2 ) .

T h e purpose o f this chapter is to review the psychosocial aspects and behavioral management o f D M 2 . First, information

regarding

the nature o f the illness, including etiology and

Short-Term Complications Hypoglycemia and hyperglycemia are two

complications, is reviewed. Then, psychologi-

short-term

cal factors and symptomatology commonly

DM2.

associated with D M 2 are presented. N e x t , the

glucose declines to less than 6 0 milligrams per

complications that result

Hypoglycemia occurs when

from blood

assessment and treatment o f the medical and

deciliter (mg/dl). Symptoms include shakiness,

psychological aspects o f D M 2 are discussed,

perspiration, rapid heartbeat, hunger,

including a review of psychosocial interven-

ache, mood changes, confusion, and attentional

head-

tions focused on improving global adjustment

difficulties. If hypoglycemia is left untreated,

to diabetes. It should be noted that there are

seizures or loss o f consciousness may eventually

a number o f studies reviewed here that used

occur. Conversely, hyperglycemia is defined as

combined samples of individuals with type 1

a blood glucose level greater than 1 4 0 mg/dl.

and type 2 diabetes. Where possible, informa-

Symptoms include increased thirst,

frequent

tion specific to D M 2 is presented and indi-

urination, and glucose in the urine. T h e major-

cated as such.

ity of long-term complications associated with D M 2 are the result of recurrent hyperglycemia (American Diabetes Association [ADA], 1 9 9 8 ) .

BACKGROUND AND ETIOLOGY There are two primary types o f diabetes: type

Long-Term Complications

1 and type 2 . Type 1 diabetes (often referred to

Long-term complications can be classified

in the past as juvenile diabetes or insulin-

into two types: macrovascular and microvas-

dependent diabetes mellitus) occurs when the

cular. Macrovascular diseases include heart

islet cells o f the pancreas are destroyed and

disease, stroke, and

cannot produce insulin. Consequently, exoge-

orders. T h e leading cause o f diabetes-related

nous insulin is required for survival. In con-

deaths is heart disease. Adults with diabetes

trast,

DM2

is characterized

by

other circulatory dis-

chronic

are two to four times more likely to die from

hyperglycemia due to impaired insulin secre-

heart disease than are adults without diabetes

tion and increased insulin resistance in the

(National Institute o f Diabetes and Digestive

body's cells. Insulin resistance refers to a defect

and

Kidney

Diseases

[NIDDK],

2000).

in glucose transport and metabolism. As a

Individuals with D M 2 are also at two to four

result, glucose does not enter the body's cells

times greater risk for stroke than are their

where it can be used as fuel, and subsequently,

medically well counterparts.

a higher level o f glucose remains in the blood-

approximately 73% o f adults with diabetes

stream. Early in the course o f D M 2 , the pan-

have circulatory disorders (e.g., high blood

creas attempts to counteract the high levels o f

pressure), many o f which require prescription

blood glucose by producing increased amounts

medications for hypertension ( N I D D K , 2 0 0 0 ) .

of insulin. However, because of the sustained

Microvascular

Furthermore,

complications

constitute

need for high amounts o f insulin over long

some

periods o f time, the pancreas gradually loses its

tions associated with D M 2 . Microvascular

of the

most

debilitating

complica-

Type 2 Diabetes

\

complications include retinopathy, nephropathy,

DM2

and neuropathy. Diabetic retinopathy is caused

1 9 9 8 ) . Furthermore, women who experience

than do other ethnic groups (Harris,

by changes in the tiny vessels that supply the

gestational diabetes during one or more o f their

retina with blood. It is the leading cause o f

pregnancies are at greater risk for developing

visual impairment among adults ages 2 0 to 7 4

D M 2 later in life than are women who do not

years, resulting in an estimated 1 2 , 0 0 0

to

(NIDDK, 2 0 0 0 ) . Finally, those with a family

2 4 , 0 0 0 new cases o f blindness in the United

history of diabetes are also at heightened risk.

States each year (NIDDK, 2 0 0 0 ) .

Nephro-

Indeed, first-degree relatives of individuals with

pathy, another microvascular complication

early-onset D M 2 are 4 0 % more likely to

associated with diabetes, is the result o f damage

develop diabetes than are individuals with no

to the blood vessels of the kidneys. In severe

family history o f the disease (Owen, Ayers,

cases, it can result in kidney failure, a condition

Corbett, & Hattersley, 2 0 0 2 ) . Thus, there are a

referred to as end stage renal disease (ESRD).

number o f demographic factors that are associ-

E S R D can be a life-threatening complication,

ated with a heightened risk for D M 2 .

and individuals who experience kidney failure must undergo dialysis or a kidney transplant.

Obesity.

T h e previously mentioned risk

The relationship between diabetes and E S R D is

factors can be mitigated by the most critical and

clear; diabetes accounts for 4 3 % o f new cases

modifiable risk factor for D M 2 , that is, obesity.

of E S R D (NIDDK, 2 0 0 0 ) .

It is estimated that up to 7 5 % o f the risk for

Neuropathy (neuronal disease) is a com-

D M 2 is directly attributable to obesity (Manson

m o n microvascular complication affecting

& Spelsberg, 1 9 9 4 ) . For example, Fullier and

approximately 6 0 % to 7 0 % o f individuals

Pedula (2001) demonstrated an inverse linear

with mild to severe forms o f nervous system

relationship between the Body Mass Index

damage ( N I D D K , 2 0 0 0 ) . Characteristic symp-

(weight in kilograms divided by height in

toms include pain, numbing, burning, loss o f

squared meters) and age at diagnosis o f D M 2 .

feeling, and (in more severe cases) paralysis in

In other words, those who are more overweight

the extremities. Neuropathy may also cause

are more likely to be diagnosed with D M 2 at a

digestive problems, impotence, and inconti-

younger age. Although the mechanisms respon-

nence. Severe forms o f nerve damage are a

sible for the relationship between weight and

major cause o f lower extremity amputations.

D M 2 are not entirely clear, recent evidence suggests that body weight is associated with insulin resistance and subsequently glycémie control

Etiological Risk Factors

(Maggio &c Pi-Sunyer, 1 9 9 7 ) . Consequently, the A

majority of D M 2 prevention and intervention

number o f demographic and genetic factors are

programs target weight loss (for a review, see

associated with D M 2 , including age, race, prior

Wing et al., 2 0 0 1 ) . Such weight loss efforts have

history of gestational diabetes, family history of

been shown to be effective in preventing the

diabetes, and obesity. In terms o f age, those

onset of D M 2 (Diabetes Prevention Program

over age 4 5 years are at the highest risk for

Research Group [DPPRG], 2 0 0 2 ) . A primary

developing D M 2 , and approximately 2 0 % of

challenge for behavioral researchers and those at

individuals over age 6 5 years have diabetes

risk for diabetes is to determine effective meth-

Demographic

and

Genetic

Factors.

(NIDDK, 2 0 0 0 ) . Similarly, differential rates of

ods to maintain long-term weight loss given that

D M 2 are found among various ethnic groups.

it is well known that maintenance of weight loss

For

Native

is difficult to achieve (Wing et al., 2 0 0 1 ). In sum-

Americans, and Hispanic/Latino Americans

mary, the most influential risk factor for D M 2 is

have demonstrably higher prevalence rates for

also potentially the most modifiable.

example, African

Americans,

305

306

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS correlates o f sexual dysfunction and visual

PSYCHOLOGICAL

impairment. Sexual dysfunction is a prevalent

FACTORS AND TYPE 2 DIABETES

problem among men with diabetes; approxiIndividuals with D M 2 constitute a population

mately 5 0 % of men with diabetes experience

at risk for experiencing both illness-related and

impotence. Although the prevalence of sexual

general distress. M a n y individuals experience

dysfunction is not known for women, one

subclinical adjustment problems directly related

study

to living with diabetes, including

distress

reported significantly lower levels of sexual

associated with the onset o f diabetes, diabetes

desire or orgasmic capacity, lubrication, and

reported

that

women

with

DM2

complications, and the treatment regimen. Still

sexual satisfaction in their relationships than

others experience clinically significant levels o f

did nondiabetic control participants (Schreiner-

psychological distress, including depression and

Engel, Schiavi, Vietorisz, & Smith, 1 9 8 7 ) . T o

anxiety. This section reviews both diabetes-

date, little research has specifically examined

specific distress, as outlined by Rubin

the treatment o f impotence among those with

and

Peyrot ( 2 0 0 1 ) , and more general distress, such

diabetes

as depression and anxiety.

1 9 8 6 ) . As such, it has been recommended that

(McCulloch, Hosking, &

Tobert,

treatment for impotence proceed in accordance with the standards established for medically

Distress Related to Diabetes Onset T h e diagnosis o f diabetes represents

well individuals (Rubin & Peyrot, 2 0 0 1 ) . a

period o f crisis for many. Unfortunately, few

Visual impairment due to diabetic retinopathy is another complication that

appears

empirical studies have examined levels o f dis-

to have profound psychological consequences

tress immediately following diagnosis of D M 2

for the patient. Individuals diagnosed

among adults. However, increased levels of

progressive

diabetic

retinopathy

with

(PDR)

distress immediately following diagnosis is

reported a greater number o f negative life

common among children diagnosed with type

experiences and psychiatric distress during the

1 diabetes. For most, this distress then dissi-

2 years following diagnosis with P D R (Wulsin

pates over the first year following diagnosis

&

(Kovacs, Brent, Steinberg, Paulauskas, & Reid,

R a n d , 1 9 8 7 ) . Distress related to P D R appears

1 9 8 6 ) . Thus, Rubin and Peyrot ( 1 9 9 4 ) recom-

to be independent o f the severity o f vision loss

mended regular monitoring o f patients' distress

and

levels following diagnosis. Individuals experi-

restored (Wulsin 6c Jacobson, 1 9 8 9 ; Wulsin et

encing clinically significant distress should be

al., 1 9 8 7 ) . Moreover, individuals who experi-

referred for intervention as a means of mini-

enced fluctuating levels of visual impairment

mizing the impact on diabetes management.

experienced more distress than did those with

J a c o b s o n , 1 9 8 9 ; Wulsin, J a c o b s o n ,

remains elevated even after vision is

more stable and severe visual

Distress Related to Medical Complications T h e onset of medical complications can trigger a crisis for many individuals, and health

&

(Bernbaum,

Alpert,

&

impairment

Duckro,

1988).

C o m m o n feelings related to vision loss include failure, uncertainty, and fear. Nevertheless, few

studies

to address onset

have e x a m i n e d

interventions

the emotional consequences of

care providers should not underestimate the

PDR

potential emotional impact of new complica-

Therefore, it is recommended that clinicians

(Bernbaum

et

al.,

1988).

tions. However, research examining the impact

regularly assess psychological distress, espe-

of specific diabetes complications is quite lim-

cially among patients w h o have been diag-

ited and has primarily examined psychological

nosed with P D R .

Type 2 Diabetes Little

is

currently

known

about

psychological sequelae o f other

\

the

Wensloff, Gronsman, & Jaber, 1 9 8 9 ) , other

diabetes-

studies have not (Griffith, Field, & Lustman,

specific complications. However, it has been

1 9 9 0 ) . T h e equivocal findings are likely due

demonstrated that the more complications a

in part to the wide variety o f methodologies

person experiences, the more likely he or she is

employed, including types o f stressors targeted,

to manifest psychological distress (Trief, Grant,

durations o f the stressors, measures of subjec-

Elbert, & Weinstock, 1 9 9 8 ) . Thus, health care

tive stress, interval between the stressors and

professionals should remain cognizant o f the

the blood glucose tests, and baseline blood

psychological consequences of new or accruing

glucose levels. Obviously, the

diabetes complications for their patients.

between stress and blood glucose is a complex

relationship

one that involves multiple variables, including cognitive and physiological factors.

Psychosocial Stress

Indirectly, stress is thought to adversely

Stress, often conceptualized as the interac-

influence metabolic control through changes

individual's

in self-management behaviors. T h e ability to

response to that event, is one o f the most

maintain the demands o f a c o m p l e x treat-

widely studied psychosocial factors associated

ment regimen may be compromised by the

tion between an event and an

with D M 2 (Goetsch & Wiebe, 1 9 9 5 ) . It has

demands o f daily life (e.g., eating fast food

been hypothesized that stress affects metabolic

instead o f taking the time to prepare a proper

control both directly and indirectly (Peyrot &

meal, skipping regular exercise to catch up

M c M u r r y , 1 9 8 5 ) . First, stress is believed to

on work) (Marlatt & G o r d o n , 1 9 8 5 ) . Future

through

research studies are needed to identify psy-

physiological mechanisms. Theoretically, stress

chological and physiological markers o f indi-

triggers the natural physiological responses

viduals w h o are m o r e susceptible to stress

("fight or flight" response), resulting in the

and to shed light on appropriate interven-

release of counterregulatory hormones. T h e

tions. Interventions that directly target stress,

directly affect

metabolic control

release o f these hormones triggers an increase

such as relaxation training and stress manage-

in sympathetic activity to the pancreas, thereby

ment, are discussed later in the chapter.

inhibiting insulin and stimulating the release o f glucagons (Goetsch &

Wiebe,

1995).

Glucagon then stimulates the liver to convert glycogen to glucose and release hepatic glucose

Depression Empirical research indicates that depression

stores into the bloodstream. As a result, there

is quite prevalent among individuals

with

can be increases in blood glucose levels inde-

diabetes. Meta-analytic data indicate

that

pendent

approximately 3 1 % o f individuals with dia-

of

consistent

diabetic

regimen

adherence. A number o f animal models have

betes report clinically elevated

supported the link between acute stressors and

symptoms. Furthermore, the accrued lifetime

metabolic control (Kuhn, Cochrane, Feinglos,

prevalence of major depression among individ-

& Surwit, 1 9 8 7 ; Surwit, Feinglos, Livingston,

uals with diabetes is estimated to be 2 8 . 5 %

depressive

Kuhn, & M c C u b b i n , 1 9 8 4 ; Surwit et a l ,

(Anderson et al., 2 0 0 1 ) .

1 9 8 6 ) . However, generalization of these results

Zheng, and Simpson ( 2 0 0 2 ) found that indi-

Similarly, Egede,

to humans has been difficult. Although some

viduals with diabetes (type 1 or type 2 ) , when

studies have reported significant associations

compared with a healthy control group, are

between life stress and hemoglobin A

twice as likely to be diagnosed with depression.

independent adults

with

l c

of regimen adherence diabetes

(Demmers,

(HbA ) lc

among

Depressive episodes also tend to occur more

Neale,

frequently and last longer among individuals

307

308

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS with D M 2 than among those without D M 2 (Lustman,

Clouse,

Alrakawi,

Rubin,

et al., 1997]). In fact, the prevalence of depressive

&

symptoms among those with diabetes argues

Gelenberg, 1 9 9 7 ) . Finally, consistent with the

for the routine integration o f screening for

general population, the prevalence o f depres-

mood

sion is greater among women with diabetes

providers into their patients' treatment plans

disorders

by primary

health

care

than among men with diabetes (Anderson

as a means o f improving their patients' psy-

etal., 2001).

chological and physical health.

The

demonstrated

association between

depression and diabetes provides the most striking example of the interwoven relationship between psychological functioning and diabetes outcome. Depression is strongly asso-

Anxiety As with depression, rates o f anxiety are significantly higher a m o n g individuals

with

ciated with metabolic control among individu-

diabetes than among the general population.

als with D M 2 (Lustman et al., 2 0 0 0 ) . In their

In fact, rates o f clinically significant anxiety

meta-analysis, Lustman and colleagues ( 2 0 0 0 )

among those with diabetes may be as high as

found that depression accounted for approxi-

4 9 % (Peyrot & Rubin, 1 9 9 7 ) . Gender, age,

mately 3 % o f the variance in glycated hemo-

and education were variables that predicted

globin, a salient finding given that a

greater anxiety symptoms (Peyrot & Rubin,

1%

decrease in glycated hemoglobin results in a

1997).

33%

between ages 4 0 and 4 9 years, and individuals

decrease in the progression rate o f

In particular, females,

individuals

retinopathy (Morisaki et al., 1 9 9 4 ) . Further-

with lower educational backgrounds

more, treatment o f depression could poten-

more likely to report symptoms o f anxiety.

were

tially increase the proportion of individuals in

Individuals who had more diabetes complica-

good glycémie control from 4 1 % to 5 8 % in

tions also reported more anxiety symptoms.

the diabetic population (Lustman et al., 2 0 0 0 ) .

N o t surprisingly, 3 8 % o f those reporting anx-

Thus, psychological functioning has direct

iety

implications for illness outcomes.

(Peyrot & Rubin, 1 9 9 7 ) . Thus, regular screen-

T h e r e also appears to be a relationship

also

reported

comorbid

depression

ing for anxiety among patients with diabetes is

depressive

also recommended, especially among those

symptoms among patients with diabetes. For

with a greater number o f diabetes-related

example, individuals with depression

complications.

between health

care use and

and

diabetes had higher ambulatory care use ( 1 2 vs. 7 visits) and filled more prescriptions ( 4 3 vs. 2 1 ) than did their counterparts without a diagnosis o f depression. A m o n g individuals with diabetes, total health care expenditures

Other Psychosocial Factors Social Support.

Social support has been asso-

ciated with physical and psychological health

for individuals with depression and diabetes

among those with D M 2 . Individuals with D M 2

were four and a half times higher than those

who perceive more social support from friends

for

($247

and family engage in more diabetes self-care

million vs. $ 5 5 million) (Egede et al., 2 0 0 2 ) .

than do those who perceive less social support

individuals without

depression

Despite the influence o f depression

on

(Garay-Sevilla et al., 1 9 9 5 ; Peyrot, McMurry,

D M 2 outcome and health care use, t w o o f

& Davida, 1 9 9 9 ) . In fact, social support may

undiagnosed.

account for as much as 1 7 % of the variance in

Undiagnosed depression is likely due to the

self-reported diabetes self-care behaviors (Wang

fact that many o f the symptoms for depression

8c Fenske, 1 9 9 6 ) . Social support has also

and diabetes overlap (e.g., fatigue [Lustman

been consistently associated with decreased

three cases o f depression go

Type 2 Diabetes

\

psychological distress among medically well and

internal locus of control orientation (i.e., the

diabetes populations (Connell, Davis, Gallant,

belief that a person can manage his or her ill-

&

ness) was significantly associated with fewer

Sharpe, 1 9 9 4 ) . Those who report more

general social support are more likely to have

symptoms

more diabetes-specific social support and subse-

Conversely, a self-blaming internal locus of

quently

symptomatology

control (i.e., the belief that a person is respon-

less

depressive

of

depression

and

anxiety.

(Littlefield, Rodin, Murray, & Craven, 1 9 9 0 ) .

sible for his or her negative illness outcomes

As such, social support appears to serve a pro-

such as poor metabolic control) was associ-

tective function against depressive symptoms in

ated with high blood glucose levels and binge

the context of diabetes.

eating. In addition, participants who thought that diabetes control was a matter of chance Illness intrusiveness,

or fate were more likely to be depressed and

which refers to the perception o f the extent to

anxious and to have lower self-esteem (Peyrot

disrupts

& Rubin, 1 9 9 4 ) . Certainly, more research is

valued activities, has also been associated with

needed to determine how perceived control

depressive symptoms among individuals with

and health outcomes are causally related.

diabetes (Devins, Hunsley, Mandin, T a u b , &c

However,

Paul, 1 9 9 7 ) . T o illustrate, T a l b o t , Nouwen,

perceptions o f control are important cognitive

Gingras, Bélanger, and Audet ( 1 9 9 9 ) exam-

mechanisms to assess and are potentially effec-

ined depressive symptoms in a sample o f 2 3 7

tive targets for treatment.

Illness

Intrusiveness.

which an illness constrains and

it

appears

that

health-related

individuals with D M 2 cross-sectionally and found that illness intrusiveness accounted for

Coping

Style.

T h e inconsistent

findings

6 1 % o f the variance in depressive symptoms.

regarding the relationship between stress and

Such findings suggest that individuals who

glycémie control may be partially due to dif-

tend to perceive their diabetes as restricting

ferences in h o w individuals cope with stress.

activities in valued domains (e.g., family, rela-

Stress has been significantly associated with

tionships, spirituality) are at greater risk for

higher H b A

l c

values among those individuals

depression than are those who do not. T o

who reported "ineffective" coping styles (i.e.,

date, relatively little research has been con-

emotional or angry responses to stress) but

ducted examining cognitive factors such as

not among those w h o reported

intrusiveness and their relationship to depres-

coping styles (i.e., tendency to not respond

sion in the c o n t e x t o f diabetes.

emotionally to stress) (Peyrot & M c M u r r y ,

Further

"effective"

research is needed in this area to determine

1 9 9 2 ) . Coping styles have also been directly

whether these cognitive variables mediate the

related to glycémie control. For example,

relationship between diabetes and depression.

Peyrot and colleagues ( 1 9 9 9 ) found that after controlling for regimen adherence, individuals

Perceived

Control.

Another

cognitive

with D M 2 w h o reported m o r e pragmatic and

appraisal variable, perceived control, has also

stoic coping styles showed better glycémie

been related to levels o f psychological distress

control. Such findings suggest that changing

among individuals with diabetes. Using a mea-

the manner in which individuals respond to

sure o f diabetes-specific control, Peyrot and

stressors may mitigate the impact that stress

Rubin ( 1 9 9 4 ) found that the type o f locus o f

has on glycémie control o f those with D M 2 .

control resulted in either positive or negative health outcomes. Their w o r k suggests that

Quality

of Life.

Quality o f life ( Q O L ) is a

control:

global construct that refers to health-related

autonomous and self-blaming. Autonomous

physical and social functioning as well as

there are t w o types o f internal

309

310

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS perceived physical and

mental

well-being.

among these minority groups than

among

Overall, a number of studies indicate that Q O L

Caucasian populations (Cowie et al., 1 9 8 9 ;

is compromised in individuals with diabetes.

Franklin,

M o r e specifically, those with diabetes reported

Hamman,

reduced

Rowland,

role and

physical functioning

as

Kahn,

Baxter,

1 9 9 0 ; Harris, &

Byrd-Holt,

Marshall, Klein,

&

Cowie,

1 9 9 8 ; Resnick,

well as decreased perceptions o f overall health.

Valsania, &

These findings are congruent with studies indi-

potential explanations have been posited to

Phillips, 1 9 9 9 ) . A number of

cating that the presence of two or more com-

account for these observed differences, includ-

with

ing decreased health care access, physiological

decreased Q O L (Rubin & Peyrot, 1 9 9 9 ; Trief

factors, and psychological factors. As an exem-

et al., 1 9 9 8 ) . As seen with depression, gender

plar, findings from a select number o f studies

differences also exist, as women report lower

with African Americans are presented here.

plications is consistently

associated

Q O L than do men. Accordingly, women tend

A number o f differences have been observed

to be less satisfied with their treatment regi-

in health-related beliefs, attitudes, and coping

men, miss more work, and are involved in

styles. For instance, Samuel-Hodge and col-

fewer leisure activities as compared with men

leagues ( 2 0 0 0 ) found that African American

(Rubin & Peyrot, 1 9 9 8 ) .

women reported that they often feel "nervous

Because o f the required changes in lifestyle

and tired" and worry about diabetes compli-

and rigid adherence to treatment regimens,

cations. Furthermore, many African American

it is not surprising that perceived Q O L is

women tend to respond to the needs of others

affected. In fact, it has been demonstrated that

and neglect their own care in accordance with

patients controlling their diabetes solely with

their caretaking role within the family. Coping

diet and exercise had fewer diabetes quality o f

methods may also substantially differ given

life ( D Q O L ) assessed worries than did those

that African American women tend to rely on

taking oral medications. Furthermore, those

spirituality and their belief in G o d to provide

taking oral medications reported more D Q O L

the strength to cope with diabetes (Samuel-

satisfaction with treatment and less burden o f

Hodge

illness than did those taking insulin (Jacobson,

factors are just a few examples o f potential

deGroot, &c Samson, 1 9 9 4 ) . It appears, then,

ethnic and cultural differences in psychological

that certain components o f an

adjustment and coping style that may exist and

treatment

regimen affect

individual's

Q O L . However,

findings on the relationship between glycémie control and Q O L are less clear. Although

et al., 2 0 0 0 ) . T h e

aforementioned

so should be considered in treatment

plan

development. Unfortunately

only a limited number o f

some studies have found significant relation-

studies have examined the effectiveness of inter-

ships between D Q O L and H b A

ventions designed for specific ethnic groups. The

l c

(Trief et al.,

1 9 9 8 ) , others have not (Peterson, Lee, Young,

few that have been conducted

Newton, & Doran, 1 9 9 8 ) .

improvements in glycémie control, blood pres-

Ethnic and Cultural Considerations

Have, & Adams-Campbell, 1 9 9 7 ) , and weight

demonstrate

sure control (Agurs-Collins, Kumanyika, Ten

As stated previously, rates of D M 2 are clearly higher among some ethnic

loss (Mayer-Davis et al., 2 0 0 1 ) . Such positive outcomes underscore the importance of devel-

groups,

oping culture-specific interventions The rele-

including African Americans, Native Americans,

vance of these findings is also reflected in

and Hispanic Americans (Harris, 2 0 0 1 ) . Further-

culturally centered diabetes outreach programs

more, the frequency and severity o f micro-

(e.g., African American, Native American,

vascular complications are more

Latino) recently developed by the A D A (2002b).

common

Type 2

Diabetes

In the future, research is needed to determine

drug intervention took metformin, which is

the culture-specific factors that contribute to

designed to promote glucose homeostasis, or

diabetes adjustment and effective interventions.

were administered a placebo. Overall, results

A complete review o f the literature on culture

for the lifestyle intervention were promising

and D M 2 deserves far more consideration than

( D P P R G , 2 0 0 0 ) . At follow-up (average 2 . 8

can be achieved within the scope o f this

years), the lifestyle intervention group demon-

chapter. However, it is strongly emphasized

strated a 5 8 % reduction in diabetes develop-

that sociocultural factors must be considered

ment, and the drug intervention demonstrated

when intervening in the context o f D M 2 .

a 3 1 % reduction in diabetes development, relative to the placebo group ( D P P R G , 2 0 0 2 ) . Similar results were found in the Finnish Diabetes Prevention Study (FDPS) (Tuomilehto

ASSESSMENT AND T R E A T M E N T

et al., 2 0 0 1 ) , which randomized 5 2 2 overweight

Primary Prevention: Risk Reduction

individuals

with

impaired

glucose

tolerance to an intensive lifestyle intervention

role o f modifiable risk

(targeting weight loss, food intake, and physical

factors in the etiology o f D M 2 makes preven-

activity) or to a control group (brief diet and

T h e substantial

tion efforts a primary health care objective. T h e

exercise counseling). As in the DPP, Finnish

majority o f prevention efforts involve lifestyle

participants in the lifestyle intervention group

as

showed a 5 8 % reduction in the incidence o f

obesity, overeating, and physical inactivity. F o r

diabetes as compared with the control group.

interventions,

targeting

factors

such

recent large-scale prevention

Clearly, both the DPP and FDPS provide evi-

studies highlight the critical role o f behavioral

dence for the impact o f influential changes in

example, two

change in diabetes care. T h e first, the Diabetes

eating and exercise habits on the development

Prevention Program (DPP), involved a multi-

of diabetes.

center study o f individuals at risk for diabetes

T h e robust findings o f the t w o large-scale

conducted by the National Institutes o f Health

prevention studies just described are reflected

(Diabetes Prevention Program Research Group

in the A D A ' s 2 0 0 2 position statement on

[DPPRG], 1 9 9 9 ) . Participants were randomly

the prevention or delay o f D M 2 . T h e A D A ' s

assigned to one o f three groups, including a

statement consists o f recommendations for

drug intervention (metformin vs. placebo) or an

health care providers to (a) increase patient

intensive lifestyle intervention.

Participants

awareness o f the benefits o f modest weight

receiving the intensive lifestyle intervention

loss and regular exercise, (b) conduct regular

met for at least 1 6 sessions with case managers

screenings o n high-risk populations, and (c)

trained in nutrition, exercise, and behavioral

provide weight loss and exercise counseling

modification over the first 2 4 weeks o f the

for those w h o are found to have impaired

study and monthly thereafter. T h e curriculum

glucose tolerance (ADA, 2 0 0 2 c ) . Although the

consisted o f general information about diet and

A D A ' s recommendations clearly acknowledge

exercise and behavioral interventions, including

the importance o f lifestyle interventions in the

self-monitoring, goal setting, stimulus control,

prevention o f D M 2 , the feasibility o f large-

problem solving, and relapse prevention train-

scale implementation o f these interventions

ing. Participants in the lifestyle intervention also

m a y be problematic within the existing health

attended group courses that focused on exer-

care system. F o r example, use o f an effective

cise, weight loss, and behavioral issues. Group

lifestyle intervention program requires a large

courses lasted 4 to 6 weeks, with additional

number o f well-coordinated resources over an

optional groups offered quarterly. Those in the

extended period o f time. Often, such resources

312

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS do not exist or are not accessible. Thus, future

individuals

research efforts should focus on h o w to trans-

self-monitor blood glucose. For individuals with

late the DPP and FDPS findings into cost-

D M 2 , glucose levels should fall between 8 0 and

effective interventions that can be feasibly

1 2 0 mg/dl before meals and between 1 0 0 and

implemented in real-world settings.

with

diabetes must

frequently

1 4 0 mg/dl at bedtime (ADA, 1 9 9 8 ) . It is also recommended that physicians check H b A ularly. H b A

Medical Interventions

l c

l c

reg-

is an average measure of blood

glucose for the previous 3 months and is an

T o prevent diabetes-related complications,

important

indicator o f metabolic control.

individuals with D M 2 must manage a c o m -

Individuals who do not have diabetes typically

plicated treatment regimen on a daily basis.

have an H b A

l c

percentage of less than 6 %

Such treatment regimens are individualized

(ADA, 1 9 9 8 ) . It is recommended that individu-

according to patients' medical needs

als with D M 2 maintain an H b A

and

l c

of between

resources. They typically consist o f a nutri-

7 % and 8 % . Diabetes-related complications are

tional regimen, an exercise program, and oral

greatly reduced though good metabolic control;

Nutritional

for every 0 . 9 % reduction in H b A , the risk of

plans generally consist o f eating prescribed

developing microvascular diabetic complica-

proportions

tions (eye, kidney, and nerve disease) is reduced

medication

(NIDDK,

2000).

o f protein,

fat,

and

carbo-

hydrates as well as fiber, cholesterol, and

lc

by approximately 2 5 % (ADA, 2 0 0 2 a ) .

sodium. It is also recommended that a regular exercise plan involve aerobic and musclestrengthening exercises. F o r many individuals

Preventive tions.

Screening

of Diabetes

Complica-

Preventive screening and practices is

with diabetes, changes in diet and exercise are

also a vital component o f the diabetes treat-

sufficient to achieve euglycemia (near-normal

ment regimen, particularly as it concerns

glucose levels). However, if diet and exercise

diabetes complications. As stated previously,

cannot adequately sustain euglycemia, oral

hypertension is c o m m o n among individuals

medications that decrease blood glucose are

with diabetes and so must be monitored

incorporated

regimen.

regularly. Adequate blood pressure control

Oral medications lower blood glucose either

can subsequently reduce cardiovascular dis-

into the treatment

by stimulating the pancreas to produce more

ease, such as heart disease and stroke, by

insulin or by increasing the efficiency o f

approximately 3 3 % to 5 0 % and can reduce

insulin use. W h e n oral medications are not

microvascular disease by approximately 3 3 %

sufficient to maintain euglycemia, exogenous

( N I D D K , 2 0 0 0 ) . Cholesterol and lipids must

insulin injections are integrated into the treat-

also be monitored among individuals with

ment regimen. Nearly 4 0 % o f individuals

D M 2 ; cardiovascular complications can be

with D M 2 are treated with insulin to improve

reduced by 2 0 % to 5 0 % through improved

metabolic control. Clearly, the responsibility

control o f cholesterol and lipids. Medications

for diabetes self-management rests on the

are commonly required to control cholesterol

individual with diabetes. Therefore, the pre-

and

ceding treatment regimens require a number

diabetes. In addition, preventive screenings for

o f substantial behavioral and lifestyle changes

diabetic eye disease are important.

for most individuals.

detection and treatment o f diabetic eye disease

blood

pressure

among

those

with Early

with laser therapy can reduce the development T h e fundamental pur-

of severe vision loss by an estimated 5 0 % to

pose of a diabetes treatment regimen is to

6 0 % . Similarly, early detection and treatment

achieve near-normal metabolic control. Thus,

of diabetic kidney disease can reduce the

Metabolic

Control.

Type 2 Diabetes

\

development o f kidney failure by 3 0 % to

It is important to recognize that diabetes

7 0 % . Finally, comprehensive foot care pro-

self-management is a complex, multidimen-

grams can reduce amputation rates by 4 5 % to

sional construct. Typically, individuals

85%

adherent to certain components of their treat-

(NIDDK, 2000).

Given the

multi-

are

systemic nature o f D M 2 , regular screenings

ment regimens but not to others. Indeed, per-

for these difficulties are clearly an essential

fect adherence to every aspect o f the treatment

component o f the treatment regimen.

regimen is extremely rare and (for many) unrealistic (Wysocki & Buckloh, 2 0 0 2 ) . Therefore, Regimen.

clinicians should identify the components of

There are a number o f diabetes-related adjust-

the treatment regimen to which patients are

Difficulties

With

the Medical

ment problems that are directly associated

adhering well and those to which they are not.

with attempts at treatment adherence. O n e

It is c o m m o n for individuals frustrated with

such frustration commonly expressed by indi-

one aspect o f their treatment regimen to gener-

viduals with diabetes is the sense o f being food

alize and conclude that they are "bad patients"

deprived (Rubin & Peyrot, 2 0 0 1 ) . Some indi-

or are "nonadherent" patients. Clinicians can

viduals may subsequently develop poor eating

help such individuals by identifying

small

habits, whereas others report that they do

specific goals to work toward. Subsequently,

not monitor their glucose as often as indi-

the treatment regimen will appear much more

cated. Adhering to monitoring glucose levels is

manageable to individuals with D M 2 .

also problematic. T w o commonly cited reasons for not monitoring blood glucose are the

Diabetes

Self-Management

Education.

pain associated with drawing blood and the

Diabetes self-management education ( D S M E )

inconvenience o f monitoring in certain settings.

equips individuals with the knowledge and

Still other individuals have negative responses

skills to manage their diabetes successfully.

to excessively low or high blood glucose read-

M e t a b o l i c control is potentially optimized,

ings (Rubin & Peyrot, 2 0 0 1 ) . Motivation to

and

adhere to the monitoring portion of the treat-

when the following information and skills are

future

complications are

minimized,

ment regimen is difficult to maintain when the

taught: nutritional

feedback is often negative in nature.

recommendations, self-monitoring o f blood

An additional problem often encountered

information,

exercise

glucose ( S M B G ) , insulin administration, and

by individuals with D M 2 is the frustration

managing

associated with unpredictable blood glucose

glycemic events. Given that patients perform

of

hypoglycemic

and

hyper-

levels, often leading to less active self-care. T o

approximately 9 5 % o f this daily care inde-

help alleviate frustration,

are

pendently (Anderson, 1 9 8 5 ) , D S M E is con-

encouraged to develop realistic standards and

sidered to be the central component o f the

expectations regarding diabetes outcomes.

medical treatment for those with diabetes.

individuals

Finally, the fear o f taking insulin can prevent

Despite the central nature o f D S M E , only

optimal management o f blood glucose levels.

4 0 % o f individuals with diabetes receive for-

Clinicians should attempt to identify specific

mal diabetes management education (U.S.

fears related to taking insulin, including the

Department o f Health and H u m a n Services,

pain associated with the injection, interfer-

1 9 9 8 ) , and 5 0 % to 8 0 % o f individuals have

ence

hypo-

severe deficits in their diabetes self-care

glycemia, and being treated differently by

knowledge (Clement, 1 9 9 5 ) . These estimates

with

lifestyle,

experiencing

others (Rubin & Peyrot, 2 0 0 1 ) . F o r a more

indicate that many individuals do not receive

thorough description o f the fears related to

adequate D S M E and suggest that the method

taking insulin, see Rubin and Peyrot ( 2 0 0 1 ) .

and delivery o f D S M E require improvement.

313

314

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS There is an extensive body o f literature that

psychological outcomes makes it quite difficult

evaluates various methods o f delivery and out-

to determine specific psychological factors

comes related to D S M E . Still, no particular

that

intervention method has been identified as

Furthermore, very few studies have reported

optimally efficacious. Because o f the multidi-

long-term treatment outcomes. This is notewor-

mensionality o f diabetes treatment regimens,

thy given that long-term follow-up studies are

D S M E interventions are differentially effective

less likely to find positive outcomes regarding

depending on the aspects o f the regimens that

glycémie and behavioral outcomes than are

influence

self-management

behaviors.

are assessed (Norris, Engelgau, & Narayan,

those with short-term follow-ups (Norris et al.,

2 0 0 1 ) . In other words,

are

2 0 0 1 ) . It may be that program interventions lead

generally effective in changing certain out-

to short-term behavioral change but that the

interventions

comes but not others. However, a recent

newly acquired behaviors do not necessarily

review article by Norris and colleagues ( 2 0 0 1 )

persist. Consequently, "refresher" sessions over

outlined several consistent findings that have

the course of the illness may be warranted. It is

emerged from the D S M E literature and are

unlikely that one intervention that improves all

summarized here.

self-management behaviors, and that is appro-

Specifically, short-term D S M E interventions

priate throughout the course of the illness, will be

have been found to be fairly effective in yielding

found. Therefore, future research needs to deter-

improvements in knowledge levels, S M B G

mine which types of interventions, or combina-

skills, and dietary habits but not in yielding

tions of interventions, are most effective for

improvements in weight loss and physical activ-

specific

ity levels (Norris et al., 2 0 0 1 ) . Group interven-

research has examined how adherence changes

outcomes. Moreover, virtually

no

improving

over time for adults with diabetes. Thus, longitu-

knowledge and S M B G and may be more effec-

dinal studies are needed to determine whether

tion

formats

are

effective

in

tive than individual formats for lifestyle inter-

self-management behaviors follow a develop-

ventions. However, it is important to note that

mental pattern.

improvements in knowledge or S M B G do not necessarily translate into improvements

in

glycémie control. Notably, interactive, individualized, repetitive interventions

are

more

effective in improving lipid levels than are

Psychological Interventions for Diabetes-Specific Problems Over the past 2 0 years, behavioral interven-

single-session or short-term interventions. In

tions for diabetes-specific problems

addition,

patient

shifted from knowledge- and education-based

participation or take a collaborative approach

interventions to patient-centered interventions

programs

that

promote

have

to instruction appear to be more effective than

emphasizing patient efficacy, esteem, and con-

didactic approaches in affecting outcomes such

trol (Glasgow et al., 1999).

as glycémie control, weight loss, and lipid pro-

interventions appear to be effective in improv-

Patient-centered

files. Finally, Norris and colleagues ( 2 0 0 1 ) con-

ing both physical and psychological health out-

cluded that, by and large, self-management

comes. Three empirically supported examples

interventions that have consistent reinforce-

of patient-centered

ment over long periods o f time are more

specific coping skills training, empowerment,

effective

than single-session or

short-term

interventions.

and

interventions—diabetes-

stress management

interventions—are

discussed here.

Norris and colleagues (2001) also pointed out limitations in the existing D S M E literature. They recognized that the dearth of research examining

Diabetes-Specific

Coping

Skills

Training.

Diabetes-specific coping skills training (DSCST)

Type 2 Diabetes is a cognitive-behavioral, psychoeducational

Stress

\

A number o f stress

Management.

group intervention designed to optimize emo-

management interventions have been devel-

tional functioning, diabetes self-management,

oped based on the strong theoretical link

and metabolic control (Rubin 8c Peyrot, 2 0 0 1 ) .

between stress and metabolic control. A variety

During the intervention, individuals are encour-

of techniques aimed at decreasing stress have

aged to identify patterns of self-care and barri-

been evaluated, including biofeedback (Surwit

ers to self-care and, subsequently, to problem

8c Feinglos, 1 9 8 8 ) , relaxation training (Surwit

solve strategies to address identified problems.

et al., 2 0 0 2 ) , and cognitive-behavioral strate-

A series of studies evaluating D S C S T have

gies (Henry, Wilson, Bruce, Chisholm, 8c

found the program to be effective in improving

Rawling, 1 9 9 7 ) . For instance, studies examin-

psychological outcomes such as depression,

ing the efficacy o f biofeedback-assisted relax-

anxiety, self-esteem, and diabetes self-efficacy.

ation training found significant improvements

Moreover, improvements have been observed

in various measures o f metabolic control,

in diabetes self-care (e.g., diet, exercise, diabetes

including improved glucose tolerance, reduced

knowledge, S M B G ) and metabolic control

long-term hyperglycemia (Lammers, Naliboff,

(Rubin, Peyrot, 8c Saudek, 1 9 8 9 , 1 9 9 1 , 1 9 9 3 ;

8c Straatmeyer, 1 9 8 4 ; Surwit 8c Feinglos,

Rubin, Waller, 8c Ellis, 1 9 9 0 ) . Several key ele-

1 9 8 8 ; Surwit, Ross, McCaskill, 8c Feinglos,

ments of diabetes-specific coping skills training

1 9 8 9 ) , postprandial (i.e., after eating) blood

were outlined by Rubin ( 2 0 0 0 ) , including indi-

glucose levels, and plasma Cortisol, as com-

vidualized treatment plans, problem specificity,

pared with control participants (Surwit 8c

goal setting, reinforcement, problem solving,

Feinglos, 1 9 8 3 ) . Overall, stress management

emotional coping skills, and family involve-

interventions show improvements in metabolic

ment (for a more detailed description, see

control parameters but have not been consis-

Rubin, 2 0 0 0 ) .

tent at reducing psychological distress (Henry et al., 1 9 9 7 ; Surwit et al., 2 0 0 2 ) . Future studies

Empowerment.

Patient empowerment inter-

ventions also appear to be effective in addressing many o f the diabetes-specific difficulties that frequently accompany D M 2 . Empower-

need to determine whether some individuals are more susceptible to the effects o f stress than are others and which types o f interventions effect specific stress-related outcomes.

ment interventions are designed to enhance goal setting, problem-solving, coping, stress management, social support, and self-motivation. Anderson and colleagues ( 1 9 9 5 ) evaluated

Technology-Based Interventions Currently,

greater

attention

has

been

an empowerment intervention that consisted of

directed toward developing cost-effective inter-

six 2-hour group sessions. At a 6-month follow-

ventions that can be easily disseminated. T o this

up, the treatment group demonstrated signifi-

end, Glasgow, Toobert, and Hampson (1996)

cant increases in self-efficacy

(setting goals,

evaluated a brief office-based computer inter-

solving problems, emotional coping, obtaining

vention aimed at improving diabetes self-

support, self-motivation, and decision making)

management. Individuals in the intervention

and positive diabetes-specific attitudes as well

completed a computerized assessment o f self-

as decreases in negative diabetes-specific atti-

management behaviors and then were provided

tudes. Small improvements were also observed

feedback on self-management, participated in

in glycémie control. This study lends further

goal-setting exercises, and selected individual-

support to the value o f patient-centered care

ized interventions. Participants also received a

that addresses the psychological aspects of

one-page feedback form outlining individual-

living with diabetes.

ized

obstacles

to

self-management.

The

315

316

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS computer-assisted

intervention

was

fairly

also

showed

greater

improvements

in

successful in producing dietary improvements

glycémie control than did the self-management

and serum cholesterol levels but did not yield

group. Thus, C B T appears to be an effective

significant improvements in glycémie control

treatment

or Q O L (Glasgow et a l , 1 9 9 6 ) . A later study

diabetes (Lustman et al., 1 9 9 8 ) .

for depression

for those

with

by Glasgow and Toobert ( 2 0 0 0 ) examined the

Although C B T has been shown to be effec-

effects o f a telephone follow-up on providing

tive in treating depression, the combination of

community resource information to the patient

behavioral interventions with

in addition to the computer-assisted interven-

medication may be clinically indicated in some

tion. Neither strategy improved the outcomes

cases. Selective serotonin reuptake inhibitors

of the computer-based intervention. Given

such as fluoxitine are effective in treating

these findings, the expanding use of home com-

depressive symptoms and are associated with

puters, and the increasing need for cost-effective

improvements in glycémie control (Rubin &

antidepressant

health care, it is likely that use o f computer-

Peyrot, 1 9 9 4 ) . Furthermore, fewer than 1 0 % of

based interventions will continue to increase

patients with diabetes taking fluoxitine experi-

(Gonder-Frederick, C o x , & Ritterband, 2 0 0 2 ) .

ence significant side effects (Lustman et al., 2000).

Treating Psychological Distress As

Tricyclic

medications

have

also

been shown to decrease depressive symptoms (Turkinton, 1 9 8 0 ) ; however, the use of tricyclic

indicated previously, there is high

medication among those with D M 2 has been

comorbidity between diabetes and psycholog-

associated with adverse side effects, including

ical distress, especially depression and anxiety.

hyperglycemia,

Recommended

hypotension, and other cardiovascular events

treatment

approaches

for

depression and anxiety in the context o f D M 2

weight

gain,

orthostatic

(Lustman, Griffith, Gavard, & Clouse, 1 9 9 2 ) . Although the treatments for depression

are reviewed here.

just described appear to be effective, the conDepression.

Despite the high prevalence o f

clinically significant depressive

symptoms

stellation o f organic and psychosocial factors contributing to depression among those with

among individuals with diabetes, few treat-

diabetes may well be unique. Therefore,

ment outcome studies have been conducted.

researchers and clinicians should not assume

A notable exception is Lustman and col-

that the research findings in medically well

leagues' 1 9 9 8 study, which compared the

populations generalize to those with

efficacy o f cognitive-behavioral therapy (CBT)

betes. Future research should focus on h o w

dia-

plus self-management training with that o f

cognitive processing mechanisms interface

self-management training alone in decreasing

with diabetes-specific experiences and subse-

depressive

quently

symptoms

among

individuals

influence

p s y c h o l o g i c a l distress.

with diabetes (Lustman, Griffith, Freeland,

During the interim, it is recommended that

Kissel, & Clouse, 1 9 9 8 ) . Remission o f depres-

clinicians use treatments for depression that

sion was observed at a 10-week follow-up; at

are empirically supported among medically

that time, 8 5 % o f those in the C B T group

well populations

had remitted as compared with 2 5 % o f those

therapy). Such interventions might be tai-

in the self-management group. Moreover,

lored to diabetes by including the identifica-

treatment effects persisted; at the 6-month

tion and modification o f thoughts and beliefs

follow-up, the rates o f depression remission

related to D M 2 (for a review o f empirically

were 7 0 % for the C B T group and 3 3 % for

supported treatments, see also DeRubeis &

the self-management group. T h e C B T group

Crits-Christoph, 1 9 9 8 ) .

(e.g., C B T , interpersonal

Type 2

Diabetes

CASE S T U D Y T o illustrate the potential role o f psychology in optimizing both physical and psychological outcomes, the following case study is presented. In this particular case, the individual has a number o f diabetes-specific problems as well as clinically significant psychological distress. " A . J . , " a 51-year-old male, presented to a diabetes clinic with a 6-year history o f D M 2 . Since being diagnosed with diabetes, he had closely adhered to his medication regimen but inconsistently practiced dietary and exercise recommendations. T h u s , A. J . was still able to maintain an acceptable (but not optimal) level o f glucose control throughout the first few years o f his illness. However, during the past year, A. J . had gained 3 0 pounds and his H b A

l c

value had risen to 1 0 . 5 % . In addi-

tion, a recent examination by his family physician revealed an ulcer on his left foot. Concerned by the rapid decline in A. J . ' s metabolic control, the physician incorporated insulin into his treatment plan and referred him to a health psychologist to facilitate his regimen adherence. During initial therapy sessions, A. J . admitted to having difficulty in adhering to his treatment regimen, citing large Sunday dinners when traditional family recipes high in fat and carbohydrates were served. H e stated that he refused to miss out on this special family time by declining to eat or eating off o f a different menu. Furthermore, he admitted that it was easier to ignore the problem than to change his lifestyle. H e stated that his exercise regimen consisted solely o f playing with his kids on the weekends and doing yard w o r k . In the third session, A. J . revealed that he had been laid off from his position at a local computer company approximately 4 months earlier. H e stated that after he was laid off, he did not feel like playing with his kids anymore, found it difficult to get up in the morning, and felt hopeless about the future. H e also reported that his wife had been nagging him more about "everything," including his diet, completing chores around the house, and being "grouchy." Like many clients that are referred to therapy, A. J . reported both diabetes-specific problems and general psychological distress. After a thorough assessment, he was diagnosed with major depressive disorder. Given A. J . ' s presentation, the focus o f therapy shifted from diabetes-specific problems to treating depression. A. J . was referred to a psychiatrist for a medication evaluation and was subsequently prescribed antidepressant medication. Psychological treatment consisted of C B T in which A. J . explored his beliefs related to himself, losing his j o b , and the difficulty in finding employment. W h e n appropriate, beliefs related to having diabetes were also explored, and where indicated, A. J . ' s beliefs were challenged and modified. Pleasant events scheduling was also conducted. After 3 months o f C B T and medication therapy, A. J . ' s symptoms o f depression had decreased substantially and he reported increased motivation to improve his diabetes management. Thus, a long-term treatment plan was implemented consisting o f monthly meetings with the health psychologist to discuss issues surrounding weight

317

318

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

loss, exercise, and

behavioral issues as well as ongoing stress

management.

Specifically, A. J . learned ways in which to identify healthier alternatives for his favorite foods and instituted a regular exercise regimen consisting o f running and weightlifting. A. J . and his family also joined the local diabetes support group, where he shares with others what he has learned about coping with diabetes. As a result o f his efforts, A. J . lost 2 0 pounds and did not develop any additional diabetes complications. H e also reported that he felt more confident in his ability to manage his diabetes successfully.

Anxiety.

As mentioned previously, anxiety

symptoms are also c o m m o n among individuals with D M 2 (Peyrot &

Rubin,

effective

treatment

approach

for anxiety

symptoms in individuals with diabetes.

1997).

M o s t individuals with diabetes seeking

Remarkably, no validated randomized con-

psychological services will likely have both

trolled trials have evaluated the efficacy of

general distress (e.g., depression) and diabetes-

behavioral treatment interventions targeting

specific issues. W h e n treating clients with

anxiety among those with diabetes. A number

poor regimen adherence and high levels o f

o f authors have suggested that biofeedback -

psychological distress, it m a y be difficult to

assisted relaxation training (described earlier

determine the initial target o f intervention.

in the chapter), although not yet empirically

In the majority o f cases, it may be advisable

tested to target anxiety symptoms, may be an

to address general distress first (Rubin, 2 0 0 0 )

effective treatment for anxiety among those

because it is unlikely that individuals experi-

with diabetes. At this time, it is recommended

encing high levels o f distress are going to

that clinicians use treatments for anxiety that

have the organizational ability or motivation

have been empirically supported among med-

necessary to effect diabetes-specific behav-

ically well populations (for a review o f empir-

ioral changes. As levels o f general psycholog-

ically supported treatments, see DeRubeis &

ical distress decrease, diabetes-specific issues

Crits-Christoph, 1 9 9 8 ) .

can be addressed more effectively.

Studies examining the effectiveness o f pharmacological

treatments

for

anxiety

among those with D M 2 are limited. H o w -

CONCLUSIONS

ever, initial reports suggest that pharmacological treatments may be potentially effective

D M 2 is a chronic illness characterized by a

(Lustman et al., 1 9 9 5 ) . F o r example, individ-

dysregulation o f blood glucose levels. D M 2

uals treated with alprazolam ( X a n a x ) dis-

requires individuals to manage a complex

played improvements

treatment regimen so as to prevent severe med-

in glycémie control

when taking this medication regardless o f a

ical complications. Fortunately, it is a poten-

formal diagnosis o f anxiety (Lustman et al.,

tially manageable disease, and many of the

1 9 9 5 ) . Although results are promising, fur-

negative physical and psychological health

ther research is needed to determine the most

sequelae are preventable. However, preventing

adverse

diabetes

outcomes

requires

that

individuals with diabetes make multiple behav-

colleagues ( 2 0 0 1 )

Type 2 Diabetes

\

advocated the need

for

public policy and community-based interven-

ioral and lifestyle changes, a task that over-

tions, citing the role o f environmental factors

whelms many. Because o f the unpredictable

in the development and prevention o f obesity

and complex nature o f D M 2 , interventions

and D M 2 . High-fat, high-calorie foods and

may be necessary to facilitate these behavioral

sedentary activities, such as watching television

changes and to promote optimal health out-

and using computers, pervade contemporary

comes. A number o f behavioral interventions

society and shape health-related behaviors and

have proved to be effective in preventing D M 2

outcomes. Thus, studies are needed to further

as well as in improving the psychological and

delineate which environmental variables influ-

physical outcomes o f those w h o have diabetes. Although great progress has been made in understanding the behavioral aspects of D M 2 during the past two decades, a number of areas

ence eating and physical activity and

to

develop community-based interventions that promote positive health behaviors. Importantly, the development

o f more

are in need o f further investigation. First, there

cost-effective interventions will also require

are virtually no longitudinal studies examining

the role o f behavioral scientists to change

the developmental course of self-management

(Gonder-Frederick et al., 2 0 0 2 ) . Rather than

among adults. Furthermore, additional research

providing direct care, behavioral scientists will

should address the cultural-specific impact o f

increasingly provide training and supervision

D M 2 . N o t only are certain cultural groups at

to other health care professionals who directly

high risk for D M 2 , but research suggests that

assess and implement behavioral

there also are potential culture-specific patterns

tions. As a result, behavioral scientists will

of illness appraisal and coping strategies. In

also be required to further examine the role o f

addition, studies that will help to determine the

the provider-patient relationship in influenc-

most effective treatments for clinically signifi-

ing psychological and physical outcomes and

cant psychological distress among individuals

to develop interventions targeting health care

with diabetes, specifically depression and anx-

providers accordingly. In sum, the fundamen-

iety, are warranted.

tal challenge for behavioral scientists will be to

interven-

During the coming decade, there will be an

translate available findings into feasible, cost-

increasing need for cost-effective interventions

effective interventions that can be widely dis-

aimed at preventing and treating obesity and

seminated to psychologists and health care

D M 2 . An exceptional review by Wing and

professionals (Gonder-Frederick et al., 2 0 0 2 ) .

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BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS Lustman, P. J . , Griffith, L. S., Clouse, R. E., Freeland, K. E., Eisen, S. Α., Rubin, Ε. H., Carney, R. M., & McGill, J . B. (1995). Effects of alprazolam on glucose regulation in diabetes. Diabetes Care, 18, 1 1 3 3 - 1 1 3 9 . Lustman, P. J . , Griffith, L. S., Freeland, Κ. E., Kissel, S. S., & Clouse, R. E. (1998). Cognitive behavioral therapy for depression in Type 2 diabetes mellitus: A randomized, controlled trial. Annals of Internal Medicine, 129, 6 1 3 - 6 2 1 . Lustman, P. J . , Griffith, L. S., Gavard, J . Α., & Clouse, R. E. (1992). Depression in adults with diabetes. Diabetes Care, 15, 1 6 3 1 - 1 6 3 9 . Maggio, C. Α., & Pi-Sunyer, F. X . (1997). The prevention and treatment of obesity: Application to Type 2 diabetes. Diabetes Care, 20, 1 7 4 4 - 1 7 6 6 . Manson, J . , & Spelsberg, A. (1994). Primary prevention of non-insulin-dependent diabetes mellitus. American Journal of Preventive Medicine, 10, 1 7 2 - 1 8 4 . Marlatt, G. Α., & Gordon, J . R. (1985). Relapse prevention: Maintenance strategies and addictive behavior change. New York: Guilford. Mayer-Davis, E. J . , Antonio, A. D., Martin, M., Wandersman, Α., Parra-Medina, D., &c Schulz, R. (2001). Pilot study of strategies for effective weight management in Type 2 diabetes: Pounds Off With Empowerment (POWER). Family and Community Health, 24(2), 2 7 - 3 5 . McCulloch, D. K., Hosking, D. J . , & Tobert, A. (1986). A pragmatic approach to sexual dysfunction in diabetic men: Psychosexual counseling. Diabetes Medicine, 3, 4 8 5 - 4 8 9 . Morisaki, N., Watanabe, S., Kobayashi, J . , Kanzaki, T., Takahashi, K., Yokote, K., Tezuka, M., Tashiro, J . , Inadera, H., & Saito, Y . (1994). Diabetic control and progression of retinopathy in elderly patients: Five year follow-up. Journal of the American Geriatrics Society, 41, 1 4 2 - 1 4 5 . National Institute of Diabetes and Digestive and Kidney Diseases. (2000). National diabetes statistics fact sheet: General information and national estimates on diabetes in the United States. Bethesda, M D : National Institutes of Health. Norris, S. L., Engelgau, M . M., & Narayan, Κ. M. V. (2001). Effectiveness of selfmanagement training in Type 2 diabetes: A systematic review of randomized controlled trials. Diabetes Care, 24, 5 6 1 - 5 8 7 . Owen, K., Ayers, S., Corbett, S., & Hattersley, A. (2002). Increased risk of diabetes in first-degree relatives of young-onset Type 2 diabetic patients compared with relatives of those diagnosed later. Diabetes Care, 25, 6 3 6 - 6 3 7 . Peterson, T., Lee, P., Young, B., Newton, P., & Doran, T. (1998). Well-being and treatment satisfaction in older people with diabetes. Diabetes Care, 21, 930-935. Peyrot, M., & McMurry, J . F. (1985). Psychosocial factors in diabetes control: Adjustment of insulin treated adults. Psychosomatic Medicine, 47, 5 4 2 - 5 4 7 . Peyrot, M . F., & McMurry, J . F., Jr. (1992). Stress buffering and glycémie control. Diabetes Care, 15, 8 4 2 - 8 4 6 . Peyrot, M . F., McMurry, J . F., & Davida, F. K. (1999). A biopsychosocial model of glycémie control in diabetes: Stress, coping, and regimen adherence. Journal of Health and Social Behavior, 40, 1 4 1 - 1 5 8 . Peyrot, M. F., & Rubin, R. R. (1994). Psychosocial problems in diabetes treatment: Impediments to intensive self-care. Practical Diabetology, 13, 8 - 1 4 . Peyrot, M. F., & Rubin, R. R. (1997). Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care, 20, 5 8 5 - 5 9 0 . Ray, N. F., Thamer, M., Gardner, E., & Chan, J . K. (1998). Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care, 21, 2 9 6 - 3 0 6 . Resnick, H. E., Valsania, P., Sc Phillips, C. L. (1999). Diabetes mellitus and nontraumatic lower extremity amputation in African-American and Caucasian Americans: the National Health and Nutrition Examination Survey

Type 2 Diabetes Epidemiologic Follow-up Study, 1 9 7 1 - 1 9 9 2 . Archives of Internal Medicine, 159, 2 4 7 0 - 2 4 7 5 . Rubin, R. R. (2000). Psychotherapy and counseling in diabetes mellitus. In F. J . Snoek Se T. C. Skinner (Eds.), Psychology in diabetes care (pp. 2 3 5 - 2 6 3 ) . New York: John Wiley. Rubin, R. R., Sc Peyrot, M . (1994). Psychosocial problems in diabetes treatment: Impediments to intensive self-care. Practical Diabetology, 13, 8 - 1 4 . Rubin, R. R., Sc Peyrot, M . (1998). Men and diabetes: Psychosocial and behavioral issues. Diabetes Spectrum, 11, 8 1 - 8 7 . Rubin, R. R., Sc Peyrot, M . (1999). Quality of life and diabetes. Diabetes Metabolism Research Reviews, 15, 2 0 5 - 2 1 8 . Rubin, R. R., & Peyrot, M. (2001). Psychological issues and treatments for people with diabetes. Journal of Clinical Psychology, 57, 4 5 7 - 4 7 8 . Rubin, R. R., Peyrot, M., & Saudek, C. D. (1989). Effect of diabetes education on selfcare, metabolic control, and emotional well-being. Diabetes Care, 12, 6 7 3 - 6 7 9 . Rubin, R. R., Peyrot, M., Sc Saudek, C. D. (1991). Differential effect of diabetes education on self-regulation and lifestyle behaviors. Diabetes Care, 14, 3 3 5 - 3 3 8 . Rubin, R. R., Peyrot, M., Sc Saudek, C. D. (1993). The effect of diabetes education program incorporating coping skills training on emotional well-being and diabetes self-efficacy. Diabetes Educator, 19, 2 1 0 - 2 1 4 . Rubin, R. R., Waller, S., & Ellis, A. (1990). Living with diabetes: A rationalemotive therapy perspective. Journal of Rational-Emotive Cognitive-Behavioral Therapy, 8, 2 1 - 3 9 . Samuel-Hodge, C. D., Headen, S. W., Skelly, A. H., Ingram, A. F., Keyserling, T. C , Jackson, E. J . , Ammerman, A. S., & Elasy, T. A. (2000). Influences on day to day management of Type 2 diabetes among African-American women. Diabetes Care, 23, 9 2 8 - 9 3 4 . Schreiner-Engel, P., Schiavi, R. C , Vietorisz, D., 8c Smith, H. (1987). The differential impact of diabetes type on female sexuality. Journal of Psychosomatic Research, 31, 2 3 - 3 3 . Surwit, R. S., & Feinglos, M. N. (1983). The effects of relaxation on glucose tolerance in non-insulin-dependent diabetes mellitus. Diabetes Care, 6, 1 7 6 - 1 7 9 . Surwit, R. S., & Feinglos, M . N. (1988). Stress and autonomic nervous system in Type II diabetes: A hypothesis. Diabetes Care, 11, 8 3 - 8 5 . Surwit, R. S., Feinglos, M . N., Livingston, E. G., Kuhn, C. M., & McCubbin, J . A. (1984). Behavioral manipulation of the diabetic phenotype in ob/ob mice. Diabetes, 33, 6 1 6 - 6 1 8 . Surwit, R. S., McCubbin, J . Α., Kuhn, C. M., McGee, D., Gerstenfeld, D. Α., & Feinglos, M . N. (1986). Alprazolam reduces stress hyperglycemia in ob/ob mice. Psychosomatic Medicine, 48, 2 7 8 - 2 8 2 . Surwit, R. S., Ross, S. L., McCaskill, C. C , & Feinglos, M . N. (1989). Does relaxation therapy add to conventional treatment of diabetes mellitus? Diabetes, 3S(Suppl. 1), A9. Surwit, R. S., van Tilburg, M. A. L., Zucker, N., McCaskill, C. C , Parekh, P., Feinglos, M . N., Edwards, C. L., Williams, P., 8c Lane, J . D. (2002). Stress management improves long-term glycémie control in Type 2 diabetes. Diabetes Care, 2 5 , 3 0 - 3 4 . Talbot, F., Nouwen, Α., Gingras, J . , Bélanger, Α., & Audet, J . (1999). Relations of diabetes intrusiveness and personal control to symptoms of depression among adults with diabetes. Health Psychology, 18, 5 3 7 - 5 4 2 . Trief, P. M., Grant, W., Elbert, K., & Weinstock, R. S. (1998). Family environment, glycémie control, and the psychosocial adaptation of adults with diabetes. Diabetes Care, 21, 2 4 1 - 2 4 5 .

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BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS Tuomilehto, J . , Lindstrom, J . , Eriksson, J . G., Valle, T. T., Hamalainen, H., Ilanne-Parikka, P., Keinanen-Kiukaanniemi, S., Laakso, M., Louheranta, Α., Rastas, M., Salminen, V., & Uusitupa, M . (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, 344, 1 3 4 3 - 1 3 5 0 . Turkinton, R. W. (1980). Depression masquerading as diabetic neuropathy, Journal of the American Medical Association, 243, 1 1 4 7 - 1 1 5 0 . U.S. Department of Health and Human Services. (1998). Diabetes: A serious public health problem. At a Glance, pp. 1-4. (Washington, DC: Author) Wang, C. Y . , &C Fenske, M. M . (1996). Self-care of adults with non-insulin-dependent diabetes mellitus: Influence of family and friends. The Diabetes Educator, 22, 465-470. Wing, R. R., Goldstein, M . G., Acton, K. J . , Birch, L. L., Jakicic, J . M., Sallis, J . F., & Smith-West, D. (2001). Behavioral science research in diabetes: Lifestyle changes related to obesity, eating behavior, and physical activity. Diabetes Care, 24, 1 1 7 - 1 2 3 . Wulsin, L., &C Jacobson, A. M . (1989). Visual and psychological function in PDR [abstract]. Diabetes, 3S(Suppl. 1), A242. Wulsin, L., Jacobson, A. M., & Rand, L. I. (1987). Psychosocial aspects of diabetes retinopathy. Diabetes Care, 10, 3 6 7 - 3 7 3 . Wysocki, T., & Buckloh, L. M. (2002). Endocrine, metabolic, nutritional, and immune disorders. In S. Bennett Johnson, N. W. Perry, Jr., & R. H. Rozensky (Eds.), Handbook of clinical health psychology (pp. 6 5 - 9 9 ) . Washington, DC: American Psychological Association.

CHAPTER

17 10

Psycho-oncology SHULAMITH KREITLER

C

ancer is a c o m m o n l y dreaded disease

of the malignant cells and secondarily on an

that is the second leading cause o f

estimate o f their growth rate). T h e major treat-

death

The

ment modalities are surgery, radiation therapy,

incidence o f cancer, especially o f specific

chemotherapy, immunomodulation, and bone

in the Western world.

diagnoses (e.g., breast, m e l a n o m a , thyroid,

marrow transplantation. Treatment may last

esophagus, liver), has increased during recent

for months and may need to be administered

years, even when improvements in diagnosis

repeatedly. Following the initial diagnosis of the

and age-related trends are considered ( S E E R

disease and its treatment, remission may set in

Program, 2 0 0 2 ) . I f current trends continue,

for differential periods o f time. T h e disease-free

cancer diagnoses

interval ends if the disease recurs. Recurrence

are expected to

double

over the next 5 0 years (Hoyert, K o c h a n e k , &

usually denotes a deterioration but not neces-

M u r p h y , 1 9 9 9 ) , with m o r e than 1.3 million

sarily death.

new cases o f cancer diagnosed annually in the United States alone (Garfinkel, 1 9 9 5 ) .

Cancer affects individuals of both genders and o f all ages and ethnic backgrounds, albeit

Cancer denotes a family o f diagnoses that

to different degrees, so that specific cancers

may affect different body sites, including the

may be more prevalent in individuals o f a par-

breasts, prostate, lungs, brain, gastrointestinal

ticular gender, ethnic background, geographi-

organs, skin, soft tissues, and blood. It mostly

cal area, or age group. T h e pathogen o f cancer

consists of a tumor in a specific site but may

has not been identified, although several risk

spread to other sites (i.e., metastases), and this

factors are known, ranging from genetic back-

is one of the reasons why it is commonly con-

ground to more behavioral factors such as

sidered as a systemic disease. Based on the size

smoking, exposure to the sun, contact with

of the primary lesion and the spread o f the

particular carcinogens, and diets that

disease at diagnosis, different stages (mostly

increase the incidence o f particular cancers

four with subdivisions) are identified, reflecting

(Garfinkel, 1 9 9 5 ) .

may

increasing severity. In distinction from staging,

Psycho-oncology is the discipline o f health

tumor grading indicates the similarity of the

psychology that deals with the psychological

tumor cells to their normal tissue counterparts

aspects of cancer. It is often considered as one

(based primarily on the degree of differentiation

of the most comprehensively studied domains 325

326

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS of health psychology. This is probably due to

security grounded in characteristic attitudes

the high levels of distress bound with cancer.

and beliefs, entrenched coping styles of passivity

Cancer is an anxiety-provoking disease that

and denial, and preexisting emotional difficulties

readily evokes the connotations o f suffering

(Green, Rimer, & Elwood, 1981). As a result,

and death. For patients, cancer is often associ-

cancer is often diagnosed in a later stage than

ated with considerable physical and psycho-

would have been possible and beneficial for the

logical suffering (e.g., pain, fatigue, and diverse

patient. The delayed diagnosis not only may

symptoms that may be debilitating

result in a compromising prognosis but also

either

temporarily or permanently) that may affect

may

most of the domains of their lives and last for

sequelae: sense of guilt and loss o f the sense o f

have

two

significant

psychological

long periods. Cancer also poses difficulties for

physical security and confidence (Kreitler,

health professionals. In particular, physicians

Chaitchik, &

Kreitler, 1 9 9 0 ) . T h e former

often accompany patients for long periods o f

reflects thoughts such as the following: "In ret-

time, sometimes without being able to offer

rospect, I can see that if I had paid more atten-

the expected and desired recovery or even the

tion to myself, I could have avoided

required extent of palliation to moderate the

catastrophe." The latter reflects thoughts such as

patients' pain and suffering. This state of

the following: " H o w come I did not know for so

affairs has enhanced awareness for the poten-

long that something is wrong with my body?"

the

tial contributions o f psychology in oncology

and " H o w could I be sure now that I am not

and has opened many venues for clinical and

terribly sick, although I feel nothing is wrong?"

research psychologists in this domain.

Diagnosis O V E R V I E W O F SPECIAL

Because of the alarming connotations of

CRISES A N D P R O B L E M S

cancer, the diagnosis of cancer often has a shocking effect on the patient. Even the mere

It is o f special importance to identify the

initiation o f a series o f tests in response to the

crisis situations and problems characteristic

patient's complaints may evoke increased anx-

of cancer patients. These form special foci for

iety and a sense of life being set " o n hold" until the tests are concluded. If the diagnosis of

intervention and research.

cancer arrives, the shock may be so great that even the risk o f suicide cannot be ruled out

Prevention

(Campbell, 1 9 9 6 ) . This state of increased stress

Despite knowledge that early

diagnosis

and panic is usually resolved partly through

and treatment of most cancer types facilitates

denial and mainly through speeded-up transfer

treatment and enhances survival rates, many

to the stage o f treatments in which both the

individuals

patient and the physician are interested.

do not undergo

the medically

recommended periodical tests for the early detection of cancer and might even overlook early symptoms if these occur. This is mostly due not to lack o f information on the part o f

Decision Making Following diagnosis, the patient is often

patients or physicians but rather to psycholog-

called on t o participate

ical factors, such as excessive fear of cancer,

about the kind of treatment (surgery, kind o f

in the

decisions

that may even reach the level of the psychiatri-

surgery, chemotherapy, specific protocol of

cally meaningful syndrome o f cancerophobia

chemotherapy,

(Ingelfinger, 1 9 7 5 ) , a false sense of physical

tary/alternative treatment, each singly or in

radiation,

and

complemen-

Psycho-oncology

\

combination), the place o f treatment (which

Chaitchik, Algor, &c Weissler, 1 9 9 3 ; Sneeuw,

hospital or clinic and sometimes in which

Aaronson, & Yarnold, 1 9 9 2 ) .

country),

and

treatment

Chemotherapy may be administered as a

(which doctor). T h e tendency to transfer to

major therapeutic agent for controlling the

patients part o f the responsibility for the deci-

disease and promoting remission, as adjuvant

sions is in accord with the generally increased

treatment subsequent to surgery for eradicat-

empowerment

the

agent

of

in

ing presumptive micrometastases, or as neoad-

for

juvant treatment for reducing the tumor prior

patients because they mostly do not possess

to surgery. Chemotherapy mostly consists o f

treatment

o f patients. Participating

decisions is often

enough expert knowledge

difficult

in the

relevant

a combination o f drugs that are administered

domains. T h e difficulty is further increased by

through infusion (or sometimes tablets), in the

the large amounts of information that need to

hospital or clinic (or sometimes at home),

be mastered, the time pressure, the awareness

according to a certain regimen (e.g., once every

of the momentous importance o f the conse-

2 or 3 weeks) over months.

quences o f the involved decisions, the nearly

may adversely affect the patient's quality of life

Chemotherapy

continuous anxiety, and the overall emotional

( Q O L ) . T h e most salient effects are due to the

stress. Patients who tend to withdraw from the

toxicity o f the drugs themselves. Some o f these

task of deciding are often exposed to the pres-

effects

sure from friends and family members, who

dementia, delirium, lethargy, depression, and

remind the patients o f the importance of taking

even psychosis that may be evoked by pred-

are

neuropsychological,

including

responsibility for their health and may con-

nisone as well as delirium following the use o f

tinue to question the recommendations of their

vincristine or cisplatin. In addition, the drugs

doctors and the patients' initial tentative deci-

may cause nausea and vomiting, alopecia (e.g.,

sions. T h e problems o f decision making may

adriamycin), weight changes (gain or loss),

reemerge during later stages of the disease.

insomnia, gonadal

dysfunction,

difficulties

with concentration and short-term memory, and disorders of fertility and sexuality. T h e

Undergoing Treatments

short-term effects are mostly stronger followdiffi-

ing the administration o f the drugs and get

often

weaker after a few days. T h e side effects

include surgery, chemotherapy, and radiation.

together with the generalized weakness and

Treatments in oncology are both cult

and

mostly

protracted.

They

Surgery m a y be undertaken for

different

fatigue disrupt the patient's

daily

routine

purposes: diagnostic (i.e., biopsy), therapeutic

and render it difficult for the patient to keep

(i.e., removal o f tumor or metastases), recon-

up work or carry out planned commitments

structive (e.g., esophagus, bladder, breast), or

(Clark & Fallowfield, 1 9 8 6 ) .

palliative (e.g., biliary or urethral diversions,

Radiation may be undertaken as a major

pleurodesis or analgesic such as cordotomy).

therapeutic agent, as an adjunct to chemother-

Surgery is often accompanied by intense anxi-

apy designed to minimize the chance of recur-

ety, especially if it is diagnostic or results in

rence, or for palliative and analgesic purposes.

bodily changes such as stoma, loss of an organ

It is often o f shorter duration than chemo-

(e.g., breast, limb), loss o f a function (e.g.,

therapy but may also be accompanied by side

talking, walking), or visible

effects

disfigurement

(e.g., nausea, fatigue, or anorexia,

(e.g., face, neck). Changes of this kind are

depending on the site, dose, and volume of

often accompanied by changes in body image

treatment).

that reflect on the patient's sense o f selfesteem and self-identity (Rapoport, Kreitler,

Other frequent treatments include immunotherapy

(e.g., interferon), with side

effects

327

328

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS similar to those of chemotherapy, and bone

desire t o reestablish their daily

marrow transplantation, which involves isola-

patients may minimize their references to the

tion

disease and put on a cheerful mask o f "busi-

and

possible medical complications

routines,

often accompanied by serious psychological

ness as usual." This may enhance their isola-

responses (e.g., intense anxiety, psychotic

tion and speed up the process o f patients'

symptoms) (Andrykowski, 1 9 9 4 ) .

"burnout" (Kreitler & Chaitchik, 1 9 9 3 ) .

In the course o f treatments, the patient is highly vulnerable and needs a lot o f support and encouragement to overcome the difficulties. However, getting treatment makes the

Disease Recurrence and Deterioration

patient feel that there is hope for recovery,

Disease recurrence is a particularly difficult

thereby contributing to improving the patient's

phase for patients because it represents a shat-

Q O L (Kovner &c Kreitler, 1 9 9 6 ) .

tering of their hopes for complete recovery or

Being a Chronic Cancer Patient in Remission

necessity to undergo a series of treatments,

at least ensured survival. It also indicates the

Although remission is a positive state from

some o f which may be more difficult than those during the initial phase. T h e situation may be exacerbated through the appearance of differ-

the medical point o f view, it is not necessarily

ent physical symptoms signaling deterioration.

so psychologically. During the first stage o f

As a result, patients may find it difficult to

remission, patients may feel anxious because

avoid thinking about death as a real possibility.

of the need to learn to function on their own

Hence, fear o f death is a theme that occurs with

and handle different bodily reactions without

increasing intensity during this phase.

the continuous contact with the medical staff that characterized the phase of treatments. Furthermore, patients w h o have completed a protracted series o f treatments start to recon-

Terminal Stage Physical symptoms

(e.g., pain,

fatigue,

sider whether their lives are satisfying and

motor disabilities) as well as psychological

meaningful enough, especially in view o f the

symptoms

suffering they incurred during treatment. In

may turn this phase into a particularly difficult

(e.g., disorientation,

depression)

view o f the close encounter with death that

one for patients and

patients have undergone, they may also expe-

impending problem is the need to decide

rience the pressure to use advantageously the

whether to continue medical treatments, given

time they have gained by enjoying themselves

that their contribution to prolonging life may

their families. O n e

or doing things they consider relevant and

be small and uncertain and their effect on Q O L

important for themselves. Moreover, anxiety

is negative, or whether to stop treatments alto-

about the possible recurrence o f the disease

gether and enjoy a certain modicum o f Q O L

persists. It may be further enhanced by regular

that may still be possible. Thus, during this

follow-up visits to their doctors and is often

phase, some patients may be getting curative

also maintained by continuous medical treat-

treatments, whereas others may be getting only

ments (e.g., tamoxifen tablets in breast cancer

palliative treatments or none at all. This phase

patients). In addition, patients may feel the

is characteristically marked by the phases of

need to normalize their interpersonal relations

dying, that is, gradual withdrawal from differ-

after a period characterized by getting help

ent preoccupations and interests (e.g., work,

and social support from relatives and friends.

profession, friends, entertainment) that may be

For this reason, as well as because o f their

accompanied by gradual physical weakening.

Psycho-oncology Notably, the different processes described by

\

patient's need to gain a modicum o f control in

Kubler-Ross ( 1 9 6 9 ) , such as anger and despair,

a situation marked by extreme helplessness.

may occur in the course o f these phases, but

These observations suggest that the desire for

they tend to show up concomitantly, and often

hastened death may be a cry for help when

together with other processes, rather than in

basic psychological and physical needs are

consecutive stages. Other themes that

may

unmet. Taking care o f these needs may well

show up during this stage are confronting death

result in a significant decrease in the patient's

in a personal way, taking leave o f beloved ones,

interest in assisted suicide.

and finalizing issues with which patients have dealt in the past (e.g., trying to make up with friends, finishing jobs). However, sometimes

BRIEF OVERVIEW OF

patients may be expected, or even pressured by

RESEARCH IN T H E AREA

their friends and relatives, to deal with such issues even though they might not feel any ten-

As noted earlier, psycho-oncology has stimu-

dency to do so.

lated much research. This section presents

During recent years, the issues o f "physician-

the major domains o f research in psycho-

assisted suicide" and "right to die" have been

oncology. E a c h subsection includes a brief

increasingly discussed in regard to the terminal

description o f issues and major findings.

stage. O n the basis o f questionnaire surveys, it seems that about 8 % to 2 5 % of oncology patients with advanced disease express interest

Cancer Prevention and Screening

in death alternatives (Chochinov et al., 1 9 9 5 ; Emanuel, Fairclough, Daniels, &

A typical assumption is that at least a third

Clarridge,

of the cases o f cancer could be prevented

1 9 9 6 ) , citing mostly reasons such as fear o f

by controlling behaviors such as smoking,

becoming a burden on their families or o f

drinking alcohol, prolonged exposure to the

losing dignity, lack o f social support (Back,

sun, and contact with carcinogens. Another

Wallace, Starks, & Pearlman, 1 9 9 6 ) , disease

assumption is that undergoing regular tests in

status, pain, and other bothersome physical

adherence with the screening regulations for

(Massie, G a g n o n , &

Holland,

the various cancers (e.g., annual PSA test for

1 9 9 4 ) . In general, the desire for hastened death

men over age 5 0 years, repeated self-examina-

is more a function o f psychological and psychi-

tion o f the skin for melanoma or o f the breasts

symptoms

atric factors, such as depression, than o f pain

for

and physical problems (Cherny, 1 9 9 6 ) .

reduced the lethality o f the disease. Despite

suspicious lumps) could have

further

The desire for hastened death is an issue

increased efforts at information dissemination,

that deserves consideration apart from the

prevention and screening have not reached the

operational implication o f aiding the patient

desirable levels. For example, although the

to die. T h e desire is unstable (Chochinov,

contribution o f smoking to cancers of all kinds

Tataryn,

Clinch, &

increases when

Dudgeon,

the patient

1999),

is lonely

it

has been established and is well known, only

and

about half o f the smokers have quit smoking,

depressed (Rosenfeld, 2 0 0 0 ) , it decreases after

and very low percentages persist in not smok-

the patient gets social support and exposure to

ing for longer durations (for 1 year, 1 % to 5 %

empathie listening (Severson, 1 9 9 7 ) , and it is

of smokers after treatment or

not a function o f current pain (Emanuel et al.,

[Cinciripini, 1 9 9 5 ] ) . T h e same is true for

1996;

&

screening. In regard to breast screening, only

Chapman, 1 9 9 7 ) . It is likely that considering

about 1 5 % to 3 0 % o f women get screened,

the

and even individuals at risk do not comply as

Sullivan,

option

Rapp,

o f euthanasia

Fitzgibbon, expresses

the

self-quitters

329

330

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS required. If screening is done once, it is often

increased attendance (Chaitchik & Kreitler,

not repeated. This cannot be accounted for by

1 9 9 1 ) . Second, women of a specific personality

the difficulty of performing

the screening,

type (e.g., higher on negative emotions, with a

given that it is often made very easy, or by for-

restricted self-concept) were found to be more

getfulness, given that health authorities often

likely than other women to undergo screening

remind

for

tests (Kreitler et al., 1 9 9 0 ) . Findings o f this

screening (U.K. Trial o f Early Detection o f

kind suggest that screening may resemble other

people o f their appointments

Breast Cancer Group, 1 9 8 4 ) . Although self-

behaviors in being controlled by motivational

examination is still widely promoted (in regard

dispositions, for example, in line with the cog-

to breast cancer or melanoma [Berwick, Begg,

nitive orientation theory (Kreitler &c Kreitler,

Fine, Roush, Roush, & Barnhill, 1 9 9 6 ; Kreitler

1 9 8 2 ) . This theory assumes that behavior is

et al., 1 9 9 0 ] ) , it is not a reliable method for

guided by motivational vectors defined by four

early detection of cancer and may lead to dan-

types o f beliefs (about oneself, reality, norms,

gerous

delays

in

diagnosis

(Kreitler

&

and goals) reflecting dynamically meaningful themes rather than by conscious, voluntary,

Chaitchik, 1 9 9 5 ) . A great number o f studies have been done

rational decisions reflecting cost-benefit con-

to understand the causes o f noncompliance

siderations. Identifying the motivationally rele-

and to increase compliance in these areas (e.g.,

vant beliefs enabled the successful prediction o f

Cinciripini, 1 9 9 5 ; DiPlacido, Zauber, & Redd,

who

1 9 9 8 ; Rossi, Biais, Redding, & Weinstock,

colorectal, and cervical cancers (Kreitler, 1 9 9 8 ) .

would

undergo

screening for

breast,

1 9 9 5 ) . Studies have shown that information

The prediction for breast cancer held in regard

about risks, benefits, and dangers of doing or

to different populations

avoiding certain behaviors do not suffice for

place) and different kinds o f screening (e.g.,

motivating people to comply with the medical

induced, spontaneous, personal initiative or

(e.g., urban,

work-

recommendations. T h e health beliefs model

not, examination by self or doctor), whereby

assumes that four components play a signifi-

the best results were obtained with repeated,

cant role in screening behavior: beliefs about a

self-initiated screening by a doctor (Kreitler,

person's susceptibility to the disease, beliefs

Chaitchik, Kreitler, Sc Weissler, 1 9 9 4 ) .

about the severity of the disease, beliefs about the barriers and difficulties of the behavior, and beliefs about the benefits of the behavior (Janz & Becker, 1 9 8 4 ) . However, these variables often have proved insufficient for pre-

Coping and Adaptation Coping

is

the

general

concept

that

describes strategies for dealing with threat.

dicting or generating the desired behavior and

Strategies o f coping are triggered whenever

had to be supplemented by various circum-

there is a large gap between the extent o f the

stantial factors (e.g., J a n z & Becker, 1 9 8 4 ;

resources appraised by an individual as nec-

Murray & M c M i l l a n , 1 9 9 3 ) . Some studies

essary for handling a situation and the extent

suggest that noncompliance with

o f resources appraised as available to the

screening

may have deeper dynamic roots. First, because

individual

higher perceived risk among women with a

Coping is evoked when the gap in appraised

(Lazarus

&

Folkman,

1984).

family history o f breast cancer reduces fre-

resources is indeed large but less than in the

quency o f mammography screening (Polednak,

case o f despair, often characterized as hope-

Lane, & Burg, 1 9 9 1 ) , it is likely that increased

lessness/helplessness, and more than in the

fear may deter women from undergoing tests.

case o f mere challenge, often experienced as

Accordingly, reducing the anxiety by framing

" I could handle it if I tried hard enough." A

the medical test in a nonthreatening

large variety o f coping mechanisms

setup

have

Psycho-oncology

\

been identified (e.g., humor, denial, fighting

Concerning the often-discussed mechanism of

spirit), differing

to

denial, the most adequate conclusion is that it

reducing the gap in appraised resources (e.g.,

may be very helpful during specific stages o f

social support increases the amount o f avail-

coping, especially when applied selectively

able resources, humor and denial reduce the

(e.g., to emotions and not to reality appraisal)

in their contributions

a m o u n t o f required resources). T h e coping

(Kreitler, 1 9 9 9 ) . However, it seems warranted

mechanisms used by a cancer patient are not

to assume that the quantity and variety o f cop-

necessarily the same as those used previously

ing mechanisms that a person has at his or

by the individual in other situations. Multiple

her disposal constitute a better guarantee for

determinants affect the use o f one or another

adjustment than does a specific coping mech-

coping mechanism, mainly personal predis-

anism, regardless o f how efficacious it may be.

previous

Some studies have investigated the efficacy

personal experiences, modeling o f others,

positions,

beliefs

and

values,

of coping mechanisms in regard to the course o f

and the severity o f the problems that need to

disease. Efficacy can be assessed in terms of the

be handled (Rowland, 1 9 8 9 ) .

patient's adjustment. For the most part, results

There have been numerous attempts

to

identify the efficacy of coping mechanisms,

show that low adjustment

is significantly

related to recurrence (Rogentine et al., 1 9 7 9 )

in terms o f

and that better adaptation 1 year after diagno-

improving the patient's adjustment and Q O L .

sis is significantly related to fewer recurrences

M o s t prior research suggests that there is no

after 3 years and to longer survival in 5- and

one specific coping mechanism that can be

7-year follow-ups (Kreitler, Kreitler, Chaitchik,

considered as the best because the efficacy o f a

Shaked, & Shaked, 1 9 9 7 ) . Only one study

whereby

efficacy

is defined

strategy depends on (a) the individual (e.g.,

found that adjustment was unrelated to recur-

one patient may find comfort through faith

rence (Temoshok Sc F o x , 1 9 8 4 ) . However,

and religion, another through emotional sup-

studies of specific coping mechanisms did not

port, and another through going back to w o r k

yield clear results about the benefit of any spe-

[e.g., Schonfield, 1 9 7 2 ] ) and (b) the stage o f

cific coping mechanism in regard to survival.

the disease and the problems confronting the

Thus, active behavioral coping was related to

individual. Thus, the individual changes in

survival (Fawzy, Fawzy, & Canada, 2 0 0 1 ) , but

the use o f different coping mechanisms in the

the active means o f distraction and problem

course o f different stages of coping with the

tacking were unrelated to survival (Buddeberg

disease

1 9 9 6 ; Heim,

et al., 1 9 9 6 ) . Again, hopelessness/helplessness

Augustini, Schaffner, & Valach, 1 9 9 3 ) . In

was related to recurrence (Jensen, 1 9 8 7 ) but

general, the more efficacious coping mecha-

also was unrelated to recurrence and survival

nisms are those focused on solving problems,

(Cassileth, Lusk, Miller, Brown, 8c Miller,

(Buddeberg et al.,

confronting real-life issues, actively searching

1 9 8 5 ; Cody et al., 1 9 9 4 ; Ringdall, 1 9 9 5 ) . One

for information (Felton &c Revenson, 1 9 8 4 ;

reason for the lack of clarity o f the findings is

Weisman & Worden, 1 9 7 6 - 1 9 7 7 ) ,

having

that in some studies basic medical prognostic

emotional discharge (e.g., through

humor,

criteria, such as the number of affected lymph

through sharing experiences [Penman, 1 9 8 0 ] ) ,

nodes, were not considered. This was the case

and cultivating hope and optimism (Scheier &

in the famous series o f the Royal Mardsen stud-

Carver, 2 0 0 1 ) .

ies, which reported that fighting spirit and per-

T h e least effective coping

mechanisms are those focused on avoidance,

haps denial had a positive effect on survival,

passivity, pessimism, yielding, blaming, acting

whereas stoic acceptance, anxious preoccupa-

past

tion, and hopelessness/helplessness had a nega-

(O'Malley, Koocher, Foster, & Slavin, 1 9 7 9 ) .

tive effect (Greer, Morris, & Pettingale, 1 9 7 9 ;

out, apathy,

and regrets a b o u t

the

331

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

332

Greer, Morris, Pettingale, & Haybittle, 1 9 9 0 ;

made to reinstate the optimal level as much as

Morris,

1992;

possible by establishing the new Q O L level on

Pettingale, Morris, Greer, & Haybittle, 1 9 8 5 ) .

improvements and increases in a variety of

Pettingale,

&

Haybittle,

The results were not obtained when medical

other domains such as entertainment, dwelling

variables were adequately controlled in a repli-

conditions, and meaningfulness o f occupation

cation (Watson, Haviland, Greer, Davidson, Sc

(Kreitler, Chaitchik, Rapoport, Kreitler, &

Bliss, 1 9 9 9 ) .

Algor, 1 9 9 3 ) . This homeostatically grounded tendency is probably also responsible for the increases in levels o f Q O L (even over the pre-

Quality of Life

disease levels) that are sometimes observed in

Quality o f life is defined as the subjective evaluation by the individual o f his or her own well-being

and

functioning

in

cancer patients who find new venues for creativity and personal growth.

different

domains o f life. T h e major characteristics of Q O L are that it is subjective (hence, it is assessed by self-reports), based on evaluation,

Effect of Psychological Factors on Disease Incidence

phenomenological (causes not considered),

The major psychological factors investi-

dynamic (changes in line with changes in situ-

gated are stressful life events, psychopathology,

ations and conditions), and multidimensional

and personality tendencies. This subsection

(refers to various domains such as physical

focuses on each in turn. Table 1 7 . 1 presents

functioning, eating, sleeping, sex, emotional

the basic research designs in this domain.

state, cognitive functioning, family life, social relations, meaning, and coherence in life).

Stress. Animal models show that stress has-

Q O L differs from functional indexes that

tens the onset and further growth o f most

assess mainly functioning or ability o f the indi-

virally induced tumors and inhibits the onset

vidual to take care o f himself or herself in

and growth o f nonviral ones (Justice, 1 9 8 5 ) .

daily life

But the results o f studies investigating the rela-

(e.g., Karnofsky's

Performance

Status Rating). Q O L assessments mostly fail

tions o f stressful life events and cancer inci-

to distinguish among groups with different

dence

in

humans

are

equivocal.

Thus,

clinical disease statuses or different levels

case-controlled studies have shown that can-

of

Aaronson,

cer patients, as compared with controls,

Ahmedzai, Bergman, Bullinger, & Cull, 1 9 9 3 ;

had more stressful events in their earlier

M c H o r n e y , W a r e , & Raczek, 1 9 9 3 ) but are

lives (Courtney, Longnecker, Theorell,

performance

ratings

(e.g.,

&

sensitive to effects in different domains o f life,

Gerhardsson de Verdier, 1 9 9 3 ; Geyer, 1 9 9 1 ) ,

for example, in the course of treatments (Ganz

had the same number o f stressful

Sc Coscarelli, 1 9 9 5 ) . T h e assessment of Q O L

(Edwards et al., 1 9 9 0 ) , or had fewer stressful

plays an important role in clinical trials, in

events (Priestman, Priestman, S i Bradshaw,

events

decisions about treatments, and in evaluating

1 9 8 5 ) . Large-cohort studies have yielded sim-

the costs o f treatments in terms o f Q O L as

ilar results; no relation was found between

compared with their contribution to survival

stressful events earlier in life and cancer mor-

(de Haes et al., 2 0 0 0 ) . O n e important finding

bidity in prisoners of war (Joffres, Reed, &

is that Q O L tends to maintain a stable optimal

Nomura,

level based on the appraised status in the

Goldberg, & Beebe, 1 9 7 4 ) or between stress-

major domains o f health, work, and family or

ful events earlier in life and bereaved spouses

social ties. I f status in any o f these domains is

(Helsing, Comstock, Sc Szklo, 1 9 8 2 ; Kaprio,

lowered for a longer duration, attempts are

Koskenvuo, Sc Rita, 1 9 8 7 ) , but more cancer

1 9 8 5 ; Keehn,

1980;

Keehn,

Psycho-oncology

\

Basic Designs Used in Studies on the Effect of Psychological Factors on Incidence and Course of Disease in Cancer

Table 17.1

Design

Description

Advantages

Shortcomings

Retrospective

Psychological variables are assessed after cancer diagnosis

Large samples and immediate availability of all medical information

Cancer diagnosis may affect reports of premorbid personality and events

Quasi-prospective

Psychological variables are assessed after addressing doctor but prior to diagnosis

No biases of recall of the past; medical information available in short time

Psychological assessments affected by the anxiety of waiting for diagnosis and presentiments

Retro-prospective

Psychological variables are assessed long before cancer diagnosis in a cohort studied for another reason/purpose

No biases of recall of the past; medical information available in short time

Psychological assessments may be biased or not quite relevant

Prospective

Psychological variables are assessed before cancer diagnosis; course of disease is checked in follow-ups

Reliability of baseline data; control of selection biases in sample

Difficulty with follow-ups for prolonged periods of time

S O U R C E : For the designs, see T e m o s h o k and Heller (1984).

hematopoietic

Depression is another pathological condi-

malignancies) was found over 2 0 years in

(melanoma, lymphatic

and

tion that has been associated with cancer,

parents o f accident victims and among parents

especially on the evidence o f a

who had lost sons in the Y o m Kippur war in

study at an electric plant in Chicago (Persky,

Israel (Levav et al., 2 0 0 0 ) .

Kempthorne-Rawson

cohort

8c Shekelle, 1 9 8 7 ;

Shekelle, R a y n o r , Ostfeld, Sc Garron, 1 9 8 1 ) . Earlier studies

Psychopathology.

sug-

Y e t other cohort studies did not confirm this

get

finding. T h e combined evidence supported

cancer less often than did others. Y e t later

merely a null or weak relationship between

analyses o f the findings showed that the early

depression and risk for cancer ( F o x , 1 9 8 9 ) .

gested that

studies had

schizophrenics tended

led to erroneous

to

conclusions

because they were based on calculating pro-

Personality.

It has been often claimed that a

portional mortality from cancer instead o f

certain pattern o f personality characteristics,

absolute mortality rates ( F o x , 1 9 7 8 ) . Studies

Type C, presents a risk for cancer. Type C has

based on absolute rates show that schizo-

been described as compliant, unassertive, sub-

phrenics do not have a reduced rate o f cancer

missive, and avoiding the expression of nega-

(Gulbinat et al., 1 9 9 2 ) and that

tive emotions, especially o f anger (Temoshok,

patients

diagnosed with reactive psychosis may even

1 9 8 7 ) . Studies have supported some Type C

have a slightly increased rate o f cancer as

tendencies. For example, one study enabled sig-

compared

nificant identification o f cervix cancer patients,

with

the

general

(Jorgensen & Mortensen, 1 9 9 2 ) .

population

as compared with controls, on the basis of high

333

334

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS defensiveness and extraversion scores (Kreitler, Levavi, & Bornstein, 1 9 9 6 ) . Suppression of

Stress.

There is no definitive evidence that

stress influences the course o f cancer or sur-

emotions is the most widely investigated o f the

vival rates. F o r example, no relationship was

Type C tendencies. T h e studies of this tendency

found between stressful events and breast

(1998b)

cancer survival (Barraclough et al., 1 9 9 2 ) .

reported that five of the main studies sup-

However, bereavement (losing a son in a war

ported the tendency, four did not support it,

or in a traffic accident) increased the risk of

and three had mixed findings. Furthermore, the

death from different types o f cancer, but only

apparent nonemotionality in cancer patients

if the cancer had been diagnosed before the

may be due to their intention to suppress emo-

loss (and not after it) (Levav et al., 2 0 0 0 ) .

have yielded mixed results. F o x

tions as part o f their effort to appease others rather

than to

an

authentic

alexithymia

Psychopathology.

T o date, the evidence

(Servaes, Vingerhoets, Vreugdenhil, Keuning,

concerning the effect o f depression is equivo-

& Broekhuijsen, 1 9 9 6 ) . Moreover, comparing

cal. O n e early study indicated higher rates of

the repressiveness of women before and after a

depression and psychiatric disorders in patients

biopsy for breast cancer and for nonrelevant

with shorter survival periods (Weisman &

control surgery showed that before surgery all

Worden, 1 9 7 5 ) . Another study showed the

women had a comparable level of repressive-

reverse; long-term survivors were in greater

ness (measured by high defensiveness and low

distress,

anxiety) but that after surgery there was a sig-

were well adjusted

nificant rise in the repressiveness o f only those

Melisaratos, 1 9 7 9 ) . Still other studies indicated

women who were given the diagnosis o f cancer

that recurrence and survival in cancer patients

(reflecting a rise in defensiveness to combat

are not related to distress (as assessed by the

whereas

short-term

survivors

(Derogatis, Abeloff,

&

anxiety) (Kreitler, Kreitler, & Chaitchik, 1 9 9 3 ) .

Symptom Checklist-90) (Holland et al., 1 9 8 6 )

Hence, it is likely that suppression of emotions

or to anxiety, depression, and anger (Jamison,

subserves the need to control anxiety. How-

Burish, & Wallston, 1 9 8 7 ) . Indeed, the recent

ever, the theory of cognitive orientation that

replication o f the Royal Mardsen

enables a more extensive approach to measur-

showed that depression was the only psycho-

ing personality tendencies relevant for cancer

logical variable that predicted earlier mortality

studies

showed that limited expression o f emotions

from cancer, but there were too few cases to

may be one o f several tendencies included in the

make the finding reliable (Watson et al., 1 9 9 9 ) .

profile characterizing specific types of cancer patients. For example, it was found to be part of the profile characterizing colon cancer patients as compared with healthy controls, whereby it is probably not a result of the disease because it does not change with disease duration (Figer, Kreitler, Michal, & Inbar, 2 0 0 2 ) .

Personality.

O f the Type C components,

defensiveness was related to shorter survival (Ratcliffe, Dawson, & Walker, 1 9 9 5 ) as well as to a particular personality type whose major characteristics are dealing with loss by despair and retaining closeness to people with whom one's relationship

Effect of Psychological Factors on Disease Course and Survival The main investigated factors were stress,

has

ended

(Grossarth-

Maticek, Kanazir, Schmidt, & Vetter, 1 9 8 5 ) . However, the latter study was severely criticized in regard to reliability (Schueler & F o x , 1 9 9 1 ; V a n der Ploeg, 1 9 9 1 ) . Concerning emotional suppression, the findings are unclear;

psychopathology, and personality (see also

F o x ( 1 9 9 8 b ) found three studies with positive

Table 17.1).

results, three with negative results, and three

|

Psycho-oncology with mixed results. There is also evidence o f no

recurrence was found (Burman & Margolin,

correlation of psychosocial variables to recur-

1992). In regard to survival, studies showed a

rence or survival (Cassileth et al., The

cognitive o r i e n t a t i o n

1985).

small effect o f better survival for married

theory

has

women

(Goodwin, Hunt, Key, &

Samet,

enabled identifying a set o f characteristics

1987), but only when they are young (Neale,

(e.g.,

Tilley, 8c Vernon, 1986) and not for older

readiness

to

expose

a

person's

8c Lusk, 1988).

weaknesses, self-confidence, low seeking o f

women (Cassileth, Walsh,

approval, low obsessiveness and compulsive-

However, there is also evidence o f shorter sur-

ness) that differentiated significantly between

vival for married women (Ell, Nishimoto,

patients with recurrence and those without

Mediansky, Mantell, 8t Hamovitch,

recurrence at 3 years follow-up and survival

and o f no relation between survival and being

1992)

8c Surtees, 1989). T h e

at 5 years onward. During the initial years,

married (e.g., Dean

psychological factors contributed less to pre-

results are inconsistent, possibly because can-

dicting survival than did medical factors, but

cer site, gender, and quality o f marriage have

the former's relative and absolute impacts

not been considered.

increased with time (Kreitler et al.,

1997).

In conclusion, there are two main reasons

In regard to size of social network, studies show no relation to incidence (Reynolds &

unclear. O n e is disregard for the fact that prog-

1990), recurrence (Cassileth et al., 1985), or survival (Vogt, Mullooly, Ernst, Pope, &c Hollis, 1992). In contrast, active social

nosis o f survival should consider conjointedly

participation and active involvement have a

why most of the findings examining the impact of psychological factors on survival have been

Kaplan,

medical and psychological factors. T h e second

positive effect on reduced recurrence (Hislop,

is the tendency to narrow research down to a

Waxier, Coldman, Elwood, 8c Kan, 1987) and

1992), more so

specific set o f psychological variables rather

on longer survival (Vogt et al.,

than to expand the search for new psychologi-

with friends than with relatives (Waxier-

cal variables by applying new methodologies.

Morrison, Hislop, Mears,

8c Kan, 1991).

Cancer patients often refer to their need for emotional support, which is widely believed

Social Relations and Support

to positively affect the course o f disease. In one

It has long been surmised that the social

study, perceived family support did not pre-

environment in which people function affects

dict recurrence (Levy, Herberman, Lippman,

cancer incidence and prognosis. T h e question

D'Angelo, & Lee,

of whether social ties affect cancer incidence

vival was related to feeling isolated and lonely

1991). However, shorter sur-

has been studied by examining two aspects of

(only in women) and to having few contacts (in

social relations: static-descriptive aspects (i.e.,

men) (Reynolds 8c Kaplan, 1990) as well as to

marital status and number o f social ties) and

having a high need for emotional support

8c Stewart, 1988),

active-functional aspects (i.e., extent o f partici-

(Stavraky, Donner, Kincade,

pation and involvement in social relations). In

whereas longer survival was related to per-

regard to cancer incidence, various studies

ceived adequacy of family support (Stavraky

found that married people had a lower inci-

et al., 1988) and to getting adequate emotional

dence o f cancer (Reynolds & Kaplan,

1990),

that they had a higher incidence of cancer

support (only in women) (Ell et al.,

1992). It is

likely that social participation positively affects

Sc M c C r a e , 1989), and

survival and disease progression because it has-

that the findings probably varied with cancer

tens diagnosis (Neale et al., 1986) and pro-

site, gender, and ethnicity (e.g., Swanson, Belle,

motes compliance with treatment (Richardson,

(Zonderman, Costa

& Satariano,

1985). N o effect o f marriage on

Shelton, Krailo, 8c Levine,

1990).

33S

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

336

There are often cited studies that supposedly

stresses (e.g., children of sick parents, parents

support the effects o f social support inter-

of sick children regardless o f the children's

ventions on survival. T h e best known is the

ages, partners of patients) (Keller, Henrich,

Stanford University study that claimed an

Sellschopp, & Beutel, 1 9 9 5 ; Koch, Hàrter,

additional

advanced

J a k o b , & Siegrist, 1 9 9 5 ) . Fourth, the family is

18 months of life for

breast cancer patients who got social support

exposed to severe stresses due to the patient's

as compared with controls (Spiegel et al.,

sickness and everything else it involves, includ-

1 9 9 9 ) . However, the study was criticized for

ing the changes in daily routine and roles, the

methodological reasons, mainly sample choice

threat o f impending death, and/or conflicts

and differences between the two groups (Fox,

with the medical staff (Jacobs, Ostroff,

1 9 9 8 a ; Kogon, Biswas, Pearl, Carlson,

&

Steinglass, 1 9 9 8 ) . Families vary greatly in the

Spiegel, 1 9 9 7 ) and failed to be replicated

manner in which they cope with the difficulties

&

(Goodwin et al., 2 0 0 1 ; Spiegel et al., 1 9 9 9 ) .

and respond to the stresses. Some mobilize

Methodological criticism was also leveled

resources and are even strengthened, whereas

against other studies in regard to the effects o f

others disintegrate. Some families

social support (Gellert, Maxwell, & Siegel,

support or solve problems, whereas others are

1 9 9 3 ; Morgenstern, Gellert, Walter, Ostfeld,

hostile

&

McKenzie, M c D o w a l l , & Nitzan, 1 9 9 8 ) . T h e

Siegel, 1 9 8 4 ) . In contrast, many studies

or

withdrawn

provide

(Kissane,

Block,

show clearly the beneficial effect o f social sup-

state o f the family is an important factor in

port on patients' Q O L (e.g., Bloom, 1 9 8 6 ;

the patient's well-being, not least because the

Dunkel-Schetter, 1 9 8 4 ; Spiegel et al., 1 9 9 9 ) .

family is a serious provider o f care to the

Future research in social support could

patient. T h e family's coping depends on sev-

benefit from considering the following: (a) the

eral factors such as how it interprets external

differential effects of various types of social

reality and defines its identity (Jacobs et al.,

support (e.g., informational, emotional), (b) the

1 9 9 8 ) as well as the degrees of communication,

source o f support (e.g., relatives, health profes-

emotional expressiveness, and cohesion in the

sionals), and (c) the dependence of the need for

family (Kissane et al., 1 9 9 8 ) . There is a grow-

support

ing awareness in health professional circles

on

personality

and

availability

that family members deserve special psycho-

(Dunkel-Schetter, 1 9 8 4 ) .

logical support so that they can withstand adequately the hard and prolonged stresses of

Family

cancer, provide the patient with an adequate

T h e family is involved in psycho-oncology in different

aspects. First, the family is a

environment, and avoid turning into "secondorder patients" (Jacobs et al., 1 9 9 8 ) .

provider of care for the patient (e.g., providing emotional

support,

getting

information,

offering help in decision making, giving concrete help, sharing financial costs, meeting social needs and costs, maintaining routine)

Getting Information and Truth Telling Information

about

diagnosis, prognosis,

(Lederberg, 1 9 9 8 ) . Second, the family under-

and treatment is one o f the most central issues

goes serious changes due to the patient's dis-

for the cancer patient. Its importance has been

ease and the involved stresses (e.g., changes in

enhanced by the tendency during past genera-

routines, roles, attachment relationships, man-

tions to keep the diagnosis secret and by the

ner o f functioning, structure, and sense o f well-

current tendency to involve the patient in deci-

being) (Weihs & Reiss, 1 9 9 5 ) . Third, specific

sions about

family members may be exposed to special

theme that occurs primarily during the first

treatments.

Information

is a

Psycho-oncology following

different

\

phase o f the disease but that continues to play

remission

an important role in the further phases o f the

Hence, patients are often frustrated. Another

treatments.

disease, mainly whenever there is a recurrence,

complicating factor is the conflict that many

a need to decide about treatment options, or

patients experience among the kind o f infor-

any change in the disease, down to the preter-

mation they want to get (e.g., good news),

minal and terminal phases. T h e kind, amount,

the kind they think they should get (e.g., how

information

long they have to live), and the kind they

change during the different stages o f the

get (e.g., facts about diagnosis and prognosis).

meaning,

and

disclosure

of

disease. Patients often use multiple sources o f

Moreover, patients may be reluctant to ask for

information that vary in completeness and

information they want or think they are enti-

reliability such as physicians (first and second

tled to get because they believe that their doc-

opinions), nurses, social workers, psychol-

tors k n o w best what is good for them, so that

ogists, other patients, relatives, friends, the

if the doctors did not provide that information,

Internet, and the media (Kreitler, Chaitchik,

it is probably not good for the patients to have

Rapoport, Sc Algor, 1 9 9 5 ) . Some patients find

it (Chaitchik et al., 1 9 9 2 ; Kreitler, Chaitchik,

it difficult to understand the information and

Kovner, & Kreitler, 1 9 9 2 ) .

its implications, to evaluate the sources, and to integrate them, especially when

there

After getting the relevant information, the

are

major issue becomes living with the informa-

inconsistencies. Some patients ( 1 3 % during

tion. For example, a study with head and neck

initial phases to 5 7 % during later phases) may

patients showed that those w h o had a large

tend to renounce the effort to deal with the

amount o f information had improved rela-

information and decide to rely instead on their

tions with family members and friends but

primary oncologists. However, this response

functioned less well at work and suffered from

often calls forth pressure o f family members

anxiety about their medical state, those who

and friends on the patient to be empowered

had a little information had tense and poorer

and actively involved in getting information.

relations with family members and friends but

Getting information may turn into a coping

functioned well at work and did not suffer

mechanism for patients (Watson et al., 1 9 8 8 )

from undue anxiety, and those w h o had a

but also for caretakers who feel that they will

medium amount o f information had tense

be best able to help the patient in this way.

relations with others as well as problems with

This is probably due to the fact that dealing

work and anxiety (Kreitler et al., 1 9 9 5 ) .

with information may give rise to the feeling

Another aspect o f information in cancer

or illusion o f having control over the disease.

patients concerns the communication of infor-

Studies show that patients often view the

mation by the patient to others. Patients are

amount of information they got from their

often concerned with issues such as h o w much

doctors as less than the amount the doctors

and which information

estimate they have transmitted

of health to disclose, to whom, and when.

(Chaitchik,

about their states

Kreitler, Schwartz, Shaked, & Rosin, 1 9 9 2 ) .

Considerations include not wanting to bother

There is also a difference in the kind o f infor-

others or to burden them emotionally, pre-

mation expected and that obtained. Patients

serving patients' self-esteem, avoiding the pity

often expect to get information about whether

of others, and maintaining patients' denial o f

their doctors believe the treatment will help

the disease. Notably, one study showed that

them, what their real states are, whether they

even spouses o f cancer patients k n o w rela-

are about to die, and h o w long they have to

tively little about what cancer patients experi-

live. In contrast, the information they get refers

ence and know, indicating a low degree o f

to diagnosis, stage, grade, and percentages o f

communication (Chaitchik et al., 1 9 9 2 ) .

337

338

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

Pathogen

Disease

Figure 17.1

The Stimulus-Background Model of Disease

Genetic Testing and Counseling

Models of the Problem genetic

Models in psycho-oncology about the etiol-

research have increased the importance o f

ogy and prognosis o f cancer form part o f the

three categories o f genetic

determinants

more encompassing approach of biopsychoso-

related to cancer: (a) cytogenetics, which con-

cial medicine, which has replaced the more

cerns abnormal chromosomes; (b) single-gene

limited approach o f biomedical medicine and

traits, which concern hereditary

mutations

assumes that psychological factors are involved

(c) ecogenetics, which

in physical disorders. Thus, in regard to disease

The

spectacular

(e.g., BRCA1);

and

advances

of

concerns gene and environment interactions

incidence, it is assumed that each disease is

(e.g., Epstein-Barr virus causing lymphoma

caused by some pathogen (e.g., microbe, virus,

in individuals with specific genes). Genetic

material with detrimental effects for the organ-

information may have serious psychological

ism such as radioactivity or carcinogens). As

effects, including anxiety and stress in healthy

illustrated in Figure 1 7 . 1 , the effect of the

and sick individuals as well as in their chil-

pathogen is not automatic; rather, it depends

dren. Studies have shown that individuals at

on background factors such as the organism's

risk might not undergo screening, especially if

genetic tendencies, nutritional state, immune

their fear is high. Furthermore, their readiness

system, comorbidity, psychological factors,

to participate

proce-

and characteristics specific to the particular

treatment,

disease (e.g., lipids and blood pressure in car-

dures,

in health-promoting

including

prophylactic

and

diological disorders). Likewise, the effect of the

beliefs about their likelihood o f getting sick

treatment on recovery is not automatic; rather,

(Kash & Lerman, 1 9 9 8 ) .

it depends on background factors that are o f

depends on their anxiety, education,

Psycho-oncology

Treatment

Disease

Health Figure 17.2

The Stimulus-Background Model of Recovery

similar categories as the factors relevant for disease occurrence (Figure

17.2). Notably,

Garssen &

Goodkin,

1999). The effect of

psychological factors on cancer is assumed to be

background factors always include psycholog-

through the immune

ical factors, but their role and extent o f impact

Valdimarsdottir,

may vary in the case of different diseases and

overall effect of the immune system on tumor

perhaps also across individuals. M o s t of the etiological models in psycho-

system (Bovbjerg Sc

1998). However, because the

growth appears to be moderate on the whole, a variety of pathways are explored to account for

psychoneuroim-

the effects of psychological factors. One such

munology (Bovbjerg & Valdimarsdottir, 1998;

pathway is infections, to which cancer patients

Goodkin & Visser, 2000). According to this dis-

may be particularly vulnerable and

cipline, the causal matrix consists of a multiplic-

form the major cause of cancer-related deaths

ity of factors derived from different domains,

(Bovbjerg Sc Valdimarsdottir,

oncology

are

based

on

1998;

which White,

mainly the neurological, immune, endocrinolog-

1993). T w o other likely pathways are stress,

ical, and psychosocial domains. However, the

which functions through alterations in the

models differ in the interactions assumed among

hypothalamic-pituitary-adrenal

the factors, in the nature of the embedded causal

hypothalamic-sympathetic-medullary

axis and the axis

Sc Glaser, 1999), and depression,

links, in the emphasis placed on factors o f dif-

(Kiecolt-Glaser

ferent domains, and in the manner in which the

which functions through alterations in the

different factors are structured and positioned in

hypothalamic-pituitary-adrenal axis, the hypo-

relation to one another. M o s t often, the immune

thalamic-pituitary-thyroid

system is placed in a central position and the rest

hypothalamic-growth hormone axis (Mussel-

axis,

and

the

Sc Nemeroff, 1998).

of the factors are considered insofar as they

man, McDaniel, Porter,

affect immunological parameters (Finn, 2001;

Notably, it has been suggested that more weight

340

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS should be attributed to psychological factors in

7 1 % were completely symptom free, whereas

psychoneuroirnmunology to gain a better under-

2 1 % had deteriorated into major depression

standing of the immune effects on cancer and

or alcoholism (Andreasen & Hoenk, 1 9 8 2 ) .

evidence of the full extent of the immunological

Depressive

are the most fre-

symptoms

impact on cancer incidence and progression

quent kind o f mental health problem in can-

(Bovbjerg & Valdimarsdottir, 1 9 9 8 ) .

cer patients. T h e estimates o f their prevalence range from 1 % to 5 3 % in the various studies (DeFlorio & Massie, 1 9 9 5 ) . T h e reasons for

DIAGNOSTIC AND

the variation are differences in the tools of

E T I O L O G I C A L ISSUES

assessment, in the diagnoses (e.g., major depression, unipolar depression, dysthymic

Clinical Description

disorder), in the group o f cancer patients in

A great number of studies have examined

which depression is assessed (e.g., pancreatic,

the prevalence of mental health disorders in

breast), and in the phase o f the disease in

cancer patients. According to a review based

which depression is assessed (e.g., prelimi-

on the findings of the first cooperative group

nary, advanced). T h e tools o f assessment vary

organized for the study of these issues, 5 3 % o f

in the ways in which they solve the problem

cancer patients had "normal responses to can-

o f overlap in symptoms between depression

cer," whereas 4 7 % had different psychiatric

proper and cancer (i.e., the disease and its

diagnoses: 3 2 % adjustment

with

treatments). There are four major approaches

symptoms of depression and anxiety, 6 %

to this issue: (a) the inclusive (counts all

disorders

major depression, 4 % organic mental disor-

symptoms regardless o f origin), (b) the etio-

ders (dementia or delirium), and 5 % preexist-

logical (counts only symptoms due to depres-

( 3 % personality

sion proper), (c) the substitutive (replaces

disorders, 2 % anxiety disorders) (Derogatis

indeterminate symptoms such as fatigue with

et al., 1 9 8 3 ) . O f all psychiatric

disorders

cognitive symptoms such as brooding), and

observed, 8 9 % were related to the disease and

(d) the exclusive (eliminates all symptoms due

the treatments, whereas only 1 1 % represented

to the disease or treatment and uses other

prior psychiatric problems. Other

depression criteria). T h e narrower the defini-

ing psychiatric disorders

studies, and

tion, the lower the observed prevalence o f

criteria, reported 1 4 % to 3 1 % of cancer sur-

depression. O n the whole, depression is also

using various assessment instruments

vivors with psychiatric diagnoses (for a review,

quite frequent in other medically sick people,

see Kornblith, 1 9 9 8 ) . T h e estimates o f the

with its prevalence ranging from 5 % to 5 5 %

reviewed studies resemble the earlier estimate,

(Popkin 8c Tucker, 1 9 9 2 ) .

considering that adjustment disorders are an intermediary state between normal

prevalent in cancer patients is depressed mood

is

followed by unipolar depression. Depression

under stress and pathology. The prevalence o f adjustment

O f the varieties of depression, the most

coping

coupled with a general adjustment disorder, disorders

due to the special stresses o f cancer: the dura-

is higher in some cancer diagnoses than in

tion and difficulties of treatments, the side

others, for example, breast cancer survivors

effects of treatments, the fear of recurrence, the

versus testis cancer survivors (Gritz, Wellisch,

impairment

o f body

image, and

so

on.

&

Landsverk, 1 9 8 8 ; Sneeuw et al., 1 9 9 2 ) .

Adjustment disorders are more frequent during

Advanced disease stage is often correlated

the early phases of cancer and often subside

with more depression. T h e factors contribut-

with time or evolve into another diagnosis. In

ing to depression in cancer patients include

one study with adult patients, after 5 years,

disabling

symptoms,

lower

Karnovsky

Psycho-oncology scores, uncontrolled pain, exhaustion/fatigue,

Anxiety may also be evoked by

metabolic abnormalities (e.g., anemia, hyper-

metabolic states (e.g., hypocalcemia, hypo-

calcemia),

endocrinological

abnormalities

(e.g., hyper- or hypothyroidism),

different

glycemia), hormone-secreting drugs

various

different

tumors,

(e.g., corticosteroids).

Its

chemotherapeutic agents (e.g., vincristine, vin-

manifestations

blastine), diverse medications (e.g., steroids,

tension, fear, dependence, withdrawal, and an

interferon,

enhanced

interleukin-2), and psychosocial

characteristics (e.g., recent loss o f spouse or friend, poor social support, previous Although

the total n u m b e r

o f cancer

tendency

to

become

lability, nauseous

(Noyes, Holt, & Massie, 1 9 9 8 ) .

psy-

chopathology) (Massie & Popkin, 1 9 9 8 ) .

include emotional

and

During recent years, increasing attention has been devoted to posttraumatic stress disorder (PTSD) in cancer patients

and

survivors.

patients who commit suicide is low, the risk of

Research was spurred particularly by the high

suicide in cancer patients is double that in the

prevalence o f avoidant and intrusive symptoms

general population (Campbell, 1 9 9 6 ) . Factors

in

correlated with the risk for suicide include gen-

Gebhardt, Petersen, & Hirji, 1 9 9 4 ) . In some

this

population

(Greenberg,

Goorin,

der (being male [in adults], being female [in

studies, up to 4 4 % o f patients reported P T S D -

adolescents]), site of cancer (particularly oral,

like symptoms (Cordova et al., 1 9 9 5 ) . Y e t only

pharyngeal, and lung cancers), medical state

4 % to 1 0 % of cancer survivors actually met

(e.g., advanced disease, poor prognosis, suffer-

criteria for a diagnosis o f P T S D (Alter et al.,

ing due to pain and fatigue), and preexisting

1 9 9 6 ) , as compared with 2 5 % to 3 3 % o f indi-

psychopathology (e.g., suicide attempts, psy-

viduals exposed to traumatic events (Yehuda,

chosis). Suicide ideation seems to be much

Resnick, Kahana, & Giller, 1 9 9 3 ) . One impor-

more frequent than suicide intent or actual sui-

tant result of P T S D is that it renders recurrent

cide

exposures to medical tests and treatments more

attempts

(Breitbart, 1 9 9 0 ) .

Suicidal

thoughts expressed during preterminal stages also are often not steady; may subside when patients

get empathy

and

social support.

difficult emotionally for patients. O f particular importance are chiatrie

effects

neuropsy-

due to side effects o f chemo-

Suicidal ideation o f patients may at times

therapeutic

express primarily their desire for control, their

states often observed in cancer patients. F o r

need to test their relatives, and/or attempts to

example, 5-fluorouracil may cause memory

reduce

their

fear

o f death

(Kreitler &c

Merimsky, in press).

agents or abnormal

metabolic

loss and confusional episodes; ifosfamide may cause hallucinations, somnolence, and mutism

in can-

(Tuxen & Hansen, 1 9 9 4 ) ; interferon alpha

cer patients is probably higher than in other

may cause agitation, emotional lability, and

medical conditions but its extent is uncertain

personality change (Quesada, Talpaz, Rios,

due to varying criteria, assessment

instru-

Kurzrock, & Gutterman, 1 9 8 6 ) ; and hypo- or

The prevalence o f anxiety

disorders

ments, and samples. Estimates vary from 1 5 %

hypercortisolism and hypo- or hypercalcemia

to 2 8 % (Carroll, Kathol, Noyes, W a l d , &

may cause depression, delirium, and dementia

Clamon, 1 9 9 3 ) . There are no consistent find-

(Fleishman, Lesko, & Breitbart, 1 9 9 3 ) .

ings about the gender, cancer site, age, and marital status correlates o f anxiety. Anxiety appears to increase in the course o f treatments (surgery and chemotherapy) and particularly

Typical Etiologies In trying to understand the psychological

with the advance o f disease. It may be viewed

state or reactions o f cancer patients, it is always

as a more or less constant accompaniment o f

recommended to apply a broad multidisci-

the

plinary approach and to assume interactions o f

different

vicissitudes

o f the

disease.

342

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS factors of diverse domains. For example, the

their psychological distress because they may

causes of anorexia, a typical symptom in cancer

regard it as a sign of weakness. T h e evaluations

patients (Lesko, 1 9 9 3 ) , may be disease related

are usually based on a structured interview or

(e.g., early stages of pancreatic or gastrointesti-

self-report measures. T h e best known is the

nal cancer, tumor obstruction in advanced

package referred

disease, uremia, anemia) or treatment related

Instruments, which is a structured interview

(e.g., radiation that may cause malabsorption

combined with a self-report measure. It enables

to as O m e g a

Screening

of food, nausea, or changes in taste of nutrients;

constructing the patient's profile on the basis

chemotherapy that may cause stomatitis o f the

of his or her responses to questions about past

alimentary canal or frequent diarrhea; analgesic

history (e.g., mental health, substance abuse)

drugs that may cause constipation and appetite

and social support (e.g., marriage, church),

loss; surgery

[e.g., esophagectomy, gastrec-

answers to the Inventory of Current Concerns,

tomy] that may cause chewing and swallowing

and demographic facts (Weisman, Worden &

difficulties). Further contributors to anorexia

Sobel, 1 9 8 0 ) . T h e four measures that are com-

are psychological factors such as depression,

monly used and are most reliable among

hopelessness/helplessness, withdrawal, anxiety,

the self-report tools are the Brief Symptom

and perhaps patient burnout coupled with an

Inventory (BSI) (Derogatis, 1 9 9 3 ) , which con-

unconscious desire to hasten death. Also to be

sists o f 5 3 items and provides scores on 1 0

considered are preexisting psychological ten-

scales (e.g., hostility, anxiety, paranoia) and 3

dencies, such as expressing noncompliance or

global scores (Global Severity Index, Positive

dissatisfaction by diminished eating, certain

Symptom

food aversions, or phobia of obesity, that may

Symptom Total); the Profile of M o o d States

be evoked by responses to steroids. Finally, it is

(POMS)

not uncommon for patients to believe, on their

1 9 7 1 ) , which consists of 6 5 items and provides

own or following some esoteric "alternative"

scores on 6 scales (e.g., anger-hostility, tension-

or dietary treatment, that they can "starve the

anxiety) and

cancer to death" by avoiding eating. Similarly

Disturbance);

complex etiologies are to be considered in

Depression Scale (HADS) (Johnson et al.,

Distress

Index,

and

Positive

( M c N a i r , Lorr, Sc Droppelman,

1 global score (Total M o o d the

Hospital

Anxiety

and

regard to depression, fatigue, lethargy, anxiety,

1 9 9 5 ) , which consists of 1 4 items and provides

and

scores on 2 scales (anxiety and depression); and

other

common

symptoms

in cancer

the Medical Outcomes Study Short Form

patients.

Health Survey ( M O S SF-36) (McHorney et al., 1 9 9 3 ) , which consists of 3 6 items and provides ASSESSMENT AND T R E A T M E N T

vitality).

Assessment The

major

scores on 8 scales (e.g., physical, pain, social,

assessments

in

psycho-

oncology are focused on evaluating psychological distress, Q O L , physical

symptoms,

and cognitive state.

Quality

of

Life.

Major

assessment

instruments o f Q O L include the European Organization for Research and Treatment of Cancer ( E O R T C ) , which is based largely on particular modules for different cancer diseases

Psychological

Distress. Evaluating or screen-

ing for current or future psychological distress

(Aaronson

et al., 1 9 9 3 ) ;

the

Functional

Assessment o f Cancer Therapy (FACT) scale

is of great importance in view o f the relative

(Cella et al., 1 9 9 3 ) , which is also based on spe-

paucity of professional psycho-oncologists and

cific modules for each cancer disease and

sometimes the reluctance o f patients to admit to

requests evaluation o f extent to which Q O L

j

Psycho-oncology was affected by the disease in each domain o f

Cognitive Capacity Screening Examination

life; and the Cancer Rehabilitation Evaluation

(CCSE)

System (CARES)

(Ganz, Coscarelli Schag,

organic mental syndromes, and the Mini-

Kahn, Petersen, & Hirji, 1 9 9 3 ) and M O S 3 6 -

Mental State E x a m ( M M S E ) (Folstein, Fetting,

item short form health survey (McHorney

L o b o , Niaz, & Capozolli, 1 9 8 4 ) , which is the

(Jacobs, 1 9 7 7 ) , which screens for

et al., 1 9 9 3 ) , both of which include diverse

standard mental state instrument, are based on

scales for the assessment of specific domains in

examining basic processes such as orientation

addition to the more physical one.

in time and place, instantaneous recall, shortterm memory, simple number calculations,

Physical

T h e assessment o f

Symptoms.

and the use o f language. T h e Neurobehavio(NCSE)

physical symptoms may be part o f the assess-

ral Cognitive Status Examination

ment o f Q O L or independent o f it. M o s t often,

(Kiernan, Mueller, Langston, & V a n Dyke,

it is based on self-report symptom checklists

1 9 8 7 ) assesses level o f consciousness, orienta-

that refer to multiple or single symptoms. T w o

tion, attention, and five major ability areas

examples o f multiple symptom

are

(language, constructions, memory, calcula-

the M e m o r i a l Symptom Assessment Scale

tions, and reasoning). M o r e specific delirium

(MSAS), which refers to 3 2 physical and psy-

assessment tools, based on clinicians' ratings,

chological symptoms

tools

(e.g., feeling nervous,

lack o f energy)—each rated in terms o f intensity, frequency, and distress—and

provides

scores on a Global Distress Index and the two

include the Delirium Rating Scale, with 1 0 items based on D S M - I I I (Diagnostic Statistical edition

Manual

of Mental

and third

Disorders,

[American Psychiatric Association,

physical and psychological subscales (Portenoy

1 9 8 8 ] ) criteria scanning diverse aspects such as

et al., 1 9 9 4 ) , and the Rotterdam Symptom

perceptual disturbance, psychomotor behav-

Checklist, which refers to 3 0 physical and psy-

ior, hallucinations, and

chological symptoms, assesses their impact on

(Trzepacz, Baker, & Greenhouse, 1 9 8 8 ) , and

physical activity and function, and provides the

the M e m o r i a l Delirium Assessment

same scores as does the M S A S (de Haes, van

with 1 0 items based on DSM-EV (American

Kippenberg, & Neijt, 1 9 9 0 ) .

Psychiatric Association, 1 9 9 4 ) criteria scan-

Examples o f frequently used tools that measure specific symptoms include the Brief Pain Inventory (BPI) (Daut, Cleeland, & Flanery,

lability o f m o o d Scale,

ning disturbances in arousal and consciousness as well as in cognitive functioning and psychomotor activity (Breitbart et al., 1 9 9 7 ) .

1 9 8 3 ) , which assesses pain history, intensity, location, quality, and interference with overall functioning; the McGill Pain Questionnaire (MPQ)

(Melzack, 1 9 7 5 ) , which

Goals of Treatment

evaluates

There are a great many psycho-oncologi-

through verbal descriptors the sensory, affec-

cal interventions with a diversity o f goals.

tive, and evaluative dimensions o f pain; the

M o s t are tailored to the specific needs and

20-item Multidimensional Fatigue Inventory

benefits o f the patients. T h e main six goals o f

(MFI) (Smets, Garssen, Bonke, 8c de Haes,

interventions are crisis overcoming, problem

1 9 9 5 ) ; and the Visual Analogue Scale (VAS)

solving, patient education, adjustment, med-

for dyspnea (Borg, 1 9 8 2 ) .

ical survival, and prevention. T h e first five deal with treating the patients and sometimes

Cognitive

State.

Some o f the tools for

assessing mental state focus on cognitive deficits, whereas others deal more specifically with delirium and confusional states. T h e

also family members. T h e sixth targets primarily the population at large. Crisis overcoming

is designed to help the

patient through the most difficult physical and

343

344

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS psychological phases

and

happiness beyond the levels attained prior to

treatment process. It is a kind o f "psychologi-

o f the

disease

the disease. Living with cancer and living well

cal first aid" and consists in applying a variety

are the goals o f adjustment.

of procedures geared to resolve the specific

Medical

survival

is focused on using psy-

emergency situation at hand (e.g., breakdown

chological processes to improve the patient's

due to disclosure o f the diagnosis or finding

chances for longer survival or to extend the dis-

out about disease recurrence, suicide intent,

ease-free intervals. Sometimes, this goal is con-

withdrawal from treatment). Stress, emotional

sidered as strengthening the patient's immune

intensity o f reactions, immense fear, and a

system (Finn, 2 0 0 1 ) .

sense o f being unable to go on or o f having been beaten are some of the characteristics o f a

Prevention

is focused on reducing the preva-

lence o f cancer by enhancing compliance with

crisis. Resolving the crisis satisfactorily may

screening guidelines in the population at large,

help to prevent later stress reactions, adjust-

and particularly in individuals at risk, and by

ment disorders, P T S D , and further crises.

modifying behaviors that increase the risk o f

W h e n the crisis is the patient's death, the inter-

cancer (e.g., improper diet, exposure to the sun,

vention may be focused on the family members

use of tobacco) (Cohen & Baum, 2 0 0 1 ) .

and is sometimes called "grief counseling." Problem

solving

is designed to help the

patient solve typical disease- or treatment-

Types of Treatment

related problems such as whether or h o w to

There are great variety of psychological

tell others (e.g., parents, partner, children, col-

treatments applied in the framework o f psycho-

leagues at work) about the disease or its recur-

oncology. Often, more than one are used con-

rence and whether to go on working during

jointly or within the same setup. The major

chemotherapy. Some o f the patient's problems

types of interventions are counseling, dynamic

may have existed before the disease but were

psychotherapy, cognitive therapy, behavioral

exacerbated through it (e.g., family tensions

therapy, existential therapy, psychoeducational

concerning partner behavior or finances).

therapy, group therapy, social support, art ther-

is designed to provide the

apy, and guided imagery. Although the names

patient with information and skills to enable

of most of these interventions are familiar from

optimal use o f medical resources and services

other domains in psychology, their application

Patient education

(e.g., getting services such as psychological

in psycho-oncology is specific in several

help, sex counseling, t a x deductions, and social

respects. First, treatments are focused on the

benefits) while minimizing harassment

and

disease with the more or less implicit assump-

different avoidable difficulties. It also includes

tion that the major goal is to minimize the dis-

skills at getting and evaluating medical infor-

tress occasioned by the disease and

mation, assistance in clarifying misperceptions

treatments. Second, another implicit assump-

and

tion is that if it were not for the cancer, the

misinformation,

and

suggestions

for

improving doctor-patient communication. Adjustment

is designed to reduce as much

the

patient would not be exposed to that particular psychological intervention. Third, interactions

as possible the patient's psychological distress

between psychological and physiological pro-

in the course o f treatment or remission periods

cesses constitute an integral part o f the treat-

by controlling anxiety and depression on a

ment, sometimes as a focal theme (e.g., in the

long-term basis; reducing feelings o f loneli-

life-extending therapies) and other times merely

ness, isolation, and hopelessness; improving

as a fact that is taken into consideration (e.g., in

coping skills; raising the level o f Q O L ; and

treating insomnia, the chemotherapeutic agents

possibly even promoting personal growth and

that the patient is getting are considered).

|

Psycho-oncology are

(Fawzy et al., 2001). Each is based on using the

individual therapy and group therapy. Indivi-

components mentioned previously in a more or

Two

major

modes

of

treatment

dual therapy is more costly in resources but is

less structured manner. Thus, Spiegel's group

tailored better to the needs o f the specific

therapy is based on supporting other patients

patient and shields him or her against the anx-

and receiving support from them, getting family

ieties evoked by the vicissitudes in the state o f

support, getting social support, improving emo-

other patients (i.e., downward comparisons)

tional expression, detoxifying death, reordering

and against the tendency to devote himself

life priorities, facilitating communication with

or herself too much to helping others. For

one's physician, and controlling symptoms (by

objective reasons, individual therapy may be

self-hypnosis, meditation, biofeedback, etc.).

the only option for patients with advanced

Fawzy's psychoeducational

disease. Group therapy is more economical,

based on getting health education

enjoys a good "reputation" in many commu-

informed about cancer), managing stress (iden-

nities, and may be less threatening for patients

tifying sources of stress, identifying one's reac-

(Helgeson, Cohen, Schulz,

8c Y a s c o , 2001).

Each o f the major kinds o f treatment has

intervention

is

(being

tions to stress, and controlling these reactions by hypnosis, relaxation, guided imagery, etc.),

been used for attaining the different goals o f

learning coping skills (using problem-solving

treatments. Thus, group therapy has been used

techniques based on promoting

for life extension, adjustment, and psycho-

approach and weakening avoidance coping),

educational purposes (Fawzy 8c Fawzy, 1998;

and getting psychological support from the staff.

Spira,

1998), and art therapy has been used for

adjustment and vocation o f self-healing potentialities (Luzzatto

8c Gabriel, 1998).

the active

There are four major therapeutic orientations used in the various treatments:

the

dynamic approach, the cognitive-behavioral or

approach, the existential approach, and the

processes used in the various treatments are

cognitive orientation approach. T h e dynamic

T h e major therapeutic

components

getting the support o f others (e.g., patients,

approach is rooted in classical psychotherapy,

health professionals), eliminating mainly neg-

so that it is based on applying transference and

ative affect, sharing one's experiences with

countertransference,

others, learning coping skills, facing one's

past, interpreting dreams and free associations,

fears (including fears o f suffering, pain, and

and using a specific structure o f interplay contents

exploring the

and

process

patient's

death), overcoming despair and strengthening

between

hope, gaining a better understanding o f one-

Massie,

(Sourkes,

self and one's responses, gaining a better

behavioral approach emphasizes the acquisi-

understanding o f the situation (e.g., the dis-

tion o f skills (thoughts, beliefs, or behaviors)

ease, treatments), strengthening one's sense o f

that enable controlling symptoms,

control, and gaining a modicum o f control

stress, pain, and anxiety. T h e most often used

over one's symptoms. Some o f these elements

means are hypnosis, relaxation, systematic

are stronger in some o f the treatments; for

desensitization, guided imagery, and coping

8c Holland, 1998). T h e cognitive-

mainly

8c Hann, 1998). T h e

example, getting support is often stronger in

self-statements (Jacobsen

group therapy,

better

existential approach is based on exploring the

understanding o f oneself and one's responses

function, role, and meaning o f the lives o f

whereas

gaining

a

humans in general and the life o f the patient in

is more salent in individual therapy. There

exist

some

better-known

treat-

particular while examining the authenticity o f

ment protocols, mainly Spiegel's supportive-

assumptions about oneself and the world in

8c Diamond, 2002)

the framework o f one's culture and society

expressive therapy (Spiegel

and Fawzy's psychoeducational

intervention

(Spira,

2000). Finally, the cognitive orientation

345

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

Dispositio Disposition

Figure 17.3

Motivational Disposition

Formation of the Motivational Disposition ("behavioral intent") According to Cognitive Orientation Theory

approach is based on the assumption that any

However, as noted earlier, their study had

behavior—emotional, motor, cognitive, or

serious methodological shortcomings ( F o x ,

physiological—is the product o f a motivational

1 9 9 8 a ; K o g o n et a l , 1 9 9 7 ) and failed to be

disposition expressing the general direction o f

replicated (Goodwin et al., 2 0 0 1 ; Spiegel

the behavior (formed as a vector based on four

et al., 1 9 9 9 ) . T h e replications showed that

types o f beliefs reflecting underlying meanings)

the

and an operational program implementing the

patients'

actual performance (Figure 1 7 . 3 ) . In the case of

Spiegel et al., 1 9 9 9 ) and did this for only a

physical disorders, the motivational disposi-

short

tion reflects the directionality inherent in spe-

Cunningham, 1 9 9 9 ) .

cific themes unique for each disorder, whereas

intervention

proved

mood

duration

(Goodwin

to

affect

only

et al., 2 0 0 1 ;

(Edmonds, L o c k w o o d , Sc

Fawzy and colleagues ( 2 0 0 1 ) showed that

the operational program is the set o f physio-

their intervention

logical processes underlying the pathological

immune system parameters 6 months after

process (Kreitler & Kreitler, 1 9 9 1 ) . T h e treat-

treatment, but the effects did not differ signif-

ment consists in strengthening

icantly between the intervention and control

the specific

themes expressing health rather

than

the

tendency toward the disorder.

on

groups after 1 year. Furthermore, when the treatment

M o s t treatments report effects in terms o f

had positive effects

and

Breslow depth were

used

together as predictors, treatment did not pre-

improving

dict recurrence of disease but instead predicted

their emotional well-being (Fawzy Sc Fawzy,

survival. T h e results were explained as due to

1 9 9 8 ; Fawzy et al., 2 0 0 1 ; J a c o b s e n S c H a n n ,

better adjustment and coping in the experi-

1998).

on

mental group. However, the number o f par-

survival are less clear. Spiegel and colleagues

ticipants was very small (3 were dead and 3 1

reducing

patients'

T h e effects

distress and

o f the treatments

( 1 9 9 9 ) initially reported a remarkable effect

were alive in the experimental group, and 1 0

o f their intervention on prolonging survival.

were dead and 2 4 were alive in the control

Psycho-oncology

CASE S T U D Y " S . M . " was a 37-year-old w o m a n , married with three daughters, w h o was diagnosed with m e l a n o m a (Stage lib) in the cervix. She underwent surgery and was prescribed a course o f chemotherapy. She kept delaying the beginning o f the treatment with different excuses until she was given up in the hospital files as a case o f "treatment resistance." A year later, she showed up for a regular follow-up, and it turned out that there had been disease recurrence. W h e n the doctor raised the need for chemotherapy, S. M . again declared that she would not undergo any kind o f treatment—"not n o w , not ever." T h e doctor responded by saying, " N o one can be forced to undergo treatment, but I suggest that since you are already here you see the attending psycho-oncologist." S. M . said, " I will do so, but only because you are such a kind doctor w h o has agreed not to prescribe chemotherapy for m e . " At the beginning o f the meeting with the psycho-oncologist, S. M . said that she did not believe in psychology and that all that psychologists had to say was mere "literary fiction." T h e psychologist suggested that S. M . might want to tell the psychologist some "fictional story." S. M . readily agreed and started to tell a story about two sisters, 1 year apart in age, who were so close and inseparable that most of those w h o knew them thought they had a lesbian relationship, which of course was not true. W h e n they were ages 1 6 and 1 7 years, they were invited by their uncle to spend a vacation in Canada. It is there that they went on a boat tour on the St. Lawrence River and one sister accidentally fell off the boat into the water and drowned. T h e other sister did not jump in to try to save her, even though she was a much better swimmer. T h e surviving sister went back to her own country, and because she was now the only child, she was spoiled by her parents and lived happily ever after. T h e psychologist assumed the role o f a "literary critic" and offered the remark that the end o f the story was not convincing from a literary point o f view because it seemed likely that the surviving sister suffered from a sense o f guilt. S. M . rejected the criticism but agreed to explore the possibility that some readers o f such a story might get the " w r o n g " idea that the surviving sister felt guilty. S. M . suggested that the surviving sister m a y have wished the other sister dead for fear that the dead sister would not have allowed her to marry and have children because "they loved t o o m u c h . " T h e psychologist then remarked, " S o m e people w h o feel guilty for actual or imaginary things they have done or felt consider undergoing chemotherapy as a kind o f punishment. W h a t do you t h i n k ? " " F u n n y , " S. M . said, " I thought chemotherapy was quite the contrary—the means for life." S. M . did not c o m e back to the psycho-oncologist, but she underwent the whole course o f chemotherapy without any resistance. At the end o f the treatment, she left the psycho-oncologist a note stating, " F o r me chemotherapy was a punishment, and n o w I have earned my right to live." H e r response to the treatment was good, and after 5 years she was still in full remission. This case illustrates the use o f a brief psychological intervention for resolving noncompliance with treatment and possibly also the contribution o f psychological change to medical remission.

347

348

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS group, at 5- to 6-year follow-up), so that the

for itself a relatively central role in health

stability o f the findings needs to be examined

psychology as well as in oncology. The two

in further replications (Fawzy et al., 2 0 0 1 ) .

main reasons for this are (a) the great need for

As discussed previously, the cognitive ori-

psychological help on the part o f patients and

entation approach has also led to significant

physicians alike (albeit for different reasons)

increases o f survival

and (b) the theoretical and empirical advances

in the

intervention

group that lasted for 1 2 years, which is the

in gaining knowledge and understanding in

follow-up period to date. N o t a b l y , the cogni-

oncology contributed by adding the psycholog-

tive orientation variables predicted survival

ical perspective to the scientific and clinical

together with the medical prognostic vari-

research. Psycho-oncology has become deeply

ables, and the effect o f the psychological fac-

interwoven in the daily practice of and research

tors became more evident the longer the time

in oncology. This has made it possible to detect

since diagnosis (Kreitler, Inbar, & Kreitler,

its contributions in the most varied domains of oncology, ranging from prevention, genetic

1 9 9 9 ; Kreitler et al., 1 9 9 7 ) . Furthermore, there are less conventional

testing, and counseling to decisions about treat-

interventions of the mind-body sphere that

ment, launching of new drugs supported by

mostly share several o f the following compo-

Q O L arguments, and euthanasia. However, if

nents: emphasis on a holistic approach, posi-

psycho-oncology is to maintain its very unique

tive attitude,

mind-body

unity,

personal

responsibility for one's health, belief in the pos-

status in practice and research, three recommendations seem appropriate.

sibility to control bodily processes, and fre-

T h e first recommendation

is increased

quent use o f procedures from the Kabala,

emphasis

Reiki, meditation, and spiritual approaches.

ground variables. This would entail assuming

Results are mostly not evidence based and

an inherently interactional and synergistic

remain equivocal at best. Finally, many cancer patients use psy-

on

considering multiple

back-

approach in every act o f applying psychooncology. T h e second is increased emphasis

chopharmacological drugs for the control o f

on

symptoms in one or another phase o f the dis-

medical variables such as histology, type o f

considering

ease. T h e most frequently prescribed drugs

tumor, and genetic aspects. This would lead

are antidepressants and antianxiety medica-

to widening the scope and generalizability o f

tions as well as analgesics and insomnia-

psycho-oncological findings. T h e third

controlling drugs (Massie & Lesko, 1 9 8 9 ) .

adopting

a

a variety o f specifically

broader

and

more

is

creative

approach to identifying and testing purely psychological variables. This would enable SUMMARY AND CONCLUSIONS

enriching the host o f familiar variables, such as depression and emotional suppression, that

Psycho-oncology is one of the most active

have contributed to advancing the field up to

domains of health psychology and has earned

the current level.

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CHAPTER

Sexual

10 18

Dysfunctions

Etiology and Treatment SHEILA GAROS

S

tudies indicate that problems in sexual

D S M - I V (Diagnostic

functioning

Mental

may

be

quite

common

(Spector & Carey, 1 9 9 0 ) . As early as

Disorders,

and Statistical

Manual

of

fourth edition [American

Psychiatric Association, 1 9 9 4 ] ) . Sexual dys-

that

functions are further classified into three sub-

5 0 % of couples in the United States suffered

types: pain disorders, arousal disorders, and

from a sexual dysfunction (Masters & Johnson,

orgasmic disorders. T o understand the etiol-

1 9 7 0 , Masters and Johnson estimated

1 9 7 0 ) . Other estimates suggest that up to 2 4 %

ogy and treatment o f sexual disorders, it is

of the U.S. population will experience a sexual

necessary to have some knowledge of the

dysfunction at some point in their lives (Robins

psychobiology o f the human sexual response.

et al., 1 9 8 4 ) . In 1 9 9 2 , Laumann and colleagues conducted a study to assess the prevalence and risk o f experiencing sexual dysfunction across social groups (Laumann, Gagnon, Michael, 8c Michaels, 1 9 9 5 ) . They found that sexual dysfunction was more prevalent in women ( 4 3 % )

BACKGROUND AND ETIOLOGY

The Human Sexual Response

than in men ( 3 1 % ) and was associated with

Biomedical advances and clinical studies

characteristics such as age, educational attain-

suggest that for most people, human sexual

ment, poor physical and emotional health,

functioning proceeds sequentially and rudimen-

experiences in sexual relationships, and overall

tarily involves a biphasic response that is com-

well-being. Having a sexual problem or dys-

posed o f (a) tumescence,

function

fear,

the genitals with blood that leads to erection in

shame, and feelings o f inadequacy. For these

men and vaginal lubrication and swelling in

reasons, the number of individuals who suffer

women, and (b) detumescence,

with a sexual dysfunction is often greater than

of blood from the genitals following orgasm

can invoke embarrassment,

what reported statistics reflect. Table 1 8 . 1 outlines the current classification scheme o f sexual disorders found in the

or the engorgement of

or the outflow

(Bancroft, 1 9 9 5 ; Herbert, 1 9 9 6 ; Schiavi & Segraves, 1 9 9 5 ; Wincze &

Carey,

1991).

However, the psychobiological mechanisms 359

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

360

Table 18.1

Pain

Disorders

DSM-IV Classifications of Sexual Dysfunctions

Desire

Arousal

Disorders

Disorders

Orgasm

Disorders

Miscellaneous Classifications

Dyspareunia

Hypoactive sexual desire disorder

Female sexual arousal disorder

Female orgasmic disorder

Sexual dysfunction due to a medical condition

Vaginismus

Sexual aversion disorder

Male erectile disorder

Male orgasmic disorder

Substance-induced sexual dysfunction Sexual dysfunction not otherwise specified

Premature ejaculation

that underlie the sexual response are far more

or occur secondarily to, a sexual dysfunction

investigation

(Pollets, Ducharme, & Pauporte, 1 9 9 9 ) such as

(Davis, 2 0 0 1 ; Gaither & Plaud, 1 9 9 7 ; Jupp &

conflict (Metz & Epstein, 2 0 0 2 ) , guilt (Walser

complex and warrant further

M c C a b e , 1 9 8 9 ; Meston & Frohlich, 2 0 0 0 ;

& Kern, 1 9 9 6 ) , depression and other affective

Pfaus, 1 9 9 9 ; Regan, 1 9 9 6 ; Stoleru et al., 1 9 9 9 ) .

states (Seidman & Roose, 2 0 0 1 ) , trauma (van

Masters and J o h n s o n ( 1 9 7 0 ) described a

Berlo &c Ensink, 2 0 0 0 ) , and anxiety (Shires 8 t

physiological model o f the sexual response

Miller, 1 9 9 8 ) . Likewise, principles o f learning

that

phases:

and conditioning in regard to the sexual

excitement, plateau, orgasm, and resolution

response must be considered (Lalumiere &

included

four

physiological

(Table 1 8 . 2 ) . However, this model failed to

Quinsey, 1 9 9 8 ) , as should cognitive appraisals

address those patients w h o reported difficulty

and expectancies about sexual arousal (Palace,

1 9 9 5 ; Weisberg,

and

in becoming aroused or who expressed an

desire

aversion to sex (Kaplan, 1 9 7 7 ) . Subsequently,

Wincze, & Barlow, 2 0 0 1 ) , relationship distress

Brown,

was

(Metz & Epstein, 2 0 0 2 ) , and developmental

believed to precede the "excitement" phase

issues such as age and a person's stage in life

a

"desire stage" was conceived that

described by Masters and J o h n s o n . Desire

(Avina, O'Donohue, & Fisher, 2 0 0 0 ; Bartlik &

involves a patient's "cognitive and affective

Goldstein, 2 0 0 1 ; Dennerstein, Dudley,

readiness for, and interest in, sexual activity"

Burger, 2 0 0 1 ) . M a n y patients develop sexual

(Wincze & Carey, 1 9 9 1 , p. 4 ) .

dysfunctions as the result o f medical conditions

&

such as spinal cord injuries (Sipski, Alexander, & Rosen, 2 0 0 1 ) , kidney disease (Malavaud,

Etiological Factors

Rostaing, Rischmann, Sarramon, & Durand, 2000),

cancer

mance, sexual desire, sexual satisfaction, and

(Merrick, Wallner, Butler, Lief, &

Sutlief,

meaning o f sexual behavior that is constructed

2 0 0 1 ; Shifren et al., 2 0 0 0 ) , and other chronic

Given the complexity o f sexual

perfor-

2000),

diabetes

(Bhugra,

from dominant culture and beliefs, one must

illnesses (Schover, 1 9 8 9 ) . Finally, medications

not rely exclusively on physiological models to

prescribed to treat a variety of medical and

describe or assess sexual functioning (Laqueur,

psychological conditions can often lead to

1 9 9 0 ; Tiefer, 1 9 9 1 ) . Diagnosis and assessment

reduced sexual desire or other interference with

must include an evaluation o f organic causes as

sexual performance (Gelenberg, Delgado, &

well as psychogenic factors that contribute to,

Nurnberg, 2 0 0 0 ; Waldinger et al., 2 0 0 2 ) .

Sexual Table 18.2

Dysfunctions

Sexual Response Phases and Associated Dysfunctions

Phase

Characteristics

Dysfunction

1. Desire

Characterized by subjective feelings of sexual interest, desire, urges, and fantasy; no physiological correlates

Hypoactive sexual desire disorder Sexual aversion disorder

2. Excitement

Characterized by subjective and physiological concomitants of sexual arousal such as penile erection in men and vaginal engorgement and lubrication in women

Female sexual arousal disorder Male erectile disorder

3. Orgasm

Characterized by climax or peaking of sexual tension, with rhythmic contractions of the genital musculature and intense subjective involvement

Female orgasmic disorder Male orgasmic disorder Premature ejaculation

4. Resolution

Characterized by a release of tension and a sense of pleasure or well-being

Dyspareunia Vaginismus

S O U R C E : Adapted from Weiner and Davis ( 1 9 9 9 , p. 4 1 1 ) . In T. Millon, P. H . Blaney, & R . D . Davis (Eds.), O x f o r d T e x t b o o k o f P s y c h o p a t h o l o g y . Copyright © 1 9 9 9 by Oxford University Press, Inc. Used by permission.

ASSESSMENT AND TREATMENT

psychosexual history, a description o f the

Basic Principles of Sex Therapy

tion o f the quality o f their relationship, the

Traditionally, sex therapy is a short-term therapy designed for the special treatment o f sexual dysfunctions. Sex therapy is a behaviorally based, systematic protocol designed to move patients through a series o f "graded experiences, from an avoided, partial, or pleasureless

response

to

response" (Birk, 1 9 9 9 ,

a

fully

p. 5 2 5 ) .

pleasurable

Contemporary

approaches to sex therapy often address issues in the patient as well as in his or her partnership more systemically. Emotional, spiritual, cultural, affective, cognitive, and social factors are addressed and evaluated. Thus, effective treatment o f psychogenic sexual dysfunctions requires knowledge o f family systems and family therapy as well as extensive experience in working with couples in general.

Overall Evaluation and Assessment During an initial evaluation the clinician will typically seek demographic information, the nature and development of the dysfunction, a

patient's current sex life, the partners' percepdegree o f psychopathology of one or both partners, physical health, and the patient's motivation

for

and

commitment

to

treatment

(LoPiccolo & Heiman, 1 9 7 8 ) . T h e initial evaluation can seem quite invasive for the patient, and it is important to inform him or her why the type of information sought is necessary. Questions must be specific to ascertain the nature and degree of dysfunction and to help delineate between possible organic and psychogenic causes o f the problem. Additional information that may be sought includes, but is not limited to, the patient's personality, professional life, education, sexual development, sexual values, experiences with other partners, history o f masturbatory behaviors, and attitudes about pleasure, family life, and religious background.

Overall Treatment Approach Thoughts, attitudes, and feelings play a significant role in mediating

physiological

362

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS responses to sex. T h e goal o f many techniques

In the D S M - I V

(American Psychiatric

1994), sexual desire disorders fall

is to "replace antisexual anxiety with sexual

Association,

pleasure" (Heiman, 1978, p. 123). Thus, facili-

into two categories: hypoactive sexual desire

tation and maintenance of arousal and associ-

disorder ( H S D D ) , defined as a "deficiency or

ated thoughts, feelings, and attitudes are an

absence of sexual fantasies and desire for sex-

important component in treating sexual dys-

ual activity" (p. 496), and sexual aversion dis-

functions. Psychophysiological measures such

order (SAD). Diagnosis o f H S D D generally

as nocturnal penile tumescence and daytime

involves clinical judgment as well as corrobo-

arousal evaluation can be used to assess

rating information from the patient's partner

subjective and objective measures o f arousal.

(Rosen & Leiblum,

In addition, men being evaluated for erectile

keep in mind that often a partner with higher

1989). It is important to

dysfunction (ED) may undergo a penile blood

desire becomes the referent for the partner

pressure examination.

with lower desire, in which case it may be

A number of psychosocial interventions are

indicative o f a desire discrepancy as opposed

available to help with sexual difficulties. Perhaps

to a desire disorder. Clinical judgment must

the most common is sensate focus, which

also take into account interpersonal determi-

involves teaching patients and their partners

nants, frequency and chronicity o f the symp-

to engage in intimate physical and emotional

tom, subjective distress, effect on other areas

closeness in a gradual nonthreatening manner.

of functioning, and the person's current life

Homework is assigned in which couples engage

situation. Some individuals have difficulty in

in various stages of the protocol. Explicit

initiating sexual activity; others are unrespon-

instructions are given to couples as to how

sive to sexual advances from their partners

to approach each stage of treatment. "Rules" of

(i.e., lack o f receptivity). It is important to

engagement are oudined, with some of these

determine whether H S D D is global, with the

rules prohibiting genital contact during the

patient lacking interest in any or all sexual

earlier phases o f the exercise. Modifications

activity, or situational, with the patient's lack

can be made to best address the needs o f

of desire occurring only with a specific partner

the patient and the type of dysfunction being

or type o f activity.

treated. Inclusion o f steps and the duration

H S D D can occur as a secondary condition

of each is left to clinical judgment. An outline

when other sexual dysfunctions are present

of sensate focus is presented in Table 18.3.

(e.g., anorgasmia in women, E D in men). H S D D may also result from a number of physiological or psychological conditions, including other

Female Sexual Dysfunctions Hypoactive

Sexual

Desire

medical conditions (Phillips 8c Slaughter,

2000),

Disorder.

stress, substance use, low self-esteem, anhe-

According to Laumann, Gagnon, Michael, and

donia, hormonal changes, and negative self-

(1994), approximately 33% of women

evaluation

experience a lack of sexual interest at some point

Morokoff,

in their lives. From ages 18 to 24 years, about

Medication side effects are another possible

32.0% of women report some difficulty with

cause of reduced desire (Wincze

sexual desire; at ages 30 to 34 years, this number

Finally, a history of sexual abuse or trauma,

Michaels

29.5%. The largest group affected is women ages 35 to 39 years (37.6%). Among decreases to

(Heiman

Sc

Meston,

1997;

1985; Rosen Sc Leiblum, 1989). Sc Carey, 1991).

abuse, or assault can lead to decreased desire due to "chronic fears of vulnerability of loss of con-

women ages 40 to 54 years, the number of

trol, inability to establish intimate relationships,

women reporting desire disturbances declines,

or a conditioned aversion to all forms of sexual

only to increase once again after that.

contact" (Rosen 8c Leiblum, 1989, p. 27).

Sexual Dysfunctions

Table 18.3

\

Treatment Stages of Sensate Focus

Stage I: Nongenital pleasuring At this stage, each partner will touch one another for at least 2 0 minutes. One partner will initiate and touch for the specified time, and then the two will switch roles and positions. The partner who is touching should be assertive by touching the other in ways and places (minus breasts, buttocks, and genitals) that are pleasing for the one doing the touching. Experimentation with touching each partner in new places and in new ways is encouraged. A partner can use his or her legs, hands, face, arms, and the like when touching the other partner. The partner being touched should concentrate on relaxing his or her whole body and the sensations that touch by the other partner is creating. If spectatoring or anxiety is a problem, the couple should stop for a few moments until relaxed and then start again. If either partner becomes aroused, it is permissible to masturbate to relieve tension so long as the person does it himself or herself. In some cases (e.g., a past history of trauma), the partners can begin this stage with their clothes on. Stage II: Touching for One's Own and One's Partner's Pleasure This stage is similar to Stage I. Each stage has two parts, with one partner caressing and touching the other first and then the partners switching roles. What differs is that at Stage II, each partner indicates to the other what he or she would like the other to do. A hand can be placed over that of the partner to demonstrate how one would like the touch to feel (e.g., faster, harder, softer, slower, more to the right). It is still up to the person who is doing the caressing to decide what he or she will do. Partners are encouraged to discuss their experience after each stage. Stage III: Sensate Focus With Genital Focus The same basic principles apply to this and the remaining stages of treatment. A ban on intercourse remains; however, genital contact with the mouth and/or hands is now permitted. A will caress B , and then Β will caress A. During this stage, change in the pressure, speed, or direction of touch can profoundly affect the sensation received. Thus, communication is of utmost importance. Couples are told not to focus on genital regions exclusively and to spend as much time as before on genital kissing and touching. At this stage, lubricants, oils, and lotions are permitted to enhance pleasure of both partners. The main objective is still to concentrate on and enjoy the bodily sensations being experienced. Should one of the partners become aroused or experience orgasm, the session can continue. It is important to remember that orgasm is not the "goal" of the session. Stage IV: Sensate Focus With Genital Contact and Simultaneous Caressing The focus of this stage is on simultaneous caressing that enables both partners to give and receive pleasure at the same time. Partners are encouraged to communicate to each other when one is doing something that feels particularly nice. Self-assertion and self-protection are also encouraged. Stage V: Vaginal Containment Once the sensate focus is established with consistency, some ejaculatory control is exercised, and erections can remain reasonably firm, the couple is ready for Stage V. This stage is designed to facilitate sensory focus and enjoyment without performance anxiety. Once the partner is ready and the patient is able to maintain a reasonably firm erection, the partner will guide the patient's penis into her vagina. The most accommodating position for this is the "female superior" position, where the patient lies flat on his back with the partner kneeling above him with her knees on either side of his body, roughly at the level of his nipples. The woman will gently insert her partner's penis into her vagina. This allows the partner to have greater control. The goal of this stage is for the partners to reorient themselves with the sensation of the penis and the vagina. The woman should tighten and relax her vaginal muscles on her partner's penis. Genital caressing may resume. The patient is told to concentrate on sensations while the partner keeps control of what is happening. Couples are also to resist the desire to thrust. (Continued)

363

364

I

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

Table 18.3

(Continued)

Stage VI: Vaginal Containment With Movement It is important to remind the partners at this stage that they are to employ the same principles concerning physical contact that they used at the beginning of treatment. Giving and receiving pleasure, and touching each other in a way that is pleasing to both partners, remains the aim of treatment. Mutual caressing continues and involves both genital and nongenital areas. Each partner should feel aroused and receptive before vaginal entry takes place. After vaginal containment is tried for some time, limited thrusting can be tried to assess each partner's sensations and feelings. Either partner is allowed to tell the other to stop at any time so as to set limits and boundaries without fearing that the partner will become angry. It is also important to remember that responsiveness will vary from stage to stage and from month to month. At this point, the clinician should reiterate that orgasm, particularly mutual orgasm, is not the goal that must be satisfied to meet the expectations of the patient or his partner. Cognitive restructuring techniques, such as challenging negative attitudes and learning to reduce intrusive thoughts, are often incorporated into treatment. Communication training is often a vital element in the treatment of sexual dysfunctions because many couples lack effective communication skills in general and are particularly reluctant to communicate their sexual needs, likes, dislikes, and desires. The use of erotic materials or "toys" is sometimes recommended to patients and should be approached as exposure to a sexual experience with attention paid to mood and setting. Of course, it is essential to assess the patient's or couple's views about the use of such materials to determine whether these approaches are viable and would not be considered offensive or objectionable. Masturbation training with fantasy should be approached with similar caution. It should not be assumed that all patients know how to masturbate or how to do f ι effectively. Masturbation training, when used successfully, can help to build sexual confidence and desire. Other treatments for male sexual dysfunctions include vasoactive therapies, which involve the use of intracorporeal injections of papaverine or transurethral alprostadil suppositories. These agents act as vasodilators. Surgical approaches can be used to correct male erectile dysfunction and include the placement of an implantable penile prosthesis, penile arterial revascularization, and penile venous ligation. Vacuum devices can also be used to draw blood into the corpora cavernosa of the penis. Placing a band around the base of the penis then traps the blood. Among pharmacotherapeutic agents, the most recent, and perhaps most popular, is sildenafil (Viagra).

In the assessment o f H S D D , frequency of

Masturbatory practices vary, as do cognitive

activity should not be considered a reliable indi-

correlates o f desire such as fantasy (Schreiner-

cator of sexual desire. However, initiation is

Engel & Schiavi, 1 9 8 6 ) . Moreover, gender dif-

an important consideration because it serves

ferences must be taken into account in the

as an indicator of female motivation to engage

evaluation o f cognitive descriptors o f desire

in sexual behavior (Wallen, 1 9 9 0 ) . Often, a

(Denney, Field, & Quadagno, 1 9 8 4 ; Jones &

patient will engage in frequent coitus or other

Barlow, 1 9 9 0 ; McCauley & Swann, 1 9 7 8 ,

sexual activities out of a sense o f obligation,

1 9 8 0 ; Person, Terestman, Myers, Goldberg, &

coercion, or an attempt to please or accommo-

Salvadori, 1 9 8 9 ) .

date his or her partner's wishes and preferences.

A

number

o f treatment

strategies

are

Likewise, one must consider that symptoms o f

available t o

low desire may reflect problems of relationship

with sexual desire disorder (for a review, see

address

problems associated

intimacy, power differentials, or territoriality in

O'Donohue, Dopke, &c Swingen, 1 9 9 7 ) . These

the relationship (Verhulst & Heiman, 1 9 8 8 ) .

approaches include (a) psychotherapy (Kaplan,

Sexual Dysfunctions

\

1 9 7 7 ; Scharff, 1 9 8 8 ) , (b) cognitive-behavioral

negative learning experiences (Halvorsen &

approaches (Rosen & Leiblum, 1 9 8 9 ) , (c) cog-

Metz, 1992).

nitive restructuring (LoPiccolo & Friedman,

In treating S A D , it is important to under-

1 9 8 8 ) , (d) analysis o f interactional and c o m -

stand the "approach-avoidance" conflict that

munication patterns (Schwartz & Masters,

exists in many o f these patients (Ponticas,

1 9 8 8 ) , (e) "territorial interactions" (e.g., "When

1 9 9 2 ) . Given that most causes o f S A D are not

you touch my body, I feel like you are

physiological, addressing psychological issues

invading my space"), (f) "rank-order" c o m -

that underlie the disorder is o f particular

munication

(e.g., " I always feel like the

underdog in sexual r e l a t i o n s h i p s " ) ,

and

importance in treatment. In addition to psychotherapy, systematic desensitization

and

(g) "attachment interactions" (e.g., " I find it

vicarious extinction techniques can be used to

hard to trust you after my feelings have been

reduce or minimize the patient's anxiety and

hurt") (Verhulst & Heiman, 1 9 7 9 , 1 9 8 8 ) .

fear response (Wincze, 1 9 7 1 ) .

Other strategies include the use o f pharmacological agents, hormonal treatments, and the

Female

Orgasmic

Disorder.

Anorgasmia is

"coital alignment technique" that can help to

regarded as the most common sexual dysfunc-

increase effective stimulation for women dur-

tion in women (Heiman &c Grafton-Becker,

ing intercourse (Pierce, 2 0 0 0 ) . In some cases,

1 9 8 9 ; Spector & Carey, 1 9 9 0 ) . Moreover,

the use o f sex toys and other stimuli (e.g., fan-

approximately 8 5 % to 9 0 % of women report

tasy, erotic material) and "orgasm consis-

having orgasms without difficulty; however,

tency" training (Hurlbert, White, Powell, &

only one third have had an orgasm during

Apt, 1 9 9 3 ) may be helpful.

intercourse (Seeber &c Gorrell, 2 0 0 1 ) . In addition, the incidence o f orgasmic difficulty

Sexual

Aversion

Disorder.

S A D is a more

severe disruption in desire. S A D is characterized by a "marked aversion to, and active

tends to be higher in single women (Laumann et al., 1 9 9 4 ) . Female orgasmic disorder is characterized

avoidance of, all genital contact with a sexual

by "a persistent or recurrent delay in, or absence

partner" (American Psychiatric Association,

of, orgasm following a normal sexual ex-

1 9 9 4 , p. 4 9 9 ) . T h e aversion to genital contact

citement

"may be focused on a particular aspect o f sex-

Association, 1 9 9 4 , p. 5 0 5 ) . Clinical judgment

ual experience (e.g., genital secretions, vaginal

is an important factor in diagnosing this con-

p e n e t r a t i o n ) . . . [or] revulsion to all sexual

dition given that a woman's orgasmic capac-

stimuli, including

touching"

ity must be determined to be less than would

(p. 4 9 9 ) . This disorder is often accompanied

be "reasonable for her age, sexual experience,

by poor body image and avoidance o f nudity

and the adequacy o f sexual stimulation she

(Katz, Gipson, & Turner, 1 9 9 2 ; Ponticas,

receives" (p. 5 0 5 ) . M a n y w o m e n express con-

1 9 9 2 ) . W o m e n with S A D may experience

cern that something is "wrong with t h e m " if

kissing and

phase"

(American

Psychiatric

reactions such as terror, panic, and nausea.

they do not experience orgasm during inter-

Efforts to cope with the disorder may include

course or if they have multiple or simultane-

avoidance o f sexual contact, substance use,

ous orgasms. Patients need to k n o w

and neglect o f one's personal

appearance.

many women do not reach orgasm during

Although S A D and H S D D are distinct, the

coitus because penile stimulation is often not

two conditions are often related and have

intense or direct enough to produce orgasm.

that

similar causes such as endocrine alterations,

Women's orgasmic potential and type of

medical conditions, psychological distress,

orgasm are variable. Orgasmic capacity has

relationship factors, prior sexual trauma, and

been

associated with

sexual

assertiveness

365

366

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS (Hurlbert, 1 9 9 1 ) , comfort with masturbation

levels of marital adjustment

(Kelly, Strassberg, & Kircher, 1 9 9 0 ) , and rela-

Khalife, & Cohen, 1999).

(Meana, Binik,

tionship and psychological distress (Kaplan,

Pain is a subjective experience. In dyspareu-

1 9 9 2 ; McGovern, Stewart, & LoPiccolo, 1 9 7 5 ) .

nia, the phenomenology o f pain is genital and

M o s t women have clitoral orgasms that result

associated with intercourse. In some cases,

from stimulus to the clitoris and surrounding

pain occurs before or after intercourse as

tissues. Fewer women have pelvic floor or vagi-

well. In women, "the pain may be described as

nal orgasms, and for some women orgasm

superficial during intromission or as deep

involves a combination of the two. It is impor-

during penile thrusting..., [with] symptoms

tant to discern whether the patient's orgasmic

rang[ing] from

disorder is situational (i.e., the patient is able to

pain" (American Psychiatric Association, 1 9 9 4 ,

reach orgasm via masturbation but not by man-

p. 5 1 1 ) . Vulvodynia refers to pain located

ual stimulation or intercourse) or generalized

specifically in the vulva. Dyspareunia can be

(i.e., occurring across all situations and part-

lifelong or acquired as well as generalized or

mild discomfort to

sharp

ners). Female orgasmic disorder typically does

situational. Abarbanel ( 1 9 7 8 ) suggested four

not arise from a physiological condition and

phenomenological categories o f pain associ-

is generally not correlated with vaginal size or

ated with dyspareunia:

pelvic muscle strength. However, some condi-

sharp but momentary pain that varies in inten-

tions (e.g., spinal cord injuries, vaginal excision

sity, (b) repeated

and reconstruction) have been associated with

(c) aching, and (d) intermittent painful pangs

(a) perception o f a

and intense

discomfort,

orgasmic difficulty. Medications such as benzo-

or twinges. A thorough medical examination

diazepines, antihypertensives, neuroleptics, and

must be conducted to rule out physical factors

antidepressants

may contribute to orgasmic

difficulty, as can substance use and abuse.

such as pelvic tumors, hymeneal remnants, prolapsed ovaries, and scarring that occurs as

Often, the source of orgasmic difficulty in

a result o f either an episiotomy or vaginal

women is their own or their partners' lack of

repair (Bancroft, 1 9 9 5 ) . Hormonal changes that

knowledge about the female sexual response and

result from contraceptive use or menopausal

female genitalia. The problem is often resolved

changes can lessen vaginal lubrication and sub-

by helping clients and their partners learn to

sequently cause soreness and irritation during

extend stimulation and lovemaking

beyond

intercourse or penetration. Once organic causes

genitally focused sex. Greater sensate exchange

of pain are ruled out, psychological factors such

between partners, expanding women's arousal

as anxiety, poor body image, religiosity, anger,

pattern, directed masturbation,

and

anxiety

and distrust toward the patient's partner should be investigated.

management also can be helpful.

Psychotherapy is an important element in Dyspareunia

and Vulvodynia.

Estimates of

the treatment of dyspareunia and should be

the prevalence of dyspareunia range from 8 . 0 %

approached in a multimodal framework

(Osborn, Hawton, & Gath, 1 9 8 8 ) to 3 3 . 5 %

examine the patient's (a) behavior (e.g., deficits

(Glatt, Zinner, & McCormack, 1990). Although

and

shortcomings

in sexual

to

techniques),

accurate prevalence rates are difficult to deter-

(b) affect (e.g., feelings of guilt, shame, and

mine, studies have shown that causal attributions

anger), (c) sensation (e.g., assessment o f the

of pain are related to levels of adjustment. For

location, type, frequency, and intensity o f

example, women who cited psychosocial attri-

pain), (d) imagery (e.g., body image, negative

butions indicated greater psychosocial distress,

memories), (e) cognition (e.g., negative self-

more problems with sexual function, and more

statements, dysfunctional beliefs), (f) interper-

frequent reports of sexual assault as well as lower

sonal

functioning

(e.g.,

communication,

Sexual Dysfunctions

\

climate between partners), and (g) biological

response. Psychotherapy can be used to explore

factors (e.g., improper hygiene, medications)

unconscious fears and conflicts that may under-

(Leiblum 8c Rosen, 1 9 8 9 ) .

lie the disorder. Therapy should include progressive relaxation techniques and

Vaginismus.

Vaginismus is a relatively rare

disorder characterized by "recurrent or persis-

fantasy

exercises to help alleviate fears o f gynecological exams as well as intercourse.

tent involuntary contraction of the perineal muscles surrounding the outer third o f the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted" (American Psychiatric Association, 1 9 9 4 ,

Male Sexual Dysfunctions Male

Erectile

Disorder.

An estimated 3 0

million men suffer from E D in the United

p. 5 1 3 ) . In some women, thoughts o f penetra-

States. E D prevalence rates increase to more

tion alone can create spasms. Contractions

than 5 0 % in men ages 5 0 to 7 0 years, and E D

can be mild, creating tightening and discom-

occurs in approximately 4 0 % of men with

fort, or severe, preventing any penetration.

diabetes

Sexual desire, pleasure, and orgasmic capacity

Hatzichristou, & Krane, 1 9 9 4 ) . In men under

can be impaired as a result o f the disorder.

age 3 5 years, approximately 7 0 % suffer from

The patient should be screened for potential

psychogenic E D , whereas 8 5 % o f men over

organic factors that can contribute to forma-

age 5 0 years have organic E D (Weiss &c

tion o f the disorder such as vaginal hysterec-

Mellinger, 1 9 9 0 ) .

(Feldman, Goldstein,

McKinlay,

tomies or other surgeries, atrophic vaginitis,

E D has been defined as an inability to

endometriosis, painful hymenal tags, and ure-

achieve or sustain an erection o f sufficient

thral caruncle (Lamont, 1 9 7 8 ; Tollison &

rigidity or duration to enable satisfactory

Adams, 1 9 7 9 ) . Although many of these con-

sexual performance

(American Psychiatric

ditions are not directly responsible for vaginis-

Association, 1 9 9 4 ) . Often, E D is associated

mus, they may be associated with the disorder

with older age ( M a r u m o , Nakashima,

indirectly through classical conditioning.

M u r a i , 2 0 0 1 ) . There are different patterns

&

The main objective is to eliminate the "spas-

to E D , with some patients reporting an inabil-

modic reflexive contraction of the muscles con-

ity to obtain an erection from the onset o f

trolling the vaginal entrance typically through a

sexual activity and others reporting having a

series o f gradual approximations with the inser-

satisfactory erection at the onset o f sex but

tion of increasingly larger dilators" (Leiblum,

then losing the erection when

Pervin, & Campbell, 1 9 8 9 , p. 1 1 3 ) . Use o f

penetration or once penetration is complete.

attempting

graduated rubber or plastic catheters helps to

Particularly when E D is psychogenic, patients

extinguish the conditioned spasmodic response

will frequently report having an erection on

via systematic desensitization. T h e patient or

awakening

or

during

self-masturbation.

her partner's fingers can also do insertion. In

Subtypes include lifelong versus acquired and

addition, it is important that the patient feel in

generalized versus situational.

control of what is happening, and this extends

T o obtain a diagnosis of E D and an accurate

to her guiding penile entry during coitus. Use of

understanding of the etiology of the disorder,

the female superior position during intercourse

assessment should include a detailed sexual and

should be suggested because this can help

medical history, physical examination, and psy-

the patient to maintain control o f entry and

chological interview. A medical history and a

movement. Cognitive-behavioral

physical examination are particularly impor-

approaches

are also used to challenge underlying thoughts

tant because a number of physiological factors

and beliefs that drive the conditioned fear

contribute to the pathophysiology o f E D . These

367

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

368

conditions include, but are not limited to,

Pena, & Mishra, 2 0 0 2 ) . Studies suggest that

(a) cardiovascular disease and

hypertension

sildenafil is particularly effective in cases of

(Burchardt et al., 2 0 0 1 ) , (b) other vascular dis-

arterial insufficiency and psychogenic causes o f

orders and neuropathy associated with diabetes

E D (Basar, Tekdogan, et al., 2 0 0 1 ) and that

(Dey & Shepherd, 2 0 0 2 ; Hecht, Neundorfer,

the drug is well tolerated in men over age

Kiesewetter, & Hiltz, 2 0 0 1 ) , (c) prostate cancer

6 5 years (Tsujimura et al., 2 0 0 2 ) . However,

or prostate cancer treatments (Incrocci, Slob,

even when the patient is treated effectively with

&

sildenafil, it is important

Levendag,

2002;

McCullough, 2 0 0 1 ;

Potters, Torre, Fearn, Leibel, & Kattan, 2 0 0 1 ) ,

to address

the

psychosocial factors that either preceded or

(d) spinal cord lesions (Biering-Sorensen &

developed as a result of E D (Dunn, Croft, &

Sonksen, 2 0 0 1 ) , and (e) hyperparathyroidism

Hackett,

(Chou et al., 2 0 0 1 ) . Depression (Seidman &

Bond, 2 0 0 1 ) , given that sexual satisfaction

1 9 9 9 ; M c D o w e l l , Snellgrove,

&

Roose, 2 0 0 0 ) , cigarette smoking (McVary,

(Shirai, Takimoto, Ishii, & Iwamoto, 2 0 0 1 ) ,

Carrier,

quality o f partnership

&

Wessells,

2001;

Spangler,

(Muller, Ruof, Graf-

Summerson, Bell, & Konan, 2 0 0 2 ) , and medi-

Morgenstern, Porst, & Benkert, 2 0 0 1 ; Paige,

cations

Hays, Litwin, Rajfer, & Shapiro, 2 0 0 1 ) , and

(Gelenberg

et

al.,

2000;

Rizvi,

Hampson, &c Harvey, 2 0 0 2 ) can also affect

attitudes toward interventions have important

erectile function.

consequences for the planning and treatment

Other assessment techniques include measurement

o f voluntary

contractile activity

of sexual problems and partner satisfaction. Intracavernosal

are

another

o f the ischiocavernosus muscle (Kawanishi e t a l . , 2 0 0 1 ) , penile pharmacotesting

Shalev, & Nissenkorn, 2 0 0 1 ) . Intracavernosal

with

option

injections

treatment

(Richter, Vardi, Ringel,

alprostadil (Aversa et al., 2 0 0 2 ) , sexual stim-

injection o f alprostadil (Caverject) has resulted

ulation penograms (Choi et al., 2 0 0 2 ) , and

in reported success rates o f 6 7 % to 8 5 %

measures

(Engelhardt, Plas, Hiibner, & Pfliiger, 1 9 9 8 ) .

o f nocturnal

penile

tumescence

W h e n injected directly into the corpus caver-

(Basar, Atan, & Tekdogan, 2 0 0 1 ) . Several treatment options are available for

nosum,

alprostadil

causes

the

arteriolar

organic causes of E D . There are pharmacolog-

smooth muscle cells to relax. N o more than

ical agents such as apomorphine (Altwein &

three injections per week, with a period o f

Keuler, 2 0 0 1 ; Mulhall, Bukofzer, Edmonds, &

2 4 hours between administrations, is recom-

George, 2 0 0 1 ) , yohimbine (an alpha-adrenore-

mended.

ceptor blocker) (Tam, Worcel, & Wyllie,

alprostadil. O n c e the suppository is inserted, it

2001),

will first diffuse into the corpus spongiosum

hormonal

treatments,

and

(most

the

is

corpus

transurethral

and

has been shown to be efficacious in treating E D

whereby the arteriolar smooth muscle relaxes,

in men who suffer from mild to

resulting

depressive illness (Muller & Benkert, 2 0 0 1 ;

into

option

recently) sildenafil citrate (Viagra). Sildenafil moderate

then

Another

in an erection

cavernosum,

(Viera, Clenney,

Shenenberger, & Green, 1 9 9 9 ) .

Seidman, Roose, Menza, Shabsigh, & Rosen,

A third option in the treatment of organic

2 0 0 1 ) and spinal cord injury (Sanchez et al.,

E D is a vacuum erection device. M o s t devices

2 0 0 1 ) . Sildenafil has also been shown to be

work by creating a vacuum in a cylinder placed

a safe and effective treatment of E D in both

over the penis. T h e vacuum

long- and short-term treatment (Burls, Gold,

into the corpora cavernosa and is trapped by

&

draws blood

&

placing a constricting band at the base of

Shabsigh, 2 0 0 1 ; Steers et al., 2 0 0 1 ) and has

the penis. Another option is the penile pros-

been found to improve the quality of life in

thetic implant. T w o types of implants exist: a

those patients w h o use sildenafil (Giuliano,

semi-rigid silicone implant (Small, Carrion, &

Clark, 2 0 0 1 ; Fagelman, Fagelman,

Sexual Dysfunctions

\

Gordon, 1 9 7 5 ) and a hydrolic inflatable device

exercises and cognitive-behavioral therapy can

(Scott, Bradley, & T i m m , 1 9 7 3 ) . However,

be used to confront performance anxiety, dis-

factors such as poor marital adjustment and

pute irrational

poor coping ability have been associated with

body image issues, and heighten sensuality.

poor postsurgical results (Meisler, Carey, &

Sensate focus is a central aspect of treatment

Krauss, 1 9 8 8 ; Schover, 1 9 8 9 ) .

(Table 1 8 . 3 ) . In addition to using these behav-

In cases o f psychogenic E D , the patient

beliefs, counteract

negative

ioral approaches, the couple needs to be edu-

should be referred for sex therapy, the goal o f

cated about sexual function and

which is to restore the patient's potency to the

Therapy can also address the destructive sex-

best level possible. T h e meaning o f impotence

ual system and

must be explored and transformed into cogni-

dynamics that inevitably develop in these cases.

dysfunctional

anatomy.

relationship

tive and emotional experience because "attentional processes are highly salient in creating disruption o f genital responsivity"

(Beck,

Male disorder

Orgasmic

Disorder.

M a l e orgasmic

is characterized by "persistent

or

1 9 8 6 , p. 2 1 8 ) . M e n with psychogenic impo-

recurrent delay in, or absence of, orgasm fol-

tence often express feelings o f inadequacy,

lowing a normal sexual excitement phase"

confusion, fear, anger, and shame. Perfor-

(American

mance anxiety becomes central in their sexual

p. 5 0 7 ) . Consideration o f this diagnosis must

Psychiatric Association, 1 9 9 4 ,

experience as they take on a "spectator" role,

take into account the patient's age and whether

watching to see whether their penises will

the amount o f stimulation the patient receives

"perform" at will as expected. O n c e an erec-

is adequate in duration and intensity. Delayed

tile "failure" occurs, the cycle o f anxiety, fear,

ejaculation can occur during

and shame repeats itself. Self-generated dis-

and/or during masturbation. M o s t men with

traction techniques that use cognitive interfer-

orgasmic disorder report feeling sufficiently

ence have been used successfully to

help

aroused at the onset o f sex. However, coital

manage anxiety in patients with E D (Beck,

thrusting soon feels like a chore rather than a

1 9 8 6 ; Beck & Barlow, 1 9 8 6 a , 1 9 8 6 b ) .

source o f pleasure. Maintaining an erection is

lovemaking

Partners o f men with psychogenic impo-

not a problem. Soreness and discomfort due to

tence experience their own fears and frustra-

prolonged rubbing can aggravate matters and

tions. It is c o m m o n for a partner to think that

often makes for greater frustration for both the

she is somehow responsible for the patient's

patient and his partner. Certain medical condi-

difficulties. For example, the partner may think

tions (e.g., spinal injuries, nerve damage, dia-

that she is no longer attractive to the patient or

betes), substance abuse, and medications (e.g.,

that the patient is having an affair. Thus, it is

beta blockers, antidepressants) can cause the

important to include the partner in treatment

disorder. In fact, drug therapies are the most

so that the relationship can be treated as well

c o m m o n cause of the dysfunction. A thorough

(Leiblum, 2 0 0 2 ) . M e n with psychogenic E D

examination by a physician is

can overcome the disorder "by understanding

Psychological problems, such as

their responses to their dilemmas, integrating

childhood experiences, extreme anxiety or

previously unacknowledged feelings, seeking

guilt, ridicule from a past partner, and feelings

new solutions to old problems, increasing

of anger, can also contribute to the disorder.

communication, surmounting the barriers to

warranted. traumatic

A distinction must be made between male

intimacy, and restoring sexual confidence"

orgasmic disorder

(Althof, 1 9 8 9 , p. 2 3 9 ) .

tion." Normally, ejaculation is caused by con-

Various interventions can be used in the treatment

o f psychogenic E D . Behavioral

and

"retrograde

ejacula-

traction o f the pelvic muscles, which are behind the penis and expel semen out o f the penis

369

370

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS through the urethra. Retrograde ejaculation is a

age, novelty of the sexual experience or partner,

condition in which semen travels back into the

and frequency of sexual activity. Relationship

bladder instead o f forward through the urethra

stress, anger at one's partner, anxiety about

(Wolf, 2 0 0 1 ) . Although semen is absent, the

intimacy, and low frequency o f intercourse are

sensation of orgasm is still usually pleasant.

other possible causes of PE. Assessment of PE

A third type of orgasmic disorder is called

should include an investigation of neurological

anejaculation. In this condition, the patient is

conditions, acute physical illness, physical

unable to ejaculate at all. Anejaculation can be

injury, and medication side effects (Metz Sc

caused by spinal injury or duct abnormalities

Pryor, 2 0 0 0 ) . It is also important to determine

(Cole, 2 0 0 2 ; Goldstone, 2 0 0 0 ) or by psycho-

whether early ejaculation occurs during mas-

logical factors. A thorough medical examina-

turbation and whether it is partner specific.

tion is necessary to rule out any physiological

It is helpful to understand the physiology

causes, at which point referral to a sex thera-

of the male orgasm to better understand P E .

pist or psychologist is warranted.

Ejaculation occurs as a result o f many differ-

If an orgasmic disorder is caused by medi-

ent physiological events. M a n y young men

cation, symptoms should remit once the med-

think that orgasm and ejaculation are the

ication is discontinued or the dose is adjusted.

same when in fact the two are related but sep-

In the case o f retrograde ejaculation, oral med-

arate processes. It is possible for men to have

ications are available that can help to contract

an orgasm without ejaculating (dry orgasm),

bladder neck muscles. Psychotherapy can help

just as it is possible to experience a partial

by giving the patient "permission" to concen-

ejaculation without the sensation o f orgasm.

trate on his own pleasure as well as by examining underlying psychological factors

that

may be contributing to the problem.

Early in sexual development, masturbation is often practiced in a rapid, intense, and goaloriented fashion. As a result, the "adolescent male focuses only on penis stimulation and is

Despite

intent on reaching orgasm and the associated

its common occurrence, it is difficult to estimate

few seconds o f intense pleasure" (McCarthy,

the frequency of premature ejaculation (PE).

1 9 8 9 , p. 1 4 5 ) , and this is counter to the pro-

Estimates have ranged from as low as 4 % (Metz,

cess o f learning ejaculatory control. Feelings

Early

or Premature

Ejaculation.

Pryor, Abuzzahab, Nesvacil, & Koznar, 1 9 9 7 )

of guilt, anxiety, shame, and/or fear of being

to as high as 3 6 % (Nettelbladt & Uddenberg,

caught

1979). It is estimated that approximately 2 5 % of

Eventually, a combination of high anxiety and

may

contribute

to

the

problem.

men report having an unsuccessful first inter-

sexual excitement can create a pattern of early

course experience, with the most common rea-

ejaculation, which is often made worse by the

son being that ejaculation occurs before vaginal

tendency o f the patient to self-monitor his

penetration (McCarthy, 1989). The D S M - I V

orgasmic response. Thus, an important com-

(American

ponent o f treatment is teaching the patient to

Psychiatric

Association, 1 9 9 4 )

defines PE as the "persistent or recurrent onset o f

experience masturbation and intercourse as a

orgasm and ejaculation with minimal sexual

more sensual, pleasure-focused, and "whole

stimulation before, on, or shortly after penetra-

body" experience.

tion and before the person wishes it" (p. 5 0 9 ) .

Orgasm in males is a two-phase process

Definitions of PE vary, and this is reflected in

consisting of the emission phase and the ejacu-

experimental and clinical research (Rowland,

latory phase. Emission is the movement of

Cooper, Sc Schneider, 2 0 0 1 ) .

semen into the urethra.

Expulsion is the

W h e n considering a diagnosis of PE, it is

propulsion o f semen out of the urethra at

important to take into account the patient's

orgasm. A reflex of pelvic floor muscles that

Sexual

Dysfunctions

CASE S T U D Y "Reggie," age 3 0 years, and "Marsha," age 2 7 years, sought therapy with a presenting complaint o f marital discord. T h e partners stated that their marriage o f 2 years was already in trouble and that therapy was their "last resort." Both Reggie and M a r s h a said that they loved one another and did not want to separate or pursue a divorce. Neither was married before. T h e partners had no children but expressed that having children was something they would like to do in the future. M a r s h a was in the third year o f her doctoral program in education. Reggie was currently working two parttime jobs while searching for employment as a data operations manager. Reggie had his B.S. degree but had "no desire to go back to graduate school." T h e partners agreed that over the past 8 months their relationship had become more and more strained. M a r s h a expressed aggravation with what she termed "Reggie's lack o f motivation in seeking stable employment." Marsha was feeling extremely pressured with graduate school, and although she earned a small income by teaching, the couple was having to rely on school loans as its main source of support. Reggie disagreed with Marsha's assessment of his j o b search efforts. H e maintained that Marsha's anger was due to her desire to start a family and that she interpreted his "lack o f motivation" as an indicator that his desire for children was not as great as hers. As the assessment continued, more information was gained about the partners' respective developmental histories, family lives, family compositions, and medical conditions. Neither had any past psychiatric history. Both were occasional "social" drinkers, with no history o f substance abuse. Neither partner smoked. W h e n asked about previous relationships, Reggie stated that he had been engaged at age 2 2 years but that his fiancé had called off the wedding. Since that time, he dated and had sexual relationships with several w o m e n until he began dating M a r s h a 3 years ago. M a r s h a dated in high school. She had two long-term relationships; one lasting 2Vi years and the other lasting 6 years. T h e 6-year relationship was with her "high school sweetheart" and began when M a r s h a was age 1 7 years. T h e other relationship t o o k place with a m a n she met in college when M a r s h a was age 2 4 years. Reggie and M a r s h a had experience with sex prior to their marriage. Reggie claimed that he found sex pleasurable but that he recently had trouble maintaining an erection. H e stated that he had less interest in sex. H e denied any past erectile difficulties. In contrast, M a r s h a suffered pain with intercourse that worsened over time. She began having pain at age 2 3 years. M a r s h a described the pain as a "sharp stab high up inside m e " that occurred after entry and during intercourse. M a r s h a was recently referred to a urologist, w h o told her that one reason for her pain was that her urethra was situated very close to her vagina, and this could create abdominal pain during intercourse, particularly during orgasm. She was given an antispasmodic medication. M a r s h a complained about using the medication because it had to be taken with a lot o f water several hours prior to intercourse.

372

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

M a r s h a a n d R e g g i e were seen individually for o n e session. In the session w i t h M a r s h a , she stated t h a t she is able t o lubricate w i t h o u t difficulty a n d c a n experience o r g a s m during o r a l s e x a n d m a s t u r b a t i o n . She a l s o reiterated her suspicion t h a t R e g g i e might n o t w a n t children after all. She expressed feeling angry and betrayed. M a r s h a also described herself as " f o c u s e d a n d i n t e n s e " and stated t h a t R e g g i e tends t o be m u c h m o r e passive in the r e l a t i o n s h i p , causing M a r s h a t o feel as though she has t o be "the responsible o n e . " M a r s h a reported that a n o t h e r source o f discord w a s R e g g i e ' s avoidance o f conflict. M a r s h a insisted t h a t Reggie will "tell me w h a t I w a n t t o h e a r " rather t h a n w h a t he really thinks. In the session with Reggie, he disclosed that he was not ready t o have children and felt great pressure from M a r s h a t o "get his act together" so that the couple will be in a better financial position to start a family. Reggie expressed that he moved across the country and left a good-paying position so that M a r s h a could attend graduate school. H e felt resentful that M a r s h a "seems to forget that." Reggie stated that since his erectile difficulties began, he has been able to maintain an erection on some occasions during masturbation. H e has also awakened with an erection periodically. Reggie stated that he rarely initiates sex. W h e n M a r s h a initiates sex, he tells her that he is tired or not in the m o o d . Reggie and M a r s h a had a number o f relational issues that needed t o be addressed in therapy before sex therapy would become the focus o f treatment. During the first month o f treatment, the couple's relationship was the focus o f therapy. Reggie and M a r s h a were asked not t o engage in sexual activity during this time. T h e y were encouraged to show affection and be close if and when they were comfortable with doing so. As the partners' relationship began t o improve, they began spending more time with each other, reported enjoying each other's c o m pany more, and were expressing more affection toward one another. W o r k i n g on their relationship in general helped t o move them to greater nonsexual intimacy, and this is often an important step in sex therapy. Despite the request not to do so, the couple attempted intercourse twice before sex therapy began. E a c h time, Reggie was unable to maintain his erection. M a r s h a complained that she was still finding the experience painful. It is c o m m o n for couples to " b r e a k the rules" during treatment and t o engage in sexual intercourse or other forms o f genital contact. Thus, it is important t o let the couple k n o w that unsuccessful attempts are a frequent and " n o r m a l " occurrence so as t o avert further setbacks. Reggie had expressed feeling upset with himself. M a r s h a admitted that she would become frustrated and angry when " s e x didn't w o r k . " Reggie was experiencing interfering thoughts prior t o and during sexual relations. H e admitted feeling "like less o f a m a n " since his problem began. H e readily became worried about the quality and duration o f his erection as well as images o f M a r s h a ' s displeasure, disappointment, and anger. These thoughts would lead to greater anxiety and depression.

Sexual

Dysfunctions

It was important to w o r k with Reggie to help him restructure his thoughts and focus on thoughts that would facilitate feeling pleasure rather than those that would inhibit his sexual function. O n c e Reggie was better able to establish a positive sexually facilitating thought process, he was ready to proceed with sensate focus. During this time, M a r s h a ' s fear that she was s o m e h o w responsible for her husband's lack o f sexual interest, and the subsequent feelings o f inadequacy and frustration, were explored. This was an important component in assessing M a r s h a ' s cognitive process. Misunderstandings on the part o f the partner c a n sabotage treatment. Educating the couple about E D helped to alleviate some o f M a r s h a ' s fears and resentment. T h e couple also had to be educated about sensate focus and why certain restrictions were warranted during the intervention. Prior to beginning sensate focus, couples should be told to assert and protect themselves during each session. Self-assertion involves the expression o f phrases such as " I would like you to . . ." and " W h y don't you . . . " E x a m p l e s o f selfprotective phrases would include " I don't find that pleasing" and "Please touch me somewhere else." A gentle removal o f a partner's hand c a n also serve this purpose. O n e reason for this is that partners need to realize that likes and dislikes can be communicated without personalizing one another's statements. A formal agreement is made between the partners to ban attempts at intercourse or other genital contact during early stages o f the program. This agreement removes the pressure to "succeed" or perform. Goals o f sensate focus include (a) learning to touch one's partner for one's

own pleasure, (b) relaxing when being caressed and using a pro-

tective statement or gesture when one finds the touch unpleasant, (c) learning to recognize when one is "spectatoring," (d) recognizing h o w nice it is to touch and be with one's partner, (e) recognizing h o w nice it is to be touched, and (f) becoming more acutely aware o f what one is feeling physically and emotionally during the session. Reggie and M a r s h a began sensate focus treatment that, in their case, lasted approximately 3 months. T h r o u g h o u t the treatment process, it was necessary to monitor the partners' communication with one another regarding both sexual and nonsexual matters. It was also important to check out the couple's comfort levels during the duration o f treatment and to attend to any interfering thoughts o r c o m pliance problems that surfaced during the intervention period. Reggie and M a r s h a also were instructed to conduct their "sessions" in an environment that was free o f distractions and conducive to facilitating an erotic experience. T h i s meant that they also needed to schedule their sessions when they had adequate time to be together. Relational issues and the general quality o f the couple's relationship continued to be an integral part o f therapy. T a b l e 1 8 . 3 outlines the progressive stages o f sensate focus therapy. T h e couple was to spend at least 3 0 minutes together, three times per week. As M a r s h a and Reggie approached the fifth stage o f sensate focus, which involved vaginal containment without thrusting, certain modifications had to be made to try to alleviate

373

374

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

M a r s h a ' s pain and discomfort. During this stage, the receptive partner controls activity. In this way, the amount o f movement and depth o f penetration can be controlled by the partner. Having M a r s h a assume the " t o p " position further enhanced her control. By doing so, she was better able to angle her pelvis in such a way that she had less discomfort. In the supine position, M a r s h a was encouraged to place pillows under her hips and to experiment with the height and angle that is most comfortable. During the final stage o f sensate focus treatment when intercourse resumed, it was suggested that M a r s h a use a certain lubricant to ensure adequate lubrication and t o heighten arousal. O n c e Reggie's E D resolved, the couple was given videotapes that demonstrated varied sexual positions and techniques. These tapes gave the couple additional information about positions that would be most comfortable for M a r s h a and satisfying to both partners. Eventually, Reggie and M a r s h a were able to resolve their sexual difficulties. Treatment success was due in large part to the partners' commitment to the therapeutic process, their resolve to w o r k through their marital and relational issues, and their compliance with the sensate focus intervention. T h e y were seen approximately 6 months after the termination o f therapy for a follow-up visit. N o problems were noted at that time.

rhythmically contract causes ejaculation. There

stimulation with the partner. T h e couple can

is a point at which men are not able to volun-

institute the technique by having the partner on

tarily control ejaculation. This is called the

top with the patient instructing the partner to

point of "ejaculatory inevitability," which is

stop movement when he senses he is losing

usually a few seconds before the start o f ejacu-

control. Often, the couple can progress to

lation. A central intervention in the treatment

simply slowing down when the patient begins

of PE is to help the patient learn to identify and

to feel close to ejaculating.

control the point of ejaculatory inevitability.

A second method o f intervention is the use

O n e method used to accomplish this involves

of the "squeeze technique," which involves

what is called the "stop-start" technique. T h e

stimulation to the penis until the patient is

patient begins by instituting the "start-stop"

close to ejaculation. Just prior to ejaculation,

technique during masturbation. Usually this

the patient or his partner places his or her

begins without the use o f lubrication. This

hand just below the head o f the penis and

allows the patient more privacy and control.

squeezes hard enough to cause partial loss o f

T h e patient stops self-stimulation until he feels

the patient's

like he has regained control. At that time, he

meant to help the patient become aware

erection. T h i s technique

is

begins stimulating his penis again. This proce-

o f sensations that precede orgasm and to

dure is repeated over time until the patient is

then control and delay orgasm on his own.

able to prolong his engagement in sexual stim-

This technique progresses from manual stim-

ulation while controlling his urge to ejaculate.

ulation to motionless intercourse and eventu-

Eventually, this procedure is transferred

ally to intercourse with movement.

to

Sexual Dysfunctions Drug therapy can also be effective. L o w doses o f antidepressant medications such as

compromises

our

effectiveness in

\

helping

those who struggle with issues pertaining to

Zoloft, Anafronil, and Prozac are often used

sex and sexuality. Treatments have continued

because o f their

that

to be more technologically or pharmacologi-

include the prolongation o f orgasm. M o r e

cally advanced. Granted, sex therapy can be

recently, topical agents such as anesthetics

credited for its ability to treat sexual problems

and herbal medications have been investi-

quickly and effectively; however, the goal

sexual side effects

gated as a possible treatment option (Choi

of most approaches is performance

et al., 1 9 9 9 , 2 0 0 2 ; M o r a l e s , 2 0 0 0 ) .

By shifting the traditional behavioral or cognitive-behavioral

approaches

based.

"to one

that

moves beyond behavior and communication CONCLUSIONS

to personal growth in relationship, we discover new horizons in human sexual poten-

The field o f sexual science has advanced con-

tial" (Kleinplatz, 2 0 0 1 , p. 1 9 0 ) . An important

siderably; however, the conceptual framework

factor in sex therapy is to help guide individu-

that guides the practice o f sex therapy has tra-

als in exercising greater personal agency over

ditionally been, and continues to be, rooted in

their relational needs as well as their erotic

biological science. A failure to broaden our

potential. Interventions

understanding and integration o f individual,

toward treating the individual as a whole,

relational, spiritual, and psychosocial factors

not simply as a malfunction

that may contribute to the problem at hand

equipment.

should

be

geared

in biological

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CHAPTER

19

Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome ANDREW C . BLALOCK AND PETER E . CAMPOS .

A

cquired immune deficiency syndrome

called combination therapy or cocktail therapy)

(AIDS) is characterized by severe

has

immunosuppression

and

ensuing

opportunistic infections that result from infec-

extended

the

lives o f many

living with HIV/AIDS. Called the

patients "Lazarus

syndrome," the extended survival period has

virus

brought hope and new challenges to H I V

(HIV). The disease was first recognized in 1 9 8 1

patients and their caregivers. As the number o f

tion with

h u m a n immunodeficiency

with the unexplained occurrence o f clusters of

persons living with H I V increases, psychologists

cases of Pneumocystis carinii pneumonia and

whose clinical activity once focused on crisis

Kaposi's sarcoma among young homosexual

management and bereavement counseling will

men. As such, it was initially referred to as

be faced with a wider, more diverse spectrum of

gay-related immune disorder. As similar cases

psychosocial issues, including the emotional,

of these and other opportunistic infections asso-

behavioral, cognitive, social, and

ciated with unexplained

aspects o f chronic illness coping and adjustment.

immunosuppression

vocational

were subsequently reported in persons with hemophilia, recipients o f blood transfusions,

and

products/

injecting drug users

and

their heterosexual partners, the disease entity was renamed

acquired immune

BACKGROUND AND EPIDEMIOLOGY

deficiency

syndrome. In 1 9 9 6 , pharmacological treatment advances

In 2 0 0 1 , the Centers for Disease Control and Prevention ( C D C ) estimated that 8 0 0 , 0 0 0 to

introduced a new era to the epidemic and shifted

9 0 0 , 0 0 0 individuals in the United States were

HIV/AIDS from an acute, irnminently terminal

living with H I V , with approximately 4 0 , 0 0 0

medical condition to a more chronic illness. By

new H I V infections occurring in the U.S. every

significantly slowing disease progression, highly

year ( C D C , 2 0 0 1 a ) . By gender, about 7 0 % o f

active antiretroviral treatment (HAART) (also

the new infections are in men, whereas 3 0 %

384

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

70 70 70 70 70

70 1986

1988

1990

1ΘΘ2

1994

1996

1998

2000

>fearof Report Figure 19.1

Proportion of AIDS Cases, by Race/Ethnicity and Year of Report, 1 9 8 5 - 2 0 0 0 , United States

are in women. In terms of race/ethnicity,

1 9 9 8 , 3 0 0 , 0 0 0 in 1 9 9 9 , and 3 2 3 , 0 0 0 in 2 0 0 0 .

5 4 % o f the new cases are among African

This

Americans, 2 6 % among Caucasians, 1 9 %

increasing need for prevention and health care

growing

population

represents

an

among Hispanics, and 1 % among other ethnic

services ( C D C , 2 0 0 1 c ) .

minority groups (see Figure 1 9 . 1 ) . In terms of the major exposure/risk factor category, approximately 4 2 % o f new H I V cases are

The HTV Disease Spectrum

men w h o have sex with men, 3 3 % are from

Because HTV causes subtle changes in the

heterosexual contact, and 2 5 % are from intra-

immune system long before an infected person

venous drug use (Figure 1 9 . 2 ) . Nearly all o f

feels sick or develops disease symptoms, the

the pediatric AIDS cases reported (more than

term "HTV disease" is used to cover the entire

9 0 % ) resulted from perinatal H I V transmis-

HEV illness spectrum, from initial infection to

sion. In 1 9 9 9 , the annual number o f AIDS

full-blown AIDS (also called advanced HTV

cases appeared to level, while the decline in

disease). T h e time that it takes for each individ-

AIDS deaths slowed considerably. Although

ual person to go through disease stages varies

the rate o f reported AIDS cases has declined

widely. For most people, however, the process

gradually among Caucasian gay/bisexual male

of HEV disease is fairly slow, taking several

adults over age 2 5 years, epidemiological

years from infection to the development o f

trends show increasing rates o f infection in

severe immunodeficiency (Cohen, 1 9 9 8 ) .

women (particularly women o f color), African

Behavioral health and health psychology

American men, and young adults under age

issues are an important part o f comprehensive

2 5 years (Figure 1 9 . 3 ) . Moreover, despite the

health care across the entire H I V disease spec-

decline in deaths and cases, more people are

trum. Although much o f behavioral

living with H I V than ever before: 2 7 5 , 0 0 0 in

care focuses on prevention and psychosocial

health

HIV

385

and AIDS

70

M e n w h o h a v e sex with m e n ( M S M )

60 CO

«

S *

I

50 0

30

Injection d r u g use ( I D U )

MSM & I D U 1986

1988

' 1990

' 1992

1994

1998

1996

' 2000

>fear of Diagnosis Figure 19.2

Proportion of Estimated Adult/Adolescent AIDS Cases, by Exposure Category and Year of Diagnosis, 1 9 8 5 - 2 0 0 0 , United States

N O T E : Data adjusted for reporting delays and proportional redistribution of cases reported without risk.

some

serum at that particular time. M a n y HFV

psychological problems, such as m o o d dis-

patients are knowledgeable about these disease

orders and cognitive changes, are directly

parameters and frequently use them to describe

related to the effect of H I V on the central ner-

their illness status. F r o m a psychological per-

vous system. In medical and behavioral clinical

spective, these numbers may take on particular

care, there are two HIV-specific disease param-

meaning and may be associated with a range of

eters (laboratory test results) that are c o m -

emotional reactions. For example, a patient

monly used to gauge an individual's illness

may be relieved that C D 4 has risen with med-

status or progression. First, C D 4 count is an

ication or frightened that there has been no sig-

index of immunosuppression. C D 4 is a type o f

nificant change in viral load after beginning a

issues o f chronic illness adjustment,

lymphocyte destroyed by HFV. In a nonin-

new regimen. For these reasons, psychologists

fected individual, a C D 4 count of 5 0 0 to 1,200

who work with H I V patients and their families

is considered within normal limits, whereas a

should be familiar with C D 4 and viral load.

C D 4 count o f less than 2 0 0 is considered significantly immunosuppressed and is one o f the criteria for an AIDS diagnosis. Second, viral load or viral burden is an index o f virus concentration in body fluids such as blood or cere-

Transmission Risk Factors and Infection HIV is transmitted in infectious body fluids

brospinal fluid. Current laboratory technology

through unprotected

measures viral load in a range o f undetectable

blood contact (including injection drug nee-

to more than 7 5 0 , 0 0 0 . It is crucial for patients

dles, blood transfusions, accidents in health

and caregivers to remember

that

"unde-

sexual contact, direct

care settings, and certain blood products), and

tectable" does not mean the absence o f virus;

mother-to-baby

rather, it means a very low concentration in the

through breast milk). Infectious body fluids

(prenatally/perinatally

or

386

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

Women

Exposure Category Men who have sex with men Injection drug use (IDU) MSM/IDU

Hemophilia Other/not identified

Figure 19.3

Estimated AIDS Incidence Among Adults/Adolescents Diagnosed in 2 0 0 0 , by Sex and Exposure Category, United States

N O T E : Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. Data reported through June 2 0 0 1 .

include blood, semen, vaginal secretions, and

symptoms or look sick to have H I V . In fact,

breast milk, whereas noninfectious body fluids

people may look perfectly healthy for many

include saliva, tears, sweat, urine, and feces.

years despite the fact that they have H I V in

Contact with the virus, called exposure, does

their bodies. T h e only way in which to find out

not always lead to infection. Healthy unbroken

whether a person is infected is to take an H I V

skin is an excellent barrier to H I V infection

antibody test.

because it does not allow viral entry. HEV can only enter through an open cut or sore or through contact with the mucous membranes. The likelihood of infection is a function o f the viral concentration in the particular

fluid;

Primary (or Acute) Infection Primary or acute H I V infection is the first stage o f H I V disease, when the virus estab-

blood contains the highest viral concentration,

lishes itself in the body. Up to 7 0 % o f people

followed by semen and vaginal fluids. Breast

newly infected with H I V will experience some

milk can contain a high concentration o f the

"flu-like" symptoms that usually last no more

virus and so is a high-risk factor for infants

than a few days and include fevers, chills,

because they have developing immune systems

night sweats, and rashes (not cold-like symp-

and consume a high volume o f breast milk

toms). T h e remaining percentage o f people

relative to body weight (American Psychiatric

either do not experience acute infection or

Association, 1 9 9 8 ; Kalichman, 1 9 9 8 ) . People

have symptoms so mild that they might not

with HTV are considered to be infectious

notice them. During acute H I V infection, the

immediately after infection. Although "infec-

virus infiltrates the lymph nodes, a process

tivity" is a function o f viral load and may fluc-

that is believed to take 3 to 5 days. Then H I V

tuate accordingly, individuals are infectious at

actively reproduces and releases new virus

all times. Also, a person does not need to have

particles into the bloodstream. This burst of

HIV and AIDS rapid H I V replication usually lasts about 2 months. People at this stage often have a very high H I V viral load (Cohen, 1 9 9 8 ) .

illness, is the current criterion for an AIDS diagnosis (also called full-blown AIDS or

antibodies

to

the virus. Approximately 9 5 % o f the people infected with H I V will develop antibodies within 3 months after infection. Nearly all them

will develop

T h e concurrent combination of two factors, of an opportunistic infection or AIDS-defining

"Seroconversion" refers to the time when

of

AIDS a C D 4 count o f less than 2 0 0 and the presence

Seroconversion and Asymptomatic HIV Disease the body begins producing

387

antibodies

within

6 months after infection. Given these time frames, individuals w h o seek H I V testing should wait at least 3 months after suspected exposure for the test. If their first result is negative, they should c o m e b a c k for a second

advanced H I V disease). These illnesses are called opportunistic because they are caused by organisms that cannot induce disease in people with normal immune systems but take the "opportunity" to flourish in people with H I V . Common

opportunistic

infections

are

described in Table 1 9 . 1 . Receiving an AIDS diagnosis does not necessarily mean that the person will die soon. In fact, with treatment, many individuals live for many years after their diagnosis (Cohen, 1 9 9 8 ) .

test 3 months later. T h e period o f viral replication is quite variable because the virus slowly damages the immune system for years after

infection. D u r i n g

this period,

the

individual will not experience or exhibit any

PREVENTION AND ADHERENCE

Primary Prevention: Risk Reduction

signs o f AIDS-defining illnesses because the

Over the years, the behavioral health care

level of immunosuppression is not critical.

community has acquired a formidable litera-

However, it is extremely important

ture base that addresses H I V prevention at

that

people with H I V seek appropriate care even

both the individual and community levels. A

if they feel fine at the m o m e n t because the

review o f this literature is well beyond the

virus

scope o f this chapter; however, the C D C ' s

could

immune

already

systems

be

damaging

(American

their

Psychiatric

Association, 1 9 9 8 ; Cohen, 1 9 9 8 ) .

(2001b)

Compendium

provides

a summary

o f this research. In

general, prevention strategies are based on

Symptomatic HTV Disease O n c e the immune system is

o f H I V Prevention

Interventions W i t h Evidence o f Effectiveness

reducing or eliminating behaviors that put an damaged,

individual

at

risk

for

contracting

HIV.

many people will begin to experience some

Consistent with the two largest risk factor

mild symptoms (e.g., skin rashes, fatigue,

categories, prevention efforts are focused on

slight weight loss, night sweats). M o s t will

changing sexual behavior and drug use behav-

have mild symptoms such as these before

ior. Although there are numerous

developing more serious illnesses. Although a

about behavior change, some o f the most pop-

person's prognosis varies greatly depending

ular and widely used ones in H I V prevention

theories

on his or her ability to access support, ser-

are the harm reduction models. Unlike tradi-

vices, and preventive treatment, it is generally

tional models that emphasize abstinence from

believed that it takes the average person 5 to

high-risk behavior, the harm reduction models

7 years to experience the first mild symptom

assess the individual's psychological readiness

(Cohen, 1 9 9 8 ) .

to

change

high-risk

behavior

and

then

388

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Table 19.1

Common Opportunistic Infections

Opportunistic

Infection

Common

Name

Etiology/Symptoms

Candidiasis

Thrush

Fungal infection of the mouth, throat, or vagina

Cytomegalovirus

CMV

Viral infection that causes eye disease that can lead to blindness

Herpes simplex viruses

Oral herpes or genital herpes

Lesions or "cold sores"

Mycobacterium avium complex

M A C or MAI

Bacterial infection that can cause recurring fevers, general sick feelings, problems with digestion, and serious weight loss

Pneumocystis carinii pneumonia

PCP

Protozoal infection that causes pneumonia

Toxoplasmosis

Toxo

Protozoal infection of the brain

KS

Type of skin cancer

Kaposi's sarcoma

design/negotiate interventions that match that

Project, a synthesized compendium of more

readiness. F o r sexual behavior change, pre-

than 2 0 0 programs with demonstrated positive

vention strategies involve education

about

the range o f transmission risk across various

outcomes, successful prevention

programs

generally have several elements in common.

sexual behaviors, negotiation/refusal skills,

First, they address specific goals and objectives,

appropriate

condom use, and the role o f

target specific audiences, and concentrate on

mood-altering substances in sexual behavior

specific learner priorities and behaviors to meet

decision making. For drug use

behavior,

needs identified by the community. Second,

prevention strategies involve elimination o f

they are developed from existing social and

sharing injection equipment, disinfection o f

behavioral science theory. Third, they provide

" w o r k s " or injection equipment, condom use,

opportunities

and

enrollment in drug abuse

treatment

(American Psychiatric Association, 1 9 9 8 ) .

for patients to develop

and

practice prevention skills and for program providers to learn how to enhance those skills.

Even the most widely used prevention coun-

Fourth, they are appropriate for and accept-

seling models acknowledge that knowledge

able to the targeted audience culturally, develop-

about H I V transmission and prevention is nec-

mentally, and sexually ( C D C , 2 0 0 1 b ) .

essary but not sufficient for behavior change (Ajzen &c Fishbein, 1 9 8 0 ; Fisher &c Fisher, 1 9 9 7 ) . M o r e effective interventions rely on skills training and take into account individual psychosocial and

Secondary Prevention: Medication Adherence

cognitive strategies

Highly active antiretroviral therapy con-

(Kalichman & Hospers, 1 9 9 7 ) . Effective psy-

sists o f a protease inhibitor combined with at

chological interventions help patients to per-

least t w o other drugs. H A A R T has been

ceive themselves as at risk for HFV infection,

shown to suppress H I V viral load, increase

help patients to address motivation to reduce

C D 4 count, improve clinical health,

risk, and ensure that patients have the skills

decrease AIDS-related mortality (Carpenter

and resources to implement risk reduction

et al., 1 9 9 8 ; Catz, Kelly, Bogart, Benotsch, &

strategies. According to the C D C ' s ( 2 0 0 1 b )

McAuliffe, 2 0 0 0 ) . T h e success o f these c o m -

H I V / A I D S Prevention

bination

Research Synthesis

therapies

is patient

and

adherence.

HIV and AIDS Table 19.2

Nucleoside Analog Reverse Transcriptase Inhibitors

Year

Generic

1987 1991 1992 1994 1995 1997

Zidovudine Didanosine Zalcitabine Stavudine Lamivudine Zidovudine/ Lamivudine Abacavir Zidovudine/ Lamivudine/ Abacavir Tenofovir

1998 2000

2001

389

Name

Trade

Name

Retrovir Videx Hivid Zerit Epivir Combivir Ziagen Trizivir

Viread

Also known as AZT, Z D V ddl ddC, dideoxycytidine d4T 3TC Combines Z D V and 3 T C 1592U89 Combines AZT, 3TC, Abacavir bis-poc PMPA

N O T E : These were the first anti-HIV drugs. They block reverse transcription (the creation of viral D N A from R N A ) by providing "decoy" building blocks that interrupt the process.

H A A R T regimens require that

individuals

adherence rates of 7 0 % to 8 0 % , which would

take multiple daily doses o f each medication

be considered favorable in other medical con-

in the prescribed combination. T h e regimens

ditions, have been associated with high rates

may involve as many as 2 0 or more pills, and

(over 7 5 % ) o f treatment failure (Montaner

each medication carries specific dose-spacing

et al., 1 9 9 8 ; Paterson, 1 9 9 9 , 2 0 0 0 ) . Successful

requirements. Depending on the c o m b i n a -

adherence is not only related to

tion, different medications may need to be

treatment outcome but also related to future

taken with food, without food, with water,

treatment outcome. With inconsistent or poor

or in temporal sequence relative to other

adherence, H I V infection can become "resis-

drugs in the c o m b i n a t i o n (Catz et al., 2 0 0 0 ) .

tant" to many current antiretrovirals,

Some

refrigeration.

subsequent treatment efforts often fail. Thus,

medications

require

current

and

Given these requirements, adherence can be a

patients may have a limited number o f combi-

formidable challenge for even the most con-

nation regimens to try. Furthermore, persons

scientious patient. T h e y present even greater

who develop drug-resistant H I V can transmit

barriers to patients w h o have concurrent

these strains to others during high-risk activi-

psychiatric illness or psychoactive substance

ties (Hecht et al., 1 9 9 8 ; Kelly, Otto-Salaj,

abuse/dependence or w h o simply need to

Sikkema, Pinkerton, &c Bloom,

maintain privacy about their illness in their

number o f barriers to adherence have been

social

environments.

described in the prevention literature. These

Because medication and adherence are such

barriers include (a) factors associated with the

and

occupational

1998). A

core issues for patients with ΗΓν illness,

medications themselves such as adverse side

health psychologists should become familiar

effects, large numbers of pills, dosing restric-

with various H A A R T medications (Tables

tions (frequency and

1 9 . 2 , 1 9 . 3 , and 1 9 . 4 ) .

ments), and medication containers that are too

food/water

require-

Treatment success typically requires strict

numerous or too large to carry and (b) factors

adherence rates (i.e., 9 0 % to 9 5 % ) , and

associated with stigma and confidentiality such

some research has shown that even partial

as being reminded o f one's HFV status, not

nonadherence to H A A R T greatly diminishes

wanting other people to know one's H I V

the

status, inability to take medications privately

benefits

o f treatment.

For

example,

390

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Table 19.3

Non-nucleoside Reverse Transcriptase Inhibitors

Year

Generic

1996 1997 1998

Nevirapine Delavirdine Efavirenz

Name

Trade

Name

Viramune Rescriptor Sustiva

Also known as NVP, BI-RG-587 DLV EFV, DMP-266

N O T E : These also interrupt reverse transcription by binding to the reverse transcriptase enzyme and restricting its activity.

Table 19.4

Protease Inhibitors

Year

Generic

Name

1995 1996 1996 1997 1997 1999 2000

Saquinavir Ritonavir Indinavir Nelfinavir Saquinavir Amprenavir Lopinavir

Trade

Name

Invirase Norvir Crixivan Viracept Fortovase Agenerase Kaletra

Also known as SQV RTV IDV NFV SQV APV, 141W94 ABT-378/r

N O T E : Protease inhibitors block the action of protease, an enzyme that cuts H I V protein chains into specific proteins needed to assemble a new copy of the virus.

while at work or in public, and integrating

self-care, and illness progression. Sadness and

one's medication schedule into daily life (Catz

grief

et al., 2 0 0 0 ) . By considering these barriers,

responses to the multiple stressors and losses

psychologists can help patients to organize and

associated with HFV illness. However, when

are

considered

normal

emotional

manage their medication-taking routines, plan

depressed mood persists for more than 2

and problem solve how they will handle medi-

weeks and is accompanied by social with-

cation taking in the context o f their other life

drawal, lack of motivation/participation in

activities, use strategies to make complex regi-

usual activities, and additional physical and

mens easier to recall, and consult with their

cognitive symptoms, a serious depressive dis-

health care providers when questions about

order requiring professional care may be

regimens arise or when treatment side effects

present (Rabkin, 1 9 9 7 ) . Depression is the most

are encountered.

c o m m o n psychiatric disorder found

among

HIV-infected individuals (Elliot, 1 9 9 7 ) . CrossASSESSMENT AND T R E A T M E N T OF PSYCHOLOGICAL DISORDERS IN HIV ILLNESS

both

H I V + and at-risk HEV populations estimate that the lifetime prevalence o f depressive disorders ranges from 2 0 % to 6 0 % . Current prevalence (6 to 1 2 months) ranges from 0 %

Depression Introduction

sectional and prospective studies in

to 1 8 % in HEV-positive populations and from and Epidemiology.

Depres-

sion has a significant effect on quality o f life,

0%

to 9 % in HIV-negative populations.

These rates are generally higher than estimates

HIV and AIDS in

community

samples

(Rabkin,

1997;

thoughts and emotions and their underlying assumptions. Group therapy has been used

M c D a n i e l & Blalock, 2 0 0 0 ) .

extensively with HIV-positive individuals in a Assessment/Diagnosis.

Diagnosing depres-

variety of contexts and is highly efficient. It

sion in the context o f H I V disease can be c o m -

provides

plicated because some diagnostic criteria, such

regarding misperceptions about the illness, and

psychoeducation,

confrontation

as loss of sexual desire, loss of appetite,

shared

insomnia, slowed movements, impaired con-

improve these individuals' mood and quality o f

experiences, all o f which help

to

centration, low energy, and fatigue, are also

life (Elliot, 1 9 9 7 ) .

caused by HlV-related illnesses, HlV-related pain, or the side effects o f H I V medications

Pharmacotherapy.

T h e approach to phar-

(Elliot, 1 9 9 7 ) . This diagnostic confounding is

macotherapy for HIV-positive individuals with

partially addressed by making a distinction

a major depressive disorder may be slightly

between the somatic symptoms o f depression

different from that for the general adult popu-

just listed and cognitive or affective symptoms

lation. HIV-positive individuals often respond

such as diminished ability to concentrate and

more sensitively to medications and may need

m a k e decisions, loss o f interest/pleasure, and

a "start low and go slow" approach. In addi-

feelings of worthlessness, guilt, hopelessness,

tion, individuals with advanced H I V infection

and helplessness. These symptoms, occurring

are often on multiple medications, thereby

together, are more clearly indexes o f depres-

increasing the probability o f drug-drug inter-

sive disorder and cannot be accounted for by

actions. Also, side effects may occur differently,

the presence o f medical conditions

with some being helpful and some aggravating

alone

(Rabkin, 1 9 9 7 ) .

current symptoms o f H I V infection itself or HIV-related illnesses (Rabkin, 1 9 9 7 ) . In genPsychotherapy or counsel-

eral, the selective serotonin reuptake inhibitors

ing with HIV-positive individuals has been

(SSRIs) (e.g., fluoxetine, paroxetine, sertraline)

Psychotherapy.

approached from several models, including

are more tolerable with fewer side effects and

cognitive-behavioral therapy (CBT), supportive

so may lead to an increased overall effective-

psychotherapy, and group therapy. C o m m o n

ness. Testosterone replacement

themes for clients during therapy are loss o f

shown to improve depressive symptoms in with

low

has

testosterone

been

relationships and autonomy, vocational issues,

individuals

physical health and appearance, spirituality, and

especially for those with decreased libido, sexual

levels,

stigma/discrimination. Supportive psychother-

dysfunction, and diminished energy. In addi-

apy examines mood changes in response to

tion, stimulants have been shown to improve

disease-related stressors and role changes.

mood, energy, and alertness and to be effective

Typically, the therapist and patient work on

in medically ill populations

exploring sources of sadness/grief,

McDaniel &

building

social support, and increasing self-care. In contrast, C B T focuses on reality testing

and

(Elliot, 1 9 9 7 ;

Blalock, 2 0 0 0 ) . Psychologists

should be aware o f the potential interaction effects o f some H A A R T medications

and

restructuring distorted, pessimistic, or unrealis-

some H I V medications. Ritonavir, indinavir,

tic thinking patterns that perpetuate a depressive

saquinavir, and nelfinavir all are metabolized

outlook or attributional style. T h e therapist is

in the same hepatic enzyme system as are many

more directive, helping the patient with setting

psychotropic drugs. Consequently, the simul-

goals, defining target symptoms, problem solv-

taneous use o f both classes o f drugs may alter

ing, and investigating relationships

the clearance rate o f one or the other. T h e

between

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

392

interaction effect may alter the serum levels of

may be directly caused by viral involvement in

either kind o f drug, thereby increasing the risk

the central nervous system, the role o f the

of side effects or potentially decreasing the

AIDS virus in the etiology o f anxiety disorders

therapeutic effect (McDaniel & Blalock, 2 0 0 0 ;

is unclear and remains under investigation

Rabkin, 1 9 9 7 ) .

(Sciolla, Atkinson, 8c Grant, 1 9 9 8 ) . In patients with HEV/AIDS, anxiety symptoms may occur in several HFV-related medical conditions and

Anxiety

with psychoactive substance intoxication or

Introduction

and Epidemiology.

Anxiety

withdrawal (American Psychiatric Association,

disorders may occur at any time during the

1 9 9 8 ) . Similarly, anxiety may also be a mani-

course of H I V illness, particularly at pivotal

festation of side effects from H I V medication

points in disease progression, and are often

regimens, psychotropic medication, or other

considered a normal psychological response

pharmacological agents used to treat HEV-

to stress. In general, most patients respond

related medical problems (American Psychiatric

adequately to the stress of living with H I V and

Association, 1 9 9 8 ) .

limit the impact o f disease-related anxiety on their daily functioning and quality o f life. For

Psychological treatment o f

Psychotherapy.

some patients, however, the severity and dura-

anxiety disorders usually involves a two-phase

tion o f anxiety can cause significant, or even

process: acute symptom reduction in the short

debilitating, impairment o f daily functioning.

term and development o f more adaptive cop-

As with other chronic medical conditions, the

ing skills in the long term. In general, C B T is

entire spectrum of D S M - I V (Diagnostic

particularly useful in the treatment o f anxiety

Statistical

Manual

edition)-defined

of Mental

Disorders,

anxiety disorders

and fourth

may

disorders

because it focuses on

distorted

be

cognitive schémas and maladaptive behaviors.

seen in patients with HIV/AIDS (American

Progressive muscle relaxation and breathing

Psychiatric Association, 1 9 9 4 ; Blalock

exercises are often used to treat the physiolog-

&

McDaniel, in press). Prevalence rates for anxi-

ical manifestations o f anxiety and

ety disorders among patients with H I V disease

impending panic attacks. For specific phobias

range from 5 % to 4 0 % (McDaniel & Blalock,

and situationally determined panic attacks,

2 0 0 0 ) . But despite this wide range in preva-

systematic desensitization is helpful and is

lence estimates, a pattern o f findings

frequently

has

used

prevent

in conjunction with

the

emerged over the past 5 years: T h e prevalence

relaxation techniques. For more generalized

of

anxiety or anxious personality styles, tech-

anxiety disorders

in

HIV-seropositive

patients is not significantly different from that

niques such as

in HIV-seronegative patients. However, life-

therapy

time rates among patients with HLV disease are

designed to identify

generally higher than rates found in the general

pessimistic, and self-defeating thought patterns

and

rational-emotive-behavioral

cognitive

restructuring

and refute

are

irrational,

population or community samples (Dew et al.,

and attributional styles (McDaniel & Blalock,

1997;

2 0 0 0 ) . W i t h all types o f anxiety disorders,

R a b k i n , Ferrando, J a c o b s b e r g ,

&

Fishman, 1 9 9 7 ; Sewell et al., 2 0 0 0 ) .

therapist modeling and therapist-client roleplaying are concrete learning experiences

Assessment/Diagnosis.

A successful treat-

that can be beneficial. M o s t o f the cognitive-

ment plan for anxiety disorders in HEV/AIDS

behavioral techniques can be

relies on a thorough assessment of the patient's

into individual psychotherapy sessions, short-

incorporated

presenting anxiety symptoms, preferred stress

term psychoeducational groups, or ongoing

coping style, and repertoire o f stress coping

interpersonal process therapy groups (Karasic

skills. Unlike mood disorders in H I V , which

& Dilley, 1 9 9 8 ) .

HIV and AIDS Unless contraindicated

Pharmacotherapy. by a history

of psychoactive

substance

393

et al., 1 9 9 8 ) . According to a national cohort study, the incidence rate o f HIV-associated

dependence, benzodiazepines are frequently

dementia over a 5-year period was approxi-

prescribed for short-term treatment o f acute

mately 7 % for those with a C D 4 count o f

anxiety symptoms. Ideally, they are

then

less than 1 0 0 , 3 % for those with a C D 4

learns

count between 1 0 1 and 2 0 0 , and 2 % or less

more psychologically or behaviorally based

for those with a C D 4 count o f more than

gradually tapered as the individual

coping strategies. Antidepressants, particu-

2 0 0 . T h u s , HIV-associated dementia is prin-

larly SSRIs, may also be quite

cipally a disease found in advanced H I V ill-

effective

(Blalock & M c D a n i e l , in press).

ness (Price, 1 9 9 8 ) . Assessment/Diagnosis.

Cognitive Disorders Introduction

and

As with any sus-

pected cognitive impairment, HIV

Epidemiology.

penetrates the blood-brain barrier early in

interview with

a collateral

a caregiver o r significant

other is a crucial part o f assessment. Cognitive

the course o f infection and can be found in

problems may be episodic or subtle and may

the cerebrospinal fluid in nearly half o f

escape detection by short cognitive screening

infected individuals before the development

or brief interviewing techniques. Thorough

of AIDS-defining illnesses. Early or subtle

neuropsychological testing can detect mild

impairment may manifest as HIV-associated

problems across the spectrum o f cognitive and

minor cognitive m o t o r disorder: mild deficits

psychomotor functions. T h e neuropsycholog-

o f attention, information processing speed,

ical evaluation also includes assessment o f

learning and

psychomotor

personality functioning to help identify other

skills. T h e problems may be quite mild such

psychiatric disorders and to distinguish the

as loss o f train o f thought, word-finding dif-

cognitive problems associated with

m e m o r y , and

mood

ficulties, short-term memory problems, and

disturbance and more disease-based cognitive

decreased efficiency in fine m o t o r speed and

problems (Grant & Martin, 1 9 9 4 ; M o o r e ,

dexterity. HIV-associated minor cognitive

van Gorp, Hinken, & Stern, 1 9 9 7 ) .

disorder may be complicated by the presence of depression or anxiety but is not caused by psychiatric problems (American Psychiatric

Psychotherapy.

Depending on the extent o f

cognitive impairment, traditional psychother-

Association, 1 9 9 8 ; G r a n t & M a r t i n , 1 9 9 4 ) .

apies may be o f limited use. For mild to mod-

In more advanced disease stages, neurocogni-

erate impairment, patients often find it helpful

tive impairment may be quite

prominent

to explore fear, anger, and sadness about loss

with HIV-associated dementia, a progressive

of previous level o f functioning. T h e degree o f

disorder that initially presents as

distress is frequently related to the real-life

apathy,

inertia, cognitive slowing, memory loss, and

impact o f the patient's cognitive impairment.

social withdrawal.

For some individuals, the changes interfere

As the dementia

pro-

gresses, multiple cognitive functions become

minimally with daily functioning and

are

increasingly impaired. T h e terminal phases

helped by simple strategies such as using

are characterized by global cognitive impair-

written reminders and simplifying sequential

ment,

psychomotor

tasks. For others, however, the changes may

retardation. Unlike minor cognitive disorder,

necessitate a réévaluation o f vocational/leisure

HIV-associated

abilities or even daily living and self-care skills.

mutism,

and

severe

dementia

rarely

develops

prior to constitutional problems and usually

Conjoint therapy (e.g., family, partner, care-

does not develop prior to other AIDS-defin-

giver) is usually indicated in patients with

ing illnesses (Grant &c M a r t i n , 1 9 9 4 ; Sciolla

HIV-associated cognitive disorders because

394

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

CASE S T U D Y " R i t a " is a 44-year-old, bisexual Caucasian female with a 12-year history o f H I V disease w h o was referred for a crisis evaluation by her medical provider. T h r e e months prior to consultation, her viral load increased markedly from a previously undetectable level and her C D 4 count decreased from 2 5 0 t o 7 5 , prompting a change in her antiretroviral regimen from zidovudine, didanosine, and indinavir to stavudine, lamivudine, and efavirenz. T h r e e months later during a medical followup visit, Rita became acutely agitated when she learned that her C D 4 and viral load had remained unchanged despite the new regimen. She considered herself a "treatment failure" and was convinced that she would die. Rita described herself as a recovered alcoholic with 7 years o f sobriety. She also reported a long-standing history o f marijuana use and had continued to smoke daily over the past 2 years, finally quitting only recently because she could no longer afford to use marijuana. O n c e Rita was substance free, her underlying psychiatric symptoms emerged. She revealed a long history (preceding her H I V diagnosis) o f obsessive worrying, restlessness/irritability, sleep disturbance, and p o o r stress coping that was consistent with a diagnosis o f generalized anxiety disorder. She also reported a history o f sub-syndromal depressive symptoms and fear o f being open with others about her sexual identity. Although she was eventually able to abstain from alcohol, she continued to use marijuana as a way in which to diminish her chronic anxiety. Rita was finally diagnosed with generalized anxiety disorder after a stable drugfree period, with her differential diagnostic picture also including major depressive episode, depression/anxiety secondary to a general medical condition, and substance/medication-induced depression/anxiety. T h e long-term treatment plan for her anxiety included a combination o f medication and cognitive-behavioral psychotherapy. Benzodiazepines were contraindicated given her history o f substance dependence. Instead, she was prescribed the antidepressant mirtazepine ( 1 5 milligrams at bedtime) to alleviate her anxious/depressive symptoms. Her weekly psychotherapy focused on preventing substance use relapse and strengthening problem-solving and stress-coping skills. During therapy, Rita made progress in several important areas that improved her overall psychological functioning, including disclosing her HEV status and sexual orientation to family members, applying for disability income benefits, and finding a suitable housemate to reduce living expenses. Rita's case illustrates three important issues for treating anxiety disorders in H I V clinical care. First, anxiety disorders or anxious character styles may precede infection and increase vulnerability to problems with chronic illness coping. Second, psychoactive substances are frequently part o f a c o m p l e x history and symptom picture and require careful consideration in assessment and treatment. Third, a thorough differential diagnosis, including medical and medication-induced causes, must be considered when assessing and treating anxiety-related symptoms.

HIV and AIDS these patients may require a range of assistance

CONCLUSION

from others. This becomes particularly crucial for medication adherence due to forgetfulness or confusion.

Although patients

health with

psychologists may

H I V disease

treat

independently,

Pharmacological treatment

health psychologists are typically part o f a

strategies for cognitive disorders can be divided

multidisciplinary treatment team composed

Pharmacotherapy.

therapies,

of infectious disease specialists, psychiatrists,

(b) therapies aimed at immunological measures

nurses, and social service workers. An inte-

or inflammatory mediators, (c) therapies aimed

grated knowledge base helps to bridge exist-

at bolstering the response of the brain to the

ing gaps

onslaught of the infection (e.g., neurotransmitter

health, and it positions health psychologists

manipulation), and

to be uniquely skilled professionals in the

into four types: (a) antiretroviral

(d) nutritional

therapies

(American Psychiatric Association, 1998).

between

medicine and

mental

H I V health care arena.

REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (1998). Practice guidelines for the treatment of patients with HIV/AIDS. Washington, DC: Author. Ajzen, I., & Fishbein, M . (1980). Understanding attitudes and predicting behavior. Englewood Cliffs, NJ: Prentice Hall. Blalock, A. C , & McDaniel, S. J . (in press). Anxiety disorders in HIV infection and AIDS. In A. Beckett, K. Citron, & M. J . Brouillette (Eds.), HIV and psychiatry. Cambridge, MA: Cambridge University Press. Carpenter, C , Fischl, M., Hammer, S., Hirsch, M., Jacobsen, D., Ketzenstein, D., Montaner, J . , Richman, D., Saag, M., Schooley, R., Thomson, M., Vella, S., Yeni, D., & Volberding, D. A. (1998). Antiretroviral therapy for HIV infection in 1 9 9 8 : Updated recommendations of the International AIDS Society, U.S. Panel. Journal of the American Medical Association, 280, 7 8 - 8 6 . Catz, S. L., Kelly, J . , Bogart, L., Benotsch, E., & McAuliffe, T. (2000). Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychology, 19, 1 2 4 - 1 3 3 . Centers for Disease Control and Prevention. (2001a). A glance at the HIV epidemic (HIV/AIDS Update). Atlanta, GA: Author. Centers for Disease Control and Prevention. (2001b). HIV/AIDS Prevention Research Synthesis Project: Compendium of HIV prevention interventions with evidence of effectiveness. Atlanta, GA: Author. Centers for Disease Control and Prevention. (2001c, February). HIV/AIDS surveillance report midyear 2001 edition (Vol. 13, No. 1). Atlanta, GA: Author. Cohen, P. T. (1998). Clinical overview of HIV disease. HIV Insite Knowledge Base Chapter. (San Francisco: University of California, San Francisco) Dew, Μ. Α., Becker, J . T., Sanchez, J . , Caldararo, R., Lopez, O. L., Wess, J . , Dorst, S. K., & Banks, G. (1997). Prevalence and predictors of depressive, anxiety, and substance use disorders in HIV-infected and uninfected men: A longitudinal evaluation. Psychological Medicine, 27, 3 9 5 - 4 0 9 . Elliot, A. (1997, May). Depression and HIV: Assessment and treatment. San Francisco: Project Inform.

395

396

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS Fisher, J . D., 8c Fisher, W. A. (1997). Changing AIDS-risk behavior. Psychological Bulletin, 111, 4 5 5 - 4 7 4 . Grant, I., 8c Martin, A. (Eds.). (1994). Neuropsychology of HIV infection. New York: Oxford University Press. Hecht, F. M., Grant, R. M., Detropolus, C. J., Dillon, B., Chesney, Μ. Α., Tian, W., Hellman, N. S., Brandapalli, N. L, Diglio, L., Bronson, B., & Kahn, J . O. (1998). Sexual transmission of an HIV-1 variant resistant to multiple reverse-transcriptase and protease inhibitors. New England Journal of Medicine, 339, 3 0 7 - 3 1 1 . Kalichman, S. (1998). Understanding AIDS: Advances in research and treatment (2nd ed.). Washington, DC: American Psychological Association. Kalichman, S. C , Sc Hospers, H. J . (1997). Efficacy of behavioral-skills enhancement: HIV risk-reduction interventions in community settings. AIDS, 11 (Suppl. A), S 1 9 1 - S 1 9 9 . Karasic, D. H., Sc Dilley, J . W. (1998). Anxiety and depression: Mood and HIV disease. In J . W. Dilley 8c R. Marks (Eds.), The USCF AIDS Health Project guide to counseling (pp. 2 2 7 - 2 4 8 ) . San Francisco: Jossey-Bass. Kelly, J . Α., Otto-Salaj, L. L., Sikkema, K. J . , Pinkerton, S. D., 8c Bloom, F. R. (1998). Implications of HIV treatment advances for behavioral research on AIDS: Protease inhibitors and new challenges in HIV secondary prevention. Health Psychology, 17, 3 1 0 - 3 1 9 . McDaniel, S. J . , 8c Blalock, A. C. (2000). Diagnosis and management of HIVrelated mood and anxiety disorders. In New directions in psychiatric services (No. 87, pp. 5 1 - 5 6 ) . San Francisco: Jossey-Bass. Montaner, J . S. G., Reiss, P., Cooper, D., Vella, S., Harris, M., Conway, B . , Weinberg, Μ. Α., Smith, D., Robinson, P., Hall, D., Myers, M., 8c Lange, J . M . Α., for the INCAS Study Group. (1998). A randomized, double-blind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIVinfected patients. Journal of the American Medical Association, 279, 9 3 0 - 9 3 7 . Moore, L., van Gorp, W., Hinken, C , 8c Stern, M. (1997). Subjective complaints versus actual cognitive deficits in predominantly symptomatic HIV-1 seropositive individuals. Journal of Neuropsychiatry and Clinical Neuroscience, 9(1), 3 7 - 4 4 . Paterson, D., Swindells, S., Mohr, J., Brester, M., Vergis, R., Squier, C , Wagener, M., 8c Singh, M . (1999, January). How much adherence is enough? A prospective study of adherence to protease inhibitor therapy using MEMS caps. Paper presented at the Sixth Conference on Retroviruses and Opportunistic Infections, Chicago. Paterson, D., Swindells, S., Mohr, J . , Brester, M., Vergis, R., Squier, C , Wagener, M., 8c Singh, M . (2000). Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine, 133, 2 1 - 3 0 . Price, R. (1998). AIDS dementia complex. HIV Insite Knowledge Base Chapter. (San Francisco: University of California, San Francisco) Rabkin, J . (1997, October). Meeting the challenge of depression in HIV. GMHC Treatment Issues, 11(10). (New York: Gay Men's Health Crisis) Rabkin, J . G., Ferrando, S. J . , Jacobsberg, L. B., Sc Fishman, B. (1997). Prevalence of Axis I disorders in an AIDS cohort: A cross-sectional, controlled study. Comprehensive Psychiatry, 38(3), 1 4 6 - 1 5 4 . Sciolla, Α., Atkinson, J . , 8c Grant, I. (1998). Neuropsychiatrie features of HIV disease. In W. G. van Gorp 8c S. L. Buckingham (Eds.), Practitioner's guide to the neuropsychiatry of HIV/AIDS (pp. 1 0 6 - 2 0 0 ) . New York: Guilford. Sewell, M. C , Goggin, K. J . , Rabkin, J . G., Ferrando, S. J . , McElhiney, M . C , 8c Evans, S. (2000). Anxiety syndromes and symptoms among men with AIDS: A longitudinal controlled study. Psychosomatics, 41, 2 9 4 - 3 0 0 .

CHAPTER

Irritable Bowel

10 20

Syndrome

JEFFREY M . LACKNER

I

rritable bowel syndrome (IBS) is a chronic

individuals in the United States and Canada

gastrointestinal (GI) disorder character-

experience symptoms

consistent with IBS

symptoms,

(Drossman et al., 1 9 9 3 ) . In the United States,

including abdominal pain/discomfort associ-

approximately 2 0 to 4 0 million individuals—1

ated with altered bowel function (e.g., diar-

in 6 Americans—suffer from IBS (Lynn &

rhea, constipation) that occurs in the absence

Friedman, 1 9 9 3 ) . These figures make IBS not

of organic disease. Because the locus o f the

only one o f the most prevalent chronic pain

ized by a constellation o f

problem is in h o w the gut functions and not in

disorders (Crombie, Croft, Linton, LeResche, &

abnormalities o f its physical structure, IBS is

V o n Korff, 1 9 9 9 ) but also one of the most

considered a functional disorder. There are 2 5

prevalent chronic illnesses in general. T h e

functional G I disorders concentrated in one

prevalence rate o f IBS is at least as common as,

of five anatomic regions: esophagus, gastro-

if not more common than, that of hypertension

duodenal, biliary, intestines, and anorectum

and is much more common than the prevalence

(Drossman, 1 9 9 4 ) . Other functional G I disor-

rates o f asthma, diabetes, and congestive heart

ders include functional dyspepsia, functional

failure (Adams & Benson, 1 9 9 1 ) . Although the

constipation, and chronic functional abdomi-

great majority ( 8 0 % to 9 0 % ) of IBS patients

nal pain. O f the functional G I disorders, IBS is

do not seek medical attention, the 1 0 % to 2 0 %

the most prevalent, costly, and disabling.

who do consult physicians represent 2 8 % o f all visits to GI practices and 1 2 % o f all primary care visits, making IBS one of the most com-

BACKGROUND AND ETIOLOGY

Epidemiology

mon disorders seen by physicians, according to Scott-Levin's Physician

Drug

and

Diagnosis

Audit, a commercial database derived from a monthly survey o f physicians in active office-

Epidemiological studies conducted over the

based practice in the United States. Factors that

past two decades indicate that 1 0 % to 2 0 % of

differentiate treatment-seeking individuals from

A U T H O R ' S N O T E : Preparation of this chapter was supported in part by National Institutes of Health Grant D K - 5 4 2 1 1 .

397

398

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS non-treatment-seeking individuals include the

stools, a sense o f urgency (a strong sensation

severity of abdominal pain, psychological dis-

of the immediate need to move the bowels), a

tress, and sociocultural influences. T o illustrate,

feeling o f incomplete evacuation, flatulence,

IBS is more common among males in rural pop-

and abdominal bloating. Although bloating is

ulations in India and Sri Lanka, where gender

not a diagnostic feature of IBS, it is a particu-

identity strongly influences help-seeking behav-

larly bothersome clinical feature that warrants

ior (Jain, Gupta, Jajoo, & Sidwa, 1 9 9 1 ) . O n the

attention

( M a x t o n , M o r r i s , Sc Whorwell,

other hand, in the United States, where females

1 9 8 9 ) . T h e duration of IBS symptoms is rela-

outnumber males in medical care clinics that

tively short, with the longest set o f symp-

treat IBS, IBS is four times more common

toms—pain/discomfort and bloating—lasting

among females than among males. The finan-

for 5-day periods (Hahn et al., 1 9 9 9 ) . For pur-

cial costs on the U.S. health care system were

pose o f treatment planning, patients are often

estimated in 1 9 9 5 to have been $ 8 billion annu-

classified on the basis o f the relative predomi-

ally (Talley, Gabriel, Harmsen, Zinsmeister, 8 t

nance o f their bowel symptoms

Evans, 1 9 9 5 ) . T h e course of IBS varies greatly

constipation, or pain) at the time of diagnosis.

among people, but episodes can have serious

Diarrhea-prominent

debilitating effects on physical function. IBS

more

has been identified as second only to the

day, loose or watery stools, and

than

three

(diarrhea,

IBS patients experience bowel

movements

per

urgency.

common cold as a cause o f work absenteeism

Constipation-predominant

(Drossman et al., 1 9 9 3 ) . It has been reported

the other hand, are typically characterized by

IBS patients,

on

that approximately 3 0 % of IBS sufferers take

having two or more o f the following symp-

sick leave because o f the disorder, with half of

toms: fewer than three bowel movements per

these individuals being absent from work at

week; hard, pellet-shaped, or lumpy stools;

least 2 weeks per year. IBS affects quality of life

and straining during bowel movements. T h e

(QOL) as much as, or more than, does conges-

predominant classification system is particu-

tive heart failure (Whitehead, Burnett, Cook, Sc

larly useful for patients with one consistent

Taub, 1996).

predominant

symptom.

However,

for

the

majority o f patients, symptoms fluctuate over time, with the predominant symptom alter-

Clinical Features

nating among diarrhea, constipation, and nor-

Although IBS is a multisymptom problem, patients characterize abdominal pain or discomfort as their most frequent and bothersome complaint (Drossman, Whitehead, Sc Camilleri, 1 9 9 7 ; Hahn,

Y a n , Sc Strassels,

1 9 9 9 ) . For this reason, abdominal pain is con-

mal bowel function. Thus, the predominant classification system functions best as a heuristic that helps to conceptualize patients at a single point in time rather than as an empirically grounded

classification scheme

that

reflects the clinical realities of IBS over time.

sidered the cardinal feature of IBS. Pain asso-

O n e factor that complicates accurate diag-

ciated with IBS is experienced as a diffuse

nosis is the comorbidity with and/or temporal

crampy, colicky, and aching sensation concen-

contiguity

trated diffusely (as opposed to localized) in the

Harman, Kaye, Sc Whorwell, 1 9 8 3 ) . There is

o f organic

GI

disease

(Isgar,

abdomen that is often relieved with defecation

increasing evidence that a sizable, albeit minor-

or flatulence. Pain is sometimes associated

ity, group of patients develop IBS symptoms

with defecation and a change in stool fre-

following infectious enteritis (Rodriguez

quency or form (appearance). In addition to

Ruigozmez, 1 9 9 9 ) . Although the hypothesis

changes in bowel habits, IBS pain can be asso-

that acute bacterial infection is causally related

ciated with mucus found around or within the

to IBS awaits confirmation in a controlled

&

Irritable

Bowel Syndrome

\

investigation, 2 0 % to 3 0 % o f patients develop

the apparent age difference may at least partly

IBS after bouts o f acute bacterial infection

reflect the diagnostic practices used to establish

(McKendrick, 1 9 9 6 ; McKendrick 8c Read,

prevalence data (Talley, Gabriel, et al., 1 9 9 5 ) .

1 9 9 4 ) . W h a t is particularly interesting is that

Some researchers argue that correcting for this

individuals who develop IBS after a bout o f

difference would bring the prevalence rate of

gastroenteritis had higher levels of psychologi-

IBS among the elderly in line with the preva-

cal distress at the time of infection than did

lence

individuals who did not develop IBS after bac-

(O'Keefe, Talley, Zinsmeister, 8c Jacobsen,

rates

among

younger

age

groups

terial infection (Gwee, 2 0 0 1 ) . A significant

1 9 9 5 ) . W h a t information is available indicates

o f IBS patients report upper GI

that more than 1 5 % of individuals age 6 5

number

symptoms,

including

reflux,

vomiting,

years or over report IBS-like symptoms (e.g.,

nausea, noncardiac chest pain, and dyspepsia.

pain, constipation) that

Approximately 4 0 % of individuals with IBS

"painful diverticular disease" (O'Keefe et al.,

are classified as

have reflux symptoms and 4 5 % have dyspep-

1 9 9 5 ) . O n the other end o f the age spectrum,

sia. Patients' symptom patterns can transition

the occurrence of IBS in children is similar to

between disorders such that they have symp-

the rate in adults ( 5 % vs. 2 0 % ) . Symptoms

toms of one disorder (e.g., IBS) that in turn are

consistent with a diagnosis o f IBS have been

replaced by symptoms o f another (e.g., reflux).

reported in 6 % of 1 2 - and 13-year-olds and in

There is a higher prevalence o f IBS in patients

1 4 % o f 1 5 - and 16-year-olds (Hyams, Burke,

whose Crohn's disease and ulcerative colitis—

Davis, Rzepski, 8c Andrulonis,

collectively known as inflammatory

bowel

noted previously, there is a strong gender dis-

disease (IBD)—are in remission. In comparison

parity in prevalence of IBS. Community sur-

with

veys indicate that women outnumber

controls, IBS patients

report

more

1 9 9 6 ) . As

men

extraintestinal somatic symptoms, including

with IBS by a two-to-one margin. In clinical

sexual dysfunction, insomnia, fibromyalgia,

settings, the gender difference is even more dra-

facial pain, chronic pelvic pain, and chronic

matic (Drossman et al., 1 9 9 3 ) . Patients with

fatigue (Whitehead, Palsson, Sc Jones, 2 0 0 2 ) .

higher education, high income levels, and a high severity o f pain and stress are more likely to seek medical treatment for IBS. With respect

Natural History

to racial differences, the rate o f IBS is lower in

IBS is most commonly seen in patients during late adolescence and middle age. M o r e than 5 0 % o f patients are diagnosed with IBS before age 3 5 years, whereas another 4 0 % are diagnosed between ages 3 5 and 5 0 years (Dalton

8c

Drossman,

1997).

After

age

6 5 years, the incidence and onset o f IBS decreases among males and females (Maxwell, Mendall, 8c Kumar, 1 9 9 7 ; Sandler, Jordan, 8c Shelton, 1 9 9 0 ) . For these reasons, IBS has been characterized as a "young person's illness." It is unclear whether age differences reflect developmental issues (e.g., age-related differences in gut physiology), differences in health-seeking behaviors, or an alternative factor(s). Data based on epidemiological studies suggest that

Hispanic

samples

than

in

both

African

American and Caucasian samples, with the latter two groups having comparable prevalence rates

(e.g.,

Fasanmade,

Olubuyide, 1995).

Olawuyi,

Aggravating

8c

factors

include psychological stress, dietary triggers, meal consumption, and (for some females) hormonal changes around menses. T h e longterm prognosis o f IBS is favorable, with symptoms generally improving over time. Positive prognostic factors include gender (i.e., male), quality of physician-patient relationship (i.e., patients whose physicians maintain a positive sympathetic relationship with them, address patient concerns and expectations, set limits, and involve the patients in treatment decisions

399

400

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS achieve better outcomes and require fewer

criteria that tend to covary in patients with IBS,

bowel

R o m e Π includes a set o f symptoms with a

habit involving constipation or painless diar-

greater than 2 5 % occurrence that cumulatively

rhea. There is a strong family history o f IBS-

support the diagnosis but are not essential

like symptoms in first-degree relatives but not

for diagnosis. These symptoms consist o f

follow-up

visits), and predominant

spousal relatives o f IBS patients (Morris-Yates,

(a) abnormal stool frequency (may be defined

Talley, Boyce, & Andrews, 1 9 9 5 ) . Although

as more than three bowel movements per day

these data have been interpreted as suggestive

or less than three bowel movements

evidence o f a genetic component that con-

week), (b) abnormal stool form (lumpy/hard or

per

tributes to the development o f IBS, an alterna-

loose/watery), (c) abnormal

tive hypothesis that has not been ruled out is

(straining, urgency, or feeling o f incomplete

that

evacuation; passage of mucus), and (d) bloating

these familial patterns

are

acquired

through learning processes (e.g., parental modeling o f sick behavior).

stool passage

or feeling o f abdominal distension. Confirmation o f an IBS diagnosis using R o m e II criteria is conducted within the context of a thorough medical examination, which

Diagnosis

includes a comprehensive medical history and

The nonspecific nature o f IBS symptoms complicates

accurate

diagnosis.

Drossman

physical examination and the identification o f the predominant symptom. There is a consen-

(1994) identified 3 1 disorders across 13 classes

sus among IBS experts that because R o m e Π

of medical diseases whose symptoms are descrip-

offers a set of "positive" (i.e., symptom-based)

tively similar to IBS symptoms (Table 2 0 . 1 ) .

diagnostic criteria, a strategy that relies on

GI diseases whose symptoms overlap with

excessive diagnostic tests to rule out likely

IBS symptoms include colorectal cancer, I B D ,

organic disease is not only unnecessary but also

endocrine disorders and tumors, enteric infec-

inefficient and potentially harmful. For this

tions, and malabsorption syndrome. Because

reason, diagnostic testing to confirm IBS may

IBS symptoms mimic these and other diseases

be limited to a complete blood count, determi-

with detectable physical pathology,

proper

nation of erythrocyte sedimentation, and a

process:

colonoscopy for patients who are age 5 0 years

(a) excluding possible organic, infectious,

or over and report sudden onset of symptoms

diagnosis

o f IBS is a

two-part

may

and/or those with a family history of colon

account for symptoms and (b) assessing the

polyps or GI cancer (Thompson, Dotevall,

presence of IBS symptoms in accord with diag-

Drossman, Heaton, & Kruis, 1 9 8 9 ) . Because

nostic criteria known as the R o m e Π criteria

symptoms o f IBS mimic those of organic dis-

metabolic, or structural

diseases that

(Drossman, Corazziari, Talley, Thompson, &

ease, it is not prudent to diagnose IBS on the

Whitehead, 2 0 0 0 ) . R o m e Π criteria represent

basis of symptoms per se without the benefit of

the current standard for diagnosing IBS. T o

a sufficiently thorough medical examination.

meet a diagnosis for IBS, R o m e II criteria

Signs and symptoms that are not typically asso-

require that, during the preceding 1 2 months,

ciated with IBS and may signify alternative or

the patient must experience 1 2 weeks (which

coexisting GI disease include visible or occult

need not be consecutive) of abdominal pain or

blood in stool, weight loss, fever, laboratory

discomfort with two of the following three fea-

indicators o f inflammation, frequent nocturnal

tures: (a) relieved with defecation, (b) onset

symptoms, abrupt (i.e., nongradual) onset o f

associated with a change in frequency o f stool,

symptoms, and onset of symptoms in patients

and (c) onset associated with a change in form

who are age 4 0 years or over. Patients with

(appearance) of stool. In addition to delineating

these symptoms or signs may require a more

Irritable Table 2 0 . 1 Physical

Bowel

Syndrome

Differential Diagnoses of Chronic/Recurrent Bowel Dysfunction

Condition

Example

Irritable bowel syndrome Lactase deficiency Drugs

Laxative/cathartics/Mg antacids, diuretics, cholinergic agents, prostaglandins (e.g., misoprostil)

Bacterial infection

Salmonella species, Campylobacter jejuni, enterocolitica, Clostridium difficile

Parasitic infection

Giardia lamblia,

2+

Entameba

histoltica,

Yersinia

cryptosporidiosis

Inflammatory bowel disease

Crohn's disease, ulcerative colitis

Malabsorption

Chronic pancreatitis, celiac sprue, postgastrectomy syndromes

Metabolic disorders

Diabetes mellitus, thyrotoxicosis

Endocrine/ hormone-producing tumors

Gastrinoma, carcinoid, VIPoma, endometriosis

Psychiatric disorders

Depression, anxiety/panic disorders, somatization disorders

Intestinal pseudo-obstruction

Primary visceral myopathy/neuropathy (e.g., scleroderma, diabetes)

Other colonic diseases

Collagenous/lymphocytic colitis, mast-cell disease, villous adenoma

Opportunistic infections in immunocompromised hosts SOURCE: Adapted from Drossman (1994). Reprinted with permission.

extensive medical evaluation to rule out organic

from research showing that types of IBS

disease.

patients

exhibit certain disordered

motor

abnormalities throughout the G I tract, particularly in the small and large intestine. IBS

Pathophysiology

patients whose predominant bowel habit is biomedical

diarrhea may have accelerated whole gut tran-

approach has historically sought to explain IBS

sit times, a greater number o f fast contractions,

Altered

Gut

Motility.

The

symptoms in light o f underlying physiological

and more high-amplitude propagated contrac-

mechanisms within the G I tract. T h e most

tions in the colon as compared with normal

prominent biomedical theory has conceptual-

individuals (Whitehead, Engel, & Schuster,

ized IBS as a disorder of colonic motility

1 9 9 0 ) . Some patients whose

predominant

caused by alterations in the smooth muscle

bowel habit is constipation, on the other hand,

spasms o f the GI tract. T h e nature o f abnormal

may have delays in colonic transit and fewer

patterns o f motility and peristalsis presumably

high-amplitude propagated contractions than

determine the type o f bowel disturbance, with

is the case in normal individuals (Bazzacchi

hypermotility resulting in diarrhea and hypo-

et al., 1 9 9 0 ) . That being said, dysmotility may

motility resulting in constipation. According to

be more appropriate as a mechanistic explana-

the "dysmotility hypothesis," vigorous con-

tion for specific subtypes of IBS than as a

tractions of the colon aggravate pain. Findings

general rule for understanding the pathophysi-

consistent with the notion that IBS symptoms

ology o f IBS across patients. In general, how-

involve disruptions in colonic motility come

ever, clear-cut differences in colonic motor

402

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS responses between IBS patients and normal

balloon is connected to a computerized pump

controls have not been consistently replicated.

(barostat) that inflates the balloon to specific

Although IBS patients exhibit heightened

pressure levels designed to be mildly moderately

reactivity to a variety o f stimuli that stimulate

uncomfortable for a short time to simulate

colonic motility (e.g., meals, rectal distension,

abdominal discomfort. These studies

strong emotions, cholinergic drugs, injection of

demonstrated that a significant proportion o f

have

cholecystokinin fa hormone released in the

IBS patients, particularly those with diarrhea-

duodenum]), healthy controls exhibit a similar

predominant IBS, experience abdominal pain at

albeit less exaggerated motility response pat-

significantly lower levels of pressure and intra-

8c Tulin, 1949). In other

luminal volume than do controls when their

words, IBS patients show a quantitative differ-

rectums, sigmoids, or small intestines are dis-

ence but not a qualitative difference in motor

tended by a balloon (i.e., visceral hyperalgesia).

tern (Almy, Kern,

response as compared with normal individu-

They also experience distensions at a given

als. T h e lack of clear-cut clinical differences has

volume as more intense than do healthy con-

prompted researchers to study motor activity

trols (Mertz, Naliboff, Munakata, Niazi, 8c

in the small bowel. This line of research has

Mayer,

1995). IBS patients may also experience

focused on discrete clustered contractions

discomfort in the GI tract in response to normal

(DCCs), that is, abnormal bursts o f motor

gut stimuli (e.g., gas, stool) that do not typically

activity in the duodenum and ileum. D C C s are

elicit discomfort in non-IBS patients. In IBS

seen more often in IBS patients, but they are

patients, the phenomenon of visceral sensitivity

also exhibited in both healthy controls and

appears to be specific to the GI tract and does

patients with other GI disorders (e.g., pseudo-

not characterize thresholds for somatic pain

obstruction, intestinal obstruction). In other

stimuli (e.g., cold pressor test) that range from

words, D C C s are nonspecific. Perhaps most

normal to above average as compared with

problematic is the relatively weak correspon-

controls (Cook, V a n Eeeden, & Collins,

dence between D C C s and symptoms. D C C s

Visceral hypersensitivity is neither limited to the

correlate with pain in IBS patients only 25% of

colon nor restricted to pain sensation. Visceral

the time (Kellow & Phillips,

1987).

1987). Thus,

hyperalgesia has been demonstrated at different

abnormal motility may well enhance gut reac-

sites in the GI tract (e.g., stomach, colon, small

tivity in some patients, but its role is non-

intestine, esophagus). Beyond pain, visceral

specific and has limited clinical significance

hypersensitivity is reflected in IBS patients'

and explanatory value.

complaints of excess gas, even though they actually show no differences in their composi-

Visceral

Sensitivity and Perception.

Because

of the inconsistent association between the pain

tion or accumulation rate as compared with asymptomatic controls.

and measured colonic motility, there has been

Several peripheral and central neural mech-

an increased focus on the phenomenon of vis-

anisms have been proposed to explain visceral

ceral hypersensitivity, which refers to a state of

sensitivity. In peripheral sensitization, noxious

heightened awareness of and sensitivity to nor-

stimulation (e.g., acute enteric infection, injury

mal intestinal activity (e.g., gas, normal intesti-

to the viscera) reduces the threshold

nal contractions) that arises within the gut

mechanical stimuli (e.g., pinching, cutting,

for

during digestion as well as painful distension o f

stretching) in high-threshold nociceptors and

the colon. Visceral hypersensitivity research has

may recruit "silent" nociceptors that are nor-

been based largely on a series o f balloon disten-

mally unresponsive to stimuli and become

sion studies that involve placing a balloon

activated only in the presence o f inflammation

catheter in the lower large intestine (colon). T h e

(Cervero & Laird,

1999). T h e sensitization of

Irritable these nociceptors may in turn

Bowel Syndrome

\

contribute

system function differently in IBS patients, as

to pain in response to normally innocuous

compared with controls, in response to visceral

stimuli (e.g., colon contractions) that are below

pain. IBS patients, in contrast to controls, fail

the normal perceptual threshold (Cervero &

to activate the anterior cingulate cortex (ACC)

Laird,

on rectal distension (Naliboff et al., 2 0 0 1 ;

1999).

An

alternative—but

not

mutually exclusive—mechanism emphasizes

Silverman et al., 1 9 9 7 ) . Data using f M R I , on

increased excitability of the GI neural system

the other hand, indicate that painful stimuli

(i.e., central sensitization). In central sensitiza-

cause significantly greater activation of the

tion, noxious stimulation may cause structural

A C C in IBS patients than in controls (Mertz

and functional reorganization o f synaptic con-

et al., 2 0 0 0 ) . Notwithstanding disparate find-

nections in dorsal horn neurons, inducing a

ings of P E T and f M R I studies, both lines o f

hypersensitive state that Carr ( 1 9 9 6 ) aptly

research implicate abnormalities in A C C activ-

likened to a "posttraumatic stress phenomenon

ity in visceral pain perception. T h e A C C is a site

in the spinal cord . . . that persists long after

of opiate down-regulation of pain that may,

such stimuli cease"

when activated, inhibit sensory input that con-

(p. 1 1 1 4 ) .

Long-term

changes in the nervous system associated with

tributes to pain production. Based on P E T data,

central sensitization are reflected by "wind-

IBS patients not only fail to activate the A C C in

up" amplification o f pain (i.e., progressively

response to visceral pain but also demonstrate

increasing activity in dorsal

activation of the left prefrontal cortex, whereas

horn

cells),

reduced pain threshold, expansion o f recep-

no such response occurs in normal individuals.

tion fields o f spinal cord dorsal horn neurons,

The prefrontal cortex is a brain structure asso-

and persistence o f pain in the absence o f

ciated with the emotional feelings (e.g., anxiety)

input from the periphery

(Coderre, Katz,

directed partly toward long-term implications

Vaccarino, & Metzack, 1 9 9 3 ) . In effect, pain

of having pain (e.g., "suffering") in relation to

may persist because an ongoing barrage of pain

or in anticipation o f pain. Taken together, P E T

signal imprints in the central nervous system

data suggest that IBS patients may paradoxi-

(CNS) a "memory" of pain whose conscious

cally respond to visceral pain stimuli by activat-

perception no longer requires input from the

ing a brain area

periphery (e.g., inflammation). Neuroplastic

amplifies pain perception rather than a brain

(prefrontal cortex) that

changes may explain why IBS patients, particu-

area (ACC) with important pain modulatory

larly those with more severe symptoms, experi-

properties.

ence an amplification or exaggeration o f pain to a stimulus that is normally painful (e.g., rectal stimulation) and also report pain from a stimulus that does not normally provoke pain (e.g., gas, stool, small meals).

Although the concept o f visceral hypersensitivity addresses some of the limitations of the dysmotility hypothesis, it cannot be definitively characterized as an etiological mechanism for a variety o f reasons. First, the phenomenon characterizes only a subset of IBS patients.

CNS Modulation

of Visceral

Sensations.

A

I B S patients

exhibit

related theory that has grown out of visceral

Diarrhea-prominent

stronger rectal urgency at lower

balloon

sensitivity research suggests that hypersensitiv-

volumes and exhibit greater sensitivity to rectal

ity is due to abnormal central processing

distension than do constipation-predominant

defects. This line of research comes partly from

IBS patients

neuroimaging studies using both position emis-

1 9 9 0 b ) . Furthermore,

(Prior &

Whorwell,

1990a,

non-treatment-seeking

sion tomography (PET) and functional mag-

IBS patients do not exhibit visceral hypersensi-

netic resonance imaging (fMRI). Neuroimaging

tivity. Given the more psychologically dis-

research has determined that areas of the limbic

tressed profiles o f their

treatment-seeking

403

404

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS counterparts (Whitehead et al., 2 0 0 2 ) , this

the absence of peripheral injury at a physiological

suggests that psychological factors may con-

level (Fields, 1 9 9 1 ) . According to Fields (1991),

tribute to visceral hyperalgesia, perhaps by

the response of an individual to damaging or

aggravating nociception stimulation o f vis-

potentially damaging stimuli depends on the

ceral afferent nerves in at least a subset o f IBS

stimulus as well as on the stimulus context. Pain

patients.

perception and the behavioral response to noxious stimuli are controlled by CNS painLike many benign

modulating circuits that can be activated by

chronic painful medical conditions, IBS has been

environmental stimuli. This circuit is activated

Psychological

Factors.

historically conceptualized as a physical mani-

by opioids and controls pain transmission neu-

festation of a variety o f psychiatric conditions,

rons in the spinal cord. The circuit contains sev-

including hypochondriasis, personality distur-

eral opioid and nonopioid neuropeptides, three

bance, somatization, depression, and anxiety

classes o f opioid receptors, and biogenic amine

(e.g., Clouse, 1 9 8 8 ; Hislop, 1 9 7 1 ; Latimer,

neurotransmitters such as norepinephrine and

1 9 8 3 ) . Although there is no evidence to support

serotonin. Furthermore, this circuit exerts bidi-

IBS as a psychiatric disorder, psychological

rectional control of pain transmission through

factors influence onset, expression, and course,

the activity of two functional classes of brain

particularly in more severely affected patients.

stem neurons whose activity is correlated recip-

Research has pointed to three main pathways

rocally with behavioral responses to painful

through which psychological factors influence

stimulation. Neurons of one class (i.e., on cells)

IBS. The first key pathway is directly through

are activated by noxious stimuli, whereas those

physiological systems. Psychological factors

of the other class (i.e., off cells) are inhibited by

(e.g., stress, negative emotional states) can

noxious stimuli. T h e cells activated by noxious

normatively induce changes in gut function

stimuli facilitate nociception, whereas those

(Tache, 1 9 8 9 ) , and their effect is particularly

inhibited by noxious stimuli inhibit nociception.

pronounced in IBS patients (e.g., Welgan,

Fields (1991) argued that psychological pro-

Meshkinpour, 8c Hoehler, 1 9 8 5 ) . For example,

cesses (e.g., attention, expectancy) may con-

psychological factors (e.g., negative mood states,

tribute to pain production at a neurobiological

expectation, attention) can modulate pain sever-

level by "kick[ing] the responses of pain trans-

ity. The mechanism underlying benign abdomi-

mission neurons to non-noxious neurons into

nal pain perception is not well known. M a n y

the noxious range and creat[ing] pain where

IBS researchers have been guided by Melzack

there was no pain" (p. 8 8 ) . If correct, this has

and Wall's (1965) gate control theory of pain as

relevance for understanding benign

an explanatory model for understanding the

medical disorders such as IBS.

painful

relationship between psychological factors and

The second pathway through which psy-

pain. According to Melzack and Wall, afferent

chological factors influence IBS symptoms

(i.e., moving to the spinal cord) stimuli, such as

is the adoption o f illness behaviors that can

nociceptive stimuli entering the spinal cord at

exacerbate symptoms. Health behaviors are

the substantia gelatinosa, are modulated by

strongly influenced by an individual's psycho-

other afferent stimuli (e.g., counterstimulation)

logical health. IBS patients as a group show

and descending spinal pathways (e.g., higher

higher levels of psychosocial distress as mea-

order mental processes, emotions, thoughts,

sured either through standardized questions or

images, attentional focus) in a way that blocks

with structured psychiatric diagnostic inter-

or "gates" the perception of pain signals.

views (Blanchard 8c Scharff, 2 0 0 2 ) . Over the

Psychological factors not only attenuate pain

past 1 5 years, Blanchard ( 2 0 0 1 ) has conducted

but also may produce clinical pain sensations in

a series o f studies that have systematically

Irritable evaluated

levels

of

psychopathology

in

Bowel

Syndrome

seek treatment than are their nondistressed

treatment-seeking IBS patients. Whereas levels

counterparts

(Drossman, 1 9 9 9 ; Whitehead,

of depressive symptoms, as measured by the

Bosmajian, Zonderman, Costa, & Schuster,

Beck Depression Inventory, fall consistently

1988).

within "mild" diagnostic ranges, IBS patients

patients do not differ from healthy controls on

In fact, non-treatment-seeking

IBS

report higher levels o f anxiety, as measured by

measures o f psychopathology

the State-Trait Anxiety Inventory. IBS patients

et al., 1 9 8 8 ) . In other words, IBS patients with

had a mean state anxiety score of 4 7 , which

comorbid psychological symptoms are more

(Whitehead

falls at the 4 5 t h percentile for psychiatric

likely to complain o f symptoms and seek treat-

patients, the 61st percentile for general medical

ment than are their nondistressed counterparts.

patients, and the 84th percentile for normal

The precise mechanism underlying the rela-

middle-age females. Trait anxiety scores aver-

tionship between treatment seeking and IBS

aged between 4 7 and 4 8 , which falls at the 5 4 t h

symptoms has not been identified. It is possible

percentile for psychiatric patients, the 72nd per-

that

centile for general medical patients, and the

unpleasant

90th percentile for normal middle-age females.

making threat appraisals o f stimuli (Cohen,

this relationship

may

exist

because

mood states predispose

one to

The notion that IBS is a psychosomatic disorder

Kessler, 8c Gordon, 1 9 9 5 ) , which in turn lead

has also been fueled by research reporting high

to heightened physiological reactivity and the

rates of comorbid psychiatric disorders among

acquisition o f illness behaviors. Treatment-

IBS patents. T h e results of studies using well-

seeking behaviors may also be influenced by

validated semistructured methodologies with

psychological stress. Research has found that

adequate sample size indicate that

between

IBS patients report more stressful events, more

4 0 % and 6 0 % o f IBS patients have a diagnos-

stress-related changes in stool patterns, and

able psychiatric disorder, with anxiety being the

greater reactivity to stress than do controls

most common disorder (followed by mood and

(Bennet, Tennant, Piesse, Badcock, Sc Kellow,

somatization disorders). Among diagnosable

1 9 9 8 ) . Creed, Craig, and Farmer ( 1 9 8 8 ) found

anxiety disorders, the most common is general-

that major life events preceded the onset o f IBS

(Blanchard, Scharff,

in 6 0 % to 6 6 % o f IBS patients. In comparison,

Schwarz, Suis, 8c Barlow, 1 9 9 0 ) . T h e preva-

2 5 % o f controls experienced similarly severe

ized anxiety disorder

lence o f an Axis I psychiatric disorder not only

events at an arbitrary time. Lacking a suffi-

is high in IBS patients but also exceeds the

ciently developed repertoire o f coping skills

prevalence o f a psychiatric disorder

among

(Drossman, Li, et al., 2 0 0 0 ) , IBS patients may

patients with organic GI disorders

(56 vs.

respond physically to psychological stress by

1 8 % ) , whose clinical features are similar to

seeking medical attention that may in turn

those with IBS (e.g., I B D ) .

implicitly reinforce their disease conviction,

Although a select number o f studies have failed to confirm high rates o f psychiatric disorder (Blewett et al., 1 9 9 6 ) , there has emerged

promote a sense o f invalidism, and lead to maladaptive illness behaviors. A third pathway through which psycho-

a general consensus that a sizable number o f

logical factors influence IBS is by increasing

IBS patients have higher levels of distress and

the risk o f developing I B S . In general, IBS

substantial psychiatric comorbidity in propor-

researchers have focused on two types o f

tions that are conservatively at least twice as

psychosocial factors—reinforcement mecha-

high as in patients with organic GI disorders

nisms and childhood abuse—that mediate the

and healthy counterparts. IBS patients with

risk for IBS onset (Drossman, 1 9 9 4 ) . There is

comorbid psychological symptoms are more

a relatively large body o f literature linking a

likely to report more severe symptoms and

history o f early (i.e., preadolescence) abuse to

405

406

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS IBS symptoms in a sizable number o f female

that found that IBS patients were more likely

patients. A history of major traumatic events

than non-IBS respondents to recall that their

(i.e., physical and/or sexual abuse) is present

parents both responded to pain complaints

in patients with IBS more frequently than in

with the provision o f positive reinforcement

healthy controls. A history o f severe emo-

(e.g., gifts, toys) and demonstrated

tional trauma, such as physical and sexual

behaviors that can negatively reinforce illness

abuse

behaviors.

(especially during childhood), also

illness

appears to be associated with an increased risk for IBS. Drossman and colleagues ( 1 9 9 0 ) found that the frequency o f a history o f abuse among IBS patients was 3 0 % greater than in

Biopsychosocial Model Although

psychopathology,

abnormal

w o m e n with an organic GI disease. Female

motility, visceral hypersensitivity, and C N S

IBS patients with a positive history o f abuse

modulation all have been implicated in the

report m o r e pain, more sick days, a higher

expression o f IBS, none o f these processes is

level o f distress and health care use, worse

sufficient t o explain IBS symptoms within

behavioral functioning, and m o r e surgeries.

and across all patients. F o r this reason, IBS is

Although

the

currently conceptualized from the perspec-

relationship between abuse and IBS symp-

tive o f a biopsychosocial model (Drossman,

the m e c h a n i s m underlying

toms is not well defined (Drossman, Talley,

1 9 9 7 ) . T h e biopsychosocial model holds that

Olden, L e s e r m a n n , &

individual biology (e.g., genetic predisposi-

Barreioro,

1995),

abuse likely represents an important

risk

tion, G I physiology), behavior, and higher

factor for I B S symptoms and o u t c o m e in

order cognitive processes (e.g., coping, illness

select patients.

beliefs, abnormal central processing o f gut theory

stimuli) influence IBS through their interac-

(Bandura, 1 9 7 7 ) , Whitehead and colleagues

tion with each other, with early-life factors

( 1 9 8 8 ) approached early-life experiences from

(e.g., trauma, modeling), and with the indi-

a reinforcement perspective. Social learning

vidual's social and physical

theory (SLT) is arguably the prevailing theoret-

(e.g., reinforcement contingencies).

Drawing

from

social

learning

environments

ical framework used in health behavior and

At the heart o f the model is the belief that

health promotion research. In S L T , human

IBS involves a dysregulation in interactions

behavior is explained in terms o f a three-way,

among the C N S ; peripheral sensory, motor,

dynamic, reciprocal theory in which personal

and autonomic nerves; and the enteric nervous

factors, environmental influences, and behav-

system (ENS). This neural network is referred

ior interact continually. A basic premise o f S L T

to as the "brain-gut axis." T h e E N S , the sym-

is that people learn not only through their own

pathetic

experiences but also by observing the actions

parasympathetic nervous system (PNS) com-

of others (i.e., modeling) and the results o f

prise the three divisions o f the autonomic ner-

those actions (consequences). Whitehead and

vous system (ANS), the part of the nervous

colleagues argued

nervous

system

( S N S ) , and

the

that complaints o f IBS

system that regulates involuntary actions,

symptoms are partly acquired in a family

including smooth muscle, cardiac muscle, and

environment, where children learn

glands. T h e A N S ' s enteric division (i.e., ENS)

direct experience and

through

by observing

how

is located in the sheaths o f tissue lining the GI

others respond to IBS. In support o f the princi-

tract from the esophagus to the rectum. T h e

ple of familial transmission are results of a

E N S is composed o f both local sensory neu-

large telephone survey (Whitehead, Winget,

rons, which detect and

Fedoravicius, Wooley, &

regarding changes in the tension o f the gut

Blackwell, 1 9 8 2 )

relay

information

Irritable walls, and

its chemical environment

and

Bowel Syndrome

\

ASSESSMENT AND TREATMENT

motor neurons, which control muscle contractions o f the gut wall and secretion. T h e E N S

Like other chronic illnesses, IBS does not lend

plays a major role in maintaining homeostasis

itself to a " c u r e " or " f i x . " Therefore, the

in the body by controlling GI blood vessel

goals o f treatment are to normalize bowel

tone, motility, gastric secretion, and

function,

fluid

transport. Because o f its heavy concentration of neurotransmitters

(e.g., serotonin,

sub-

decrease

pain/discomfort,

and

improve the Q O L through a combination o f pharmacological

agents,

behavioral

self-

stance P, vasoactive intestinal peptide, calci-

change interventions, and lifestyle modifica-

tonin gene-related peptide), the fact that it is

tion. T h e exact constellation o f treatment

embryologically derived from the same part o f

strategies is not prescriptive but rather based

the neural crest that forms the brain, and its

on the nature (e.g., predominant bowel habit)

ability among other parts o f the

and severity o f symptoms (mild, moderate, or

unique

peripheral nervous system to mediate reflex

severe) o f the individual patient. IBS symptom

behavior (i.e., gut function) in the absence of

severity is a general term that, in the context

input from the brain or spinal cord (Gershon,

o f I B S , reflects not only the intensity and

1 9 9 8 ) , the E N S has been referred to as the

duration o f symptoms but also the emotional

"second brain."

unpleasantness

N o r m a l digestive functions involve communication links between the E N S and the CNS. These links take the form o f parasympathetic and sympathetic fibers that either connect the C N S and E N S or connect the C N S directly with the digestive tract. Through these cross-connections, sensory inputs from

treatment

and illness behaviors

seeking)

associated

with

(e.g., IBS

(Drossman, 1 9 9 9 ; Drossman et al., 1 9 9 7 ) . The

importance o f symptom severity as a

measure o f a patient's symptom experience comes from research showing that psychological functioning is strongly associated with the severity o f symptoms (Drossman, 1 9 9 9 ) .

the gut are relayed to and processed by higher cortical centers where they modulate affect, pain

perception, and

behavioral

response.

Mild Symptoms

Because the neural transmission lines of the

The majority ( 7 0 % ) of individuals who meet

brain-gut axis are bidirectional and reciprocal,

the IBS diagnosis can be classified as mild in that

the C N S receives information from the diges-

the symptoms occur relatively infrequendy (e.g.,

tive tract and modulates the E N S . T h e bidi-

two or three times per month), do not prompt

rectional relationship o f the brain-gut axis

medical care, and are not associated with

means that higher order mental processes

impairment in physical or psychological func-

(e.g., attention, emotion, sensation,

taste,

tion. First-line treatment for mildly affected

thought) can influence GI function, secretion,

patients is corrective information and education

and sensation (Drossman, 1 9 9 4 ) . N o r m a l GI

about the benign nature of IBS and dietary

function is typically characterized by a rela-

advice. For example, patients are encouraged to

tively high degree o f coordination of the brain-

exercise, eat well-balanced regular meals, avoid

gut axis. In IBS patients, however, there is a

fatty and gas-forming foods such as legumes,

persistent disruption in the interaction o f the

increase intake o f dietary fiber, and reduce

neuroenteric

in

intake of caffeine, sorbitol (e.g., sugarless gum,

abnormal motility and visceral hypersensitiv-

system that

is manifested

dietetic candy), and alcohol (Drossman et al.,

ity o f gut stimuli whose sensation/perception

1 9 9 7 ) . Fiber supplementation

is modulated by C N S regions closely linked to

bran) is often emphasized for patients with mild

emotion and pain perception.

IBS, at least for those whose symptoms do not

(e.g., psyllium,

407

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

408

include bloating. Although most physicians

diarrhea-predominant IBS, a therapeutic trial

recommend increasing fiber intake (e.g., increas-

of

loperamide

(Imodium),

diphenoxylate

ing consumption o f fruits, vegetables, and whole

(Lomotil), psyllium (Metamucil), or methylcel-

grains) for the majority of their patients, its ther-

lulose (Citrucel) or a low-dose tricyclic antide-

apeutic value has not been consistently estab-

pressant (TCA) is often pursued. Patients with

lished in quality cknical trials and is surprisingly

constipation-predominant IBS often undergo a

controversial (Jailwala, Impériale, & Kroenke,

trial o f increased dietary fiber, supplemental

2 0 0 0 ) . It appears that patients with constipation-

fiber, an osmotic laxative (e.g., milk o f magne-

predominant and mixed-type IBS are most likely

sia, lactulose), and/or a stool softener if symp-

to derive maximum benefit from fiber supple-

toms are not relieved by dietary fiber alone.

ments because they act as bulk-forming laxa-

Because o f their anticholinergic side effects,

tives that ease stool passage. However, fiber has

however, T C A s can cause or exacerbate consti-

no

pain.

pation and are often not recommended for con-

demonstrated

positive effect

on

Because bran has a normalizing effect on colonic

stipation-predominant IBS patients (Clauw &

function, it is often recommended for diarrhea-

Chrousos,

prominent patients. Pharmacotherapy is not

bloating-predominant IBS may benefit from a

1997).

Patients with

pain/gas/

typically recommended as a first-line treatment

trial o f an antispasmodic agent, such as dicy-

for mild IBS.

clomine (Bentyl) or hyoscyamine with phénobarbital (Levsin), or a low-dose antidepressant.

Moderate Symptoms In IBS patients with moderate symptoms,

Severe Symptoms

the intensity and duration o f symptoms (e.g.,

In the case o f patients with severe symp-

two or three times per week) typically interferes

toms (daily or near daily symptoms o f severe

with activities o f daily living and is associated

intensity), a tertiary treatment center where

with greater psychological distress than is the

psychotropic medications (e.g., antidepres-

case in mildly affected IBS patients. Treatment

sants), psychiatric management, and psycho-

for IBS patients with moderate symptoms may

logical

require the addition

standard medical care is recommended.

of

pharmacotherapy

interventions

are

integrated

into

directed at the gut to control symptom exacerbations, more extensive lifestyle modification, and behavioral self-management techniques

Psychological Assessment

that often begin with symptom self-monitoring.

Consistent with the biopsychosocial concep-

The goal o f treatment is to increase awareness

tualization of IBS, the protocol o f a psycholog-

and identification o f specific triggers (dietary,

ical testing battery includes measures

stress, and hormonal fluctuations) and condi-

reflect the range of psychosocial factors that

tions under which IBS symptoms are likely to

influence IBS, including psychological distress,

occur, increase patients' sense of predictability,

coping resources, negative cognitions, pain,

that

and foster self-management skills. Moderately

behavioral functioning,

affected patients may also be prescribed behav-

behaviors. T h e first step in the evaluation is

ioral interventions, including hypnosis, stress

assessing the nature and severity o f symptoms;

Q O L , and

illness

management, and relaxation techniques, in an

their natural history; the circumstances, pat-

effort to dampen arousal and increase self-care

terns, determinants,

skills. If pharmacological agents are pursued,

symptoms; and the patient's treatment history

they are structured dominant

around

symptoms.

For

and

consequences o f

the most pre-

(current and lifetime). These goals can be

patients

achieved using a three-part

with

semistructured

Irritable

Bowel Syndrome

\

interview, the Albany GI History, developed by

form used at SUNY-Buffalo was developed by

Edward

State

Blanchard and used in numerous clinical trials

University o f N e w Y o r k - A l b a n y ( S U N Y -

over 15 years. Patients make a series o f daily

Blanchard's

group

at

the

Albany) (Blanchard, 2 0 0 1 ) . T h e Albany GI

severity ratings (beginning 2 to 4 weeks before

History is organized in terms of a functional

treatment begins) for abdominal pain and ten-

analysis o f the clinical problem. Part 1 covers

derness, diarrhea, constipation, flatulence,

history and description o f G I symptoms.

belching, and bloating on a 5-point scale rang-

Symptoms o f pain, bowel disturbance, and

ing from 0 (not a problem)

associated symptoms (e.g., flatulence, bloating)

They also record feelings o f incomplete evacu-

are assessed in terms o f their severity, fre-

ation, whether pain was relieved by bowel

quency, and duration. T h e Albany GI History

movements, avoidance o f foods and activities

is sufficiently detailed to support (but not

associated with symptoms, medication use,

to 4

(debilitating).

derive) a diagnosis using R o m e Π criteria once

and (for women) the first day o f their periods.

physical pathology has been ruled out medi-

There are a number o f advantages with self-

cally, m addition, the interview covers situa-

monitoring data, including accuracy, sensitiv-

tional factors that precede the onset of a

ity to temporal variations, and objectivity

symptom and consequent events. Part 2 is

(Meissner, Blanchard, & M a l a m o o d , 1 9 9 7 ) .

devoted to exploration o f the family history o f

For these reasons, many regard GI symptom

GI disorders in the extended family, a psy-

diaries as the "gold standard" in IBS research.

chosocial history and description of psychoso-

T h e daily symptom diaries are used to calcu-

cial functioning, and related problem areas in

late Composite Primary Symptom Reduction

the patient's life (e.g., relationship with peers,

(CPSR) scores, a previously validated measure

j o b strain, marital relations). Part 3 consists o f

of symptom change that describes clinically

a brief mental status examination. In addition

significant improvements in G I

to the Albany G I History, the R o m e II

(Blanchard & Schwarz, 1 9 8 8 ) . T o calculate

Integrative Questionnaire (Talley, Drossman,

the C P S R score, one must first calculate, for

Whitehead, Thompason, & Corassiari, 2 0 0 0 )

each patient and for each primary symptom, a

symptoms

is a comprehensive assessment tool whose items

Symptom Reduction Score (SRS). T o avoid

reflect R o m e Π criteria for functional GI disor-

the statistical problem o f multiple compar-

ders. Although the R o m e Π questionnaire does

isons between groups inherent in a multi-

not assess psychosocial features o f IBS and was

symptomatic disorder such as IBS, Blanchard

designed for epidemiological research, its struc-

developed a single metric, the C P S R score,

ture, ease of use, and comprehensiveness have

for hypothesis testing. An S R S for each o f

advantages for clinicians and researchers look-

the primary G I symptoms (abdominal pain

ing for a well-designed survey measure o f

and abdominal tenderness combined, diar-

clinical symptoms o f functional GI disorders.

rhea, and constipation) was calculated. For

A major part o f data collection involves self-monitoring o f symptoms using the G I

example, a diarrhea

S R S is calculated as

follows:

symptom diary. IBS symptoms vary considerably over time and across dimensions o f frequency, duration, and intensity. T h e temporal variability makes retrospective recall imprecise

Diarrhea Reduction Score = 1 0 0 χ Baseline Diarrhea Ratings Posttreatment Diarrhea Ratings Baseline Diarrhea Ratings.

and o f questionable validity. Daily recording and daily monitoring are important in both

T h e C P S R score was calculated by averag-

clinical and research settings. Although there

ing the t w o or three symptom rating scores

is no established self-monitoring format, the

relevant to the individual patient:

409

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

410

C P S R = Pain and Tenderness Reduction Score

Research has shown that patients with persistent

+ Diarrhea Reduction Score

painful

Constipation Reduction Score

medical disorders

develop certain

strategies to cope, tolerate, and deal with pain

+ 2 or 3 (depending on number of symptoms present).

(Keefe et al., 1 9 8 7 a ,

1 9 8 7 b ) . Particularly

important coping responses include efforts to

Blanchard has defined a C P S R score o f

ignore or reinterpret pain sensations as benign,

0 . 5 0 or m o r e (an average reduction o f G I

pacing activities, increasing activity level, pray-

symptoms o f 5 0 % or more) as representing

ing or hoping, and disputing negatively skewed

clinically significant improvement.

thinking patterns using positive self-statements about patients' ability to cope or manage. Pain

Because a majority of IBS patients

coping strategies that are adopted and used

identify pain as their most bothersome symp-

over prolonged time periods may influence

Pain.

tom, clinicians may want to supplement daily

physical and psychological functioning signifi-

measurements o f abdominal pain/discomfort

cantly. In some patients, an adaptive set o f cop-

with data from additional pain instruments.

ing strategies may buffer them from

Whereas daily monitoring provides relatively

adverse effects o f medical illness. In others,

precise

maladaptive

data

regarding

the

intensity

and

coping patterns

the

may become

frequency o f pain, it provides only limited

entrenched, thereby heightening the severity o f

information regarding other important aspects

pain and the impact o f pain on behavior.

of the pain experience. T h e M c G i l l Pain

O n e coping style linked to IBS patients is an

Questionnaire ( M P Q ) provides valuable infor-

overreliance on a negatively skewed thinking

mation regarding the sensory, affective, and

pattern (i.e., catastrophizing) (Drossman, Li,

evaluative dimensions of the pain experience

et al., 2 0 0 0 ) . T h e term

(Melzack, 1 9 7 5 ) . T h e M P Q contains 7 8 pain

refers to an aberrant information processing

"catastrophizing"

words grouped into 2 0 subclasses of 3 to 5

style marked by magnification, helplessness,

descriptive words. Within these subclasses, the

and rumination toward painful stimuli. T h e

patient ranks the 3 to 5 words according to

pattern o f these data is similar to that in

the implied pain intensity. T h e 2 0 subclasses

research findings with osteoarthritis patients

are grouped into four sections: sensory (e.g.,

with persistent knee pain; those who rate

cramping), affective (e.g., agonizing), evaluative

themselves as more effective in managing pain

(e.g., intense), and miscellaneous. In addition to

and who report less catastrophizing cope with

the 7 8 pain words, the temporal pattern of pain

pain more effectively (Keefe et al., 1 9 8 7 b ) .

is assessed with 9 words (e.g., constant, peri-

Pain

odic). The location o f pain is assessed with a

effectively

Coping

Skills

drawing of the body with the words "exter-

Questionnaire ( C S Q ) (Rosenstiel &

Keefe,

coping

responses

with

the

can

Pain

be

assessed

nal/internal" added. T h e M P Q also includes a

1 9 8 3 ) . O n the C S Q , patients are asked to indi-

5-point pain rating scale that requires the

cate how they cope with everyday painful

patient to indicate his or her current level of

experiences. T h e C S Q measures the frequency

pain by choosing a description that most closely

of use o f seven pain coping strategies, six o f

matches his or her pain. Scores range from

which are cognitive (diverting

0 (mild) to 4 (excruciating). Patients' intensity

reinterpreting pain sensations, coping self-

scores reflect the word that best describes their

statements, ignoring pain sensations, praying

attention,

pain level, with higher scores indicating more

and hoping, and catastrophizing) and one o f

intensive levels of reported pain.

which is behavioral (increasing behavioral assessment

activity). T h e C S Q also includes two ratings of

includes the evaluation o f patients' behavioral

coping efficacy: one rating of perceived efficacy

and cognitive response to pain (i.e., coping).

of coping in decreasing pain and one rating of

An important

part o f pain

Irritable

Bowel Syndrome

\

perceived efficacy o f coping in controlling

Life Measure (IBS-QOL) (Patrick, Drossman,

pain. Previous research has shown that coping

Frederick, DiCesare, & Puder, 1 9 9 8 ) , whose 3 4

strategies measured by the C S Q are predictive

items each fall into one of eight domains (dys-

of pain, psychological function, activity level,

phoria, activity interference, body image, health

and physical impairment

with

worry, food avoidance, social relations, sexual

chronic pain problems independent o f disease

activity, or intimate relationships) clinically

severity. T h e C S Q provides a profile o f the use

relevant to IBS. Q O L measures are useful in

o f patients

of a range o f pain coping strategies that appear

assessing the extent to which IBS compromises

to be useful in predicting adjustments to per-

patients' general sense o f happiness and satis-

sistent medical conditions.

faction in important life domains (e.g., health, recreation). In comparison with more tradiAs noted previ-

tional biological measures that focus on infir-

ously, IBS is associated with significant psychi-

mity or disease status, Q O L measures focus on

atric comorbidity that is formally assessed using

both objective functioning and subjective well-

the Structured Clinical Interview for D S M - I V

being. These data sources are usually better for

Axis I Disorders (SCID) (First, Spitzer, Gibbon,

assessing the social and emotional outcomes of

& Williams, 2 0 0 1 ) . The SCID is a semistruc-

the treatment and disease process and for prov-

tured interview for obtaining major D S M - I V

ing an overall picture o f how treatments or ill-

[Diagnostic

Psychiatric

Comorbidity.

Mental

nesses affect patients' ability to function in life.

fourth edition [American Psychiatric

The I B S - Q O L concentrates on the perceived

Association, 1994]) Axis I and Axis Π diagnoses.

well-being of the patient and not more objective

There are other structured diagnostic interviews,

measures of physical functioning (e.g., activities

Disorders,

and Statistical

Manual

including the Anxiety Disorders

of

Interview

of daily living). Because there is general consen-

(ADIS-R) (DiNardo & Barlow, 1 9 8 8 ) , that have

sus that Q O L involves both objective function-

been used in clinical research with IBS patients.

ing and subjective well-being, the I B S - Q O L is

The SCID has some advantages over the ADIS

supplemented

and other semistmctured psychiatric interviews

M O S 36-Item Short Form (SF-36) (Ware &

in that it yields a more thorough assessment of

Sherbourne, 1 9 9 2 ) . T h e SF-36 assesses eight

non-anxiety-related disorders that may accom-

health dimensions (Stewart & Ware, 1 9 9 2 ) that

pany IBS. Several standardized self-report mea-

the I B S - Q O L does not assess directly: (a) limita-

sures provide useful information

regarding

tions in physical activities due to health prob-

psychological functioning. Additional psycho-

lems, (b) limitations in social activities due to

logical self-report measures tap psychopathol-

health or emotional problems, (c) limitations in

ogy. These include the Brief Symptom Inventory

usual role activities due to health problems,

with

information

from

the

(Derogatis, 1993) for psychopathology, the Beck

(d) bodily pain, (e) general medical health (i.e.,

Depression Inventory (Beck, Rush, Shaw, &

psychological distress and well-being), (f) limita-

Emery, 1 9 7 9 ) , the State-Trait Anxiety Inventory

tions in usual role activities due to emotional

(Spielberger, 1983), and the Perm State Worry

problems, (g) vitality (e.g., energy and fatigue),

Questionnaire (PSWQ) (Mayer & Raybould,

and (h) self-evaluation of general health status.

1 9 9 0 ) , a measure of habitual worry due to the

The SF-36 has been used to measure health-

high rate ( 4 0 % ) of generalized anxiety disorder

related Q O L in IBS patients (Hahn et a l , 1 9 9 9 ) .

comorbidity (Blanchard et al., 1 9 9 0 ) .

Treatment Efficacy Quality

of Life.

Because IBS is a chronic

condition that can compromise an patients'

Pharmacotherapy. o f dietary

As noted previously, a

emotional, social, and physical well-being,

number

patients are administered the IBS-Quality o f

agents that are currently used to treat IBS

and

pharmacological

411

412

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS represent the first- and second-line therapies

stool consistency and decrease frequency by

for IBS patients (Table 2 0 . 2 ) . T h e most c o m -

enhancing intestinal water absorption, strength-

mon classes o f medications currently used for

ening anal sphincter tone, and reducing intesti-

IBS are laxatives, antidepressants,

antidiar-

nal transit. Loperamide is preferred over other

rheals, and antispasmodics. There is n o uni-

opioid agonists (e.g., diphenoxylate) due to its

versally agreed-on medical option for IBS. N o

potency, longer duration o f action, and favor-

class o f medications or single medication

able side effect profile (e.g., lower potential for

within a class currently available has been

physical dependence). However,

demonstrated

does not appear to have an analgesic effect.

in well-designed

and

well-

controlled clinical trials to be consistently

loperamide

Bulking agents such as fiber supplements

superior to placebo treatment for the spectrum

(e.g., calcium polycarbophil, methylcellulose,

of IBS symptoms. This conclusion is based

psyllium) are often prescribed for patients with

largely on the findings of an influential 1 9 8 8

constipation-prominent IBS because these sup-

systematic review o f randomly controlled drug

plements facilitate peristalsis and

trials. Klein ( 1 9 8 8 ) concluded that because of

colonic and oral-anal transit. Although fiber

methodological flaws, " n o therapy has been

supplements may decrease constipation in a

shown to be effective in treating I B S " (p. 2 3 2 ) . Since the publication of the Klein ( 1 9 8 8 )

subset of patients, their therapeutic

improve

benefit

may come at the expense o f aggravating some

review, a slightly more positive appraisal of

IBS symptoms

pharmacological agents has emerged.

One

cramping, flatus). Furthermore, they have no

&

established analgesic properties. Dietary fiber

recent

review

(Poynard,

Regimbeau,

Benhamou, 2 0 0 1 ) o f 2 3 randomized

studies

with eight different agents published up to

(e.g., bloating,

distension,

supplements are o f conclusive benefit only in constipation-predominant patients.

2 0 0 0 offered some of the strongest existing evi-

With respect to antidepressants, the tricyclic

dence for direct smooth muscle relaxants (e.g.,

class represents the most commonly prescribed

calcium channel blockers, antispasmodics)

and investigated option. In a meta-analysis of

when pain is the predominant symptom. These

the efficacy o f T C A s on functional GI disor-

medications

ders (vs. IBS per se), J a c k s o n and colleagues

influence

motor

activity

decrease colonic responsiveness.

and

However,

none of the muscle relaxants identified as effec-

(2000)

reviewed

data

from

1 1 placebo-

controlled trials (2 non-ulcer dyspepsia and 9

tive (cimetropium bromide, panivorous bro-

IBS) and concluded that T C A s were effective in

mide, and trimebutine) is available in the

relieving pain. Furthermore, because most of

United States (Poynard et al., 2 0 0 1 ) .

the dosages given were lower than required to

T h e efficacy o f smooth muscle relaxants

achieve psychotropic effects, J a c k s o n and col-

available in the United States has not been well

leagues suggested that T C A s " w o r k " via their

established due to methodological shortcom-

neuromodulatory and analgesic properties (vs.

ings of the clinical trials. In relatively brief clin-

psychotropic effects). T h e intrinsic anticholin-

ical trials, anticholinergics (e.g., dicyclomine,

ergic effects of T C A s (e.g., constipation) may

global

broaden the therapeutic value (e.g., decrease

improvement, but the extent to which they

diarrhea) of T C A s , at least in patients with

improve specific IBS symptoms (e.g., diarrhea,

diarrhea-predominant IBS (Jailwala et al.,

constipation) is not known.

2 0 0 0 ) . Patients with constipation-predominant

hyoscyamine)

are

associated with

Patients

with

diarrhea are often prescribed antidiarrheals,

IBS appear less responsive to T C A s than do

which are designed to reduce colonic transit

those with either pain-predominant o r diar-

through direct action on the smooth muscle o f

rhea-predominant IBS. T h e four most com-

the GI tract. One example is the opioid agonist

m o n l y prescribed and

loperamide, which is designed to increase

nortriptyline (Pamelor), imipramine (Tofranil),

studied T C A s

are

Irritable Table 2 0 . 2 Agent and

Bowel Syndrome

Common Pharmacological Treatment for IBS Examples

Antidiarrheal Agents Diphenoxylate-atropine (Lomotil)

Predominant

Symptom(s)

Diarrhea

Possible

Side

Effects/Comment

Controlled substance, nervousness, drowsiness, dizziness, constipation, headache, urinary retention Preferred over diphenoxylate/atropine due to more favorable side effect profile and no abuse potential; adverse side effects include sedation, drowsiness, fatigue, dizziness, cramping, nausea, rash, and constipation; may improve diarrhea, urgency, borborygmi, frequency of bowel movement, and stool consistency but not abdominal pain or distention

Loperamide (Immodium)

a

Constipation

May worsen abdominal distension, bloating, and flatulence

Abdominal pain, diarrhea

Anticholinergic side effects (urinary retention, decreased sweating, headache, dizziness, congestion, blurred vision, dry mouth, tachycardia, rash)

Abdominal pain, nausea, nonspecific symptoms

May cause or worsen constipation; may stimulate appetite, cause urinary retention, cause blurred vision, and worsen constipation; may be useful for diarrhea-predominant IBS

Comorbid anxiety, depression

May worsen diarrhea

S-HT3 Serotonin Receptor Antagonist Alosetron (Lotronex)

Non-constipationpredominant IBS in females

May worsen constipation and headache

5-HT4 Serotonin Receptor Agonist Tegaserod (Zelnorm/Zelmac)

Constipation-predominant IBS in females

May worsen diarrhea, abdominal pain, nausea, flatulence, and headache

Bulk-Forming Laxatives Methylcellulose (Citrucel) Psyllium (Metamucil) Antispasmodic Agents Dicyclomine (Bentyl)

Hyoscyamine (Levsin) Tricyclic Antidepressants Amitriptyline (Elavil) Desipramine (Norpramin) Selective Serotonin Reuptake Inhibitors Citalopram (Celexa) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)

N O T E : IBS = irritable bowel syndrome. a. Borborygmi is noisy rumbling of air moving through the intestine.

\

413

414

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS amitriptyline

desipramine

generally modest to disappointing (with a few

(Pertofrane). Because o f their fewer side effects,

(Elavil),

and

exceptions), the track record for psychological

desipramine and nortriptyline are often pre-

interventions can be described as controver-

ferred over amitriptyline and

imipramine.

sial depending on the "eye of the beholder."

Selective serotonin reuptake inhibitors have no

Doubts about the track record o f psychological

established therapeutic effect on IBS symptoms

treatments were perhaps expressed most clearly

but are frequently used to manage the psychi-

by Talley, Fett, and Zinsmeister ( 1 9 9 5 ) , whose

atric comorbidity (e.g., anxiety, depression).

influential systematic review concluded that the

Some o f the newer

pharmacotherapies,

efficacy of psychological treatments had not

known as serotonin modulators, are directed at

been established due to methodological flaws of

specific serotonin receptor sites in the gut, which

clinical trials. Talley and colleagues' study was

contains 9 5 % of the body's serotonin. Serotonin

not so much a systematic review as an analysis

receptors are heavily concentrated in the E N S

of the methodological quality of then available

and play an important role in mediating gut

clinical trials. T h e review itself suffered from a

response and sensation. These medications

number o f methodological problems that com-

include alosetron (Lotronex), a serotonergic type

promise the interpretability of its conclusions

3 antagonist agent, and tegaserod (Zelnorm), a

(Lackner,

type 4 agonist. Alosetron is marketed for non-

Hamilton, 2 0 0 3 ) . Notwithstanding its limita-

constipated

tions, Talley and colleagues' study was a land-

females, whereas

tegaserod

is

Morley,

Dowzer,

Mesmer,

&

designed for constipated females. Both medi-

mark one in that it was the first to evaluate

cations are unique among pharmacological

systematically methodological quality of psy-

agents in their ability to target multiple symp-

chologically oriented clinical trials across multi-

toms. Alosetron has been effective in reducing

ple a priori quality criteria. O n the other side of

pain and diarrhea, ostensibly by slowing colonic

the fence are those researchers who point to a

transit time. Tegaserod has been found to be

series o f quality smaller scale studies over the

effective in reducing pain, constipation, and

past 2 0 years as evidence of the clinical effec-

bloating, perhaps by stimulating peristalsis and

tiveness of psychotherapy. A comprehensive

chloride secretion, accelerating colonic transit

review of the outcome research is beyond the

time, and blocking pain signals from the gut.

scope of this chapter but can be found in a

Neither medication has established itself as any

recent article (Blanchard & Scharff, 2 0 0 2 ) .

more effective than placebo for male IBS patients. T h e manufacturer o f Lotronex voluntarily

Four different classes o f psychological treatments—brief psychodynamic

psychotherapy

withdrew it after serious GI events, specifically

with relaxation, hypnotherapy,

ischemic colitis and complications o f constipa-

behavioral therapy, and cognitive therapy—

tion, were reported in association with its use.

have been shown to be superior to symptom

Lotronex has subsequently been reintroduced

monitoring or routine medical care in reducing

to the marketplace with F o o d and

Drug

IBS symptoms (Blanchard, 2 0 0 1 ) . Treatments

restricted

featuring cognitive therapy and hypnotherapy

Administration

approval

under

cognitive-

conditions o f use. In sum, the most positive,

have been replicated and found to be superior

evidence-based appraisal of the efficacy o f

to

attention

placebo control

conditions.

pharmacological agents can be described

According to Blanchard and Sharif's ( 2 0 0 2 )

thusly: Specific agents can be effective for

narrative

some patients with discrete symptoms and/or

strongest empirical support (Whorwell, Prior, &

specific types o f IBS.

Faragher, 1 9 8 4 ) in that its therapeutic benefit

review,

hypnotherapy

has

the

has been replicated independently by two other Psychological

Treatment.

Whereas the over-

all track record for pharmacological agents is

research groups (Galovski & Blanchard, 1 9 9 8 ; Harvey, Hinton, Gunary, 8c Barry, 1 9 8 9 ) and

Irritable is maintained over time (Whorwell, Prior, &

Bowel Syndrome

\

Complications

Colgan, 1 9 8 7 ) . The psychological treatment with the second

Successfully treating IBS is a rewarding but

most consistently positive track record is cogni-

challenging

tive therapy.

achieved and maintained,

Cognitive therapy

for IBS is

endeavor.

F o r change patients

to

be

require

designed to reduce excessive emotional or phys-

motivation and a willingness to invest the req-

iological reactions associated with GI symptoms

uisite effort, time, and commitment in self-care

by modifying or eliminating negatively skewed

skills. This can be particularly difficult among

thinking patterns (e.g., jumping to conclusions)

those patients who are not psychologically

and belief systems (e.g., perfectionism) that

minded, have a strong disease conviction, or see

underlie these reactions. A related goal of cogni-

psychological treatments as reserved for mental

tive therapy is to provide patients with a general

illness. Therefore, it should be emphasized to

set of problem-solving or coping skills to man-

patients that their treatment is really no differ-

age a wide range of situations associated with

ent from other, more widely accepted behav-

IBS. Quality data based on a series o f smaller

ioral treatments

scale clinical trials indicate that 6 0 % to 8 0 % o f

problems. Just as a cardiologist may attempt to

used for physical

health

IBS patients who undergo cognitive therapy

alter cardiac disease by prescribing behavioral

achieve at posttreatment (up to 3 months) a clin-

changes

ically significant ( 5 0 % or more) reduction in IBS

decrease stress, change diet) for a heart patient,

(e.g.,

increase

physical

activity,

symptoms and maintain these gains at 3-month

so too do the cognitive or behavioral interven-

follow-up. Treatment gains associated with cog-

tions, which form the basis o f treatment,

nitive therapy are not limited to a reduction in

attempt to alter gut function

by changing

GI symptoms alone. A significant proportion of

behaviors. By drawing a parallel between the

patients also show substantial reductions in

treatment options o f IBS and those of other,

comorbid psychological distress (e.g., anxiety) at

seemingly more legitimate medical conditions,

posttreatment.

therapists attempt to mobilize patients' change

One o f the most interesting aspects o f the psychological treatment literature is the inconsistent support for multicomponent cognitive-

resources in the direction of a self-management approach. This is not to say that change will necessarily ensue. Patients are reminded about

behavioral protocol used effectively with other

the importance of regular practice and patience.

painful medical conditions (e.g., arthritis, low

There are at least two groups o f patients

back pain, fibromyalgia). Although cognitive-

w h o seem resistant to treatment. T h e first

behavioral therapy has been found to be more

group is patients with strong disease convic-

effective than symptom monitoring, it appears

tion and ongoing investment in pursuing a

to be no more effective than a credible atten-

medical cure for symptom relief. Although

tion placebo condition (Blanchard et al., 1 9 9 2 ;

these patients may attend treatment regularly,

T o n e r et al., 1 9 9 8 ) . Drossman and colleagues

they seem to merely "go through the motions"

( 1 9 9 9 ) conducted a narrative review o f 1 5

of treatment. Their disease conviction limits

psychologically oriented clinical trials

the

derived

conclusions

similar

to

those

and

effort,

commitment,

and

motivation

of

required to complete a treatment successfully,

Blanchard and Scharff ( 2 0 0 2 ) . There was,

which places a premium on behavioral self-

according to Drossman and colleagues ( 1 9 9 9 ) ,

change. O n e approach to these patients is to

sufficient evidence in 1 0 o f 13 studies for the

encourage them to obtain whatever medical

efficacy o f psychological treatments in reduc-

care has been found to be effective and to rein-

ing bowel symptoms at posttreatment (2 stud-

force the value o f simultaneously

ies were dropped from the review because the

management skills for managing a chronic

learning self-

participation rate dropped below 4 0 % ) .

illness that currently defies a medical solution.

415

426

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

CASE S T U D Y " R a c h e l " is a 35-year-old, married Caucasian female with 1 6 years o f education w h o was referred by her gastroenterologist t o the S U N Y - B u f f a l o M e d i c a l School Behavioral M e d i c i n e Clinic for evaluation and treatment o f a 9-year history o f I B S . H e r assessment was conducted during t w o sessions as part o f the pretreatment phase o f a N a t i o n a l Institutes o f Health-funded clinical trial o f a groupbased cognitive therapy for I B S . R a c h e l ' s primary complaints were abdominal pain associated with constipation, bloating, and gas. O n the M P Q , she described abdominal pain as a cramping sensation associated with a sharp, stabbing, shooting feeling in the rectum. She characterized the affective dimension o f pain as exhausting and cruel. R a c h e l rated the typical abdominal pain intensity as being o f moderate intensity. During the clinical interview, she characterized current pain as "discomforting" and within moderate intensity on the M P Q . T h a t being said, pain occasionally reached severe levels. Pain was relieved when she either had a soft, loosely formed bowel m o v e m e n t o r exercised. Pain tended t o ease on its o w n after approximately 6 0 minutes. In addition t o pain, she experienced periods o f constipation, bloating, nausea, and gas. She characterized constipation as having n o bowel movement for 3 or m o r e days. Several times a week, she experienced a sense after a bowel movement that she had been unable to pass all o f the fecal matter (i.e., incomplete evacuation). Prior to presentation, Rachel had consulted her family physician, obstetrician/ gynecologist, gastroenterologist, and proctologist. Her gastroenterologist had diagnosed her with IBS after her family physician expressed uncertainty about whether her symptoms were symptomatic of colitis. She had undergone a variety of diagnostic tests to detect an underlying organic basis o f her symptoms. These included an upper GI series, gallbladder series, sigmoidoscopy, colonoscopy, and stool tests for ova, parasites, and blood. At the time o f the examination, she was prescribed Librax. She was also taking a number o f over-the-counter agents, including Citrucel, Colace, Triphasil, and Rosewater. Both prescription and over-the-counter agents provided limited relief of pain and bowel disturbance. With the exception o f IBS, Rachel was in generally good physical health. She was not being treated for any extraintestinal health problems. Her only prior operation was a tonsillectomy in 1 9 8 0 . There was no family history of colon polyps, I B D , colon cancer, or liver disease. Although Rachel had never been treated for a psychiatric condition, the clinical picture that emerged from testing was a nervous, tense, shy individual with strong perfectionistic inclinations. She described herself as a "longtime worrier" prone to high levels of general anxiety. M u c h o f her worries focused on interpersonal and evaluative stressors whose resolution necessitated self-assertion, conflict negotiation, and direct communication (e.g. refusing requests). O n the P S W Q , she acknowledged that her worries took on excessive ( " M a n y situations make me worry") and uncontrollable

Irritable

Bowel

Syndrome

("I know I shouldn't worry about things, but I just can't help it") qualities. She was particularly prone to worrying when she felt increased work pressure in her j o b as a social worker. Although she had no history o f a psychiatric condition, she reported a positive history o f sexual abuse that was perpetrated by an older neighborhood boy when she was approximately 9 years old. Rachel participated in a 10-session group-based treatment program that was offered as part o f a current outcome trial. She was randomly assigned to a cognitive therapy condition. T h e cognitive-based treatment for I B S , described m o r e fully in Blanchard ( 2 0 0 1 ) , is designed to teach the patient to learn to identify and correct maladaptive beliefs and information processing errors with the goal o f reducing G I symptoms and related distress. Within this treatment, cognitive interventions consist o f four overlapping phases: (a) educating the patient about IBS and the processes that maintain the disorder, with a focus on its situational, cognitive, and emotional triggers; (b) training the patient in the identification and modification o f his or her cognitive appraisals and interpretations o f situations, thoughts, and behaviors; (c) changing underlying or " c o r e " beliefs supporting negative cognitions; and (d) receiving formal training in problem solving to strengthen the ability to cope m o r e effectively with realistic stressors associated with I B S . Rachel met with four other IBS patients for 1 0 sessions ( 9 0 minutes long) in a small group setting with a single therapist over the course o f 1 0 weeks. T h e provision o f education about the nature and pathophysiology o f IBS (e.g., role o f visceral sensitivity, abnormal gut motility) and corrective information concerning the myths associated with IBS (e.g., " n o t real," "all in your head") was the first objective o f treatment. Rachel and her group members learned that IBS was a benign medical condition whose symptoms are due neither to a detectable organic problem n o r to psychopathology. Instead, IBS was presented as a legitimate illness due to a lack o f coordination in the interaction between the brain and the gut. It was explained that psychological factors (e.g., expectancies, stress, strong emotions) are capable o f disrupting h o w the brain and the gut function with each other in a w a y that aggravates symptoms in both IBS patients and nonclinical individuals. This effect is exaggerated in IBS patients. In R a c h e l ' s case, cognitive factors associated with IBS included her tendency to think the worst in the face o f uncertainty (i.e., overestimate the probability o f negative events), underestimate her ability to cope with adversity, and focus on the emotional distress o f a stressor rather than on her ability to manage it effectively regardless o f the accompanying distress. T o increase awareness o f the link between cognitive processes and symptoms, R a c h e l monitored IBS-related symptoms, their situational antecedents, her

accompanying

thoughts, and her responses (e.g., emotional, physical) using

"dysfunctional

thought records." O n monitoring sheets, she detailed the content o f her worries, their estimated "heat o f the m o m e n t " probability, and evidence to support them. T o the extent that worries could not be substantiated, she was instructed to revise her estimation o f the probability o f worrisome negative events based on realistic

417

418

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS

appraisals o f the evidence if any existed. A major goal o f this technique is to encourage patients t o treat automatic thoughts not necessarily as facts but rather as hypotheses ("dressed up as facts") whose factual basis could be determined both by using evidence-based logic and by generating alternative explanations for negatively skewed appraisals. F o r realistic stressors, R a c h e l was taught a set o f "decatastrophizing"

techniques that

emphasized

acceptance/resignation over

unmodifiable events, the importance o f both adopting a "so-what a p p r o a c h " and attending to the immediate environment, and the limited value o f responding physically to psychological stressors. T h e goals o f decatastrophizing techniques were to strengthen both R a c h e l ' s confidence that she had sufficient coping resources to endure adversity and her understanding o f the limited utility o f worrying about negative life circumstances over which she had limited, if any, control. T h r o u g h problem-solving techniques, R a c h e l learned a more flexible and varied set o f coping strategies for resolving realistic stressors that aggravated symptoms. O n c e basic cognitive restructuring skills were developed, cognitive therapy shifted toward challenging and disputing underlying core beliefs that in R a c h e l ' s case included a strong sense o f perfectionism, that is, the belief that she needed to be perfect in all endeavors and that falling short o f this standard is unacceptable. As her selfmanagement skills improved, her GI symptoms decreased. After about the fourth week, the intensity, frequency, and duration o f both pain and diarrhea decreased in c o m p a r i s o n with

pretreatment

levels. Interestingly, she experienced

no

appreciable change in bloating. W h e n R a c h e l returned for her 2-week posttreatment follow-up, she reported that GI symptoms had decreased by approximately 7 5 % and that pain had decreased by approximately 5 0 % to 6 0 % since pretreatment baseline. Consistent with her global reports o f improvement were data obtained from daily G I sympt o m diaries. Whereas symptoms occurred four or five times weekly at moderate to severe levels at pretreatment and were associated with significant distress and diminished function (e.g., role limitations, reduced Q O L ) , she n o w described onceweekly episodes o f abdominal pain whose intensity she rated as mild and nondisabling at posttreatment.

In addition t o improvement

in GI symptoms, she

completed treatment with an improved Q O L . A board-certified gastroenterologist w h o was blind to her treatment independently

evaluated her symptoms

as

"markedly improved." Beyond improvements in IBS symptoms, she demonstrated improvement in broader health status. Postsession evaluation for Axis I indicated that she no longer met full D S M - I V criteria for generalized anxiety disorder. R a c h e l was seen two additional times at 3 - and 1 2 - m o n t h follow-up to gauge her maintenance o f treatment gains. She experienced no significant exacerbation o f G I symptoms, m o o d disturbance, or functional limitations. T a b l e 2 0 . 3 illustrates the course o f Rachel's symptom severity across the treatment period.

Irritable Table 20.3

Bowel

Syndrome

Symptom Severity at Pretreatment, Posttreatment, and Follow-Up Assessments

Outcome Measure

Pretreatment

Gastrointestinal symptoms

1.27

Posttreatment

3-Month Follow-Up

0.74

12-Month Follow-Up

0.54

0.57

Monitoring index State Anxiety Trait Anxiety* Depression Quality of Life

49 50 11 35

30 30 3 17

35 37 5 15

24 34 4 14

Role limitations Emotional Pain Social functioning Mental health

45 61 70 56

45 51 44 56

45 46 44 51

45 51 44 44

1

b

c

d

d

11

d

a. State-Trait Anxiety Inventory (summed scores). b. Beck Depression Inventory (summed score). c. Irritable Bowel Syndrome-Quality of Life Inventory. d. SF-36 (T-scores).

In other words, patients are encouraged to

cognitive-behavioral techniques and learned to

treat their IBS in much the same way that they,

respond more constructively in a way that

their friends, or their family members would

decreased symptom intensity and duration.

approach any other chronic medical illness

Another

such as diabetes, asthma, or heart disease.

compliance with homework assignments. As a

The second group o f treatment-resistant

potential

complication

involves

behavioral self-management treatment, cogni-

patients is patients who are unable to link fluctu-

tive therapy necessitates active commitment to

ations in IBS symptoms to stress or other psy-

attend treatment and complete between-session

chological triggers. These patients are not

homework assignments so as to learn more

necessarily defensive or inclined to "fake good."

adaptive skills (and to unlearn

maladaptive

It is quite possible that their IBS symptoms are

ones). This can be a difficult task, particularly

subject to limited psychological meditation (e.g.,

with patients who are inclined to overschedule

dietary or hormonal fluctuations). Therefore,

their lives. It is emphasized that the degree o f

there does not seem to be much value in attempt-

relief that patients invest in treatment corre-

ing to force the patients to recognize a relation-

sponds with their investment in behavioral

ship between stress and IBS that might not exist.

assignments. N o apologies are made for the

For these patients, one approach is to encourage

behavioral tasks assigned in treatment. I f

them to use their symptoms as situational trig-

patients cannot complete time- and effort-inten-

gers of potentially maladaptive responses that

sive assignments, it is suggested that a behav-

may subsequently aggravate symptoms. T o illustrate, one patient who was unable to

ioral treatment program might not be a good match for them, and they are encouraged to

identify situational triggers discovered that she

seek alternative treatment. Patients seem more

responded

likely to carry out assignments if they have

fearfully and with

catastrophic

thoughts to symptoms that seemed to come

developed a positive expectancy regarding

"out of the blue." Although she was unable to

treatment efficacy, which is reinforced by dis-

reduce the frequency of symptoms, she used

cussing the track record of behaviorally based

\

419

420

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS treatments for IBS. Finally, patients who are

number o f factors, including abnormal motility,

undergoing a high level o f objective chronic

visceral hypersensitivity, abnormal

cerebral

stress (e.g., transportation difficulties, financial

processing of bowel stimuli, and psychological

pressures) seem to have difficulty in carrying

processes. Currently, there are no empirically

out behavioral assignments, although

validated medical options that target the full

this

observation has not been formally evaluated.

spectrum o f symptoms associated with IBS. T h a t being said, a number o f well-defined, short-term psychological treatments have been

CONCLUSIONS

developed that offer hope and symptom relief for the 3 5 million individuals with IBS. This

IBS is a chronic, potentially disabling, painful

chapter has attempted to illustrate the applica-

medical disorder that exacts a heavy toll on

tion o f a cognitive therapy approach

society, employers, and its sufferers. IBS is not

emphasizes

explainable by structural or biochemical mech-

restructuring, and problem-solving training in

anisms. Symptoms are best explained from a

relieving abdominal pain, bowel dysfunction,

biopsychosocial perspective that emphasizes a

and related distress.

patient

education,

that

cognitive

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423

424

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS Silverman, D. H , Munakate, J . Α., Ennes, H., Mandelkern, Μ . Α., Hoh, C. K., Phelps, M . E., & Mayer, E. A. (1997). Regional cerebral activity in normal and pathological perception of visceral pain. Gastroenterology, 112, 6 4 - 7 2 . Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press. Stewart, A. L., &c Ware, J . E. (1992). Measuring functioning and well-being: The medical outcomes study approach. Durham, NC: Duke University Press. Tache, Y . (1989). Central control of gastrointestinal transit and motility by braingut peptides. In W. J . Snape, J r . (Ed.), Pathogenesis of functional bowel disease (pp. 5 5 - 7 8 ) . New York: Plenum. Talley, N., Drossman, D. Α., Whitehead, W. E., Thompson, W. G., &c Corassiari, E. (2000). Rome II Integrative Questionnaire. In D. A. Drossman, E. Corazziari, N. J . Talley, W. G. Thompson, &C W. E. Whitehead (Eds.), Rome II: The functional gastrointestinal disorders: Diagnosis, pathophysiology, and treatment—A multinational consensus (2nd ed., pp. 6 9 0 - 7 1 4 ) . McLean, VA: Degnon Associates. Talley, N. J . , Fett, S. L., & Zinsmeister, A. R. (1995). Self-reported abuse and gastrointestinal disease in outpatients: Association with irritable bowel-type symptoms. American journal of Gastroenterology, 90, 3 6 6 - 3 7 1 . Talley, N. J . , Gabriel, S. E., Harmsen, W. S., Zinsmeister, A. R., & Evans, R. W. (1995). Medical costs in community subjects with irritable bowel syndrome. Gastroenterology, 109, 1 7 3 6 - 1 7 4 1 . Thompson, W. G., Dotevall, G., Drossman, D. Α., Heaton, K. W., &C Kruis, W. (1989). Irritable bowel syndrome: Guidelines for the diagnosis. Gastroenterology International, 2, 9 2 - 9 5 . Toner, Β. B., Segal, Ζ. V., Emmott, S., Myran, D., Ali, Α., DiGasbarro, I., & Stuckless, N. (1998). Cognitive behavioral group therapy for patients with irritable bowel syndrome. International Journal of Group Psychotherapy, 48, 2 1 5 - 2 4 3 . Ware, J . E., & Sherbourne, C. D. (1992). The M O S 36-Item Short Form Health Survey (SF-36). Medical Care, 30, 4 7 3 - 4 8 3 . Welgan, P., Meshkinpour, H , & Hoehler, F. (1985). The effect of stress on colon motor and electrical activity in irritable bowel syndrome. Psychosomatic Medicine, 47, 1 3 9 - 1 4 9 . Whitehead, W. E., Bosmajian, L., Zonderman, A.B., Costa, P.T., & Schuster, M . M . (1988). Symptoms of psychologic distress associated with irritable bowel syndrome: Comparison of community and medical clinical samples. Gastroenterology, 95, 7 0 9 - 7 1 4 . Whitehead, W. E., Burnett, C. K., Cook, E. W., & Taub, E. (1996). Impact of irritable bowel syndrome on quality of life. Digestive Diseases and Science, 41, 2 2 4 8 - 2 2 5 3 . Whitehead, W. E., Engel, B . T., &c Schuster, M. M . (1990). Perception of rectal distention is necessary to prevent fecal incontinence. Advanced Physiological Science, 17, 2 0 3 - 2 0 9 . Whitehead, W. E., Palsson, O., & Jones, K. R. (2002). Systematic review of the comorbidity of irritable bowel syndrome with other disorders: What are the causes and implications? Gastroenterology, 122, 1 1 4 0 - 1 1 5 6 . Whitehead, W. E., Winget, C , Fedoravicius, A. S., Wooley, S., & Blackwell, B . (1982). Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Digestive Diseases and Science, 27, 2 0 2 - 2 0 9 . Whorwell, P. J . , Prior, Α., & Colgan, S. M. (1987). Hypnotherapy in severe irritable bowel syndrome: Further experience. Gut, 28, 4 2 3 - 4 2 5 . Whorwell, P. J . , Prior, Α., &c Faragher, Ε. B . (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet, 1232-1234.

CHAPTER

Insomnia and the Sleep

21

Disorders

VALERIE A . WOLFE AND SHERI D . PRUITT

I

nsomnia and the sleep disorders present a

and medical treatments

variety of problems. Some are primarily

treatment o f sleep disorders.

behavioral, whereas others have a dominant

available for

the

Despite recommendations from the National

biological component. Regardless of etiology,

Commission on Sleep Disorders Research,

sleep

common.

physicians rarely receive training in the assess-

Approximately 6 5 million Americans suffer each

ment and treatment o f sleep problems. Medical

problems

are

remarkably

year from transient sleep difficulties, and about

students obtain between 0 and 2 hours o f train-

3 0 million more Americans have chronic insom-

ing specific to sleep disorders

nia (Hauri & Linde, 1996). Moreover, approxi-

Vaughan, 1 9 9 9 ) , and this lack of training is

mately 3 5 % of adults report some type of sleep

reflected in clinical practice. For example, many

disturbance each year, with half of these individ-

physicians do not ask about insomnia during

uals describing their sleep problems as "serious"

office visits (Dement &

(Gallup Organization, 1 9 9 5 ; Mellinger, Baiter,

Moreover, when insomnia is recognized, physi-

& Uhlenhuth, 1 9 8 5 ) .

cians defer to medication treatment rather than

(Dement

Vaughan,

&

1999).

T h e cost o f sleep disorders is exorbitant.

very efficacious behavioral treatments. In fact,

In 1 9 9 0 , the National Commission on Sleep

practice guidelines from the American Medical

Disorders Research, a commission created by

Association, the Canadian Medical Association,

Congress t o investigate sleep disorders and

and many health maintenance organizations

their effects

on the population,

reported

the annual cost o f sleep problems t o be in the tens

o f billions o f dollars

(Dement

indicate that behavioral interventions should be the treatment of choice for insomnia.

&

Vaughan, 1 9 9 9 ) . In addition, estimates indicate that 2 4 , 0 0 0 people die each year from accidents related to falling asleep while driving (Dement & Vaughan, 1 9 9 9 ) . T h e report generated

by the c o m m i s s i o n

advocated

extensive training for primary care doctors, a

BACKGROUND AND ETIOLOGY The Basics of Sleep, Sleep Architecture, and Sleep Cycles

national awareness campaign on insomnia,

Sleep is an exceedingly important activity.

and increased awareness o f the behavioral

Although scientists are not certain how sleep

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

426

helps daytime functioning, it is fairly easy

wakefulness (Gupta, Gupta, 8c

to assess the difficulties associated with sleep

1 9 8 6 ; Moldofsky, 1 9 8 9 ) .

deprivation. Without enough sleep, individu-

Haberman,

Sleep deprivation can also cause pain. When

als find themselves edgy and irritable. In addi-

individuals

tion, their concentration and ability to learn

interrupted, they complain o f musculoskeletal

new information begin to decline. O n e o f the

tenderness, which resolves after 2 nights o f

first symptoms of sleep deprivation is depres-

noninterrupted

sion. After a few days o f no sleep, some people

1 9 7 3 ) . Sleep is also essential for normal func-

will perform as if they are intoxicated. W h e n

tioning o f the body's immune system and for

people have been denied sleep for about a

healthy cell growth. This explains why sleep-

week, they can experience visual and auditory

deprived individuals are more likely to get sick

have

their

deep

sleep (Hauri

delta

8c

sleep

Hawkins,

hallucinations. Sleep deprivation impairs func-

and tend to heal less rapidly as compared with

tion in nearly everyone. However, the amount

well-rested individuals (Hauri 8c Linde, 1 9 9 6 ) .

of sleep deprivation a single person can tolerate without ill effects varies.

The amount o f sleep that humans need to function maximally varies both by individual

Fatigue also contributes to a host o f psy-

and by age. Whereas newborns need about

chiatric and medical diagnoses. Both anxiety

16 hours of sleep per day, 2-year-olds need

and depression have a strong sleep c o m p o -

about 13 hours. Teenagers require about 9 hours

nent. Among patients with depression, 8 5 %

of sleep per night, and adults need 7 to 8 hours

report insomnia and 1 0 % to 1 5 % complain

on average. Interestingly, the amount of sleep

o f hypersomnia (Ford 8c K a m e r o w , 1 9 8 9 ) .

an individual may require varies from about

Patients with

frequently

5 hours to 1 1 hours. Therefore, 7 or 8 hours

function energetically for days or weeks on a

bipolar

disorder

per night reflects an average. Adults over age

few hours o f sleep and then have periods o f

6 5 years need as much sleep as do younger

hypersomnia associated with major depres-

adults, but their sleep tends to be less deep and

sive episodes. Changes in sleep can predict

they tend to wake more during the night.

a major depressive episode (Perlis, Giles,

Researchers are not sure why this is the case,

Buyesse, T u , 8c Kupfer, 1 9 9 7 ) , and denying

but they believe that it may be a natural out-

sleep t o someone w h o has bipolar disorder

come o f aging or that it may be related to

can

8c

decreased activity, medications, and/or having a

posttrau-

variable schedule. Approximately half of adults

matic stress disorder also report sleep distur-

over age 6 5 years have a chronic sleep disorder.

trigger

Kamerow,

a

manic

1989).

episode

(Ford

Patients with

bance, including nightmares and insomnia (American Psychiatric Association, 1 9 9 4 ) . Insomnia is also associated with chronic

Sleep Cycles

obstructive pulmonary disease, osteoarthritis,

There are five stages o f sleep that occur in

asthma, fibromyalgia, headaches, and chronic

cycles during the night. These are referred to as

pain. Between 5 0 % and 7 0 % o f patients with

Stages 1 to 4 and R E M (rapid eye movement)

a pain diagnosis suffer from a sleep distur-

sleep. Each stage is defined by depth o f sleep,

bance (Moffitt, Kalucy, Kalucy, Baum, 8c

brain wave activity, eye movements, and mus-

Cooke,

8c

cle tone. Stage 1 sleep is a light sleep and is char-

Townley, 1 9 8 5 ) . Patients with fibromyalgia,

acterized by short fast brain waves (called theta

rheumatoid

waves) and slow eye movements. This type o f

1 9 9 1 ; Pilowsky, arthritis,

Crettenden,

back

pain,

and/or

headaches have been found to have alpha

sleep occurs at the beginning of the night or

wave intrusions into their delta sleep, indicat-

during the day with boredom or fatigue. People

ing that their deep sleep is interrupted

are easily aroused from a Stage 1 sleep and on

by

Insomnia wakening can perform cognitive and physical tasks without grogginess. Variable brain wave lengths (called sleep spindles and Κ complexes) characterize Stage 2 sleep. Eye movements stop and brain activity slows down. Stage 3 sleep is a deeper stage of sleep and is characterized by slower delta waves interspersed with small quick waves. Stage 4 sleep is a very deep sleep and is identified by delta wave activity that is not interspersed with shorter waves. Although it is easy to arouse someone from Stage 1 or 2 sleep, it is much more difficult to wake from Stage 3 or 4 sleep. It is during this deep delta sleep (Stage 4) that bed-wetting and sleepwalking occur. R E M sleep is distinct from the other stages of sleep. Humans are very active physiologically during R E M . For example, during R E M , the muscles o f the body stiffen, eyes move rapidly, and heart rate, blood pressure, oxygen use, and respiration become more rapid and

variable. In addition,

during R E M ,

reflexes, kidney function, and hormonal patterns change. T h e body's temperature regulation is affected such that people will not sweat or shiver. During R E M sleep, both genders experience engorgement of the genital region— causing

erections

in

males

and

clitoral

engorgement in females. It is during R E M sleep that humans dream. A typical sleep cycle lasts about 9 0 minutes, and healthy sleepers complete four to six cycles per night on average. After a few minutes in Stage 1 sleep, Stages 2 , 3 , and 4 occur. Stage 2 sleep repeats, followed by R E M sleep, before

and the Sleep Disorders

j

Insomnia Insomnia is the most c o m m o n sleep problem. It is characterized by an inability to fall asleep quickly (generally within 3 0 minutes), waking during the night with difficulty in returning to sleep, waking t o o early in the morning, and/or having nonrestorative sleep. In addition, sleep disruption must occur at least 3 nights per week. Insomnia is typically categorized in terms of chronicity. Transient insomnia typically lasts a few nights to a few weeks. M o s t people will experience transient insomnia sometime during a year. Transient insomnia can be triggered by a variety o f factors, including stress, life changes, illness, a poor sleep environment, shift work, medication changes, jet lag, and poor sleep habits. Transient insomnia can become chronic due to classical conditioning. For example, one patient described insomnia that started after a divorce. H e described waking during the night because of stress and sadness; after smoking a cigarette, he was able to fall back asleep. This patient reported that the divorce was finalized 3 years ago. H e felt like he had moved on emotionally, but he still awakened during the night and could not fall asleep until he smoked a cigarette. Unfortunately, the attempts made to try to improve sleep often worsen the problem. Chronic insomnia can last from a month to many decades, causing both functional depression)

(e.g., decreased and medical

concentration,

(e.g., headaches,

hypertension) complications.

the next 90-minute cycle begins. During the early part o f the night, a greater amount o f time is spent in deep Stages 3 and 4 sleep. Closer to morning, R E M sleep is lengthier.

Restless Leg Syndrome and Periodic Limb Movement Disorder

During the night, normal adults spend about

Restless leg syndrome (RLS) is defined as an

5 % of the night in Stage 1 sleep, 5 0 % in Stage 2

urge to move or shake the lower extremities

sleep, 5 % in Stage 3 sleep, 1 0 % to 1 5 % in

because o f an uncomfortable sensation. M o s t

Stage 4 sleep, and 2 0 % to 2 5 % in R E M sleep.

often, this affects the legs, but it also is experi-

M o s t people can function well if they are able

enced in the arms or in muscles in other parts

to complete four to six sleep cycles during a

of the body. T h e feeling typically is more exag-

night (thereby sleeping about 6 to 9 hours).

gerated in the evening and often can prevent a

427

428

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS person from relaxing enough to fall asleep.

at inopportune times, for example, while driving

Moving the legs relieves the discomfort or

or during meetings. Sleep apnea sufferers also

aching. Diabetes, anemia, chronic renal failure,

tend to snore loudly. T h e consequences o f

and certain medications can cause R L S , but

sleep apnea can be severe because patients not

often the root cause is not apparent. R L S may

only will lack sufficient oxygen in the blood but also will have excess carbon dioxide. They

worsen with age. Periodic leg movement disorder ( P L M D )

frequently have comorbidities, including car-

is an insomnia disorder that is accompanied

diac arrhythmia, headache, malaise, fatigue,

by repetitive episodes o f muscle contractions

weight gain, and night sweats. In addition,

separated

sleep apnea sufferers are frequently awakened

by intervals o f 2 0 to 3 0 seconds. Awakenings

through the night as they try to clear their

(0.5 to 5 . 0 seconds in duration)

may be associated with these movements.

airways; they rarely complete 90-minute sleep

M o s t patients with R L S have P L M D .

cycles. T o clear their airway, sufferers may

T h e prevalence of R L S and P L M D in the

gasp or describe a feeling o f drowning. They

general population is between 9 % and 1 5 %

tend to be the most fatigued patients referred

(Hening et al., 1 9 9 9 ) . T h e number o f cases

to sleep clinics for evaluation.

increases as people age and the symptoms can

become

more

intrusive

with

time.

Approximately 4 3 % o f people with R L S

Narcolepsy

describe the onset of the disorder before age

Narcolepsy is a disorder distinguished by

2 0 years (Hening et al., 1 9 9 9 ) . Prevalence rates

the rapid onset o f a sleep cycle, typically

for P L M D in people age 6 0 years or over range

triggered by periods o f excitement. People

from 2 0 % to 5 8 % (Dickel & M o s k o , 1 9 9 0 ) .

often have their first episode o f narcolepsy between ages 1 0 and 3 0 years (Hauri

&

Linde, 1 9 9 6 ) . Reports indicate that there are

Sleep Apnea

100,000

T h e definition o f a sleep apnea episode is

to

600,000

narcoleptics in

the

United States (Hauri & Linde, 1 9 9 6 ) . Narcolepsy is characterized by cataplexy

the cessation of airflow through the nose or mouth that lasts 1 0 seconds or longer. Sleep

(i.e., lack of muscle tone), hypnagogic halluci-

apnea can be caused by a variety o f conditions

nations (i.e., dreamlike hallucinations), and

and can be exacerbated by alcohol use or aller-

sleep paralysis. During a narcoleptic episode,

gies. There are three types of sleep apnea: cen-

the patient immediately will go into R E M sleep.

tral, obstructive, and mixed. Central sleep

Patients with narcolepsy often report vivid

apnea is the cessation of breathing due to lack

dreams or hallucinations. Obviously, this disor-

of respiratory effort. Obstructive sleep apnea

der is an extremely dangerous condition given

is characterized by sufficient respiratory effort

that people can fall asleep without warning

from the lungs but blockage (obstruction) o f

while driving or operating heavy machinery.

the airway. T h e mixed category refers to apnea

T h e cause o f narcolepsy appears to be

in which the obstructive phase follows a cen-

genetic, and treatment is usually medication.

tral phase, thereby combining both central and

Both stimulants

and antidepressants

have

obstructive sleep apnea. People o f any age can

been prescribed, and some patients find relief

have sleep apnea, although it is more c o m m o n

by

in older adults and in those who are obese.

recently, modafinil has improved

Patients should

be evaluated

for

sleep

taking

naps

during

the

day.

More

wakeful-

ness in patients with this problem. Although

apnea if they are experiencing excessive day-

untreated

time sleepiness. This manifests in falling asleep

rapidly and without warning during the day,

narcoleptic patients

fall

asleep

Insomnia

and the Sleep Disorders

\

they often report difficulty in falling asleep

total hours o f sleep achieved, sleep habits,

at night.

snoring, and level of fatigue during the day. Diet, caffeine, alcohol, tobacco, medications, herbs, medical conditions, and exercise should

Dreams, Nightmares, Sleep Terrors, and Sleepwalking

also be evaluated. It is important to note that patients will frequently underestimate

People dream during R E M sleep; there-

the

amount of sleep they achieve. Therefore, it can

fore, dreams typically occur at the end o f

be useful to interview a spouse to corroborate

the night when R E M sleep is longer. People

the information given. Another method o f

dream for about 2 hours every night and

evaluating sleep patterns is to have the patient

recall dreams

complete

if awakened

quickly

from

a sleep journal.

Unfortunately,

R E M sleep. Dreams can also be remembered

patients often have difficulty in complying with

through specific training strategies designed

this recommendation, or they report inaccu-

to enhance recall.

rate information.

Throughout history, people have looked to

W h e n self-report techniques are insufficient

their dreams for meaning and prophecy. There

for diagnosis and treatment planning for a

are varying theories as to the importance o f

sleep disorder, a patient may benefit from

dreams; some psychologists (e.g., Carl Jung)

a polysomnogram test. A

have spent much o f their careers investigating

involves using electroencephalography (EEG)

the role of dreams as a window to the uncon-

to monitor brain and muscle activity, heart

scious. Other professionals believe that dreams

rate, and respiration. By interpreting brain

are simply people's interpretations o f the phys-

waves and muscle activity, a specialist can

iological arousal that occurs with R E M sleep

identify the type o f sleep disorder.

polysomnogram

(Walsleben & Baron-Faust, 2 0 0 0 ) . Regardless,

If a patient complains o f loud snoring and

many laypeople believe that dreams are mean-

reports periods o f n o breathing followed by

ingful and are disturbed

gasps for air, an evaluation for possible sleep

when they have

anxiety-producing dreams or nightmares. Sleep terrors typically occur in children. Unlike nightmares, sleep terrors occur earlier

apnea should be arranged. A test for blood oxygen levels, called oximetry, is often used to evaluate for sleep apnea.

in the evening during the deep delta sleep (Stages 3 and 4 ) . Nightmares tend to occur toward the end o f the night when R E M sleep

Treatment of Insomnia

is longer. Because children have more delta

Treatment o f insomnia integrates sleep

sleep than do adults, children are more prone

hygiene (i.e., good sleep habits), stimulus con-

to night terrors.

trol, relaxation training, and sleep restriction components. These behavioral strategies are effective for 7 0 % to 8 0 % o f patients with

ASSESSMENT AND T R E A T M E N T

Evaluation/Assessment Phases

primary insomnia (Morin et al., 1 9 9 9 ) . In a review o f the literature on the use o f nonpharmacological treatments for insomnia, M o r i n and colleagues ( 1 9 9 9 ) found that

patients

Because the etiologies o f sleep disorders are

treated with behavioral interventions were

multifaceted, a thorough evaluation is impera-

"better off" (i.e., they fell asleep faster after

tive to ensure appropriate treatment planning.

treatment)

An initial interview should include questions

untreated

regarding sleep onset, number o f awakenings,

taught cognitive-behavioral skills slept longer,

than

approximately

c o n t r o l s . In addition,

8 0 % of patients

429

430

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS shorter

First, they are to use their beds for sex and

time periods, and reported higher sleep quality

awakened less frequently

and for

sleep only; they are not to read, watch televi-

after treatment than did 5 0 % to 7 0 % o f

sion, or do business or other work in bed; and

untreated controls (Morin et al., 1 9 9 9 ) .

they are not to stay in bed if awake for longer

Improvements in sleep were maintained on

than 2 0 minutes at a time. Second, they are to

follow-up. After 3 and 6 months, patients given

go to bed only when sleepy. Third, they are to

cognitive-behavioral intervention

maintain a regular wake-up time. Fourth,

maintained

gains realized in sleep onset and number of

they are to avoid napping during the day.

awakenings (Morin et al., 1 9 9 9 ) . In fact, some studies show that patients actually sleep longer at night 6 months following treatment than during the initial posttreatment

Sleep Restriction.

T h e goal o f sleep restric-

tion is to train patients to sleep more efficiently

assessment

by limiting the amount o f time spent in bed.

(Morin et al., 1 9 9 9 ) . This may be because

This strategy capitalizes on fatigue so as to

patients need a few months to fully integrate

train their bodies to fall asleep quickly and

behavioral strategies into their lives. Additional

to sleep through the night. Patients are first

long-term

benefits o f cognitive-behavioral

instructed to compute their sleep efficiency by

training for insomnia include a reduction in

dividing their time spent sleeping by their time

medication use and increased independence

spent in bed. They estimate the average

from medical intervention (Morin et al., 1 9 9 9 ) .

amount of time they spend sleeping at night.

Reflecting the breadth o f literature support-

N e x t , they choose a wake-up

time

that

ing the use of behavioral treatments for insom-

they will adhere to every day of the week.

nia and the side effect profiles of most hypnotics,

Additional recommendations are to avoid nap-

current

the

ping and to get out o f bed if still awake after

the

2 0 minutes (e.g., from stimulus control train-

best practice guidelines from

American

Medical

Association

and

Canadian Medical Association indicate that

ing). After the assessment and setup phase,

behavioral treatment should be the frontline

patients select one o f the following techniques.

treatment for insomnia. However, because of inadequate provider training and an over-

Significantly

delay going

to bed. This strat-

reliance on the "quick fix" (i.e., medication),

egy is the most difficult because it requires the

physicians rarely use structured behavioral treat-

patient to go to bed much later than usual

ments to treat insomnia. Instead, most people

while keeping his or her wake-up time con-

who suffer from insomnia use over-the-counter

stant. First, the patient determines a wake-up

medications or prescription sleep aids.

time that can be adhered to strictly. T h e initial bedtime is established using the

Core

Components

Behavioral

of

Treatment

Cognitivefor

Insomnia

average

number of hours o f sleep a patient achieves. For example, if a woman typically spends 9 hours in bed but only sleeps 6 hours because

Stimulus con-

of waking, the recommendation is to spend

trol therapy teaches patients to use environ-

only 6 hours in bed. If her wake-up time is

mental cues to augment, rather than inhibit,

6 : 0 0 a.m., she would go to bed at midnight the

sleep. T h e premise o f the therapy is that indi-

first night. She would follow the stimulus con-

viduals will be reconditioned to sleep effi-

trol strategy and get up if she is not asleep

ciently when sleep-incompatible activities are

within 2 0 minutes. She would also get out of

Stimulus

Control

Therapy.

reduced and sleep-associated activities are

bed if she wakes for longer than 2 0 minutes

increased. Patients receive the following basic

during the night. T h e patient then would con-

rules pertaining to the bedroom environment.

tinue to go to bed at midnight until she achieves

Insomnia 90%

and the Sleep Disorders

\

sleep efficiency. When this marker is

to bed too early and by failing to maintain a

reached, she would go to bed 15 minutes

consistent sleep schedule. Typically, patients will

earlier, stopping at the hour at which she can

have one or two bad nights o f sleep because of

maintain a sleep efficiency o f 8 5 % or better and

a transient event and will adjust their bedtime

wake feeling rested and refreshed. The first night

to be earlier because they feel fatigued. This is

of this program is the most difficult because

problematic because the body is not accustomed

patients who are already fatigued have a difficult

to spending additional time in bed, and in an

time staying up later than usual. Napping during

attempt to accommodate the change in bedtime,

the day or falling asleep briefly before bedtime

sleep cycles are altered and sleep becomes less

will usually sabotage this strategy.

efficient. W h e n informed o f this pattern, patients

Delay bedtime

by 15 minutes.

This strategy

advises the patient to go to bed 1 5 minutes

often

identify that

their sleep difficulties

began when they initiated a change in their

later than usual every night until he or she is

bedtime by going to bed earlier due to a

able to fall asleep quickly and sleep through

partner's schedule, an illness, or a stressful

the night. Therefore, the previously mentioned

period.

patient would still have a consistent wake-up

patients learn after a few nights o f poor sleep

time of 6 : 0 0 a.m. and would still follow the

to go to bed a little later. T h e y understand

20-minute rule, but instead o f going to bed at

that attempts to address a few nights o f poor

9:00 p.m., she would go to bed at 9 : 1 5 p.m. If

sleep by going to bed earlier is not effective,

she cannot achieve 8 5 % sleep efficiency after a

even though going to bed earlier makes intu-

few nights, she would go to bed at 9 : 3 0 p.m.

itive sense if a person is fatigued.

With

appropriate

information,

Eventually, this patient may find that if she goes to bed at 1 0 : 4 5 p.m., she is able to fall asleep quickly and sleep through the night.

Sleep

Hygiene

(i.e.,

good

sleep

habits).

Sleep hygiene refers to health practices (e.g., diet, exercise, substance use) and environmen-

Use an intermediate The

delay in going

to bed.

third strategy is an intermediate

one

between the first two strategies. T h e patient

tal factors (e.g., noise, light, a comfortable bed, a m b i e n t temperature)

that

may

be

inhibiting sleep. In terms o f health practices,

first sets a consistent wake-up time, avoids

patients are instructed to reduce caffeine use

napping, and follows the 20-minute rule. T h e

to less than five cups o f coffee or tea a day and

patient is then instructed to go to bed as late as

to avoid using any caffeine after 2 : 0 0 p.m.

possible. This intermediate strategy works well

Caffeine has a half-life o f 4 hours; therefore,

for many patients because they cannot stay up

half o f the caffeine consumed at 4 : 0 0 p.m. will

late enough to use the first strategy. Also, this

still be in the body at 8 : 0 0 p.m., and a quarter

third strategy tends to work more quickly than

of the initial cup o f coffee or tea consumed at

the second strategy. T h e previously mentioned

4 : 0 0 p.m. will be in the body at midnight.

patient would continue to stay up late until

Patients should also limit nicotine intake

she achieves above 8 5 % sleep efficiency. Then,

and never smoke if they wake during the

she would go to bed 15 minutes earlier until she

night. This suggestion will help to eliminate

found the time when she could maintain good

waking to smoke. Frequently, smokers classi-

sleep efficiency and feel rested during the day.

cally condition themselves to wake at the end

These sleep restriction techniques capitalize

o f each 90-minute sleep cycle for a cigarette.

on patients' fatigue to help them learn, adopt,

Finally, patients are told to refrain from using

and maintain good sleep habits. M a n y insomni-

alcohol as a sleep-inducing aid.

acs actually cause their own insomnia by going

alcohol can make people feel sleepy, it inhibits

Although

431

432

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS good sleep cycles and can cause nighttime

modest response to this intervention (Morin

waking.

et al., 1 9 9 9 ) . In general, sleep hygiene is con-

In terms o f sleep hygiene, patients are also educated about the benefits o f daily exercise

sidered a necessary part o f an intervention but insufficient as a stand-alone treatment.

for sleep but are cautioned to avoid vigorous exercise t o o close to bedtime. Exercising intensely before going to bed c a n cause problems with falling asleep because

Relaxation-Based

Relaxa-

Interventions.

tion techniques have also proved to be useful

people

in insomnia treatment. Studies have shown

may find themselves t o o energized (due to

that progressive muscle relaxation, biofeed-

the release of the endorphins) or t o o hot to

back, imagery training, and thought stopping

sleep. T h e body naturally cools as it prepares

all can reduce autonomic arousal and facilitate

to sleep. Therefore, if people are t o o hot due

sleep (Morin et al., 1 9 9 9 ) . Biofeedback and

to exercise or hot summer temperatures, they

progressive muscle relaxation help individuals

often have a hard time sleeping.

to relax the muscles o f the body and activate

In addition, individuals need to make sure

the parasympathetic nervous system or relax-

that their rooms are dark and quiet and that

ation response. Imagery training and thought

their beds are comfortable. Because light

stopping help to retrain the mind to focus on

helps to reset the biological clock, it is essen-

calming thoughts, thereby reducing the sym-

tial to avoid bright lights in the evening and to

pathetic nervous system response and hope-

expose the body to bright light in the morning.

fully activating the parasympathetic nervous

Shift workers can have a difficult time falling

system.

asleep after the "graveyard shift," particularly

interventions have been advocated for insom-

Although

other

relaxation-based

if they drive home in the morning light with-

nia (e.g., diaphragmatic breathing, meditation, hypnosis), these have not been adequately

out sunglasses. Patients sometimes state that their partners

evaluated (Morin et al., 1 9 9 9 ) .

snore or that there is intermittent noise com-

Relaxation-based interventions are impor-

ing from the street that keeps them awake at

tant in facilitating sleep. M a n y insomniacs

night. Unfortunately, intermittent noise is the

become so anxious about falling asleep that

worst type o f noise for sleep. T h e body can

they activate the sympathetic nervous sys-

acclimate to consistent noise (e.g., the sound

tem, thereby releasing endorphins,

of crickets or o f a nearby freeway) or to total

the muscles, and increasing heartbeat and

quiet, but intermittent noise can cause waking.

respiration rate. As one might expect, this

tensing

Suggestions for managing this include using

response is incompatible with falling asleep.

white noise (e.g., turning on a fan or a fish

T h r o u g h classical conditioning (i.e., anxiety

tank) and using earplugs. It is not uncommon

regarding falling asleep that is then paired

for couples to sleep apart if one snores loudly

with one's bed), a transient sleep problem

or has P L M D .

can become chronic. Insomniacs w h o have

M o s t often, sleep hygiene rules are inte-

developed a strong association between a n x -

grated into a treatment program. A few stud-

iety and their beds often say that they can fall

ies have evaluated the effectiveness o f using

asleep easily in a hotel r o o m or in the guest

sleep hygiene education alone and

r o o m but can never fall asleep quickly in

have

found a modest effect (Morin et al., 1 9 9 9 ) .

their own beds. T h e primary goal o f the

O n e study found that approximately 2 7 % of

relaxation therapies is to reassociate the bed

patients improved when given sleep hygiene

with a restful state and help reduce

education

(Schoicket, Bertelson, &

Lacks,

1 9 8 8 ) , but other studies have found a more

anxiety o r a u t o n o m i c arousal with sleep.

the

associated

Insomnia Paradoxical

Paradoxical intention

Intention.

included

and the Sleep Disorders

information

regarding

\

stimulus

is a cognitive technique in which the patient is

control, sleep restriction, and thought stopping.

requested to stay awake. If the patient is

The final section included a review of sleep

instructed to stay awake, falling asleep is no

hygiene, exercise, sleeping pills, herbs, and

longer the anxiety-producing goal. Thus, by

melatonin. T h e information regarding sleep

prescribing the patient's worst fear—staying

cycles and sleep architecture was designed to

awake—the patient paradoxically responds by

provide the supporting rationale for implemen-

falling asleep more quickly. In essence, this inter-

tation of sleep restriction, stimulus control, and

vention helps to reduce the performance anxiety

sleep hygiene. Patients created a personalized

associated with sleeping.

sleep plan during the group and individual appointments (Wolfe &c Helge, 2 0 0 2 ) .

Developing Sleep

a

One

Cognitive-Behavioral

Improvement

month

after

treatment,

patients'

progress was assessed by telephone follow-up.

Program

Results indicated that 9 0 % of the patients

M o s t of the treatment programs in use

who had individual appointments and 7 4 % of

today include multiple sessions and integrate

the patients who attended group appointments

stimulus control, sleep hygiene, relaxation

improved the amount of time spent sleeping at

training, and sleep restriction components.

night (Wolfe &

These programs are often six to eight sessions

gained an average o f 1.78 hours of sleep per

in length and may require additional sessions

night, and group members gained an average of

for screening and paperwork. Evaluations o f

1.90 hours of sleep per night (Wolfe & Helge,

Helge, 2 0 0 2 ) .

Individuals

these programs are often dependent on patient

2 0 0 2 ) . A second cohort o f patients (n = 35) who

self-report through sleep diaries, although a

participated in the same treatment protocol, but

few

with a different health psychologist, had results

studies use p o l y s o m n o g r a m

tests

to

slightly better than participants in the initial

measure outcome. Sacramento,

cohort (Wolfe, Helge, & Jacobs, 2 0 0 2 ) . One

California, a single-session treatment program

month after treatment, 8 7 % of these patients

was developed and evaluated using individual

reported improved sleep by an average of 2 . 3 8

(n = 2 0 ) and group (n = 7 2 ) formats (Wolfe &

hours per night (Wolfe et al., 2 0 0 2 ) . All partici-

Helge,

pants were to be reassessed 1 year following

At

Kaiser Permanente

2002).

Primary

in

care

physicians

referred patients to a health psychologist, who

treatment to determine whether treatment gains

administered an insomnia treatment protocol,

were maintained.

individual sessions were 2 5 minutes, and the

Anecdotal comments from

participants

group sessions were 9 0 minutes. Before treat-

were interesting. A c o m m o n theme was skep-

ment, each patient completed a brief question-

ticism about the techniques. F o r example, a

naire that included queries about sleep onset,

typical remark was " I thought w h a t you sug-

awakenings, daytime fatigue, and sleep habits.

gested was silly, but I decided to try it any-

In addition, there were questions regarding sub-

w a y . " Another typical patient c o m m e n t was

stance use, diet, and exercise. Approximately

" I did not think it would w o r k , but I was

7 5 % o f referred patients attended the program

amazed at the results." Finally, some patients

(Wolfe & Helge, 2 0 0 2 ) .

noted benefits from the information about

The first section o f the intervention was informational, including information

about

insomnia: " I thought I had depression, but n o w I realize I was just sleep deprived."

sleep cycles, sleep architecture, individual vari-

This intervention was developed with the

ations in sleep, and sleep changes over the life

purpose of efficiently and effectively treating

cycle. T h e second section o f the intervention

primary care patients with insomnia. T h e

433

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS

434

groups were not limited to specific populations;

prescribing, a tapering strategy should be in

any patients complaining o f sleep problems

place to minimize risk for potential problems.

were considered appropriate. However, if a

O n e strategy to avoid tolerance is to have the

physician believed that a patient would not

patient use the medication only 3 or 4 nights

do well in a group setting, or if a patient could

a week and to use the lowest effective dose. A

not attend because o f scheduling conflicts, the

patient who has an abuse history or who has

patient was seen individually. T h e findings of

to perform tasks that require alertness and

this uncontrolled clinical trial indicate that a

quick reaction times (e.g., driving) on awak-

single-session brief intervention that integrates

ening should be cautioned when prescribed

evidence-based interventions can be extremely

sleep aids. Finally, hypnotics prescribed to

effective for primary care patients experiencing

elder adults require extra care.

insomnia. However, because this study is lim-

Trazadone is an antidepressant frequently

ited from a methodological perspective, further

prescribed for people w h o have insomnia

research regarding the utility o f brief, behav-

and

iorally based interventions in primary care is

Food

essential.

a depressive disorder. and

However,

D r u g Administration

has

the not

approved the use o f trazadone for people with insomnia. Trazadone should be used

Medications

Used to Treat

with caution because it can cause daytime

Insomnia

sedation, priapism, and hypotension.

In today's "quick f i x " society, patients

Melatonin is a hormone often used for insom-

and providers alike have a penchant for med-

nia. It is released by the pineal gland into the

ications as the frontline treatment for insom-

bloodstream and is produced from tryptophan.

nia. Even before office visits, patients have

Tryptophan is converted to 5-hydroxytrypto-

often

medications

phan, then to serotonin, then to N-acetylsero-

such as diphenhydramine and Tylenol P M

tonin, and finally to melatonin. Melatonin

tried

over-the-counter

(a c o m b i n a t i o n o f diphenhydramine

and

regulates the body's sleep cycle, circadian

Tylenol) for sleep. I f these medications were

rhythm, and endocrine production

as effective as advertised, it is unlikely that

essential for sexual maturation, growth control,

patients would continue to seek assistance

pain control, balance, and regulation of sexual

from their primary care providers.

and is

activity (Natural Medicines Comprehensive

Benzodiazepines are c o m m o n l y prescribed

Database, 2 0 0 2 ) . People produce more mela-

for sleep. These agents replaced barbiturates

tonin when it is dark, thereby stimulating the

and

onset o f sleep. It may be an effective agent to

barbiturate-like substances that

were

associated with addiction, respiratory prob-

help some adults with sleep onset. Moreover,

lems, and occasional deaths. A benefit o f

melatonin may be useful for symptoms of jet

benzodiazepines and other hypnotics used

lag, for shift workers, and for insomniacs with

for

blindness. However, data demonstrating the

insomnia is that

they w o r k

quickly.

However, hypnotics can cause daytime sedation, tolerance, and rebound insomnia. Current

guidelines from

the

National

efficacy of melatonin are inconclusive. Although most consider melatonin relatively safe, it is not for use in children because it may

Institutes o f Health ( 1 9 8 4 , 1 9 9 1 ) suggest that

affect their maturation. There also is concern

short-term use o f hypnotic medications may

that taking melatonin may increase daytime

be indicated for acute insomnia, but these

somnolence.

medications should be used with caution. If

interfere with the effectiveness of cardiac medi-

prescribed for sleep, hypnotics should not be

cation and medications used to reduce immune

taken for more than 2 weeks. At the time o f

system response (e.g., steroids, other cortisone

In

addition,

melatonin

may

Insomnia

and the Sleep

435

Disorders

drugs). There is some indication that melatonin

reports suggest that the selective serotonin

can help depression, particularly when

the

reuptake inhibitor (SSRI) or tricyclic medications

depression comes with insomnia, but other

reduce symptoms o f R L S , whereas other reports

studies indicate that melatonin can

indicate that these medications can aggravate

make

depressive symptoms worse (Natural Medi-

the disorder (Hening et al., 1 9 9 9 ) .

cines Comprehensive Database, 2 0 0 2 ) . Interestingly, it has been documented that patients with depression and patients diagnosed with

Treatment of Sleep Apnea

can have low levels of melatonin

Treatment of sleep apnea is dependent on

(Natural Medicines Comprehensive Database,

the etiology. For example, in children, a com-

2002).

mon cause of sleep apnea is enlarged tonsils.

fibromyalgia

With tonsil removal, the apnea can be relieved. Other surgical techniques, lauded as permanent

Treatment of RLS and PLMD

cures for obstructive sleep apnea, have not been

Behavioral strategies for treating R L S and

as effective as originally expected. With patients

P L M D include moderate amounts of exercise

who are obese, the best treatment is weight

in the evening, hot baths, and

distraction.

reduction because this serves to open adequate

Walking before bedtime has been helpful for

space for airflow. One of the most successful

some patients. However,

treatments for other patients with obstructive

intense exercise

appears to exacerbate the symptoms for many

sleep apnea is the continuous positive airway

sufferers. H o t baths are effective for some

pressure machine (CPAP).

patients, and distraction exercises (i.e., tasks

T h e CPAP provides continuous

positive

that require intense concentration) have sup-

airway pressure through the nostrils to force

port for symptom reduction. In addition, some

the airway clear, enabling the patient

patients find relief from massage or vibrating

breathe. This treatment is effective for many

stimulation before sleep, and there is some evi-

people, but a major complaint is discomfort in

dence that reducing caffeine and

improving

wearing the apparatus. In fact, many o f the

sleep habits are useful. M o s t of the published

patients given a CPAP do not adhere to rec-

literature has focused on medication treatment

ommendations to use it. It is critical that the

for R L S and P L M D , but there is some evidence

facemask fits properly and that the patient

to support integrating behavioral strategies

acclimates to the machine. This is often done

with pharmacological regimens.

by training the patient in relaxation tech-

to

Unfortunately, many of the medications used

niques and having him or her use the machine

in treating R L S and P L M D have limited effec-

while awake but during sedentary activities

tiveness and can cause tolerance and rebound

such as watching television. Having a machine

symptoms. There are five classes o f medications

force air through one's nose can be extremely

typically prescribed: dopaminergic medications,

uncomfortable, especially while trying to initi-

opioids, benzodiazepines, adrenergic medica-

ate sleep onset. Therefore, adequate training

tions, and anticonvulsant medications. A review

and problem solving are essential given that

of the costs and benefits of these agents is

the consequences o f living with

beyond the scope o f this chapter, but Hening

sleep apnea are unfortunate and avoidable.

untreated

and colleagues (1999) provided an excellent review of the treatments for R L S and P L M D . Folic acid and iron supplements have proved

Light Therapy

to be effective for patients with R L S and P L M D

Light therapy has been investigated as a treat-

who are deficient in these minerals. Some

ment for patients with a variety of problems,

436

BEHAVIORAL ASPECTS O F MEDICAL PROBLEMS including seasonal affective disorder, shift work

should last between 1 5 and 4 0 minutes or be

sleep, delayed sleep phase syndrome,

2 hours in length. A brief nap can be very

and

advanced sleep phase syndrome. Light therapy

restorative. T h e most favorable time to take a

also has been evaluated as a potential solution

nap is early afternoon. This is when people's

for sleep complaints in the elderly (Chesson

natural biological clock indicates that it may be

et al., 1999).

time for a sleep cycle. Some patients successin

fully time their naps halfway between the time

treating delayed sleep phase syndrome and

they awaken in the morning and the time they

advanced sleep phase syndrome

(Chesson

go to bed, finding a 1 5 - or 20-minute nap to be

et al., 1 9 9 9 ) . With delayed sleep phase syn-

adequate to renew their concentration and

In general, light therapy is effective

drome, the individual has difficulty in initiat-

energy. However, insomniacs should be wary

ing sleep at the appropriate time and awakens

of napping. Napping late in the afternoon can

too late. With advanced sleep phase syndrome,

negatively influence nighttime sleep. If an

the patient falls asleep too early at night and

insomniac has rested during the day, he or she

awakens too early in the morning. With both

might not be fatigued enough to fall asleep

sleep phase disorders, the release o f hormones

quickly at night.

and the level o f body temperature indicate that the person's sleep phase is not oriented correctly. Having individuals expose themselves to bright light in the morning and wear darkened glasses at night appears to be effective in resetting the circadian rhythm

Treatment of Nightmares and Night Terrors Nightmares tend t o be more c o m m o n

and

when patients are under stress. There are two

resuming a regular sleep schedule (Chesson

main treatments to help patients cope with

et al., 1 9 9 9 ) . In addition, light therapy appears

undesirable dreams. T h e first involves reas-

to be useful with seasonal affective disorder

surance that intense dreams are c o m m o n and

(Chesson et al., 1 9 9 9 ) .

is

that dreaming about something is not an

described as a safe intervention when used

indication that one would act in a similar

according to American Academy o f Sleep

manner in real life. Often, patients present

Light therapy

Medicine guidelines. It may be useful for shift

with sexual or violent dreams and express

work problems, jet lag, and

non-24-hour

concern that these dreams are indicative o f

sleep/wake syndrome in some blind patients

underlying desires. Through reassurance and

(Chesson et al., 1 9 9 9 ) .

normalization, their distress can be reduced. Recommendations to avoid the daily news,

Napping and Sleep Deprivation

violent movies, and other negative images before bedtime also are helpful. In addition,

Approximately a quarter o f all Americans

patients can learn to dream about pleasant

are sleep deprived (National Sleep Foundation,

scenes by rehearsing these images before bed.

2 0 0 2 ) . This translates into billions o f dollars in

For recurrent nightmares (e.g., being chased

lost productivity and accidents. In response to

or pummeled by a foe), patients are instructed

this pervasive sleep debt, many businesses have

to return to the dream and change the ending.

created special environments for napping, and

This is particularly helpful with children who

there have been articles in the popular press

are taught to imagine themselves as their

describing the benefit o f quick "power naps."

favorite superhero and then turning on the foe

Sleep "debt" can be "repaid" with a brief

and winning the battle. F o r this strategy to be

nap during waking hours; however, there is an

effective, the patient should create the image

optimal strategy for napping. Ideally, a nap

that makes the most sense to him or her to be

Insomnia

and the Sleep

Disorders

CASE S T U D Y " J o h n D o e , " a 39-year-old male, presented to his primary care physician with symptoms o f anxiety, irritability, decreased concentration, headaches, and insomnia. H e stated that his problems began about 5 years ago when he relocated, married, and changed his j o b . H e reported feeling happy with his current situation and satisfied with his marital relationship and his j o b , but he revealed that he felt "run down." "When queried a b o u t sleep habits, J o h n denied having difficulty in falling asleep but stated that he awakened frequently during the night. H e said that he went t o bed at 9 : 3 0 p.m. because he was " t o o tired t o stay up any later," but then he awakened at 3 : 3 0 a.m. and drifted in and out o f sleep until it was time t o get ready for w o r k at 6 : 3 0 . H e was concerned that he m a y be depressed because he felt " w o r n out and s a d " even though his life was g o o d . J o h n noted that his sleep habits changed following his marriage. W h e n single, he would go to bed at midnight and get up at 6 : 3 0 a.m. H e reported that with this schedule, he felt rested and refreshed. However, when he married, he began to go to bed at 1 0 : 0 0 p.m. because this was his wife's bedtime. During the past year, he altered his bedtime to 9 : 3 0 p.m. in an effort to c o m b a t his ever-present fatigue. H e was concerned that his lack o f energy was beginning to affect his work and relationships. A physical e x a m i n a t i o n determined that J o h n w a s in g o o d health. L a b o r a t o r y results were within n o r m a l limits. T h e patient w a s instructed t o use sleep restriction to retrain his body to sleep well. Specifically, he was t o go t o bed later in the evening until he could fall asleep quickly and sleep through the night. H e was reminded that he felt rested after 6 . 5 hours o f sleep and that his previous sleep schedule o f going t o bed at midnight and waking at 6 : 3 0 a.m. w a s effective for him. After 1 week, J o h n reported feeling much better. H e stated that going t o bed later was very difficult at first because he was so tired, but after 3 nights his sleep had improved and he began t o feel better. In addition, he started walking daily at lunch and found that his energy level and m o o d had improved. During a follow-up visit, his progress was reviewed and recidivism was discussed. J o h n was quite pleased with his improvements because he felt more like himself again. In addition, he reported that his m o o d and concentration were better and that his headaches had decreased. One year later, he denied any ongoing problems with sleep. H e noted that during periods o f transient insomnia, he continued to use sleep restriction strategies that provide him with rapid improvement.

victorious. Nightmares can also be reduced

screaming; children m a y

open their eyes,

through psychotherapy that addresses underly-

begin perspiring, and appear t o be experienc-

ing anxiety.

ing a state o f panic. After a few minutes, a

Night terrors can be particularly alarming

calm state o f sleep returns. Usually, an indi-

to parents. T h e y often involve brief periods o f

vidual experiencing a night terror will not

437

438

BEHAVIORAL ASPECTS OF MEDICAL PROBLEMS awaken and will not remember the incident in

productivity, health care, and accidents. For

the morning. Night terrors are more frequent

the majority o f sleep problems,

during periods o f stress. They cause no harm

insomnia and nightmares, cognitive-behavioral

including

to the individual, so an optimal coping strat-

intervention is the treatment o f choice. For

egy is reassurance for the parents. Parents are

other sleep disorders, such as sleep apnea, R L S ,

instructed to either gently comfort the child

and P L M D , behavioral interventions play a

or ignore the disruption altogether.

significant role. However, it is far from routine

Three additional strategies can be helpful in

practice for patients with sleep problems to

reducing night terrors. First, psychotherapy for

receive these interventions or learn about them

stress reduction is useful. Second, advising the

during visits to primary care clinics.

patient to sleep for a longer period, thereby

Enhanced training during medical school has

reducing the amount o f deep delta sleep, can

been recommended as one strategy to improve

help. Third, physicians may prescribe a benzo-

assessment and intervention for patients with

diazepine, such as diazepam, for a few days to

sleep problems (Dement & Vaughan, 1 9 9 9 ) .

reduce the delta sleep associated with night ter-

Unfortunately, physician training continues to

rors. This last strategy may be helpful if a child

be limited in this regard, and this deficiency is

is sleeping away from home and is concerned

reflected in clinical practice; medications con-

about arousing others. However,

tinue as the first line of intervention for sleep

benzodi-

azepines should always be used with caution.

problems that would be better treated with

Sleepwalking is also associated with delta

behavioral interventions. This observation is not

sleep and is more c o m m o n with children than

too surprising. Physicians generally report diffi-

with adults. It is also more frequent when

culties in identifying behavioral problems in

people are under stress or sleep deprived,

their patients and frustration with implementing

and it can be a result of certain medications.

behavioral change strategies (Alto, 1 9 9 5 ) .

Sleepwalking

can

be

quite

dangerous.

A realistic practice solution is access to

Treatments include reducing stress, getting

behavioral experts who can provide effective

adequate sleep, ensuring a safe sleeping envi-

cognitive-behavioral interventions in primary

ronment, and taking medication.

care. This strategy is practical because many patients with a sleep disorder will also present with medical and psychiatric complaints. A

CONCLUSIONS

behavioral-medical approach, the integration of medical and behavioral sciences, appears to

Each year, sleep disorders affect millions o f

be an excellent solution for the sizable popula-

people and cost billions of dollars in lost

tion o f those suffering with sleep disorders.

REFERENCES Alto, W.A. (1995). Prevention in practice. Primary Care, 22, 5 4 3 - 5 5 4 . American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Chesson, A. L., Littner, M., Davila, D., Anderson, M., Grigg-Damberger, M., Hartse, K., Johnson, S., & Wise, M. (1999). Practice parameters for the use of light therapy in the treatment of sleep disorders. Sleep, 22, 6 4 1 - 6 6 0 . Dement, W. C , & Vaughan, C. (1999). The promise of sleep. New York: Delacorte.

Insomnia

and the Sleep

Dickel, M . J . , Se Mosko, S. S. (1990). Morbidity cut-offs for sleep apnea and periodic leg movements in predicting subjective complaints in seniors. Sleep, 13, 1 5 5 - 1 6 6 . Ford, D. E., Sc Kamerow, D. B . (1989). Epidemiologic study of sleep disturbance and psychiatric disorders: An opportunity for prevention? Journal of the American Medical Association, 262, 1 4 7 9 - 1 4 8 4 . Gallup Organization. (1995). Sleep in America. Princeton, NJ: Author. (Poll conducted for the National Sleep Foundation) Gupta, Μ . Α., Gupta, A. K., Se Haberman, H. F. (1986). Psychotropic drugs in dermatology: A review and guidelines for use. Journal of the American Academy of Dermatology, 14, 6 3 3 - 6 4 5 . Hauri, P., Sc Hawkins, D. R. (1973). Alpha-delta sleep. Electroencephalography and Clinical Neurophysiology, 34, 2 3 3 - 2 3 7 . Hauri, P., Sc Linde, S. (1996). No more sleepless nights. New York: John Wiley. Hening, W., Allen, R., Earley, C. E., Kushida, C., Picchietti, D., Sc Silber, M . (1999). The treatment of restless leg syndrome and periodic limb movement disorder. Sleep, 22, 9 7 0 - 9 9 9 . Mellinger, G. D., Baiter, M . B., Sc Uhlenhuth, Ε. H. (1985). Insomnia and its treatment. Archives of General Psychiatry, 42, 2 2 5 - 2 3 2 . Moffitt, P. F., Kalucy, E. C., Kalucy, R. S., Baum, F. E., Sc Cooke, R. D. (1991). Sleep difficulties, pain, and other correlates. Journal of Internal Medicine, 230, 245-249. Moldofsky, H. (1989). Sleep and fibrositis syndrome. Rheumatic Disease Clinics of North America, 15(1), 9 1 - 1 0 3 . Morin, C. M., Hauri, P. J . , Espie, C. Α., Spielman, A. J . , Buyesse, D. J . , Se Bootzin, R. R. ( 1 9 9 9 ) . Nonpharmacologic treatment of chronic insomnia. Sleep, 22, 1134-1155. National Institutes of Health. (1984). Drugs and insomnia: The use of medication to promote sleep. Journal of the American Medical Association, 18, 2410-2414. National Institutes of Health. (1991). Consensus Development Conference statement: The treatment of sleep disorders of older people. Sleep, 14, 1 6 9 - 1 7 7 . National Sleep Foundation. (2002). Sleep in America poll. [Online]. Retrieved January 2 0 , 2 0 0 3 , from www.sleepfoundation.org Natural Medicines Comprehensive Database. (2002). Melatonin [monograph]. [Online]. Retrieved January 2 0 , 2 0 0 3 , from www.naturaldatabase.com/ monograph.asp?mono_id=9408chilite=l Perlis, M. L., Giles, D. E., Buyesse, D. J . , Tu, X . , Se Kupfer, D. J . (1997). Selfreported sleep disturbance as a prodromal symptom in recurrent depression. Journal of Affective Disorders, 42, 2 0 9 - 2 1 2 . Pilowsky, L, Crettenden, L, Sc Townley, M . (1985). Sleep disturbance in pain clinic patients. Pain, 23, 2 7 - 3 3 . Schoicket, S. L., Bertelson, A. D., Sc Lacks, P. (1988). Is sleep hygiene a sufficient treatment for sleep maintenance insomnia? Behavior Therapy, 19, 1 8 3 - 1 9 0 . Walsleben, J . Α., Sc Baron-Faust, R. (2000). A woman's guide to sleep. New York: Crown. Wolfe, V. Α., Sc Helge, T. D. (2002, April). Utilizing a brief, behaviorally based intervention to treat insomnia in primary care. Paper presented at the meeting of the Society of Behavioral Medicine, Washington, DC. Wolfe, V. Α., Helge, T. D., Sc Jacobs, J . R. (2002, November). Effectiveness of a single session group appointment to treat insomnia in primary care. Poster presented at the meeting of the Association for Advancement of Behavior Therapy, Reno, NV.

Disorders

439

Part IV SPECIAL ISSUES Introduction

T

to Part IV

he final seven chapters o f this h a n d b o o k focus on topics that are critical for effective practice o f clinical health psychology; however, the issues are more crosscutting than those in the chapters in Parts II and III, which focused on

specific health behaviors and disease. As in any applied discipline, clinical health psy-

chologists must be sensitive to ethical issues, cultural and individual diversity, and the challenges that are unique t o this multidisciplinary field. T h e editors identified seven important topics and recruited authors to provide an overview o f the issues that are critical to clinical health psychology. Although not exhaustive o f the issues that will challenge the practitioner, the resulting chapters provide a solid foundation for the practice o f clinical health psychology. In Chapter 2 2 , Siegfried and Porter provide an overview o f the "Ethical Principles of Psychologists and C o d e o f C o n d u c t " adopted by the American Psychological Association and illustrate, through case vignettes, aspects o f the code that are o f particular importance t o the practice o f clinical health psychology. F o r each o f the principles o f the ethical code, practical advice is given and cases are used t o illustrate the issues. It is only through the maintenance o f the highest standards that clinical health psychology will have its largest influence. In Chapter 2 3 , M y e r s and H w a n g review the literature on ethnocultural issues in clinical health psychology. T h e chapter begins with a review o f the health disparity issues as they relate to various ethnic minority groups in the United States. T h e s e disparities are then discussed in terms o f a biopsychosocial model that appears t o be useful for understanding the role o f ethnic differences in functional health status. T h e

442

T H E HEALTH P S Y C H O L O G Y H A N D B O O K authors also provide an overview o f various treatment efforts that are tailored to minority communities. In addition, the chapter provides specific recommendations that should enhance the practice o f clinical health psychology. In Chapter 2 4 , C s o b o t h reviews special issues relevant t o w o m e n ' s health. T h e author provides a model that emphasizes the different life course events that w o m e n experience and discusses h o w w o m e n ' s health is differentially related t o the unique physiological and social changes during these life stages. Psychosocial factors such as stress, social support, role identity, and socioeconomic factors appear to differentially influence w o m e n and men. These differences are reviewed. T h e author also briefly reviews selected health problems that occur at greater rates in w o m e n , with an emphasis on the importance o f developing interventions specifically for w o m e n . In Chapter 2 5 , Edelstein and his colleague provide an in-depth review o f issues that are unique to working with geriatric populations. This is clearly an area where there is great demand for services and great need for specialized training. T h e authors begin with an in-depth discussion o f age-related changes, with a focus on those changes that are unique to older adults. Perhaps one o f the more critical sections o f this chapter is the discussion o f psychological manifestations and correlates o f physical disease. Effective practice o f clinical health psychology requires an understanding o f how many physical disease states in the elderly have natural symptoms that are consistent with psychiatric disorders. Recognition o f the cause o f the psychiatric symptoms is critical for working with this population. T h e authors review adverse medication effects and other problem areas that are unique to older adults. Finally, the chapter provides a thoughtful review of end-of-life issues, with a discussion o f h o w such decisions are made. In Chapter 2 6 , T u c k e r , K l a p o w , and Simpson focus their contribution on the public health approach to the treatment and prevention o f disease. T h e y challenge the notion that psychological practice needs t o be focused on the individual, and they encourage clinical health psychologists to consider the role that they can and should play in public health efforts that are m o r e population focused. T h e training program at the University o f A l a b a m a at Birmingham is presented as one model for such training, wherein students are provided with in-depth public health experiences while pursuing training in clinical health psychology. In Chapter 2 7 , Palm and her colleagues focus on the unique challenges and skills that are necessary t o conduct psychological research in medical settings. Using their o w n research as an illustrative model, the authors cover the basic questions o f the development o f a research question, design o f the study, recruitment o f participants, and recruitment o f support from administrators and staff. Problems that are unique t o medical institutions are openly discussed, and practical solutions are offered. T h e chapter concludes with a discussion o f ethical issues and conflict o f interest issues. Finally, in Chapter 2 8 , Borrego and Follette address program evaluation in medical settings. T h e authors provide a step-by-step outline for program evaluation that focuses on the development o f the question(s) to be addressed and proceeds to selection o f populations and assessment methods. A great deal o f attention is given to why program evaluation is needed and t o h o w t o conduct such evaluations. T h e authors make the case that the practice of clinical health psychology is greatly enhanced when practitioners actively evaluate the services they provide and modify services where needed.

CHAPTER

10 22

Ethical Issues for Clinicians in Behavioral Medicine Settings NICOLE J . SIEGFRIED AND CHEBON A . PORTER

T

he continued expansion and integration of health psychology into medical settings raises complex practical, ethical,

and professional issues. M u c h has been written on the logistics of integrating psychology into medicine with ethical issues often overlooked.

T h e "Ethical Principles of Psychologists and Code of Conduct"

(American Psychological

Association [ΑΡΑ], 1 9 9 2 ) is applicable to all psychologists, including those in medical and health settings. It is expected that psychologists guide their practice based on the principles o f competence (Principle A), integrity (Principle B), professional

and

scientific

responsibility

(Principle C ) , respect for people's rights and dignity (Principle D), concern for others' welfare (Principle E ) , and social responsibility (Principle F) (for a complete description of these principles, see ΑΡΑ [1992] guidelines). This chapter outlines the ethical responsibilities of health psychologists based on these principles, with a focus on issues related to health and medical

PRINCIPLE A: COMPETENCE Psychologists strive to maintain high standards of competence in their work. They recognize the boundaries of their particular competencies and the limitations of their expertise. They provide only those services and use only those techniques for which they are qualified by education, training, and experience. Psychologists are cognizant of the fact that the competencies required in serving, teaching, and/or studying groups of people vary with the distinctive characteristics of those groups. In those areas where recognized professional standards do not yet exist, psychologists exercise careful judgment and take appropriate precautions to protect the welfare of those with whom they work. They maintain knowledge of relevant scientific and professional information related to the services they render, and they recognize the need for ongoing education. Psychologists make appropriate use of scientific, professional, technical, and administrative resources (ΑΡΑ, 1992).

settings. C o m m o n scenarios with ethical implications are presented in an attempt to clarify the psychologist's role.

Α Ρ Α ( 1 9 9 2 ) guidelines clearly emphasize the importance o f pursuing and maintaining

443

444

SPECIAL ISSUES competence for psychologists. Several issues

her advertisement changed to read "clinical

related to competence are relevant to health

health psychologist specializing in motiva-

psychology, including achieving and recog-

tional treatment for health problems."

nizing boundaries o f competence, conducting

Dr. Jones failed to act ethically in this

appropriate assessment batteries, and identi-

e x a m p l e . Although

fying appropriate roles in a medical setting.

training in health psychology are not specific

recommendations

for

(e.g., Belar, 1 9 8 0 ; Stone, 1 9 8 3 ) , a weekend seminar is not sufficient to achieve compe-

Achieving Boundaries of Competence

tence. Although it may be within Dr. Jones's boundaries o f competence to treat individuals

T h e initial challenge o f achieving and rec-

with comorbid medical/health issues (so long

ognizing boundaries o f competence requires a

as she seeks consultation in areas where she is

professional commitment from health psy-

not well trained), she cannot ethically promote

chologists. M i n i m u m levels o f competence for

herself as a "clinical health psychologist."

psychologists have been defined (ΑΡΑ, 1 9 8 1 ) . Although these recommendations are guide-

Case 2. " D r . B r o o k e , " a clinical health psy-

lines and not requirements, they can be useful

chologist trained in women's health disorders,

in defining limits o f expertise. Criteria for

is treating " M s . J a c o b s , " who suffers from

competence in specialization areas o f psychol-

depression. As therapy progresses, it becomes

ogy are more ambiguous. General guidelines

clear that M s . Jacobs's sleep problems are

for adequate training in health psychology

beyond those expected for depressive symp-

have been presented and include graduate

tomatology and beyond Dr. Brooke's areas o f

coursework in health psychology and super-

expertise. Dr. Brooke continues to see M s .

vised clinical experience in health/medical set-

J a c o b s for her depression but refers her to a

tings (Stone, 1 9 8 3 ) . In the absence o f specific

sleep disorders specialist for further evaluation

guidelines, conservative estimates o f compe-

of her sleep difficulties.

tence are recommended. It is considered the

Dr. Brooke acted ethically in this example.

responsibility o f the psychologist to recognize

Her evaluation o f her training stands in stark

and practice within his or her areas o f compe-

contrast to Dr. Jones's lack o f regard to her

tence as well as to evaluate the appropriate-

limits o f expertise in the previous example. Dr.

ness o f additional training. Consultation with

Brooke found M s . Jacobs's sleep disturbance

senior colleagues can be helpful in evaluating

to exceed a typical depressive reaction and

the appropriateness o f training endeavors. In

was therefore attending to the "distinctive

addition, it is recommended that further train-

characteristics" (ΑΡΑ, 1 9 9 2 ) o f M s . Jacobs's

ing be sought via forums with

clinical presentation. Furthermore,

appropriate

although

accreditation. Someone w h o has not achieved

Dr. Brooke was trained in health psychology,

adequate training in health psychology cannot

she realized the limits o f her competence and

ethically promote himself or herself as a health

sought outside guidance when appropriate.

psychologist. Consider the following scenario.

Another instance in which health psychologists may inappropriately cross the boundaries

Case 1. " D r . J o n e s , " originally trained as a

of competence is providing medical interven-

psychoanalyst, completed a weekend seminar

tions for which they are not

on motivational therapy with cardiac patients.

trained (Belar & Deardorff, 1 9 9 9 ) . Because

After the seminar, she felt capable o f general-

psychologists in medical settings become very

appropriately

izing this therapy to many patients in health

familiar with medical diagnoses and medica-

settings. She called the yellow pages and had

tions for these illnesses, they may become

Ethical Issues

445

comfortable making unethical recommendations

patients, and it may be inaccurate or even

for medical treatment. Consider the following

inappropriate to compare a patient presenting

example.

in a medical context with psychiatric patients (ΑΡΑ, 1 9 9 2 , Standard 2 . 0 4 ) . It has been rec-

Case 3. " D r . L o g a n " trained " M r . Collins"

ommended (Belar & Deardorff, 1 9 9 9 ) that,

in relaxation training and biofeedback to help

whenever possible, psychological test results o f

control the patient's blood pressure. As M r .

medical patients should be compared with both

Collins became more skilled with his relax-

medical and psychiatric populations, and a dis-

ation training, Dr. Logan encouraged him to

cussion o f the differences should be included in

cut back slowly on his blood pressure medica-

the assessment report. W h e n comparable norm

tion so that the patient could achieve his goal

groups are not available, the clinician must con-

o f behaviorally managing his hypertension. Dr.

Logan behaved unethically in this

sider the lack o f appropriate norms in the interpretation o f the test data. In addition, it is the

example. Medication management is not part

responsibility o f the clinician to maintain exper-

of his role as a clinical health psychologist. A

tise with the instruments used. This includes

more appropriate course of action would have

maintaining knowledge o f current literature

been for either Dr. Logan or M r . Collins to dis-

and published research on the instruments.

cuss the issue with M r . Collins's physician.

Second, assessment results must be c o m -

Although health psychologists are trained for

municated to the patient in plain language. In

medical settings, they must remember that their

fact,

role is to provide psychological interventions.

assessment report also be written in clear

Medical diagnosis and intervention

require

it has been recommended

that

the

simple language given that many reports are

medical training, just as psychological interven-

read

tions require psychological training. Providing

K o o c h e r , 1 9 9 8 ) . T h e psychologist is required

medical interventions as a health psychologist is

to explain to the patient not only the purpose

practicing medicine without a license.

by

the

patient

(Keith-Spiegel &c

o f testing but also the results o f testing, avoiding psychological jargon that is difficult to interpret (ΑΡΑ, 1 9 9 2 , Standard 2 . 0 9 ) .

Conducting Psychological Assessments

Finally, although a health psychologist is often consulted to provide a report to a team

Psychological assessment plays an integral

of medical professionals, he or she is primar-

role in the practice o f health psychology.

ily accountable to the patient. It is recom-

According to Belar and Deardorff

(1999),

mended that the psychologist's allegiance to

" A s s e s s m e n t . . . is inextricably intertwined

the patient be clarified routinely at the outset

with the consultation activity" o f health

o f the consultation with the patient

psychologists (p. 3 9 ) . Multiple ethical issues

medical team.

and

surround competence and psychological assess-

T h e following scenario contains several

ment in health/medical settings. First, the

ethical issues related to psychological assess-

battery o f instruments to which a health psy-

ment in a medical setting.

chologist has access should be generally suffiunique

Case 4. " D r . Stephens" was consulted by

consultative needs and patient variables ser-

ciently broad and sensitive to the

the medical team at a chronic pain clinic to

viced. In this context, norm groups that are

provide a psychological evaluation for " M r .

used must be appropriate to the patient. M a n y

T h o m a s , " who presented with lower leg pain

norm groups for personality, behavioral, and

with

cognitive tests are comprised o f psychiatric

T h o m a s was a first-generation immigrant with

no

apparent

organic etiology. M r .

SPECIAL ISSUES

446

6 years o f formal education w h o did not speak

PRINCIPLE B : I N T E G R I T Y

English as his primary language. Dr. Stephens Psychologists seek to promote integrity in the science, teaching, and practice of psychology. In these activities, psychologists are honest, fair, and respectful of others. In describing or reporting their qualifications, services, products, fees, research, or teaching, they do not make statements that are false, misleading, or deceptive. Psychologists strive to be aware of their own belief systems, values, needs, and limitations and the effect of these on their work. To the extent feasible, they attempt to clarify for relevant parties the roles they are performing and to function appropriately in accordance with those roles. Psychologists avoid improper and potentially harmful dual relationships. (ΑΡΑ, 1992)

conducted an evaluation that consisted of projective and objective personality measures as well as a number o f other symptom checklists. After examining the results, Dr. Stephens concluded that M r . T h o m a s demonstrated personality tendencies consistent with the production of

physical symptoms

for

attention.

Dr.

Stephens concluded the consultation by reporting his findings to the medical team, which promptly

referred

Mr. Thomas

for

psy-

chotherapy targeted at his personality issues. Dr. Stephens demonstrated several ethical violations in this example. First, he should have compared his patient's test results with those o f the appropriate norm group or made adjustments to his interpretations based on differences between his patient and the com-

Psychologists are expected to behave ethi-

parison group. Dr. Stephens should have also

cally and honestly in their profession. T h e y

been more careful not to pathologize physical

present

symptoms. Health psychologists should make

integrity. They conduct their services without

it clear in their written and oral reports that

bias and avoid situations that may impair their

themselves

genuinely

and

with

the presence o f psychological symptoms does

objectivity in their relationships with their

not necessarily negate the presence o f physical

patients. Although all points in the principle o f

symptoms. Results from psychological evalua-

integrity are applicable to health psychologists,

tions are expected to augment—not replace—

perhaps the most relevant is the issue of

physical exams. Persuasive language loosely

relationships with patients and colleagues.

based on test data can be dangerous, not only because it may be inaccurate but also because it may convince medical professionals

to

Relationships With Patients

ignore valid physical symptoms in their search

Dual role relationships with patients is one

for a diagnosis. Second, D r . Stephens should

of

have shared his findings directly with

reported

the

the

most

common

ethical

dilemmas

by psychologists (Pope & Vetter,

patient. Although the ethical standards do not

1 9 9 2 ) . Although health psychologists might

mandate that results be delivered directly by

not be any more vulnerable to potential dual

the psychologist, the psychologist must ensure

relationship violations, relationship

bound-

that the patient receives a clear and accurate

aries in medical settings may be more blurred

explanation o f the evaluation findings. T h e

than in other settings. Psychologists who work

attending physician may have related findings

as part of a medical team interact with other

to the patient. However, most medical per-

medical professionals with differing sets of

sonnel are not trained in interpreting

and

ethical guidelines. For example, the American

conceptualizing psychological assessments.

Medical Association (ΑΜΑ) guidelines for sex-

Therefore, it is recommended that, whenever

ual relationships with former patients are quite

possible, the psychologist w h o conducted the

different

evaluation provide the feedback to the patient.

which clearly discourage sexual relationships

from the ΑΡΑ ethical guidelines,

Ethical

Issues

447

with former patients and mandate a 2-year

from Dr. Pressling, Dr. Goode decides to

period before a sexual relationship can be

attend the golf outing.

initiated with a former patient (for a complete

Although the Α Ρ Α ethical guidelines for

description o f sexual misconduct in medical

nonsexual

practice, see Α Μ Α , 1 9 9 1 ) . Furthermore, non-

specific as those for sexual relationships, the

sexual social relationships with patients are not

guidelines clearly state that

dual relationships

are n o t

as

addressed by the Α Μ Α . Health psychologists need to be aware that although the behavior o f other professionals may be considered ethical based on guidelines for their respective fields, this behavior might not be ethical based on psychological standards.

Relationships With Colleagues Relationships with colleagues also raise ethi-

a psychologist refrains from entering into or promising another personal, scientific, professional, financial, or other relationship with [patients] if it appears likely that such a relationship reasonably might impair the psychologist's objectivity or otherwise interfere with the psychologist's effectively performing his or her functions as a psychologist, or might harm or exploit the other party. (ΑΡΑ, 1992, Standard 1.17)

cal dilemmas for psychologists who work in medical settings. M a n y medical professionals

Although the ethics o f Dr. Goode's behavior

are not well educated as to the role of psychol-

are debatable, his golf outing with the patient

ogy in a medical setting and/or the influence o f

does raise several potential ethical violations.

psychological issues in medical diagnoses. For

First, although Dr. Goode received pressure

instance, an attending physician might unknow-

from his employer to attend the golf outing, the

ingly request inappropriate use of assessment

dual relationship with the patient was avoid-

results or recommend an unsubstantiated psy-

able. Dr. Smith was still a patient in the pro-

chological-behavioral intervention.

gram, and Dr. Goode may be called on to give

Although

this situation may be uncomfortable for the

interpretations/assessments

health psychologist, he or she must educate the

progress that might be biased by his relationship

physician and the treatment team as to his or her

with him as a golf partner. Second, based on the

role in the medical setting and on the appropri-

power differential between Dr. Goode and Dr.

ate use of psychiatric instruments for assessment

Pressling, Dr. Goode entered a professional dual

in medical populations.

relationship

with

Dr.

o f Dr.

Smith's

Pressling when

he

The following case demonstrates ethical

accepted the invitation to play golf. Although it

dilemmas related to relationships with both

can be argued that Dr. Goode may suffer the

patients and colleagues.

potentially negative repercussions of this dual relationship, there is also a potential of harm to

6. "Dr. G o o d e " recently provided a

future patients in that such a dual relationship

psychological evaluation for "Dr. Smith," a

may interfere with Dr. Goode's judgment in

physician in a nearby town and a current

future consultations. This scenario serves as a

Case

patient in a drug rehabilitation program. " D r .

nice example in that the potential for harm to

Pressling," the attending physician for the

the patient is debatable. In addition to the

treatment team, coordinated a golf outing for

responsibility to "avoid improper and poten-

the treatment team and some area physicians,

tially harmful dual relationships," Dr. Goode is

including Dr. Smith. Although Dr. Smith is still

required to "promote integrity" in his behavior

in outpatient treatment at the drug rehabilita-

(ΑΡΑ, 1 9 9 2 ) . W h e n the potential harmfulness

tion center, Dr. Goode has completed his por-

of a dual relationship is debatable, the promo-

tion of the assessment. W i t h encouragement

tion of integrity in science and clinical practice

448

SPECIAL ISSUES may prove to be a clearer guideline. This seems

remain cognizant of their role and

particularly applicable when health psycholo-

patients and colleagues o f this role. Some

gists are forced to interface with colleagues who

patients, who often have several appointments

operate under different ethical guidelines.

throughout

inform

the course of the day, may be

unclear as to the role of each o f their providers. Consider for a moment a patient who has been

PRINCIPLE C: PROFESSIONAL AND SCIENTIFIC RESPONSIBILITY

visited by a speech therapist, a physical therapist, and a physician during the first 3 hours of the morning, only to have a fourth individual, a

Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and adapt their methods to the needs of different populations. Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of their patients, clients, or other recipients of their services. Psychologists' moral standards and conduct are personal matters to the same degree as is true for any other person except as psychologists' conduct may compromise their professional responsibilities or reduce the public's trust in psychology and psychologists. Psychologists are concerned about the ethical compliance of their colleagues' scientific and professional conduct. When appropriate, they consult with colleagues to prevent or avoid unethical conduct. (ΑΡΑ, 1992) Psychologists define their role for patients and colleagues, and they strive t o perform this role appropriately. Role clarification is particularly important for health psychologists w h o

health psychologist, enter her room with a variety of questions and assessment instruments. From the patient's perspective, the role of the health psychologist may be understandably confused with the services of other providers. The health psychologist is directed to explain his or her role and the purpose of the interventions to the patient at the outset o f the session and must ensure that the patient has a clear understanding of the role that the health psychologist is expected to play. In addition to patients, members o f the treatment team may be unclear as to the health psychologist's role, training, and expertise. An interdisciplinary team consists o f several independent agendas that are coordinated to reach a collective goal. Amid the agendas, a full appreciation and understanding o f the role of fellow providers can become even more ambiguous. Therefore, it is o f utmost importance that the health psychologist define his or her purpose to team members as well as to clarify his or her professional responsibilities.

typically work as part of a multidisciplinary team. In addition, health psychologists are expected to promote the field o f psychology by consulting

with

colleagues,

behaving

responsibly, and participating in scientific and professional endeavors.

Ensuring High Standards of Professional Conduct Ensuring high standards o f professional conduct active

Clarifying Professional Roles Health psychologists typically maneuver in a

and

scientific responsibility is an psychologists

are

encouraged to routinely consult with

process. H e a l t h

col-

leagues as a means o f reinforcement, education,

and

professional

accountability. In

work environment of a variety o f health care

addition, health psychologists are encouraged

providers, including physicians, rehabilitation

to maintain a presence at patient staffings (as

therapists, nurses, and social workers. In this

opposed to sending psychological technicians,

context, it is important that health psychologists

interns, or graduate students)

as

another

Ethical Issues

449

means o f illustrating their role and taking

be established by law, institutional rules, or

responsibility for assessment and treatment o f

profession" (ΑΡΑ, 1 9 9 2 , Standard 5.02). The

their patients. Also, health psychologists are

commitment to confidentiality and the limits

encouraged to make grand rounds presenta-

of this commitment are discussed with the

tions, provide in-service training sessions, and

patient/potential patient at the outset of ther-

remain active in professional societies to facil-

apy/intervention. These limits include (a) harm

itate both public and institutional awareness.

to self, (b) harm to others, (c) child/elderly abuse or neglect, and (d) court order. Ethical dilemmas related to confidentiality are common and can become more complex in medical settings.

PRINCIPLE D: RESPECT F O R PEOPLE'S R I G H T S AND D I G N I T Y

Maintaining Confidentiality

Psychologists accord appropriate respect to the fundamental rights, dignity, and worth of all people. They respect the rights of individuals to privacy, confidentiality, self-determination, and autonomy, always being mindful that legal and other obligations may lead to inconsistency and conflict with the exercise of these rights. Psychologists are aware of cultural, individual, and role differences, including those due to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone unfair discriminatory practices. (ΑΡΑ, 1992)

Various ethical dilemmas related to the maintenance o f confidentiality are inherent in the medical setting. T h e health psychologist has a primary responsibility to the patient. T h e intricacies o f such a responsibility can at times be easily overlooked amid the shuffle of multiple interventions applied by the medical team. Therefore, it is essential that all limitations and exceptions to confidentiality be openly discussed with the patient at the outset o f assessment and/or treatment regardless of the estimated length o f contact. T h e health psychologist is also required to inform the patient as to who will have access to assessment results/reports and records o f the psychologist-

Multiple issues are pertinent to a discussion of respect o f others for health psychologists in a medical setting, including patient rights to privacy, confidentiality, and respect for diversity. Health psychologists are also sensitive to individual differences o f their patient populations and consider these differences in interactions with patients as well as with

the

treatment team.

Confidentiality

patient interactions. Although not ethically mandated, written documentation o f the clinician's explanation and the patient's understanding of confidentiality is recommended from a legal and practical perspective. The health psychologist not only must thoroughly explain confidentiality to the patient but also must ensure that confidentiality is protected. In medical settings, chart information is typically widely accessed by hospital staff. Therefore, it is recommended that, whenever possible, detailed notes be kept

separately

ΑΡΑ (1992) guidelines clearly describe the

within the psychologist's therapy records and

psychologist's commitment to confidentiality:

only cryptic general notes be included as part

"Psychologists have a primary obligation and

of the medical chart

take reasonable precautions to respect the confi-

1 9 9 9 ) . This practice protects patient data from

dentiality rights of those with whom they work

possible misinterpretation

or consult, recognizing that confidentiality may

staff

and

maintains

(Belar &

Deardorff,

by nonpsychiatric confidentiality

of

450

SPECIAL ISSUES patient

the consequences of breaching/not breaching

Another issue pertinent to maintaining con-

thorough evaluation o f suicidality in a medical

fidentiality is privacy for psychological consul-

setting. Assessments o f potentially suicidal

tations. It is often difficult to secure privacy

patients in a medical setting, particularly in the

for a clinical interview given that families

emergency room, may be rushed. Furthermore,

potentially sensitive, yet irrelevant,

confidentiality. Several issues may complicate a

information.

and/or other patients might be present in the

the clinician does not have the advantage of a

hospital room and the patient might not be

well-established relationship with the patient

ambulatory for the purpose o f moving to a

to facilitate a thorough appraisal of suicidality.

testing/interview office. W h e n possible, it is

If the patient is deemed to be a threat to him-

recommended that the health psychologist

self or herself, the health psychologist must

pre-schedule individual time in the patient's

exhaust non-confidentiality-breaching solu-

room. Coordinating in advance with other

tions prior to breaking confidentiality. When a

members o f the treatment team can often

breach is required, it is recommended that,

facilitate making such arrangements. Also, in

whenever possible, the provider inform the

cases where multiple patients share a room, a

patient o f the pending breach and reasons for

less than ideal but simple alternative is to close

such action. Obviously, the importance of the

the divider curtains around the patient's bed.

initial discussion o f the limits o f confidentiality

Finally, the issue o f confidentiality in medi-

becomes glaringly apparent. T o appropriately

cal settings can often be obscured by the numer-

protect the patient and preserve the therapeutic

ous interventions and assessments conducted

relationship, the health psychologist must be

on a particular patient. Although the patient

thoroughly familiar with guidelines related to

may have consented for some data (e.g., medi-

confidentiality. W h e n a solution to a dilemma

cal data) to be shared with family members or

related to breaching confidentiality is unclear,

with other health professionals, psychological

the psychologist should consult with other

data are considered separate and the patient

colleagues to ensure an appropriate resolution.

must consent for this information to be shared

Another exception to confidentiality occurs

with others. It is also important that the health

when the patient is assessed as a potential

the

harm to others. T h e psychologist's duty to

patient consented to in the original consulta-

warn was well established in the case o f

tion. In a hurried, sometimes chaotic medical

Tarasoffv.

setting, the precise limits o f the patient's origi-

of California

nal consent can be overlooked or misunder-

Supreme Court ruled that it is the psycholo-

stood, even with the best of intentions.

gist's responsibility to assess the threat o f

psychologist remain cognizant of what

Board

of Regents

of the

University

( 1 9 7 6 ) , in which the California

harm in patients and to take measures to pro-

Exceptions to Confidentiality Although the limits o f confidentiality are

tect potential victims. T h e Tarasoff

case has

generated confusion for psychologists as to when it is necessary to preserve or break con-

clearly stated in the ethical guidelines, these

fidentiality

with

potentially

dangerous

boundaries can be somewhat ambiguous in

patients. Moreover, much o f the controversy

medical settings. Confidentiality may need to

surrounds the degree o f intent to commit a

be breached in situations where the patient is a

violent act suggested by patients' statements

threat to himself or herself. It is important

and overt behavior. Obviously, this dilemma

from both a legal and an ethical standpoint

may become even more ambiguous in a medi-

that the health psychologist thoroughly evalu-

cal setting where threat o f harm may relate

ate the suicidal patient and carefully consider

not only to physical violence but also to the

Ethical intentional

and

unintentional

spread

of

Issues

inform others of H I V risk), it is his duty to inform the partner. Dr. Actte calls the partner

contagious diseases. For instance, based on the duty to warn, are psychologists under ethical obligation to inform

and lets him know that M s . Bowen is HIVpositive and that he is at risk.

of H I V -

Dr. Actte committed several ethical viola-

positive patients? As with all "duty to warn"

tions in this example. First, M s . Bowen was

scenarios, careful consideration of each case and

protecting her partner from her infection, so

its particular issues is imperative. Thorough

the risk o f harm was negligible. This case can

sexual or needle-sharing partners

documentation, consultation, and review of

be contrasted to cases in which the patient

specific state regulations concerning H I V

maliciously spreads the virus with the intent to

reporting are necessary before making the deci-

infect others or neglectfully engages in risky

sion to breach or preserve confidentiality. States

virus-spreading behaviors. As mentioned pre-

have differing guidelines regarding the duty to

viously, the ΑΡΑ states that when the patient

warn in infectious disease cases. T h e health psy-

takes precautions to protect his or her partner,

chologist needs to be familiar with state laws in

the clinician is not mandated to warn the

determining whether confidentiality should be

partner o f H I V risk. Second, even if Dr. Actte

breached for a specific case. W h e n state laws

determined that M s . Bowen was placing her

permit or mandate notification o f third parties

partner at risk and that he had a duty to inter-

about risk o f HTV infection, it is recommended

vene, he could have handled the situation

that confidentiality be maintained except in cir-

more responsibly. H e and M s . Bowen could

cumstances where patients are unwilling to

have discussed the risks to her partner and the

reduce the risk o f spreading infection to part-

consequences o f not informing him o f her sta-

ners (ΑΡΑ, 1 9 9 1 ) . W h e n confidentiality is

tus. Then, Dr. Actte could have encouraged

breached in these unusual cases, the practi-

M s . Bowen to tell her partner rather than

tioner must maintain detailed records providing

breaking confidentiality to inform the partner.

a rationale for breaking confidentiality, inform

Finally, if M s . Bowen refused to tell her part-

the patient that the third party will be con-

ner after this discussion and Dr. Actte found it

tacted, and attempt to conceal patient-identify-

necessary to warn the partner, he should have

ing information in the contact (ΑΡΑ, 1 9 9 1 ) .

first informed M s . Bowen o f his intentions

Consider the following scenario.

and preserved her privacy as much as possible in his report to the partner.

Case

6. "Dr. Rey Actte" is treating " M s .

Bowen." M s . Bowen reports to Dr. Actte that she is HIV-positive. She has been dating her partner for about 3 months. Although she has

Recognizing the Influence of Multicultural Issues

not informed her partner that she is HIV-

In addition to maintaining confidentiality,

positive, she has been very cautious in their

health psychologists must respect the rights o f

sexual relationship, using appropriate protec-

others by recognizing and understanding diver-

tion to prevent the exchange o f bodily fluids.

sity. Although all psychologists need to be cog-

She states that she will tell her partner at some

nizant o f cultural influences (ΑΡΑ, 1 9 9 2 ,

point but that the time has not been right. As

Standard 1.08), patient populations continue

M s . Bowen continues to describe her partner, it

to grow more culturally diverse, suggesting

becomes apparent that he is an acquaintance o f

the ever-increasing need for greater cultural

Dr. Actte. After the session concludes, Dr. Actte

awareness (Iwamasa, 1 9 9 7 ) . Clearly, health

determines that, based on the guidelines for his

psychologists should avoid prejudice and dis-

state (which allow a breach o f confidentiality to

crimination in the process o f evaluation and

452

SPECIAL ISSUES treatment. Understanding,

appreciating,

and

implementing cultural sensitivity reaches far

taking medications, to assist her in her treatment decision. Dr. Hayden has so far acted ethically in

beyond political correctness. cultural

this example. Although medication is recom-

diversity, including ethnicity, gender, socio-

mended for non-diet-controlled type 2 diabet-

economic status, geographic region, and reli-

ics, it is M s . Layten's decision as to whether

Multiple factors contribute to

gion. T h e Western medical model adhered to

she wants

in hospitals may represent viewpoints

to take

the

medication.

The

and

referring physician made pejorative assump-

expectations for behavior that stand in stark

tions about M s . Layten's motivation because

contrast to those o f cultures with which many

he ignored her cultural belief system. These

patients identify. For example, cultural belief

assumptions not only pathologized M s . Layten's

systems vary as to perceptions o f illness behav-

belief system but also potentially exacerbated

ior, use o f medication, etiological understand-

her "noncompliance." M s . Layten's case is a

ing o f illness, and family participation. T h e

good example o f multicultural

health psychologist is encouraged to be cog-

Similar to the general population, health care

nizant o f his or her own ethnocentrism and to

professionals are at risk for unintentionally

take steps to appropriately acknowledge and

stigmatizing patients based on cultural igno-

incorporate the patient's cultural belief system

rance and their own ethnocentrism. Health

whenever possible. Even the most politically

psychologists are encouraged to remain aware

correct health psychologist can provide inac-

that multicultural issues are present in nearly

influences.

contraindicated

every patient-therapist relationship and that

treatments by missing the influence o f culture.

cultural diversity surpasses race to include

Consider the following example.

factors such as nationality, disability, socio-

curate interpretations

and

economic status, gender, geographic location, Case

7. " D r . Hayden" is treating " M s .

and religion.

Layten," who has type 2 diabetes. She had not been taking her medication, and she was referred

for psychological and

behavioral

interventions. M s . Layten had been described by the referring physician as "difficult and noncompliant

with

recommended

treat-

ments." T h e referring physician reported trying several medications to no avail, and he is concerned that she may need insulin; however, he is afraid that she would refuse to take it, just like she had the other medications. After Dr. Hayden met with M s . Layten for several sessions, she shared with him that medical interventions were against her spiritual beliefs. Although she had tried to share this with the referring physician, he had told her that many diabetics do not like the thought o f medications and that she would get used to it if she just tried it for a while. Dr. Hayden discussed with M s . Layten alternatives to medication, as well as the perceived consequences o f not

PRINCIPLE E: C O N C E R N FOR OTHERS' WELFARE Psychologists seek to contribute to the welfare of those with whom they interact professionally. In their professional actions, psychologists weigh the welfare and rights of their patients or clients, students, supervisees, human research participants, and other affected persons as well as the welfare of animal subjects of research. When conflicts occur among their obligations or concerns, psychologists attempt to resolve these conflicts and to perform their roles in a responsible fashion that avoids or minimizes harm. Psychologists are sensitive to real and ascribed differences in power between themselves and others, and they do not exploit or mislead other people during or after professional relationships. (ΑΡΑ, 1992)

Ethical Issues Α Ρ Α ( 1 9 9 2 ) guidelines define the psychol-

anhedonia and insomnia. "Dr. Johnson," a

ogist's role in providing informed consent as

clinical health psychologist, is consulted to pro-

follows:

vide an assessment o f B o b . Dr. Johnson is finishing with a staffing when she gets the consult

(a) Psychologists obtain appropriate informed consent to therapy or related procedures, using language that is reasonably understandable to participants. The content of informed consent will vary depending on many circumstances; however, informedconsent generally implies that the person (1) has the capacity to consent, (2) has been informed of significant information concerning the procedure, [and] (3) has freely and without undue influence expressed consent and [that] (4) consent has been appropriately documented. (Standard 4.02a)

and figures that she does not have time to see B o b before his next appointment. Thus, she orders a small battery o f

agenda for the day. O n one o f the instruments, it is later discovered that B o b endorses suicide intent. After ordering the additional following day. Dr. J o h n s o n failed to act ethically in this example. First, she did not obtain B o b ' s consent. Measures were simply left with him, and

T h e health psychologist must be commitensuring that the patient is consenting without pressure or force. Although not mandated by ethical codes, it has been recommended that informed consent be provided in both written

form

(Keith-Spiegel

tests,

Dr. Johnson makes a note to see B o b the

ted to explaining the therapy process and to

oral and

paper-and-pencil

assessment instruments to be added to Bob's

&

Koocher, 1 9 9 8 ) . Providing both written and oral explanations o f therapy decreases confusion for the patient and provides documentation for the health psychologist. T h e consent form should be thorough yet simple and may address the following: expectations for therapy, potential risks and benefits o f treatment, commitment to and limits o f confidentiality, and an agreed-on fee.

he complied with the request to complete them. Second, she did not describe the purpose of the additional assessment procedures to B o b . T h e patient has the choice as to whether to complete these measures, and his options were not explained to him. Third, she did not describe confidentiality and its limits. Because Dr. J o h n s o n is ethically required to protect B o b from harm to himself, which may include breaching confidentiality, she is now in a precarious situation. N o t only has she potentially breached the trust in a patient-psychologist relationship, but she has essentially conducted an assessment on a patient without any permission from the patient. This is clearly a breach of ethics and a generally poor standard o f practice.

Logistics o f informed consent become more complex for the psychologist in a medical setting. In a consultation environment, the psychologist is often asked to provide a brief intervention or assessment. In these situations, informed consent is often inappropriately overlooked. Although failing to provide informed consent in itself is an ethical violation, this ethical infraction can lead to additional ethical dilemmas. Consider the following scenario.

Another situation related to informed consent that can be difficult for health psychologists in medical settings is ensuring consent for medical procedures. Psychologists often work with medical patients in exploring their perceptions and their options for medical treatment. Psychologists in health settings can facilitate informed consent for medical procedures by helping patients to understand the medical procedures, encouraging patients to ask for explanations and options from their physicians,

Case 8. " B o b " is currently in outpatient cardiac rehabilitation. H e reports symptoms of

persuading physicians and medical personnel to

provide

concise

and

understandable

453

454

SPECIAL ISSUES and

level o f suffering and emotional welfare of

assisting patients in planning for and adjust-

patients. When appropriate, it is recommended

explanations of treatment to patients, ing to the medical procedures

(Belar

&

Deardorff, 1 9 9 9 ) .

that health psychologists maintain knowledge of local resources such as low-income hospice care, psychological and psychiatric treatment, chari-

PRINCIPLE F: SOCIAL RESPONSIBILITY Psychologists are aware of their professional and scientific responsibilities to the community and the society in which they work and live. They apply and make public their knowledge of psychology so as to contribute to human welfare. Psychologists are concerned about and work to mitigate the causes of human suffering. When undertaking research, they strive to advance human welfare and the science of psychology. Psychologists try to avoid misuse of their work. They comply with the law and encourage the development of law and social policy that serve the interests of their patients and clients as well as the public. They are encouraged to contribute a portion of their professional time for little or no personal advantage. (ΑΡΑ, 1992)

table organizations, churches, and other services that may be necessary. Such information might not be a part of the consultation question and is typically viewed as a social worker's domain. However, health psychologists should be prepared to at least have reasonable referral information when confronted with inquiring patients and their families. Health psychologists must also be sensitive to the emotional needs of friends and family members of their patients. Health psychologists are obviously encouraged to maintain appropriate boundaries. However, sound professional boundaries do not necessarily exclude a few minutes of supportive contact for patients and their families.

CONCLUSIONS This chapter has provided an overview of ethical guidelines specific to health psycholo-

The principle of social responsibility stands

gists. Although the Α Ρ Α guidelines

may

as a nucleus for any professional endeavor made

appear to be straightforward, these recom-

by a psychologist and is particularly applicable

mendations are often distorted by ambiguous

to the health psychologist. M o r e than other clin-

situations. It is suggested that the health

ical specialties, health psychologists routinely

psychology student not only become familiar

interact with patients who are experiencing

with the Α Ρ Α guidelines but also review

physical suffering that may include pain, deteri-

situations that raise ethical dilemmas. This

oration of motor ability, or even impending

chapter introduced some o f these difficult

death. It is not uncommon for patients to be

situations, but further study is required to

concerned about the emotional and financial

become a health psychologist w h o behaves

welfare of their family members. Likewise,

with integrity to protect patients and pro-

family members are often concerned about the

mote the field o f health psychology.

REFERENCES American Medical Association. (1991). Sexual misconduct in the practice of medicine. Journal of the American Medical Association, 266, 2 7 4 1 - 2 7 4 5 . American Psychological Association. (1981). Specialty guidelines for the delivery of services. American Psychologist, 36, 6 4 0 - 6 8 1 .

Ethical Issues American Psychological Association. (1991, August). Legal liability related to confidentiality and the prevention of HIV transmission. American Psychological Association AIDS-Related Policy Statements. (Washington, DC: Author) American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1 5 9 7 - 1 6 1 1 . Belar, C. D. (1980). Training the clinical psychology student in behavioral medicine. Professional Psychology, 11, 6 2 0 - 6 2 7 . Belar, C. D., & Deardorff, W. W. (1999). Clinical health psychology in medical settings: A practitioner's guidebook. Washington, DC: American Psychological Association. Iwamasa, G. Y . (1997). Behavior therapy and a culturally diverse society: Forging an alliance. Behavior Therapy, 28, 3 4 7 - 3 5 8 . Keith-Spiegel, P., &C Koocher, G. P. (1998). Ethics in psychology: Professional standards and cases. New York: McGraw-Hill. Pope, K. S., & Vetter, V. A. (1992). Ethical dilemmas encountered by members of the American Psychological Association. American Psychologist, 47, 3 9 7 - 4 1 1 . Stone, G. C. (Ed.). (1983). National Working Conference on Education and Training in Health Psychology. Health Psychology, 2(Suppl. 5), 1-153. Tarasoff v. Board of Regents of the University of California, 551 P. 2d 3 3 4 (Cal. Sup. Ct. 1976).

455

CHAPTER

10 23

Ethnocultural Issues in Behavioral Medicine HECTOR F . MYERS AND WEI-CHIN HWANG

T

here are substantial and

persistent

some of the salient factors that contribute to the

health.

disparities are discussed. Third, examples o f

Compared with Caucasian Americans,

behavioral interventions with these disorders in

ethnic minorities have poorer health (Keppel,

minorities are presented. Fourth, a series of

Pearcy, & Wagener, 2 0 0 2 ; Williams, 2 0 0 0 ) ,

recommendations distilled from

receive poorer quality health care, and have

successful interventions is provided.

racial/ethnic

disparities

in

poorer prognoses and treatment (Smedley,

Stith,

&

Nelson,

the

outcomes

2002;

U.S.

Department o f Health and Human Services,

E T H N I C DISPARITIES IN H E A L T H

1999).

AND H E A L T H CARE

M o r e o v e r , these health

most

disparities

remain even after adjusting for socioeconomic status, severity o f illness, and discrepancies in

Current evidence indicates that,

access to care. T h e continued failure to close

with Caucasian Americans, African Americans

these persistent racial/ethnic disparities in

and Native Americans evidence a significant

health status, combined with the rapid increase

health disadvantage, Hispanic Americans have

in the ethnic and cultural diversity in the

equal or slightly poorer health, and Asian

United States, has serious public health conse-

Americans evidence significant health advan-

quences and results in increased demand on an

tages for some disorders (National Center for

already challenged health care system. If left

Health Statistics, 2 0 0 0 ) . F o r example, African

unattended, racial/ethnic disparities in health

Americans and other minorities are more likely

will eventually lead to a decline in quality o f

to report poorer subjective health and well-

life for all Americans (Smedley et al., 2 0 0 2 ) . This chapter is organized into four main sec-

456

compared

being (Hughes 8 t T h o m a s , 1 9 9 8 ) , poorer functional status, and greater disability than are

tions. First, a brief review of ethnic disparities in

Caucasians, but minorities are more likely to

cardiovascular disease (CVD), diabetes, cancer,

report comparable or better rates o f other indi-

and pain, conditions o f special relevance to

cators of mental health (Kington & Nickens,

behavioral medicine, is presented. Second,

2 0 0 0 ; Williams & Harris-Reid, 1 9 9 9 ) .

Ethnocultural

Issues

457

It is also well known that African Americans

evidence rates approximately twice as high as

have the highest rate of essential hypertension,

that of Caucasian Americans. They also found

develop the disease at an earlier age, develop a

higher incidence rates o f stomach cancer in

more severe form o f the disease earlier, and suf-

Korean Americans, Vietnamese Americans,

fer from more severe complications and death

Japanese Americans, Alaskan Natives, and

from the disease than does any other ethnic

Native Hawaiians.

group in the United States (National Heart,

N o t only are there ethnic differences in

Lung, and Blood Institute, 1 9 9 6 ) . A similar pat-

chronic illnesses, but several clinical and experi-

tern is observed in the prevalence and rates o f

mental studies have also reported ethnic differ-

mortality from C V D and cancer, which are the

ences in the

two leading causes o f death in the United States.

tolerance of pain as well as in pain-related

These rates are significantly higher in African

avoidance o f activity and physical and psy-

Americans and

chosocial disability (Bates 8c Edwards, 1 9 9 2 ;

are lower

Caucasian Americans

in Asian Americans,

and

Hispanic

perception,

sensitivity,

and

Edwards, Doleys, Fillingim, 8c Lowery, 2 0 0 1 ;

Americans, and Native Americans (American

McCracken,

Cancer Society, 2 0 0 2 ; Cooper et al., 2 0 0 0 ) .

2 0 0 1 ) . In their study o f ethnic differences in

However, recent reports offer some good news,

pain perception in chronic pain patients, Bates

Matthews,

Tang,

8c

Cuba,

with significant reductions in heart disease

and Edwards

reported in all ethnic groups.

patients reported significantly greater intensity

( 1 9 9 2 ) found

that

Hispanic

Unfortunately, these positive trends are not

of pain than did the Caucasian subgroups and

observed in all health problems, nor are the

that these ethnic differences were moderated

ethnic

by locus of control; Anglo-Americans and

groups. For example, the rates o f non-insulin

Polish Americans with high internal locus o f

dependent diabetes mellitus ( N I D D M )

are

control reported experiencing more intense

increasing and affect minority groups dispro-

pain, whereas high internal locus o f control

portionately. African Americans, Hispanic

respondents

Americans, Native Americans, and some Asian

reported lower pain ratings.

trends

equally

positive

for

all

from the other ethnic groups

American subgroups suffer from N I D D M at

M c C r a c k e n and colleagues ( 2 0 0 1 ) com-

higher rates than do Caucasian Americans and

pared pain experiences in treatment-seeking

are also more likely to suffer from complica-

African American and Caucasian American

tions secondary to the disease such as blindness,

chronic pain patients and found that although

end-stage renal disease, amputations, and mor-

the groups did not differ on the chronicity o f

tality (Carter, Pugh, &c Monterrosa, 1 9 9 6 ) .

pain, medical diagnosis, work status, or previ-

Also, although there has been a significant reduction in mortality rates from lung and

ous surgeries, African American

patients

reported higher pain severity, more avoidance

breast cancer in the U.S. population overall,

of

Native Americans evidenced increased mortal-

physical symptoms, and greater physical and

activity, m o r e

fearful

thinking,

more

ity rates and Asian Americans evidenced little

psychological disability than did Caucasian

reduction in mortality from these diseases

American patients. These results were also

(National Center for Health Statistics, 2 0 0 0 ) .

confirmed by Faucett, Gordon, and Levine

Miller and colleagues ( 1 9 9 6 ) also reported that

( 1 9 9 4 ) in their study o f ethnic differences in

Vietnamese Americans, Korean Americans,

acute postoperative dental pain in four ethnic

and Chinese Americans have liver cancer inci-

groups. They found that European Americans

dence and mortality rates several times higher

reported less severe pain, whereas African

than that o f the U.S. population and

American and Hispanic American

that

African Americans and Hispanic Americans

patients

reported more severe pain. T h e basis for these

SPECIAL ISSUES

458

ethnie differences in pain are unclear, but

these services, as compared with Caucasian

Bates ( 1 9 8 7 ) argued for a biosocial model o f

Americans. In contrast, Padgett, Patrick, Burns,

pain, suggesting that the observed differences

and Schlesinger ( 1 9 9 4 ) found

in pain are not due to physiological differences

Americans and Hispanic Americans used out-

that

African

but rather are likely due to differences in cul-

patient mental health services less than did

tural experiences, attitudes, and meanings o f

Caucasian Americans, even after controlling for

pain. These, in turn, influence the neurophys-

a number of demographic variables.

iological processes that govern pain percep-

Although the results from studies o f help

tion and tolerance as well as the psychological

seeking among different ethnic groups are

and behavioral responses to pain.

somewhat inconsistent, there is strong evi-

T w o factors that are implicated in the per-

dence that ethnic groups differ in the quality

sistence of many of these ethnic health dispari-

of care received once they enter the health

ties are ethnic differences in help seeking and

care system. In a recent review on racial and

quality of health care received. M a n y studies

ethnic differences in health care, Smedley and

indicate that ethnic minorities typically delay

colleagues ( 2 0 0 2 ) found that ethnic minori-

seeking professional health care for

both

ties are less likely to receive appropriate diag-

physical and mental health needs, and they

nostic tests, treatment, and follow-up care for

attribute this delay to a greater reliance on

diseases such as cancer, diabetes, C V D , and

informal sources of help than is the case with

human immunodeficiency virus (HIV). These

Caucasian Americans (Zhang, Snowden,

differences were evident even after controlling

Sue,

1 9 9 8 ) . Other more apparent

&

reasons

include financial and other barriers to access

for

factors such as delayed help seeking,

health insurance coverage, income, severity o f

such as health insurance, language barriers, and

disease, and differences in use o f services, all

stigma

of which might affect access to care.

against

mental

health

services

(Takeuchi, Leaf, &c Kuo, 1 9 8 8 ; T h o m a s &

Smedley and colleagues ( 2 0 0 2 ) also noted

Snowden, 2 0 0 1 ) . However, results from some

that a variety o f patient, provider, and health

studies on help seeking suggest that pathways

care system variables contribute to these differ-

to care are more complex than thought previ-

ences in health care. Ethnic minorities, espe-

ously. For example, Snowden ( 1 9 9 8 )

found

cially the poor, are more likely to delay seeking

that African Americans tend to rely more on

care, adhere poorly to treatment regimens, and

both formal and informal sources o f help

often refuse recommended services. Several

for

their health needs than do

Americans.

In

addition,

Caucasian

whereas

studies also indicate that physicians tend to

Asian

stereotype minority clients as less intelligent

Americans as a whole tend to seek help at the

and educated, prefer patients of certain ethnic-

lowest rates relative to their representation in

ities, and

the general population (Matsuoka, Breaux, &

patients through the type o f procedures sug-

Ryujin, 1 9 9 7 ; Ying & Hu, 1 9 9 4 ) , Southeast

gested, the amount and type o f medication

Asians evidence higher rates o f use (Ying &c

prescribed, and/or the frequency o f contact. In

Hu, 1 9 9 4 ) .

addition, a number o f health care system vari-

provide

different

treatment

to

Data from inpatient and outpatient mental

ables, such as geographic distribution of health

health services confirm this complexity. For

care facilities, health insurance coverage, avail-

example, Snowden and Cheung (1990) reported

ability

higher use of inpatient services by African

services, and effectiveness o f outreach services,

Americans and

also contribute to the disparities in health care.

Native

Americans/Alaskan

Natives, whereas Hispanic Americans

of

translation

and

interpretation

and

In summary, there is substantial evidence

Asian Americans/Pacific Islanders underuse

indicating that ethnic differences in health

Ethnocultural

Issues

459

status do exist and that there also appear to be

stresses, and personality characteristics (e.g.,

ethnic differences in perceived overall health, in

anger/hostility, neuroticism, pessimism) that

functional status, and in the availability and

serve as psychological vulnerabilities. The nega-

quality of health care provided. Moreover, the

tive effects of these adversities, in turn, are mag-

magnitude of these group differences may be

nified by health-endangering behaviors (e.g.,

underestimated

smoking, alcohol and drug abuse, sedentary

because o f the failure

to

2000;

appreciate the considerable sociocultural and

lifestyle, overeating) (Contrada et al.,

historical heterogeneity among the various

Myers, Kagawa-Singer, Kumanyika, Lex, 8c

racial/ethnic groups. In addition, ethnic minor-

Markides, 1995;

ity overrepresentation in lower socioeconomic

Dominguez,

status levels and the risks associated with low

Myers, Lewis, &

Parker-

2002).

T h e model also hypothesizes that these

socioeconomic status (e.g., environmental and

lifetime adversities exert their effects

occupational hazards, possible differences in

health

through

biobehavioral

on

pathways,

social and behavioral risks) contribute to the

including the chronic triggering o f physiologi-

persistence o f the disparities in health and func-

cal response mechanisms, constitutional pre-

tional status and to the disproportionate bur-

dispositions or vulnerabilities, and overtaxed

den of morbidity and mortality among ethnic

allostatic load (i.e., wear-and-tear

minorities and the poor.

system)

(Geronimus,

Seeman,

1999). In turn, this allostatic load is

1992;

on

McEwen

the 8c

hypothesized to contribute over time to cumulative vulnerability and ultimately to functional

FACTORS THAT CONTRIBUTE

outcomes, including physical and psychologi-

T O T H E H E A L T H DISPARITIES

cal distress and dysfunction (Seeman, Singer, Health outcomes, whether they are chronic

R o w e , Horwitz, & M c E w e n ,

1997).

conditions such as C V D and N I D D M or asso-

However, the model also acknowledges

ciated pain, are clearly the by-product o f the

that a number o f psychosocial and behavioral

complex interaction o f many factors. These

factors

serve

as

psychosocial

assets

or

include individual differences such as biologi-

advantages that can moderate risk. These

cal predispositions, behavioral lifestyle, psy-

include psychological characteristics such as

chological characteristics, and environmental

dispositional optimism and perceived control

and psychosocial factors.

(Eizenman,

Nesselroade,

Featherman,

Sc

of how psychosocial stress and related factors

1997), healthy lifestyles (Myers et al., 1995), flexible stress appraisal and coping strategies (Wong 8c Ujimoto, 1998), and the

might account for ethnic differences in func-

availability and use of adequate social support

tional health status. T h e proposed model makes

resources (Seeman, Lusignolo, Albert,

explicit

Berkman,

In a recent review, Myers and Hwang

(2002)

proposed an integrative biopsychosocial model

that

sociostructural

factors

(e.g.,

Rowe,

8c

2001). Therefore, it is hypothesized

environmental

that it is the balance between cumulative

factors, and biological factors (e.g., genetic

adversities and cumulative advantages over the

vulnerabilities, family medical and psychiatric

life course that ultimately contributes to differ-

histories) interact over time to increase the bur-

ences in functional status and health trajecto-

den of psychosocial adversities experienced over

ries (Singer 8c Ryff,

the life course. These adversities are hypothe-

imbalance between cumulative adversities rela-

sized to be the primary predictors of risk and

tive to assets that is hypothesized as contribut-

include chronic life stresses, major life change

ing to the persistence of health disparities. This

events, ethnicity-related stresses, age-related

model has not been formally tested, but it

race/ethnicity, social class),

1999), and it is the lifetime

460

SPECIAL ISSUES

offers a series of testable hypotheses to guide

improve cardiovascular health in minority

future research on ethnic health disparities.

populations. M a n y C V D risk reduction programs for African Americans have focused on blood pressure reduction and control, smoking

BEHAVIORAL HEALTH INTERVENTIONS

cessation, dietary changes, weight loss, and physical exercise. M a n y o f these programs are faith based, thereby taking advantage of the

Behavioral scientists have made a number o f

historical role o f the African American church

significant contributions toward closing the

as a credible community institution central to

health disparities gap by designing and test-

African American community life (Magnus,

ing theoretically driven, culturally appropri-

1 9 9 1 ) . Reviews o f programs such as Project

ate interventions for a variety o f medical

Joy

conditions, such as C V D , as well as risk

Koffman,

(Yanek, Becker, M o y , Gittelsohn, 2001),

behavior change, such as weight reduction,

Ascanio,

&

smoking cessation, and increased participa-

(Rosamond et al., 2 0 0 0 ) , and the Heart Smart

tion in cancer and diabetes screening.

Program (Johnson et al., 1 9 9 1 ) , as well as weight

CVD Risk Reduction Interventions Behavioral scientists have made some of their

Lighten Up

Egan,

reduction

Obarzanek,

2001),

programs

Stevens, Hebert,

&

(Oexmann, Wisewoman

(Kumanyika, &

Whelton,

1 9 9 1 ) , all indicate that cultural sensitivity, in conjunction with a focus on specific risk

addressing

behaviors that test behavioral principles, yields

ethnic issues in behavioral medicine through the

the best results. However, because many of

design and implementation o f interventions to

these community-based interventions are not

reduce C V D risks in minority

populations.

rigorously evaluated, it is difficult to identify

M o s t of this work has been conducted on

the specific mechanisms and intervention com-

African Americans and Hispanic Americans,

ponents that account for their overall success.

most significant contributions to

with a few studies targeting Asian Americans

Similar conclusions are drawn in reviews

and Native Americans. These interventions have

of C V D risk reduction programs for His-

focused attention on a variety of risk factors,

panic Americans such as the Language for

including blood pressure control, weight loss,

Health

smoking, and increased physical exercise. They

reviewed by Elder and colleagues

have also targeted different age groups (e.g.,

The

children,

adolescents, adults,

program

for

low-literate

same is true for programs

Latinos (2000). designed

the elderly),

specifically for Asians such as the Vietnamese

focused on community and clinic-based patient

Community Health P r o m o t i o n Project, the

populations, and been introduced in a variety of

Chinese Community Cardiac Council, and

settings such as schools, churches, hospitals,

the

community health centers, and social service

reviewed by Chen ( 1 9 9 3 ) . A number o f sim-

Heart

Health

for

Southeast

Asians

agencies (Magnus, 1 9 9 1 ) . These studies have

ilar programs have been designed for Native

used a variety of both quantitative and qualita-

Americans

tive methodologies. However, few of these stud-

Cardiovascular

ies have used well-controlled, large-scale clinical

Indian and Hispanic American children, and

trial methodologies to test and validate theoreti-

the A c o m a - C a n o n c i t o - L a g u n a Adolescent

cally driven interventions, and this limits the

Health Program reviewed by L e M a s t e r and

utility and generalizability o f their results.

Connell ( 1 9 9 4 ) . All o f these C V D risk reduc-

such

as

the

Curriculum

Checkerboard for

American

Nevertheless, there are a number o f success-

tion programs were conducted in community

ful approaches that have been implemented to

settings by members o f the specific ethnic

Ethnocultural

Issues

461

groups w h o understand the cultural norms o f

testing and early identification o f problems.

the groups and w h o are familiar with the

As a result, several studies have been designed

groups' specific needs (e.g., speak the native

to address this problem, and many

language, k n o w the cultural customs, use

shown measurable improvement in screening

have

culturally congruent and effective modes o f

behavior in these populations. For example,

communication and caregiving). T h e curric-

Gotay and colleagues ( 2 0 0 0 ) reported

ula are also designed specifically to address

results o f a controlled trial o f a culturally

the cultural beliefs, behavioral norms, and

tailored breast and cervical cancer screening

language

requirements

of

each

group.

intervention for Native Hawaiian

the

women.

However, as noted previously, many o f these

They used lay educator-led groups, or

Kokua

ethnic-specific programs are not rigorously

groups, to deliver culturally tailored education

evaluated, nor do they use rigorous research

and support for screening. This group-led

methodologies to test their efficacy, and this

intervention produced

tends to reduce confidence in their results.

ments in b o t h knowledge

Also, until their results are replicated, it can-

behaviors in the Native Hawaiian

n o t be determined whether their findings will

participants, and they in turn shared what they

generalize to other ethnic communities.

learned in the program with other women in

significant improveand

screening women

the community, thereby extending the program's impact to the community-at-large.

Interventions to Increase Participation in Cancer and Diabetes Screening

Similar results were obtained by Taylor and colleagues (2002) in their randomized trial to increase cervical cancer screening in Chinese

Another focus o f attention o f behavioral

American women in Seattle, Washington, and

scientists working with ethnic minority popu-

Vancouver, British Columbia. They tested the

lations is increasing participation

in early

screening programs for diseases such as cancer

impact

of a

Chinese-language

education-

entertainment video, a motivational pamphlet,

and diabetes. Both o f these diseases are very

and a fact sheet on Pap smear testing on women

prevalent and are associated with significant

who were randomly assigned to an intensive

ethnic disparities in disability and mortality.

outreach intervention versus direct mail versus

treatment

usual care. They found both higher participa-

reduces both disability and mortality risk,

tion and significant increases in Pap smear test-

ethnic minorities are significantly less likely to

ing in women in the more intensive intervention.

Although

participate

early

in

detection

early

and

programs.

Similar programs have also been developed

Therefore, a number of intervention programs

screening

for urban and rural African American women

have been designed to address this obstacle to

(Earp et al., 2 0 0 2 ; Paskett et al., 1 9 9 9 ) , for

effective treatment, especially in diabetes and

low-income Latinas (Hiatt et al., 2 0 0 1 ;

breast and cervical cancer.

Valdez, Banerjee, Ackerson, &

Fernandez,

Current evidence indicates that minority

2 0 0 2 ) , for Cambodian women (Jackson et al.,

women, especially Chinese Americans (Taylor

2 0 0 0 ) , for Alaska Native women (Lanier,

et al., 2 0 0 2 ) , Vietnamese Americans (McPhee

Kelly, &

et al., 1997), and Native Hawaiians (Gotay et al.,

American w o m e n

Hoick, 1999),

and

for

Native

(Hodge, Fredericks, Sc

2 0 0 0 ) , have some o f the lowest rates o f Pap

Rodriguez, 1 9 9 6 ) . In addition, similar pro-

smears and breast and cervical cancer testing

grams to test for prostate cancer in men have

of all ethnic groups. Deficits in knowledge,

been developed (Myers et al., 1 9 9 9 ) .

lack o f familiarity, embarrassment, and the

In one o f the most comprehensive reviews

inability to afford services pose barriers to

of the effectiveness of interventions to promote

462

SPECIAL ISSUES mammography among women who underuse

integral t o the design and

these services, Legler and colleagues ( 2 0 0 2 )

effective interventions with minority popula-

execution o f

found that the most effective interventions

tions. These include addressing

issues of

used access-enhancing (e.g., aggressive out-

acculturation and acculturative stress, pro-

reach, removal o f barriers to access) and indi-

viding indigenous support resources, identi-

vidual-directed (e.g., tailored interventions to

fying and sensitively addressing group norms

change high-risk behaviors) strategies, which

and beliefs that might undermine treatment

resulted in an estimated 2 7 % increase in

efficacy, and focusing on cultural strengths

mammography use. The combination of access-

such

enhancing and system-directed interventions—

respect for traditional values and practices.

as family support, religiosity, and

for example, interventions that improve the

In addition, behavioral health care systems

cultural competence o f health care providers,

need to learn the lessons o f the more effective

working to establish satellite facilities in ethnic

public health agencies and work to establish

communities

that

provide

ethnic-specific

meaningful working relationships with the

services—also yielded an impressive 2 0 %

ethnic communities they intend to serve. This

increase in screening. Legler and colleagues

can be accomplished by establishing relation-

concluded that access-enhancing strategies are

ships with community centers and groups,

an important complement to individual- and

with educational and vocational settings, and

system-directed interventions for women with

with faith-based organizations in the commu-

low screening rates.

nity. In addition,

meaningful

relationships

should be established with community leaders and gatekeepers w h o have community crediIMPLICATIONS AND

bility, w h o can act as cultural consultants, and

RECOMMENDATIONS FOR

w h o are able to evaluate and make culturally

BEHAVIORAL MEDICINE

congruent

suggestions for modifying

the

design, content, and implementation o f the T h e r e are a number o f ways in which behav-

planned interventions. Special effort should be

ioral health care providers can help to reduce

made to ensure that relationships formed with

the large and persistent racial/ethnic dispari-

the community are truly collaborative and

ties in health. At the systems level, these

long-lasting and are not exploitative.

current

T o increase the efficacy and use o f behav-

risk reduction interventions, reducing sys-

include expanding and improving

ioral services, interventions should be delivered

tematic barriers that limit health care use

by indigenous providers and in the communi-

and efficacy,

that

ties where the participants reside, and every

increases the cultural sensitivity and compe-

effort should be made to remove or reduce

and providing

training

tency of service providers. At the individual

barriers to participation (e.g., stigma, language,

and group levels, more attention needs to be

financial, child care, transportation). These

given to basic research about behavioral and

barriers can be removed by using community

psychosocial factors that enhance risk or

settings that participants are likely to be famil-

serve as buffers or protective factors t o illness

iar and comfortable with as well as by expand-

in racial/ethnic minority populations. Both

ing outreach by advertising information and

comparison and ethnic-specific studies are

referrals for services o f which patients might be

needed. Knowledge about these risk and pro-

unaware. Treatment participation, adherence,

tective factors, and about possible mediators

and retention may also be improved by subtle

or moderators

but important changes in treatment settings

o f risk and protection, is

Etbnoculturai

Issues

\

(e.g., decorating the setting with cultural sym-

and by hiring consultants and cultural competency

bols) and by providing linkages that facilitate

experts to teach about their communities and

patient access to other community resources as

suggest feedback on the modification of inter-

needed such as vocational, welfare, child care,

vention services. In so doing, special care

and other ancillary services.

should be taken to develop effective provider-

T h e efficacy o f behavioral health interven-

patient communication, to establish and main-

tions is also likely to be improved by increased

tain patient comfort and trust, and to establish

understanding o f h o w informal and natural

provider credibility. Assumptions should not be

support networks enhance or interfere with

made that ethnic minority providers are inter-

professional health service seeking and use.

changeable such that members of one minority

Currently, very little is known about how net-

group are culturally competent in working with

works and mechanisms in indigenous cultures

members o f other ethnic minority

identify persons in need o f services or about

Cultural competence, like any other skill, must

groups.

of

be mastered and not assumed by accident of a

services. Understanding and using indigenous

person's birth. In addition, attention should be

services and culturally sanctioned pathways o f

given to understanding possible cultural differ-

how

they

facilitate

access

and

use

and

ences in the expression and reporting of symp-

enhances the effectiveness o f more traditional

toms and illnesses as well as to identifying

behavioral interventions, for example, using

provider biases that may influence perceptions

Latina

and possible differences in treatments given to

care

often

improves

Consejeras,

the

feasibility

African American lay

counselors, American Indian talking circles, and Native Hawaiian Kokua

patients from different ethnic backgrounds.

groups.

In addition, health education and community outreach services not only are integral to

SUMMARY AND CONCLUSIONS

increasing knowledge about health care issues but also provide information about how to

Ethnic minorities, as compared with Caucasian

obtain those services. O n c e clients c o m e in for

Americans, carry a disproportionate burden of

services, special effort should be made to pro-

morbidity and mortality, receive poorer quality

vide proper education on the importance o f

health care, and have poorer prognoses and

treatment adherence. Obviously, all informa-

treatment outcomes. Although all of the reasons

tion must be provided in the clients' primary

for the racial/ethnic health disparities and the

language, with trained translators being used

disproportionate burden of disease remain to be

when native speakers are not available. This is

identified, the extant literature suggests that bio-

more desirable than using children in the

logical predispositions, behavioral lifestyle,

clients' families as translators

cultural

psychological characteristics, environmental

brokers. This resource is especially important

and psychosocial factors, and health care system

or

for recent immigrants and refugees, who may

factors all contribute to these disparities. The

be unfamiliar with the U.S. health care system

chapter authors (Myers &c Hwang, 2 0 0 2 ) have

or who may be mistrustful or too embarrassed

offered a conceptual framework that provides

to seek services.

testable hypotheses about how these disparate

At the provider level, increasing the cultural

factors might operate to produce these health

competency of behavioral health care providers

outcomes, and they hypothesize that it is the

should be a top priority. This can be accom-

balance between cumulative adversities and

plished by having health care providers take

cumulative advantages over the life course

cultural competency workshops and seminars

that ultimately contributes to differences in func-

463

464

SPECIAL ISSUES tional status and health trajectories. In addition,

services and reduce delayed help seeking and

the literature suggests that the

systematic

poor treatment adherence. Moreover, health

removal of a number o f barriers to help seeking

care providers can also reduce ethnic disparities

(e.g., financial, insurance, language, stigma

in health by improving and expanding on cul-

against mental health services) and a greater

turally sensitive interventions, increasing health

understanding and integration of indigenous

education and outreach efforts, and examining

and informal but culturally congruent services

their own biases when providing services to

may facilitate access and use of professional

culturally different clients.

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Ethnocultural risk factor intervention in low-income women: The North Carolina WISEWOMAN project. Preventive Medicine, 31, 3 7 0 - 3 7 9 . Seeman, T. E., Lusignolo, T. M., Albert, M., & Berkman, L. (2001). Social relationships, social support, and patterns of cognitive aging in healthy, high functioning older adults: MacArthur studies of successful aging. Health Psychology, 20, 2 4 3 - 2 5 5 . Seeman, T. E., Singer, B . H., Rowe, J . W., Horwitz, R. I., St McEwen, B . S. (1997). Price of adaptation-allostatic load and its health consequences: MacArthur studies of successful aging. Archives of Internal Medicine, 157, 2259-2268. Singer, B., St Ryff, C. D. (1999). Hierarchies of life histories and associated health risks. In N. E. Adler, M . Marmot, B . S. McEwen, St J . Stewart (Eds.), Socioeconomic status and health in industrial nations: Social, psychological, and biological pathways (pp. 9 6 - 1 1 5 ) . New York: New York Academy of Sciences. Smedley, B. D., Stith, A. Y . , St Nelson, A. R. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press. Snowden, L. R. (1998). Racial differences in informal help seeking for mental health problems. Journal of Community Psychology, 26, 429—438. Snowden, L. R., St Cheung, F. K. ( 1 9 9 0 ) . Use of inpatient mental health services by members of ethnic minority groups. American Psychologist, 45, 347-355. Takeuchi, D. T., Leaf, P. J . , St Kuo, H-S. (1988). Ethnic differences in the perception of barriers to help-seeking. Social Psychiatry & Psychiatric Epidemiology, 23, 2 7 3 - 2 8 0 . Taylor, V. M., Hislop, T. G., Jackson, J . C , Tu, S. P., Yasui, Y . , Schwartz, S. M., The, C , Kuniyuki, Α., Acorda, E., Marchand, Α., St Thompson, B . (2002). A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. Journal of the National Cancer Institute, 94, 6 7 0 - 6 7 7 . Thomas, K. C , St Snowden, L. R. (2001). Minority response to health insurance coverage for mental health services. Journal of Mental Health Policy and Economics, 4(1), 35—41. U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville, M D : U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Valdez, Α., Banerjee, K., Ackerson , L., 8t Fernandez, M. (2002). A multimedia breast cancer education intervention for low-income Latinas. Journal of Community Health, 27, 3 3 - 5 1 . Williams, D. R. (2000). Racial variations in adult health status: Patterns, paradoxes, and prospects. In N. Smelser, W. Wilson, St F. Mitchell (Eds.), America becoming: Racial trends and their consequences (Vol. 2, pp. 3 7 1 - 4 1 0 ) . Washington, DC: National Academy Press. Williams, D., St Harris-Reid, M . (1999). Race and mental health: Emerging patterns and promising approaches. In A. Horwitz St T. Scheid (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems (pp. 2 9 5 - 3 1 4 ) . New York: Cambridge University Press. Wong, P. T. P., St Ujimoto, V. K. (1998). The elderly: The stress, coping, and mental health. In L. C. Lee St N. W. S. Zane (Eds.), Handbook of Asian American psychology (pp. 1 6 5 - 2 0 9 ) . Thousand Oaks, CA: Sage.

Issues

467

468

SPECIAL ISSUES Yanek, L. R., Becker, D. M., Moy, T. E , Gittelsohn, J . , & Koffman, D. M . (2001). Project Joy: Faith based cardiovascular health promotion for African American women. Public Health Report, 116(Suppl. 1), 6 8 - 8 1 . Ying, Y., &c Hu, L. (1994). Public outpatient mental health services: Use and outcome among Asian Americans. American Journal of Orthopsychiatry, 64, 4 4 8 ^ 1 5 5 . Zhang, A. Y . , Snowden, L. R., & Sue, S. (1998). Differences between Asian and white Americans' help seeking and utilization patterns in the Los Angeles area. Journal of Community Psychology, 26, 3 1 7 - 3 2 6 .

CHAPTER

24

Women's Health Issues CSILLA T.

I

CSOBOTH

n the developed world, women today have

physiological and social role changes during

a longer life expectancy and lower mortal-

the life stages. Viewed from this life course

ity rates than do men at all ages, but epi-

perspective, gender influences life experience,

demiological studies show that women report

psychological development and functioning,

more chronic disease and disability (Khoury &

and the nature o f psychopathology (Zanardi,

Weisman, 2 0 0 2 ) . During the past two decades,

1 9 9 0 ) and so can result in different psycho-

the science o f behavioral medicine has recog-

logical developmental patterns. Three impor-

nized the importance of women's health in

tant

research and in patient care. Knowledge about

adolescence, pregnancy and childbirth, and

the biological, psychological, and social factors

menopause.

stages are discussed in this section:

influencing women's health has grown considerably, and efforts to change the thinking o f the scientific community and the general public

Adolescence

have led to a better understanding o f women's

T h e period o f adolescence is well known for

health. T h e enhancement of research in this

the biological, social, and cognitive changes

field resulted in more sensitive health care and

in both genders. T h e transition into adulthood

the construction o f specific preventive inter-

is usually a positive experience for young

ventions that serve to improve the health status

women, but in some the biological and psy-

of women worldwide.

chosocial changes increase the risk for certain psychopathologies, for example, the development o f depression or eating disorders. Y o u n g

LIFE C O U R S E PERSPECTIVES

women are at great risk for harmful health behaviors that influence their psychological

Although it is impossible to examine the issue

and physical well-being, including smoking,

of women's health in full detail in this chapter,

binge drinking, illicit drug use, negative conse-

an overview of special issues t o be considered

quences o f sexual behavior, and victimization.

during everyday clinical work with w o m e n is

Gender differences in psychosocial factors of

provided. Specifically, women's physical and

health-damaging behavior are already seen

mental health is influenced substantially by

during adolescence; for example, alcohol abuse 469

SPECIAL ISSUES

470

has a stronger connection to depression in girls

which might result in psychiatric disorders, is

than in boys (Clark et al., 1 9 9 7 ) .

an important task o f mental health profes-

There is evidence that emotional functional

sionals and can be achieved by developing or

are significantly

enhancing health protective factors at an early

more frequent among young females than

age. Y o u n g w o m e n need to be taught how to

among young males. In one study, female uni-

cope with different stressors, for example,

versity students were more likely to see their

functioning in multiple roles and learning to

disorders

and

symptoms

futures as hopeless and reported frequent use

resist peer or social pressure inducing them to

of

participate in harmful health habits that they

emotionally oriented coping strategies,

namely eating, drinking, and/or taking drugs

most likely will experience later on in life.

in difficult life situations. Likewise, a close relationship between different self-destructive behavioral forms was found among women.

Pregnancy and Childbirth

Smoking was closely correlated with other harmful

The transition to parenting for women and

health behaviors, namely alcohol

men is usually a normal biological task, but

consumption, sedentary lifestyle, consumption

women frequently spend a great deal of time

of high-cholesterol foods, and little sleep.

involved in caregiving and so experience many

Women

who

exercised regularly

had

a

biological and psychosocial changes during

reduced risk for suicide attempts and using

this period o f time. A woman's experience of

emotional coping strategies and also had more

pregnancy and childbirth will most likely

goals in life. In contrast, the correlation

affect her role as a mother, her perceptions of

between self-destructive behavior and psycho-

the child and herself, and her relationship with

logical symptoms was not significant among

her partner

young men (Kopp & Skrabski, 1 9 9 5 ) .

between the discrepancy o f a person's actual

Adolescence is one of the most vulnerable

(Shearer, 1 9 8 3 ) . A correlation

self-concept and his or her ideal self-concept

periods o f development. It is also a phase o f

and the amount of post-birth distress has been

constant change, and young women are more

reported (Alexander & Higgins, 1 9 9 3 ) . F o r

sensitive to conflict or change in the family

example, parents with a large discrepancy

environment. Studies have shown that

between h o w they saw themselves and what

the

timing o f pubertal development is influenced

they perceived as an

by

structure.

increases in post-birth distress relative to those

Maturation o f young women has been found

parents with a small discrepancy between

to be closely correlated with the home atmo-

actual and ideal (Alexander & Higgins, 1 9 9 3 ) .

family conflict and

family

ideal self

suffered

sphere, with earlier maturation being predicted

Studies have shown that more negative

by conflict and lack of approval in families

psychosocial outcomes appear to be associated

with both parents living at home (Graber &c

with cesarean section births than with vaginal

Brooks-Gunn, 1 9 9 8 ) . Earlier onset o f menar-

deliveries (DiMatteo et al., 1 9 9 6 ) . Cesarean

che has been reported in young women who

section not only decreases the positive experi-

live in households where there is parental con-

ence of giving birth to a child but also may have

flict or where the mother is the only parent

certain negative psychological outcomes. T h e

(Moffitt, Caspi, Belsky, & Silva, 1 9 9 2 ) . Protective health factors o f adolescence

postponed

encounter between mother

and

child may be a consequence o f breast-feeding or

include tight social network, high social sup-

bonding and may result in less positive mater-

port, development o f positive coping strate-

nal

reactions

to

the

newborn

(Cranley,

gies, resiliency, and hardiness. T h e prevention

Hedahl, & Pegg, 1 9 8 3 ) . W o m e n who experience

of the harm caused by psychological distress,

cesarean section or other interventions need to

Women's

Health

471

be given additional psychological support to

are influenced by personality, coping styles,

cope with difficulties arising after childbirth.

mood history, and exposure to a greater or

Substance use during pregnancy presents

lesser degree o f life stressors (Polit & L a R o c c o ,

Substance-

1 9 8 0 ; Greene & Cooke, 1 9 8 0 ) . Positive or

dependent women experience feelings o f low

negative expectations o f menopause are corre-

self-esteem, lower expectations for themselves,

lated with the number o f symptoms experi-

unique

problems

for w o m e n .

and higher levels o f anxiety than do men

enced; negative expectations were associated

(Jarvis & Schnoll, 1 9 9 5 ) . Pregnant, substance-

with more symptoms, whereas positive expec-

abusing women commonly present with poly-

tations were associated with fewer symptoms

substance abuse (Fischer, Bitschnau, Peternell,

(Matthews, 1 9 9 2 ) . Perception o f menopause is

Eder, & Topitz, 1 9 9 9 ) . They experience spe-

ethnically and culturally related; for example,

cific health problems, such as sexually trans-

Japanese women are far less likely to experi-

mitted diseases, malnutrition, and vitamin and

ence hot flashes than are women living in the

mineral deficiencies, but fail to acquire treat-

Western world (Lock, 1 9 9 3 ) . Research has

ment for their problems, and many do not

also shown that the menopausal experience

present to medical facilities for prenatal care.

may be influenced, either directly or indirectly,

Psychiatric comorbidities, mainly depression

by socioeconomic status. Lower educational

and chronic anxiety, and social problems,

level, lack of employment outside of the home,

chaotic familial backgrounds,

abusive

and lower socioeconomic status are associated

relationships are frequently reported by drug-

with increased severity or longer duration o f

and

abusing women. W o m e n who are convinced

menopausal

to attend prenatal care in multidisciplinary

McKinlay, 1 9 9 7 ) . Occurrence o f mood and

collaboration with

psychiatrists, gynecolo-

sleep disturbances and somatic symptoms has

gists, obstetricians, social workers, and psy-

also been found to be predicted by social class

chotherapists can reduce substance intake and

and employment status.

improve the health situation o f the fetus (Boer, Smit, VanHuis, & Hogerzeil, 1 9 9 4 ) .

symptoms

(Avis, Crawford, &c

Up to 1 0 0 symptoms have been attributed to menopause; depression, anxiety, joint pain, headaches, insomnia, loss o f sexual interest, hot flashes, and vaginal atrophy have been

Menopause

perceived as the

"menopausal

syndrome"

In the developed countries, menopause gen-

(Derry, Gallant, & W o o d s , 1 9 9 7 ) . Research

erally is viewed by women as a negative phase

has suggested that the prevalence o f depres-

of life when symptoms and loss o f well-being

sion in w o m e n is substantially higher during

and function are bound to occur (Hvas, 2 0 0 1 ) .

menopause than during other phases o f life,

Menopause involves biological and psycholog-

possibly due to the changing hormone levels

ical changes and can be an important develop-

(Kaufert, Gilbert, & T a t e , 1 9 9 2 ) . Estrogen is

mental phase that is influenced by specific

capable o f modulating serotonergic function

sociocultural factors

(Dennerstein,

1996).

in the central nervous

system, and

this

Evidence shows that women at age 5 0 years

interaction may explain the increased vulner-

are generally in good health and experience

ability to

emotional stability as well as positive personal

during menopause (Joffe 8c Cohen, 1 9 9 8 ) .

development (Fodor & Franks, 1 9 9 0 ) . Studies

Population-based

during past decades have shown that

the

failed to find a co-occurrence o f symptoms.

duration, severity, and impact of symptoms

M o s t symptoms, other than hot flashes, night

affective disorders studies,

in

women

however,

have

vary by individuals as well as by populations.

sweats, vaginal atrophy, and insomnia, do

Preconceived attitudes concerning menopause

not

increase

in

frequency

during

the

472

SPECIAL ISSUES menopausal years (Ballinger, 1 9 9 0 ) . Recent

with

studies have shown that the reductions in

modeling, learned coping strategies, and sever-

estrogen during menopause do not influence

ity of the stressor have an interlocking effect

mental well-being (Slaven &

on health.

Lee,

1998);

therefore, the occurrence o f depression can-

stress-related

Research

has

disorders.

shown

that,

Personality,

in general,

not be attributed to hormonal deficiency.

w o m e n report higher distress and lower qual-

Epidemiological studies have shown mainly

ity o f life than do men (Gamma &C Angst,

that psychosocial stressors were more likely

2 0 0 1 ) . W o m e n may also experience different

t o predict depression. Such stressors may

types o f stressors than do men. W o m e n are

include existent health problems, responsibil-

more vulnerable to specific life events causing

ity for the care o f relatives, negative attitudes

distress such as physical and sexual abuse, sex-

toward aging, and history o f previous depres-

ual discrimination, distorted body image, and

sion (Woods & Mitchell, 1 9 9 6 ) .

living with multiple roles in life. M e n , on the

In summary, menopause can be regarded as a natural process with symptoms that may vary

other hand,

experience stress from

high-

responsibility jobs or hazardous occupations

individually. Unfortunately, it is often viewed as

( O ' L e a r y S c Helgeson, 1 9 9 7 ) . Historically,

a medical problem, labeling experiences as

w o m e n have suffered more from relationship

symptoms and illness instead o f underlining the

stressors and have been more vulnerable to

positive aspects such as the possibility for inner

partnership or marital dissatisfaction. Parent

growth and the strengthening o f inner wisdom

role stress and the quality o f the parent-child

and power

relationship seem to cause greater distress for

(Hvas, 2 0 0 1 ) . Midlife distress

occurring at the time of menopause can be

women

attributed to personal, familial, or social events

w o m e n generally are more socialized to feel

that occur more frequently around the time o f

responsible for their families (Simon, 1 9 9 2 ) .

menopause. Counseling women is important.

than for men, p r o b a b l y

because

In women, marital stress has been shown to

Counseling must not only address medical risks

have a significant effect

and physical symptoms but also help women to

health. W o m e n admitted to the hospital with

on cardiovascular

overcome life event stressors, through which

an acute coronary event and w h o reported

women's inner resources are strengthened, so as

marital stress at baseline had a worse progno-

to avoid medicalization and disempowerment

sis than did those w h o did not report marital

(Hollnagel & Malterud, 1 9 9 5 ) .

stress. Moreover, women with severe marital stress had a threefold greater risk for a new coronary event than did those not experiencing

PSYCHOSOCIAL FACTORS INFLUENCING WOMEN'S HEALTH Stress and Coping

marital stress (Orth-Gomér e t a l . , 2 0 0 0 ) . In contrast to men, work stress did not have an effect on the recurrence of a new coronary episode among women. T h e experience of stress and the impact it has on health are

Stress is an everyday phenomenon that influ-

shown t o be gender specific; therefore, inter-

ences the lives o f women and men and affects

ventions designed to train women to cope with

each person differendy. Learning to cope adap-

stress must take these differences into account.

tively with everyday stressors is important for

Ways o f coping with specific stressors are

mental health in both genders. T h e amount o f

divided into problem-focused coping (i.e., chang-

stress that one can withstand, and the length o f

ing the actual stressful situation) and emotion-

time that a person experiences a stressor, is an

focused coping (i.e., attempting to palliate the

important factor to take into consideration

reaction to stress) (Lazarus & Folkman, 1984).

Women's Adaptive or maladaptive coping mechanisms are

life events and chronic strain

incorporated into a person's lifestyle during

McLeod,

Health (Kessler &

1 9 8 5 ) . W o m e n more

frequently

youth through learning and modeling from

perceive their spouses as less supportive, and

parents and peers. Strategies for coping with

this can lead to strain in relationships. A

stressful life events depend on personal character,

Swedish prospective study showed that men

relationship characteristics, and the nature o f the

usually perceive their spouses as the primary

stressor. Coping style, whether positive or nega-

providers of social support, whereas women

tive, influences health as well as the outcome of

typically name close female relatives as the per-

an illness. W o m e n have been found to use more

sons giving them support (Karasek, Baker,

expressive ways of coping (e.g., expressing feel-

M a r x e r , Ahlbom, & Theorell, 1 9 8 1 ) . Given

ings, txirning to their social support network),

women's critical need for emotional functional

whereas men use more rational ways of coping

support, the development o f community social

with stress (e.g., exercising). Coping with stress

support systems for women could lead to the

through the use o f social support seems to be

prevention o f psychological distress.

more important in women (Thoits, 1 9 9 1 ) . Ruminating over stressful events also seems to be a more common coping mechanism in women

Multiple Roles

than in men; men usually distract themselves

During the past decade, numerous studies

from the stressful situation (Nolen-Hoeksema,

have shown the positive effects o f multiple-role

1 9 8 7 ) . One can conclude that there are some

involvements on women's physical and mental

specific differences in coping strategies between

well-being (Barnett &C Baruch, 1 9 8 5 ) . T h e

the genders and that prevention of mental disor-

more roles a woman fulfills, the better physical

ders, mainly depression, can be targeted by

health, higher life satisfaction, and less depres-

developing more adaptive ways o f coping

sion she may experience. Multiple roles are

among women.

beneficial, but the quality and combination of roles can sometimes have a negative influence on a woman's life. M a n y roles drain energy,

Social Support

and this may result in conflict and have a neg-

Both the quality and quantity of a person's

ative influence on well-being (Barnett, 1 9 9 3 ) .

social network define perceived social support.

Family roles are regarded as women's core

T w o types o f social support measures are usu-

roles, and success in the roles o f wife and

ally distinguished, namely structural,

charac-

mother has been considered fundamental for

terized by the quantity and structure o f the

psychological well-being and thought to be less

reflecting

stressful than the worker role. Wife roles can

emotional, instrumental, and informational sup-

often be in conflict with mother roles, and this

port and social companionship (Wills, 1 9 9 8 ) .

can lead to distress. In today's modern society,

Social support has been recognized as a major

declaring the distribution o f roles between

social network, and functional,

protective factor for physical illness (e.g.,

both genders, but not depriving either from its

cardiovascular disease) as well as for mental

natural or assumed roles, may actually assist

disorders.

women and men in participating in both

W o m e n are extremely vulnerable to psychological distress if their social support system

family and work lives without experiencing a great degree o f role stress.

is inadequate. Perceived high emotional sup-

Studies show that women sometimes use

port is directly associated with better physical

psychoactive substances to ameliorate anxi-

usually

eties, depression, and feelings o f worthlessness

decreases health-damaging effects of negative

resulting from gender role expectations that

and

psychological health, and

it

474

SPECIAL ISSUES are difficult for them to meet (Bollerud, 1 9 9 0 ;

among women. Socioeconomic inequalities

R o o t , 1 9 8 9 ) . Results o f several studies have

result in disparities in health and determinant

found inconsistencies regarding family roles.

factors o f income inequality; for example, an

Some studies have found that there are advan-

increase in the number

tages for married women (e.g., Verbrugge,

households and an increase in the number of

o f female-headed

1 9 8 2 ) , whereas others have shown that life sat-

women in the j o b market can intensify this

isfaction and well-being are just as high or

effect on women's health. Psychosocial health

higher among single and employed women

determinants, such as j o b characteristics, j o b

(Nadelson &c Notman, 1 9 8 1 ) . Multiple roles

strain, low level o f control at work, high

clearly improve self-esteem, satisfaction with

demands, limited personal resources, frustra-

life, and well-being if the roles complement

tion, and discrimination in the workplace

each other, that is, if the roles result in the feel-

(Moss, 2 0 0 2 ) , all can lead to distress, and this

ing o f being successful both personally and

can be deleterious to health when experienced

financially.

chronically.

T w o hypotheses have been constructed to

Women

commonly work

in jobs

that

explain the ways in which social mechanisms

involve high psychological demands and offer

influence health differently between the gen-

low

ders. T h e differential

exposure

levels o f control (Karasek & Theorell,

hypothesis

1 9 9 0 ) , and this low level of control can lead to

posits that women have higher levels o f

cardiovascular disease, sickness, absence from

demands and obligations in their social roles

work, and psychological distress (Walters

and have fewer coping resources to help them

et al., 2 0 0 2 ) . Nevertheless, women working in

solve arising problems and that this leads

paid jobs generally have better health status

them to complain more about ill health than

than do full-time homemakers (Khlat, Sermet,

do men. T h e differential

vulnerability

hypoth-

& Le Pape, 2 0 0 0 ) . W o m e n working full-time

esis posits that women have stronger reactions

outside their homes are usually responsible for

to life events or stressors that men also experi-

domestic labor, sometimes leading to role

ence and that this increased reactivity and low

strain. In studying the influence of family,

levels o f coping resources lead to ill health

work, and material circumstances on health, it

(Walters, M c D o n o u g h , &c Strohschein, 2 0 0 2 ) .

was found that ill health among women was

Although the mechanisms o f gender differ-

subject not only to employment status, occu-

ences in ill health remain unresolved to this

pational class, and housing tenure (as found

day, it is obvious that social support (from

among men) but also to marital and parental

both family and society) and the development

status (Arber, 1 9 9 1 ) . Recently, a study found

of adaptive coping mechanisms should help

that the most important predictors o f good

women to overcome distress arising from mul-

health among women were being in the high-

tiple roles and that this, in turn, should lead to

est income category, working full-time, caring

better health status o f women.

for a family, and having high levels of social support (Denton & Walters, 1 9 9 9 ) .

Socioeconomic Factors

Health is determined by the coexistence of biologic, genetic, psychological, and social

It is well known that socioeconomic status

factors. Social relations, such as discrimination,

significantly influences physical and mental

exclusion, and exploitation, have an indirect

health. W o m e n around the world live in

influence on the health o f women, especially

greater poverty and have lower education and

those w h o are part o f a minority ethnic group,

employment status than do men; therefore,

through economic and social well-being. In

the impact o f socioeconomic factors is greater

studying ethnic groups, it was found

that

Women's

Health

475

health differences between the genders were

disorders. Secondary and tertiary prevention o f

accentuated, but after controlling for educa-

debilitating disability in life is crucial so as to

tional level and employment status, members

allow women to lead fulfilling lives.

o f minority groups were in equally good health as those not belonging to ethnic minority groups (Cooper, 2 0 0 2 ) .

Depression

Self-ratings of health and diseases are reli-

Depression is the second most c o m m o n

able predictors o f morbidity. A recent study

disease worldwide, with a lifetime prevalence o f

showed that personal income inequalities were

1 5 % and perhaps as high as 2 5 % for women

connected with differences in self-rated morbid-

(Kaplan & Sadock, 1 9 9 8 ) . W o m e n experience

ity in women but not as significantly as in

longer episodes of depression, symptoms can be

men. M e n were more susceptible to income

more severe, and recurrence is more common.

inequality or to the loss o f hierarchy status,

T h e occurrence o f depression during childhood

which coexists with lower socioeconomic status.

in both genders is similar, but the onset o f

Nevertheless, depression was a more important

depression is found to be earlier in women,

predictor o f self-rated morbidity than were

and depression is already found twice as fre-

socioeconomic deprivation factors. This indi-

quently in adolescent girls as in adolescent boys

cates that socioeconomic deprivation predicts

(Angold & Worthman, 1 9 9 3 ) . T h e gap in the

morbidity much more significantly if it is asso-

prevalence o f depression starts to widen during

ciated with depressive symptomatology (Kopp,

adolescence; young w o m e n

Skrabski, & Szedmâk, 2 0 0 0 ) .

already experience depressive symptoms more

It can be concluded that socioeconomic

in their teens

frequently than do their male counterparts.

factors play an important role in w o m e n ' s

Depressive

health but that w o m e n are at greater risk for

among women with low socioeconomic status,

symptoms

are more

common

these effects if they are suffering from depres-

women living in poverty, and women experi-

sive symptoms. Prevention programs should

encing role strain, marital discord, and physical

generally

or psychological abuse. Research studying the

minority women and w o m e n w h o are at risk

relationship between health-damaging behav-

for, or suffering from, depressive symptoms.

ior and depression in women has shown that

include specific target

groups,

binge drinking is closely correlated with depression (Dunne, Galatopoulos, & Schipperheijn, WOMEN'S MENTAL HEALTH

1 9 9 3 ) and that daily or weekend drinking is associated with low self-esteem (Turnbull &

There is a growing awareness o f the increasing burden o f disability associated with mental ill-

Gomberg, 1 9 8 8 ) . W o m e n are often vulnerable to depressive

ness (U.S. Department o f Health and Human

symptoms at certain periods o f the reproduc-

Services, 1 9 9 9 ) , resulting in decreased func-

tive cycle. Depressive symptoms

tioning and well-being. Depressive symptoms

experienced by w o m e n before the onset o f

and anxiety disorder are among the most c o m -

menstruation, after giving birth to a child, or

can

be

mon health problems. Depression and anxiety

at the time o f menopause. T h e changes in

are important women's health issues because

h o r m o n a l levels alone do not explain the true

these disorders occur nearly twice as often in women than in men. T h e early onset, chronic, and recurrent nature o f depression and anxiety impede the lives o f women, who are unable to function as whole humans due to their

cause o f the depressive symptoms.

Most

likely, psychosocial and biological factors both contribute to the whole clinical picture. Premenstrual syndrome (PMS) is a condition that presents during the luteal phase of the

476

SPECIAL ISSUES menstrual cycle, a few days before menstruation.

factors for postpartum depression (O'Hara,

Investigations o f P M S have not been able to

Schlechte, Lewis, & Varner, 1 9 9 1 ) .

find conclusive evidence of hormonal differ-

T h e prevention and treatment o f depres-

ences (i.e., in estrogen and progesterone) or

sion warrants the charting o f biological and

changes in the

psychosocial factors for w o m e n .

neurotransmitter

system's

Women

response to gonadal hormones. Cultural and

are predisposed to unique stressors that can

psychological factors resulting in P M S must

develop into depression, and these factors

also be taken in account when studying the

need to be addressed by screening for individ-

etiology o f the disorder. According to cognitive

uals at risk. School, community, and work-

theory, distress can be induced by the physical

place

symptoms themselves and by the meaning

specifically to prevent depressive symptoms

given to these symptoms by women. M a n y

and enhance protective factors can reduce suf-

times, the symptoms mean a lack of control of

fering from major depression and improve the

mental

health

programs

designed

a woman's own body and may result in depres-

quality o f life o f women predisposed to this

sion and anxiety. A controlled trial of cognitive-

debilitating disorder.

behavioral therapy (Blake, Salkovskis, Gath, Day, & Garrod, 1 9 9 8 ) for premenstrual syndrome was associated with significant improvement of symptoms, depression, and associated impairments.

Anxiety Disorders T h e prevalence o f anxiety disorders is nearly three times higher in w o m e n than in

Postpartum blues and postpartum depres-

men. Anxiety disorders often are

undiag-

sion are also part o f the m o o d disturbances

nosed for years, and w o m e n suffer in all func-

spectrum connected with hormonal changes.

tions o f their lives. T h e symptoms of anxiety

Postpartum blues usually presents 3 to 5 days

affect women's families and close relation-

after delivery and lasts for several days or a few

ships, resulting in overdependency, conflict in

weeks. Symptoms include dysphoria, crying

relationships, substance abuse, and/or domes-

spells, clinging dependence, irritability, and

tic violence. W o m e n with anxiety disorders

emotional lability and occur in 2 0 % to 4 0 % of

are sometimes blamed for their symptoms

women w h o give birth. Postpartum blues can

and regarded as not being strong enough to

be explained by either sudden hormonal with-

control the symptoms, and the reduction o f

drawal occurring after delivery or by the acti-

self-esteem worsens the symptoms o f anxiety.

vation of oxytocin, which is needed for the

Sensitivity to anxiety is thought to influence

development o f mother-infant

attachment

perception o f health. W o m e n with high anxi-

(Miller, 2 0 0 2 ) . W h e n mothers are supported

ety sensitivity reported more severe menstrual

by the environment and experience low levels

symptoms, more preoccupation with

of stress after childbirth, the neurophysiologi-

sensations,

cal changes promote attachment, but depres-

toward illness (Sigmon, Dorhofer, R o h a n , &

and

more

negative

body

attitudes

sion can result when mothers experience low

Boulard, 2 0 0 0 ) . These women, after perform-

levels of support and high levels o f stress

ing a rumination task, also showed greater

(Miller & Rukstailis, 1 9 9 9 ) . Postpartum blues

skin conductance response magnitude than

can lead to postpartum

did those with low anxiety sensitivity. W o m e n

depression, which

occurs in 1 0 % to 2 0 % of women in the United

suffering from panic disorder also reported

States within 6 months o f delivery. A history o f

more severe menstrual symptoms, higher anx-

major depression, a history o f P M S , the pres-

iety sensitivity, state and trait anxiety, fear o f

ence of a psychosocial stressor, and low levels

body sensations, and illness-related concerns

of social support all can act as predisposing

than did controls (Sigmon et al., 2 0 0 0 ) .

Women's

Health

477

W o m e n suffering from anxiety disorders are

was found to be lower in young (15-year-old)

at a greater risk for alcohol or other substance

women suffering from severe primary dysmen-

abuse. Agoraphobia and social phobia have

orrhea, but this loss o f self-esteem is compen-

to frequently precede alcohol

sated at about age 2 5 years by the development

use disorders (Vogeltanz 8c Wilsnack, 1 9 9 7 ) ,

of more achievement-oriented and aggressive

implying that alcohol or other substances are

attitudes (Holmlund, 1 9 9 0 ) .

been found

used as self-medication to alleviate the symp-

These results imply that social support

toms o f anxiety and to restore function to a cer-

systems o f w o m e n

tain extent. Consequences o f anxiety disorders

dysmenorrhea should be evaluated and also

seeking treatment

for

in women highlight the importance o f identify-

should be screened for depression and anxiety

ing women suffering from anxiety early and

when disrupted social support systems are

offering them effective treatment to prevent

found. Treatment interventions include relax-

further functional and health impairment.

ation alone or with imagery, effectively reducing resting time in spasmodic dysmenorrhea (Amodei, Nelson, Jarrett, & Sigmon, 1 9 8 7 ) .

SPECIAL ISSUES

Chronic Pelvic Pain

Dysmenorrhea

The relationship o f primary chronic pain

Dysmenorrhea, or painful menstruation, is the

most

common

gynecologic

disorder

and psychological factors has been studied during the past two decades, but inconclusive data

a m o n g young w o m e n , with a prevalence o f

do not clear the picture. T h e prevalence rates o f

6 0 % to 9 3 % (Banikarim, C h a c k o , & Kelder,

chronic pain range from as low as 5 % to as

2 0 0 0 ) . A variety o f symptoms, such as vomit-

high as 8 7 % (Réthelyi, Berghammer, &c Kopp,

ing, fatigue, back pain, and headaches, occur

2 0 0 1 ) , and depression has been shown to be

during the experience o f pain. Dysmenorrhea

more prevalent among chronic pain patients.

shows a strong correlation with premenstrual

Chronic pelvic pain, or pain experienced in the

symptoms but is not associated with emo-

area o f the pelvis for more than 6 months, is the

tional

(Freeman,

cause o f 1 0 % of all gynecological outpatient

Rickels, &C Sondheimer, 1 9 9 3 ) . Studies mea-

visits, 4 0 % o f all laparoscopics, and 1 0 %

suring

that

to 1 5 % of all hysterectomies (Gelbaya & El-

women with dysmenorrhea show enhanced

Halwagy, 2 0 0 1 ) and is an important women's

pain perception (e.g., Granot, 2 0 0 1 ) .

health issue.

distress pain

in

adolescents

threshold

have

shown

Research studying the psychosocial back-

T h e etiology of chronic pelvic pain, even

ground factors o f dysmenorrhea has found

after laparoscopy, remains unknown in a sig-

that dysmenorrheic women report less social

nificant proportion o f patients. Some connec-

support, characterized by inadequate and geo-

tion has been found between high scores on

graphically distant

(Whittle,

measures o f neuroticism, but other studies

Slade, & Ronalds, 1 9 8 7 ) . A disrupted social

have found no connection between chronic

support system moderates the

pelvic

relationships

relationship

pain

and

anxiety

or

depression

between distress and menstrual pain, and these

(Wilkie & Schmidt, 1 9 9 8 ) . Childhood trau-

women complained o f more symptoms than

matic events are also hypothesized to be

did those whose social network was intact

closely associated with chronic pain, and high

(Alonso & Coe, 2 0 0 1 ) . Depression and anxi-

incidences o f sexual abuse (Toomey, Hernandez,

ety were also found to be strongly associated

Gittelman, S c Hulka,

with menstrual pain. In addition, self-esteem

abuse (Rapkin, Kames, D a r k e , Stampler, Sc

1 9 9 4 ) and physical

SPECIAL ISSUES

478

Naliboff, 1 9 9 0 ) were found in chronic pelvic

life satisfaction, and more self-blame (Greil, 1 9 9 7 ) . In one study, nearly half of the women

pain patients. tremendous

reported that infertility was the worst experi-

impact on the lives o f women who suffer from

ence in their lives (Freeman, Boxer, Rickels,

this disorder. Uncertainty and anxiety con-

Tureck, Se Mastroianni, 1 9 8 5 ) . W o m e n are

Chronic pelvic pain has a

cerned with the pain plays an important role

also known to seek treatment for infertility

in

more often than are men; therefore, women

functional

impairment.

Many

times,

women are confronted with a lack of concern

also experience the distress of medicalization

and understanding or disbelief expressed by

of their problems. Psychological distress is

(Savidge, Slade,

usually caused by undiagnosed (or idiopathic)

Stewart, Sc Li, 1 9 9 8 ) . Verbal reassurance by

infertility; otherwise, the diagnosis seems to be

health care professionals

health care workers that the cause for the pain

unrelated to psychological distress (Shatford,

cannot be found does not alleviate the distress

Hearn, Yuzpe, Brown, Sc Casper,

experienced by women with this disorder.

Pregnancy has been found to decrease the level

Psychological treatment o f chronic pelvic pain of unknown cause should, after careful

1988).

of psychological distress in infertile women (Benazon, Wright, Sc Sabourin, 1 9 9 2 ) .

medical examination, include behavioral ther-

It can be concluded that infertile women

apy techniques, such as operant conditioning,

are clearly affected by their feelings of inade-

to decrease the frequency o f illness behavior

quacy to fulfill a parental role and that mental

and to strengthen health-promoting behaviors.

health professionals often need to identify and

Relaxation techniques are also recommended

treat the distress in these women. Evidence

to decrease muscle tension in the pelvic area.

shows, however, that the level of distress expe-

Cognitive therapy,

rienced by infertile women is not higher than

by treating

depressive

symptoms and anxiety accompanying chronic

that experienced by fertile women.

pain, is also an effective method o f treatment (Wilkie Sc Schmidt, 1 9 9 8 ) .

Victimization of Women

Infertility

A large percentage o f women all over the be

world are victims o f sexual, physical, and/or

attributed to either partner (Guidice, 1 9 9 8 ) .

psychological abuse. Abuse can be perpetrated

About

1 0 % o f infertility

cannot

Researchers hypothesize that infertility has

by parents, close relatives, intimate partners,

psychological causes (known as the

employers, or coworkers. Both physical abuse

psychohas

and sexual abuse have serious effects on

psychological consequences (known as the

physical and mental health, with domestic vio-

genic

hypothesis)

or that

infertility

hypothesis).

lence and rape significantly causing morbidity

Numerous studies have provided evidence

and mortality among women ages 15 to

that infertility does not have significant psy-

4 4 years worldwide, accounting for 6 % of the

chological causes (Greil, 1 9 9 7 ) .

total disability-adjusted life years o f healthy life

psychological

consequences

The experience o f infertility differs between

lost and 9 0 % of the morbidity associated with

the genders. Infertility is a more stressful expe-

disability from injury (World Bank, 1 9 9 3 ) .

rience for women than it is for men, and there

Unfortunately,

abused women rarely seek

are specific psychological measures that are

health care for their health complaints, and

more common among women, namely lower

when they do seek such help, they are secretive

self-esteem, more depressive symptoms, lower

about the causes o f their symptoms.

Women's Violence against women causes significant

Health

479

SUMMARY AND CONCLUSIONS

psychological distress, which most frequently is a direct consequence o f their experience o f

Health issues concerning w o m e n highlighted

abuse. Across all cultures, battered women

in this chapter underline the necessity o f

who are abused by their partners are charac-

health p r o m o t i o n

terized by low self-esteem, increased insomnia,

interventions designed specifically for women.

hypervigilance, an augmented startle response,

Interventions should take into account health

a sense of disorder, and unhappiness (Fishbach

problems arising in minority groups, in the

and

disease

prevention

& Herbert, 1 9 9 7 ) . Research has shown that

lower socioeconomic strata, among women

battering may subsequently result in longlasting

with lower education, and among women

psychiatric

w h o are victims o f violence.

morbidity

(Mullen,

Romans-

Clarkson, W a l t o n , & Herbison, 1 9 8 8 ) and

Especially important is the primary preven-

that abuse is considered to be a significant

tion of mental health disorders, targeting young

predictor o f the development o f lifelong men-

women and teaching them skills o f adaptive

tal health problems (Kilpatrick, Best, Veronen,

ways of coping, hardiness, and resiliency. Such

Villeponteaux, & Ruff,

Psychiatric

protective factors are important to enable young

morbidity, in association with sexual or physical

women to withstand peer pressure for health-

abuse, includes depression (Goldberg, 1 9 9 4 ) ,

damaging behavior, to prevent the disabling

posttraumatic stress disorder (Roth, Newman,

effect of chronic distress, and to take responsibil-

Pelcovitz, V a n Der Kolk, & Mandel, 1 9 9 7 ) ,

ity for their own health. Special attention needs

substance use disorders (Schafer, Schnack, &

to be given to women who are at high risk

Soyka, 2 0 0 0 ) , dissociative symptomatology

for

(Brunner, Parzer, Schuld, Sc Resch, 2 0 0 0 ) , and

example, women living in homes with parental

dissociative

identity

1985).

disorder

( H o c k e Sc

Schmidtke, 1 9 9 8 ) . A major task for medical professionals is to

developing certain mental disorders, for

conflict, women experiencing sexual or physical abuse, and women who drop out of school early. Improving

social support

systems

for

identify and give proper treatment to abused

women seems to be a crucial issue in prevent-

women. Health care providers need to be edu-

ing psychological distress and disorder as well

cated on h o w to include questions on batter-

as illnesses resulting from chronic stress.

ing and sexual abuse while taking patients'

Hotlines readily available for women in crisis

histories, h o w to react to an emerging prob-

and counseling services in schools, communi-

lem, and h o w to determine the type of treat-

ties, and workplaces are important ways of

ment to which w o m e n should be referred.

giving support to w o m e n in need. But most

Battered women are in great need o f psycho-

important o f all is raising awareness in the

logical interventions, social support, and sup-

community and among health professionals

port from culture and society. Society also has

about not only the physical but also the psy-

to be informed about the problems arising

chosocial aspects o f physical and mental ill-

from battering and needs to adopt an altitude

ness. Raising such awareness may eventually

of not tolerating violence in the culture.

result in better health among women.

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481

482

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CHAPTER

Issues With Geriatric BARRY

ADAM

T

A.

P.

EDELSTEIN, ANDREA

he U . S . older adult population

Populations

K.

S P I R A , A N D L E S L E Y P.

10 25

SHREVE-NEIGER,

KOVEN

is

older adults), hypertension

growing at a remarkable rate. There

impairments

were 3 5 million individuals age 6 5

cataracts

years or over in the United States in 2 0 0 0

(30%),

(17%),

heart

(36%),

hearing

disease

(27%),

orthopedic

impairments

( 1 8 % ) , sinusitis ( 1 2 % ) , and diabetes ( 1 0 % )

(Hetzel & Smith, 2 0 0 1 ) . This represents 1 2 . 4 %

(Administration on Aging, 2 0 0 1 ) . In 1 9 9 9 , older

of the U.S. population and a 1 2 % increase from

adults were hospitalized four times as many

1 9 9 0 . In 2 0 0 0 , there were 1 8 . 4 million individ-

days as were those under age 6 5 years (1.6 vs.

uals who were between ages 6 5 and 7 4 years,

0.4 days) and remained hospitalized longer (6.0

and there were 1 2 . 4 million individuals between

vs. 4 . 1 days). Moreover, community-dwelling

ages 7 5 and 8 4 years. Those individuals age 8 5

older adults had more contact with their physi-

years or over (i.e., the oldest old) numbered 4 . 2

cians than did younger individuals ( 6 . 8 % vs.

million and represented the most rapid growth

3 . 5 % ) (Adiriinistration on Aging, 2 0 0 1 ) .

of the older adult population (Hetzel & Smith,

The mental health problems o f older adults

2 0 0 1 ) . The number o f oldest old increased 3 8 %

also invite attention, with estimates o f approxi-

during the

there will be

mately 2 5 % o f older adults meeting criteria for

approximately 7 0 million individuals age 6 5

a mental disorder (Gatz, Kasl-Godly, & Karel,

1990s.

By 2 0 3 0 ,

years or over, twice the number reported in

1 9 9 6 ) . In addition, comorbid health and men-

2 0 0 0 (Administration on Aging, 2 0 0 1 ) .

tal health problems are c o m m o n among older

Although many adults age successfully (cf.

adults, particularly among those seen in medi-

R o w e & Kahn, 1 9 9 8 ) , most older adults have

cal clinics (Lichtenberg, 2 0 0 0 ) and in long-term

at least one chronic health problem, and many

care settings. T h e combination o f health and

have several. In 1 9 9 9 , 2 6 . 1 % o f older adults

mental health problems, coupled with multiple

rated their health as fair or poor as compared

medications and potential adverse effects and

with only 9 . 2 % o f all individuals w h o did so

interactions, yields a challenging array o f diag-

(Administration on Aging, 2 0 0 1 ) . T h e most

nostic and treatment issues for the clinician.

frequently occurring chronic health problems among older adults

are arthritis

( 4 9 % of

This chapter provides a brief review o f agerelated sensory and cognitive changes to help

485

486

SPECIAL ISSUES underscore potential limitations associated

does pigmentation

with normal aging. This is followed by a dis-

reduction in the number o f photoreceptors

o f the vitreous

humor,

cussion of various psychological correlates o f

(rods and cones), and size o f the pupil. T h e

physical disease that are particularly important

lens capsule loses elasticity with age, resulting

in light o f age-related increases in probability

in losses in accommodation and visual acuity

of debilitating diseases and conditions. This

(usually realized

is followed by a related discussion o f adverse

numerous diseases can affect the visual system

as presbyopia). Finally,

effects o f medications that are more likely in

(e.g., diabetes mellitus, cataracts, glaucoma,

older adults. T h e subsequent section discusses

macular degeneration, myotonic

some c o m m o n problem areas that, for the

hypoparathyroidism, Wilson's disease).

dystrophy,

most part, do not fall within the realm o f

Approximately 3 0 % o f adults over age 6 0

diseases but nevertheless constitute significant

years suffer from significant hearing impair-

problems with psychological implications.

ment (Zarit & Zarit, 1 9 8 7 ) . These impair-

Age-related diagnostic issues are then addressed,

ments are due not only to aging but also to

with particular attention given to differences in

drugs used by older adults (e.g., certain antibi-

the presentation of various disorders. Finally, a

otics, certain diuretics) and various diseases

brief discussion of patient decision making and

and organic disorders (e.g., acoustic neuromas,

end-of-life issues is provided.

syphilis, multiple sclerosis, cerebrovascular accidents, circulatory disorders)

(Vernon,

1 9 8 9 ) . As with visual impairment,

hearing

AGE-RELATED CHANGES

impairment

can have psychological conse-

Aging begins at birth. An exhaustive discus-

activities, suspiciousness, hostility, depression).

sion o f age-related changes in the body and

T h e ability to understand

their psychological and behavioral c o n c o m i -

speech decreases with age, due primarily to

quences (e.g., paranoia, reduction of leisure

ability to detect

conversational

tants is beyond the scope o f this chapter.

diminished

Some o f the age-related sensory and cogni-

tones. Thus, older adults may experience diffi-

high-frequency

tive changes are briefly reviewed here (for

culty in understanding the speech o f women

more thorough discussions o f theses changes,

and children in particular. Finally, the ability to

see Edelstein, Martin, & Goodie [ 2 0 0 0 ] and

understand speech in the presence o f back-

Whitbourne [ 1 9 9 6 ] ) .

ground noise can be impaired in older adults.

M a n y older adults have sensory deficits

Older adults may also experience age-

that can influence the assessment and treat-

related declines in memory and cognition,

ment process and may be associated with a

although

variety o f psychological problems (e.g., social

Difficulties with working memory may be

isolation, paranoia). Sight, hearing,

such declines are not inevitable.

touch,

experienced, as may difficulty with inhibiting

smell, and taste all suffer loss to some degree

thoughts or external stimuli, when attempting

over time. Although all o f these declines are

to learn or recall information. Inhibitory con-

c o m m o n in older adults, this chapter focuses

trol tends to be worse for older adults in the

on sight and hearing. Thickness o f the lens o f

afternoon

evening due to

age-related

the eye increases with age, causing increased

changes in circadian rhythms

(Edelstein,

and

light absorption, light scattering within the

Martin, & Koven, 2 0 0 3 ) . Age-related changes

lens, increased susceptibility to glare, and dif-

in cognitive skills include diminished informa-

ficulty in adjusting to abrupt changes in light

tion processing speed, attention, mental flexi-

intensity. T h e increased lens density reduces

bility, abstraction, calculation, and capacity

the amount o f light reaching the retina, as

for inductive reasoning (Park, 2 0 0 0 ) . Overall,

Geriatric

Populations

\

it is important to appreciate that many older

a true depressive disorder is complicated by the

adults never experience many o f the deficits

overlap between symptoms observed in PD and

discussed and that many important cognitive

symptoms o f depression (e.g., reduced appetite,

abilities are maintained.

sleep disturbances, apathy, motor retardation) (Kremer & Starkstein, 2 0 0 0 ) . This point was illustrated by Hoogendijk, Sommer, Tissingh,

PSYCHOLOGICAL

Deeg, and Wolters ( 1 9 9 8 ) , who conducted a

MANIFESTATIONS AND

study in which PD patients were assessed for

C O R R E L A T E S O F PHYSICAL DISEASE

major depressive disorder ( M D D ) using both the American Psychiatric Association's (1987)

As discussed previously, a number of changes

DSM-III-R criteria (Diagnostic

and

occur as part o f the normal aging process. An

Manual

third edition,

of Mental

Disorders,

Statistical

unfortunate factor associated with aging is the

revised) and a clinician-administered depression

increased prevalence of chronic physical dis-

rating scale. After controlling for the presence

eases (Frazer, Leicht, & Baker, 1 9 9 6 ) . In this

of M D D symptoms that could be accounted for

section, the psychological and behavioral mani-

by P D , a reduction in diagnoses o f nearly 5 0 %

festations and correlates of chronic diseases

was observed. Hoogendijk and colleagues rec-

that commonly occur in older adults are

ommended that "depressed m o o d " should be

discussed.

considered mandatory for a diagnosis of M D D for individuals with PD and that depressive symptoms that covary with P D symptoms

Parkinson's Disease

should be diagnosed as "mood disorder due to

Parkinson's disease (PD) is a chronic progressive disorder of the central nervous system involving a deficiency o f dopamine in the basal ganglia (Thompson, 2 0 0 0 ) . This leads to a range of symptoms, including muscular rigidity, difficulty in initiating movement, shuffling gait, resting tremor, and a flat unchanging facial expression. In addition to physical symp-

a general medical condition." Others have determined that most symptoms o f M D D (i.e., those other than motor retardation, anergia, and early-morning awakening) that occur in individuals with PD tend to be legitimate instances o f depression rather than symptoms of PD (Kremer & Starkstein, 2 0 0 0 ) . Psychotic symptoms are also quite c o m -

toms, P D is associated with elevated rates o f

m o n in individuals with P D , although it is

psychiatric

not always clear whether these symptoms are

symptoms,

including

anxiety,

depression, and psychosis. In a review of anxi-

due to pathophysiological changes related to

ety disorders in P D , Marsh ( 2 0 0 0 ) cited preva-

PD, delirium, medications, or other psycholog-

lence rates as high as 2 4 % for panic disorder

ical disorders (Holroyd, Currie, & Wooten,

and from 1 2 % to 3 8 % for generalized anxiety

2 0 0 1 ) . In a recent study, 1 6 % o f patients

disorder. Based on observations that anxiety

with

symptoms commonly occur before m o t o r

delusions (Aarsland, Larsen, Cummings, 8c

P D experienced hallucinations

and

symptoms of P D , elevated rates have been

Laake, 1 9 9 9 ) . R a t e s were higher among indi-

attributed to the neuropathological processes

viduals residing in institutions. Holroyd and

underlying P D (Menza, 2 0 0 2 ) .

colleagues ( 2 0 0 1 )

Elevated rates of depression have also been

found

a prevalence o f

visual hallucinations o f 26.5%

in

outpa-

observed among individuals with P D . Estimates

tients. This rate was negatively associated

suggest that approximately 4 0 % o f individ-

with visual acuity and cognitive ability and

uals with P D report depressive

was positively associated with

symptoms

(Cummings, 1 9 9 2 ) . However, the diagnosis o f

level and disease severity.

depression

487

488

SPECIAL ISSUES

Chronic Obstructive Pulmonary Disease

at least one psychiatric disorder and that the degree o f psychiatric disturbance exhibited by

Chronic obstructive pulmonary

disease

(COPD) refers to a group o f pathological processes affecting the airways (e.g., bronchial tubes,

lungs), including

emphysema

and

chronic bronchitis. C O P D is characterized by dyspnea (perceived shortness of breath), sputum production, and cough (Frazer et al., 1 9 9 6 ) . Depression and anxiety are c o m m o n psychological correlates o f C O P D . A recent meta-analysis found that depression and anxiety symptoms occur in approximately 4 0 % and 3 6 % o f older adults with C O P D , respectively ( Y o h a n n e s , Baldwin, &c Connolly, 2000).

Karajgi,

Rifkin,

Doddi, and

Kolli

(1990) reported that 1 6 % o f a sample o f outpatients with C O P D had an anxiety disorder and that 8 % of the sample had panic disorder. Results from another study indicated that 3 4 % of a sample of respiratory unit patients had an anxiety disorder (Yellowlees, Alpers, Bowden, Bryant, & Ruffin, 1 9 8 7 ) . In addition, significant relations have been shown

to exist

these individuals was inversely related to the degree o f metabolic control that they obtained. C o m m o n psychiatric correlates o f diabetes include depression and anxiety. Lustman and colleagues reported

lifetime prevalences o f

major depressive episode and generalized anxiety disorder in diabetic patients to be 3 3 % and 4 1 % , respectively, hi addition, panic-like symptoms (e.g., dizziness, rapid pulse, sweating) have been reported to occur when blood glucose drops excessively (Morrison,

1997).

Agoraphobia appears to occur more frequently among individuals with type 2 diabetes than among those with type 1 diabetes (Lustman et al., 1 9 8 6 ) . Based on the observation o f higher levels o f functioning in psychogeriatric inpatients with uncontrolled diabetes than in inpatients with hypoglycemia, Hontela and Muller (1975) suggested that the elevated levels of blood glucose might actually maintain higher levels of functioning than those observed in older adults with hypoglycemia.

between the degree of depression and anxiety and the extent o f functional impairment, even after controlling for disease severity (Kim et al.,

Thyroid Disturbances

delirium

Thyroid disturbances comprise another set

attributed to anoxia, has also been observed in

of endocrine diseases that are relatively c o m -

individuals with C O P D (Morrison, 1 9 9 7 ) .

m o n in older adults. T h e thyroid gland's pri-

2000).

Cognitive impairment,

or

mary role is the regulation

o f metabolic

rate. Thus, thyroid dysfunction can have a significant impact on metabolic processes.

Diabetes Mellitus Diabetes

mellitus

Decreased thyroid function can lead to a is a

disease

of

the

pathological condition known as hypothy-

endocrine system that appears in two forms:

roidism,

type 1 (insulin dependent) and type 2 (non-

depressed m o o d , weight gain, low energy,

which

includes

symptoms

of

insulin dependent). The symptoms of diabetes

and loss o f appetite. These symptoms closely

are attributable to pancreatic dysfunction and a

resemble, and can easily be mistaken for,

resultant deficiency in insulin excretion. This

symptoms

deficiency impairs the affected individual's abil-

( 1 9 8 7 ) reported that even minor degrees o f

ity to process glucose, and this in turn produces

thyroid deficiency can be associated with sig-

an accumulation of blood glucose, known as

nificant depressive symptoms, particularly in

hyperglycemia. In one study, Lustman, Griffith,

the elderly. In addition, hypothyroidism has

o f depressive disorders.

Krahn

Clouse, and O y e r (1986) reported that 7 1 % of

been associated with cognitive impairment,

the individuals with diabetes had experienced

even at subclinical levels o f thyroid deficiency

Geriatric (Ganguli, Burmeister, Seaberg, Belle,

&

DeKosky, 1 9 9 6 ) .

agoraphobia, irritability, and

Populations

"pathological

emotionalism" (House et al., 1 9 9 1 ) . T h e psy-

Hyperthyroidism refers to thyroid overac-

chiatric

symptoms

o f these

community-

tivity that produces excessive amounts o f

dwelling patients in this study diminished over

thyroid h o r m o n e

the course o f the year following stroke.

(thyrotoxicosis) and

the

subsequent "speeding u p " o f metabolic processes. In younger adults, behavioral symptoms

of

hyperthyroidism

can

resemble

Cancer

symptoms o f mania and include restlessness

Cancer is associated with a range of psychi-

and irritability. In older adults, however, this

atric conditions, including anxiety, depression,

is far less likely. According to Gregerman (as

and delirium

cited in Frazer et al., 1 9 9 6 ) , less than 5 0 % o f

2 0 0 0 ) . The overlap between symptoms of psy-

older

individuals

with

(Gagnon, Allard, 8c Masse,

hyperthyroidism

chiatric disorders and symptoms secondary to

report these symptoms; older adults tend to

cancer or its treatment has been known to com-

report heart palpitations and a subjective

plicate the study o f these correlates o f cancer

sense o f "racing." W h e n depression is obser-

(Pasacreta, 1 9 9 7 ) . Panic attacks were reported

ved in the context o f hyperthyroidism, it is

in approximately one fifth o f inpatients with

referred

to as apathetic

hyperthyroidism

cancer referred for psychosomatic consulta-

(Morrison, 1 9 9 7 ; T h o m a s , Mazzaferri, 8c

tions (Slaughter et al., 2 0 0 0 ) . A number of

Skillman,

generalized

studies have documented the occurrence o f

anxiety symptoms (e.g., nervousness, tremor,

depression in the context of cancer. Greenberg

tension) have

(1989) reported that information regarding the

1970).

In addition,

been reported

in 4 0 % o f

patients with hyperthyroidism (Hall, 1 9 8 3 ) .

type, course, and treatment of a tumor is important in the diagnosis o f depression in individuals with cancer. In one study, 3 0 % of

Cerebrovascular Accident A

patients referred to an outpatient oncology

cerebrovascular accident, or

stroke,

department were assessed as having a "proba-

refers to brain trauma resulting from vascular

ble"

pathology. A cerebrovascular accident may

Fallowfield, 1 9 9 5 ) ; this dropped to 2 2 % at a

occur due to anoxia caused by atherosclerosis,

6-month follow-up. Using another measure,

psychiatric disorder

(Ford, Lewis, 8c

dysfunc-

Ford and colleagues (1995) found that 2 6 % of

tion. In addition, hemorrhage due to a rup-

patients had significant anxiety problems and

tured aneurysm can cause lesions. Although

that 7 % had significant depressive symptoms;

the location in the brain o f the stroke can

anxiety symptoms decreased significantly 6

thrombosis, embolism, or cardiac

behavioral

months later. T h e treatment of breast cancer in

impact (e.g., strokes resulting in lesions in the

postmenopausal women often requires the ces-

largely

determine

\

its

specific

right hemisphere have been associated with

sation of estrogen replacement therapy to sup-

increased levels of depression more than have

press cancer cell growth (Duffy, Greenberg,

those resulting in lesions in the left hemisphere

Younger, 8c Ferraro, 1 9 9 9 ) . Clinicians working

[Dam, Pedersen, 8c Ahlgren, 1 9 8 9 ] ) , depres-

with such patients should be aware that the

sion is widely observed following strokes. It

withdrawal o f estrogen replacement therapy in

has been reported to occur in 3 0 % o f cases

this population results in a rapid decrease in

within the year following a cerebrovascular

estrogen and has been known to

accident (Wade, Legh-Smith, 8c Hewer, 1 9 8 7 ) .

depressive symptoms

Other symptoms that have been observed

Pasacreta (1997) found that depressive symp-

during the year following stroke

toms occurred in 2 4 % o f a sample o f women

include

(Duffy et al.,

produce 1999).

489

490

SPECIAL ISSUES who had been diagnosed and treated surgically

are more sensitive to some o f the side effects o f

for breast cancer 3 to 7 months prior to assess-

medications. For example, prednisone, a corti-

ment; M D D occurred in 9 % o f the sample.

costeroid used to treat chronic obstructive pul-

Within this study, 3 5 % o f the variance in func-

monary disease, can cause anxiety, euphoria,

tional status was accounted for by physical

depression, and psychosis (Frazer et al., 1 9 9 6 ) .

distress and depressive symptoms.

Beta blockers such as propranolol, taken for chronic heart failure, can cause confusion, depression,

delusions, paranoia,

disorienta-

tion, agitation, and fatigue (Salzman, 1 9 9 8 ) .

ADVERSE MEDICATION EFFECTS

Medications used to treat Parkinson's disease M o s t older adults have at least one chronic

(e.g., levodopa, carbidopa) can lead to confu-

health problem that often requires medication

sion, hallucinations, and nightmares (Smith &

(e.g., arthritis, hypertension,

Reynard, 1 9 9 2 ) . Finally,

heart

disease,

diphenhydramine,

diabetes, sinusitis, esophagitis, constipation)

taken for allergies, can cause cognitive impair-

(Administration

ment in healthy older adults (Morrison

on Aging, 2 0 0 1 ; Knight,

&

Santos, Teri, & Lawton, 1 9 9 5 ) . Older adults

Katz, 1 9 8 9 ; Oslin, 2 0 0 0 ) . Thus, clinicians are

take an average of five prescription drugs each

well advised to examine thoroughly

day (Golden et al., 1 9 9 9 ) and use 4 0 % o f all

client's medical record with an eye to current

nonprescription drugs (Conry, 2 0 0 0 ) . Stoehr,

and past prescription and

Ganguli, Seaberg, Echement, and Belle ( 1 9 9 7 )

medications and their potential adverse effects.

each

over-the-counter

found that 8 7 % o f older adults report using at least one over-the-counter medication. Each of these drugs has the potential for adverse effects, and the potential interactions among multiple drugs can compound this number. Col, Fanale, and Kronholm ( 1 9 9 0 ) found that

C O M M O N P R O B L E M AREAS

Falls

2 8 % o f 8 9 older adult hospital admissions

Falls are a c o m m o n experience among

were due to medication-related problems, and

older adults. Approximately one third o f

6 0 % o f these were attributed to adverse drug

community-dwelling older adults (Studenski

reactions.

et al., 1 9 9 4 ) , 2 0 % o f older adults in acute

Older adults are at greater risk for such

care facilities (Kay & Tideiksaar, 1 9 9 0 ) , and

adverse effects than are younger adults due to

half o f older adults in long-term care facilities

&

(Tinetti et al., 1 9 9 4 ) fall each year. Within a

W o n g , 1 9 9 8 ) . Increases in the likelihood o f

age-related physiological changes (Rho

year, half o f these fallers will have fallen again

adverse anticholinergic effects can result from

(Wolinsky, J o h n s o n , & Fitzgerald, 1 9 9 2 ) .

age-related reduced parasympathetic nervous

Falls can result in a variety o f physical con-

system activity. Reductions in gastric acidity

sequences, ranging from minor injuries (e.g.,

and gastrointestinal motility can slow drug

abrasions, contusions, sprains, lacerations) to

absorption and the drug action. T h e elimina-

serious injuries (e.g., head trauma, spinal cord

tion of drugs is slowed by reduced activity o f

injuries, fractures, internal injuries). Nearly

hepatic enzyme systems and decreased renal

one third ( 3 1 % ) o f falls result in minor injury,

functions. T h e slowed elimination o f drugs can

and

also increase the risk for drug interactions.

(Morse, Tylko, & D i x o n , 1 9 8 7 ) . M o s t deaths

W h a t appear to be symptoms o f psycholog-

another

6%

result in serious

injury

and long-term disability after falls are related

ical disorders can be the result o f medications

to complications o f fall-related fractures, espe-

taken by older adults given that older adults

cially hip fractures (Melton & Riggs, 1 9 8 5 ) .

Geriatric

Populations

\

Psychological consequences o f falls are

Dissatisfaction with sleep is more common

Koski,

among elderly women than among elderly men

common.

Depression

(Luukinen,

Laippala, & Kivela, 1995) and fear o f falling

(Newman et al., 1997) and is higher among

(Drozdick 8c Edelstein, 2001) are often experi-

individuals with lower income and education

enced following a fall. Fear o f falling is associ-

levels (Ohayon,

1996).

ated with higher dependency, greater physical

Increasing age is associated with changes

symptomatology, greater drug consumption

in the nature and duration o f sleep c o m -

8c Andrews, 1990), higher reported

plaints. Problems in getting to sleep tend to

depression and anxiety (Arfken, Lach, Birge,

be most c o m m o n in younger insomniacs,

(Downton & Miller,

1994), restriction of movement and

whereas

problems

staying asleep

become

activities (Howland, Peterson, Levin, & Fried,

increasingly c o m m o n in later life (Maggi

1993), and increased morbidity.

et al.,

Risk factors for falls can be categorized as either intrinsic or extrinsic. Intrinsic risk fac-

1998). Symptoms o f disturbed sleep

are more likely to become chronic in older age groups (Hohagen et al.,

1994).

tors include physical impairment (e.g., muscle

Continuity o f sleep, duration o f sleep, and

weakness, hearing loss, visual acuity loss), the

depth o f sleep also show differences with age.

results o f various physical impairments (e.g.,

Relative to younger adults' sleep, older adults'

ambulation,

sleep is characterized

gait, and

balance problems),

by m o r e

frequent

medical disorders (e.g., Parkinson's disease,

"shifts" from one sleep stage to another and

cardiovascular disease), psychological factors

more frequent

intrasleep arousals

(Boselli,

8c Terzano, 1998). Both

(e.g., denial o f limitations, cognitive status),

Parrino, Smerieri,

and number, types, and amount of medications

events result in sleep that is more broken and

(e.g., antidepressants, sedatives) (Edelstein &

more likely to be rated as poor in quality

Drozdick,

1998). Extrinsic risk factors include

environmental hazards, restraints,

(Oswald,

1980). Similarly, sleep efficiency

improper

(time spent asleep divided by time spent in

footwear, improper use o f a walking aid, the

bed) also tends to decrease with age (Bliwise,

winter

season, and

(Edelstein

difficulty

with

stairs

8c Drozdick, 1998).

1993). Older adults tend to be "lighter" sleep2000) and to wake more easily

ers (Morgan,

with lower levels o f noise than do younger adults (Busby, Mercier,

Sleep

8c Pivik, 1994).

In addition to changes in the structure of

Complaints o f disturbed sleep may be cate-

nighttime sleep, the circadian rhythm itself has

gorized as sleep onset problems (trouble get-

been found to show age-related decay, with

ting to sleep), sleep maintenance

problems

(trouble staying asleep), or early

morning

awakening (Morgan,

2000). These symptoms

may occur alone or in combination and may

and

more

likely to occur during the day (Morgan,

sleep becoming desynchronized

2000).

Controlled-release

melatonin

replacement

therapy has been found to correct some circa-

be transient or long term. Disturbed sleep may

dian rhythm desynchrony, leading to improve-

also present, not as a complaint of sleeplessness

ments in both sleep efficiency and sleep onset

but rather as a report o f excessive daytime

(Haimov et al.,

sleepiness (Morgan,

disturbed sleep increases with age; insomnia has been estimated to affect approximately 5% of those ages 18 to 30 years versus 30% o f those age 65 years or over (Newman, Enright, Manolio,

1995).

2000). T h e prevalence o f

Haponik,

&

Wahl,

1997).

Appetite Approximately 40%

to 70%

o f elderly

patients w h o are hospitalized or institutionalized

are

malnourished

(Brocker,

Vellas,

491

492

SPECIAL ISSUES Albarede, & Poynard, 1 9 9 4 ) . Although social

Subcortical

and financial factors play important causative

as Parkinson's disease, Huntington's disease,

dementias include disorders such

roles in malnutrition, decreased appetite asso-

subcortical vascular disease, white

ciated with aging may also contribute to

disease,

weight

Cummings, 2 0 0 0 ) .

loss and

malnutrition.

Common

physical causes o f decreased appetite in older adults include dental

and

hydrocephalus

matter

(Kaufer

&

Cortical dementias

are

characterized by deficits in elementary intel-

conditions, gastro-

lectual skills, such as language, visuospatial

intestinal disorders, side effects o f medica-

functions, and mathematical abilities, whereas

tions, loss o f taste and smell, and particular

simple sensory and motor functioning is typi-

vitamin or mineral deficiencies. Furthermore,

cally preserved. Subcortical dementias, in con-

cholecystokinin, a hormone known to sup-

trast,

press appetite, has been found in greater lev-

wasting o f executive functions, affective and

els in older adults than in younger adults

personality changes, forgetfulness, and move-

(Baez-Franceshi & Morley, 1 9 9 9 ) .

ment disorders (Cummings & Benson, 1 9 8 2 ) .

are

characterized

by slowing

and

Psychological causes o f decreased appetite

The underlying organic pathology associ-

include depression, anxiety, loneliness, and

ated with various forms o f dementia can pro-

grief 1994).

( A m e r i c a n Psychiatric A s s o c i a t i o n , Psychologists may play

duce a variety o f behavior problems, including

important

physical aggression, screaming, and wander-

roles in treating decreased appetite in older

ing. M a n y o f these behaviors fall within the

adults; however, physiological causes should

category o f "agitation." Agitation has been

be considered before treating low appetite as

defined as "inappropriate verbal, vocal, or

a psychological problem.

motor activity that is not explained by needs or confusion per s e " (Cohen-Mansfield & Billig, 1 9 8 6 , p. 7 1 2 ) and includes behavior

Dementia

that is abusive or aggressive, occurs at an inap-

The dementias refer to a broad range o f dis-

propriate frequency, or is socially inappropri-

orders characterized by memory problems and

ate (Cohen-Mansfield, Werner, Watson, &c

at least one other cognitive disturbance, such

Pasis, 1 9 9 5 ) . Agitation is problematic for the

as aphasia (language disturbance), apraxia

agitated individual, caregivers, and others in

(motor disturbance), agnosia (inability to rec-

the agitated individual's immediate environ-

ognize objects), or a disturbance in executive

ment. Such behavior puts individuals

functioning (American Psychiatric Association,

physical risk and increases caregiver stress

at

1 9 9 4 ) . Although many dementias are progres-

(Bourgeois, Schulz, & Burgio, 1 9 9 6 ) .

sive, some are nondegenerative. However, all are characterized by irreversible declines in cognitive functioning and impairment in social and occupational functioning.

Pain Pain is one of the most c o m m o n concerns

Dementia has many different etiologies,

of older adults and is associated with nearly all

each with its own range o f symptoms and pro-

illnesses and diseases (Grange & Morrison,

gression. But despite the etiologic heterogene-

2 0 0 2 ; Wallace, 2 0 0 1 ) . Pain is reported by

ity of dementias, two basic types of dementia

2 5 % to 5 0 % o f community-dwelling older

exist. Cortical

dementias, such as Alzheimer's

adults (Ferrell, 1 9 9 1 ) and by as many as 8 0 %

disease, involve pathological alterations in the

of nursing home residents (Ferrell, Ferrell, &

cerebral cortical areas o f the brain, although

Osterweil, 1 9 9 0 ) . In general, older adults are

some alterations in subcortical regions are

more likely to experience pain, and are less

also present (Kaufer & Cummings, 2 0 0 0 ) .

likely to report pain, have pain recognized,

Geriatric

Populations

and be treated for the pain, than are younger

agitation, and increased irritability (Blazer

adults (Murray 8c Seely, 2 0 0 2 ) . This is even

et al., 1 9 8 6 ; Fiske, Kasl-Godley, &

Gatz,

more likely to be the case among cognitively

1 9 9 8 ) , and are less likely to report depressed

impaired older adults (Feldt, Ryden, & Miles,

m o o d (Fiske et al., 1 9 9 8 ) , than are younger

1 9 9 8 ; Gibson & Helme, 1 9 9 9 ) . Moreover, a

adults. Patterns o f depression

study by Chakour, Gibson, Bradbeer, and

reflected what has been termed "depletion,"

have

also

Helme ( 1 9 9 6 ) suggested that older adults may

characterized by symptoms o f loneliness, guilt,

experience some forms o f pain differently than

and sleep disturbance (Newmann, Engel, &

do younger adults.

Jensen, 1 9 9 0 ) .

Pain assessment in older adults can be com-

Older adults may differ from

younger

plicated by severe cognitive impairment where

adults with regard to both the prevalence and

traditional self-reports o f pain become unob-

the content of fears and worries. For example,

tainable due to loss o f verbal abilities and sen-

Kirkpatrick

( 1 9 8 4 ) , K o g a n and

Edelstein

sory declines. An alternative to self-reported

( 1 9 9 7 ) , and Liddell, Locker, and

pain is reliance on direct observation o f non-

( 1 9 9 1 ) all found that the number o f fears

verbal pain indicators (e.g., moaning, facial

decreases with age. Although the

grimacing, bracing, restlessness, rubbing)

decreases, Kogan and Edelstein ( 1 9 9 7 ) found

(Feldt, 2 0 0 0 ) . T h e psychological (e.g., depres-

that even low levels o f fears interfered with the

Burman number

sion, diminished cognitive functioning) and

daily lives o f older adults. Finally, Kogan and

behavioral (e.g., agitation, screaming, irritabil-

Edelstein (in press) found that the nature o f

ity) consequences o f pain can pose consider-

fears also changes with age and appears to

able challenges in the assessment o f older

reflect developmentally appropriate themes.

adults. In light o f the decreased likelihood o f

There is mounting evidence that subclinical

pain reports by older adults and the tremen-

or subsyndromal

dous impact o f pain on quality o f life, the pres-

DeBeurs et al., 1 9 9 9 ; Himmelfarb & Murrell,

levels o f anxiety (e.g.,

ence o f pain should always be assessed when

1 9 8 4 ; Palmer, Jeste, & Sheikh, 1 9 9 7 ) and

observing changes in behavior, particularly

depression (e.g., Lewinsohn, Solomon, Seeley,

among cognitively impaired older adults who

& Zeiss, 2 0 0 0 ) are both c o m m o n and clini-

might have trouble reporting

Pain

cally significant among older adults. This

should always be suspected when changes in

research suggests that anxiety and depression

behavior,

particularly

among

pain.

cognitively

impaired older adults, are observed.

among older adults might be best conceptualized along continua rather than in the context of diagnostic thresholds. In addition, these findings should alert clinicians to subthreshold

D I A G N O S T I C ISSUES

levels o f anxiety and depression among older adults that could require intervention.

T h e diagnosis o f mental disorders in older adults can be quite challenging. T h e prevalence, and even the phenomenology (e.g., Blazer, George, Sc Landerman, 1 9 8 6 ) and presentation, o f mental disorders can change with age. In the latter case, for example, depressed older adults are more likely to present somatic symptoms (e.g., decreased energy, chronic pain,

DECISION MAKING AND END-OF-LIFE ISSUES

Competency and Capacity for Decision Making

changes in appetite, changes in sleep patterns,

A number o f older adults who use behav-

gastrointestinal c o m p l a i n t s ) , p s y c h o m o t o r

ioral health services experience various degrees

494

SPECIAL ISSUES of dementia or may exhibit central nervous

otherwise by a court o f law. A capacity

system damage as a result o f cardiovascular

evaluation is one method for assessing an

accident, coronary artery disease, or other

aspect o f competency, but it should not be used

chronic health problems that often result in

as the sole determinant for surrogate or legal

cognitive impairment.

these

guardian assignment. An older adult suffering

older adults' capacity to make decisions and

from dementia may have the capacity for one

overall competency may be called into ques-

type o f decision making but lack capacity in

tion and may need to be assessed.

Competency

another area.

is a legal term referring to an

individual's

Consequently,

Decision-making capacity is

frequently

decision-making abilities for a specific criminal

assessed when issues related to death and

or civil matter and so is generally declared in a

dying

court o f law (Moye, 1 9 9 9 ) . Capacity

refers to

addresses aspects o f death and dying that the

an individual's specific abilities in a number of

behavioral health care provider should be

areas and is frequently assessed by a clinician.

aware o f when treating an older adult, espe-

Capacity is defined as the ability to compre-

are at stake. T h e next

subsection

cially if the adult in question is terminally ill.

hend information relevant to the decision, the ability to deliberate about the choices in accordance with personal values and goals, and

Death, Dying, and Related Issues

the ability to communicate with caregivers

Death is one aspect o f life that is as natu-

(Hastings Center, 1 9 8 7 ) . Clinicians are fre-

ral as birth. As a result o f modern scientific

quently asked to assess decision-making capac-

advances, many medical or

health-related

ity of older adults for a number of areas,

professionals

including financial and medical decision making

death, even at the expense o f the patient's

and independent living skills (Moye, 1 9 9 9 ) .

wishes. Medical professionals are trained to

Although few measures o f capacity with established psychometrics exist, a few that

do all they can to

save lives, and

prevent

society has m a d e

great

advances in medical technology that allow

have recently been developed show promise,

people to live longer than ever before, but

including the Hopemont

Capacity Assess-

there are people for w h o m death remains

ment Interview (Edelstein, Nygren, Northrop,

imminent nonetheless. In these cases, health

Staats, &

care professionals can have a positive impact

P o o l , 1 9 9 3 ) and

the Clinical

Competency Test Interview (Marson, Cody,

on the dying process by making it a more

Ingram, & Harrell, 1 9 9 5 ) . T h e H o p e m o n t

comfortable and dignified experience.

Capacity Assessment Interview presents sce-

Fordyce ( 2 0 0 1 ) listed the health care practi-

narios to the client. Some scenarios involve

tioner's most important contributions to the

medical

involve

dying client as being (a) amelioration of any

financial or money management decisions.

unpleasant physical or mental symptoms the

decisions,

and

others

Following scenario presentations, a number

client is experiencing; (b) meeting the client's

of questions are asked to assess information

emotional needs as much as possible; (c) edu-

comprehension, understanding o f the risks

cating, reassuring, and comforting the client;

and benefits involved, and how the decision

and

(d) preventing

futile interventions

and

or choice is made. T h e same format is fol-

investigations that may result in discomfort for

lowed with the Clinical Competency Test

the client. Aiding a client in the dying process by

Interview, but

nurturing mind, body, and spirit is one o f the

in this case the

scenarios

involve medical decision making only.

most effective ways in which a health care pro-

It should be remembered that all adults

fessional can make the process easier. In addi-

are considered competent unless determined

tion to addressing spiritual or religious issues,

Geriatric

Populations

\

the dying older adult may have a desire to

and should not be discouraged; rather, it

reminisce or write the story o f his or her life in

should be encouraged by health care profes-

a journal, especially for loved ones (Tobin 6c

sionals. It is not necessary to have answers for

Lindsey, 1 9 9 9 ) . Providing favorite music,

dying people, but health care professionals

games, or hobbies for the dying client is also

should let them voice their fears, concerns,

a way to make the final days or months of his

and/or beliefs and should try to offer some

or her life meaningful and ultimately more

kind o f reassurance. It is important not to

enjoyable.

challenge a terminally ill older adult's religious

Tobin and Lindsey (1999) referred to death

or spiritual beliefs but rather to respect them

as a natural part of living that requires prepara-

(Hastings Center, 1 9 8 7 ) and be open to listen-

tion and the expenditure of considerable effort.

ing to the patient discuss aspects of faith or

Health care providers should stress to their older

religion that are especially important or even

adult clients that preparation is an important

troubling to him or her.

part of dying, and as such, these clients should

W h e n death is imminent, it is also important

be considering key decisions that may need to be

for the health care professional to recognize the

made. These decisions may involve life support,

normal physical changes associated with death;

resuscitation, whether they wish to die at home

the health care professional should not try to

or in a hospital, and which family and friends

prevent or stop them but rather should make

they would like involved in the process. In addi-

the client as comfortable as possible. T h e client

tion, older adults should feel free and be encour-

normally does not experience discomfort or

aged to discuss their living wills, who they have

pain during these changes. Loss of appetite,

chosen as proxies, and whether they have docu-

mottling o f the skin, poor circulation, and loss

mented their wishes in writing. These all are

of thirst are typical prior to death (Fordyce,

considerations to be made in advance of the

2 0 0 1 ) . In addition, marked weight loss and loss

terminal stages of illness or death. In addition to

of body functions occur in close proximity to

legal and medical considerations, other issues

death. T h e client should be kept clean, and

such as religiosity and spirituality may emerge as

adult diapers should be changed frequently to

older adults prepare for death.

aid in comfort. None of these changes is cause

R e c e n t surveys indicate that

9 4 % of

for alarm; rather, they all are part of the normal dying process ( T o b i n &

report that religious involvement is a positive

Although further

and enriching experience, and 8 8 % believe

issues is beyond the scope of this chapter, the

that religion is either very important or fairly

interested reader is referred to Benner ( 2 0 0 1 ) ,

important

in their lives (Gallup,

1994).

Religious practice is especially c o m m o n among older adults, with a large number reporting

active participation

activities and prayer

Lindsey,

1999).

Americans believe in G o d , 9 0 % pray, 7 5 %

elaboration on end-of-life

Coppola and T r o t m a n ( 2 0 0 2 ) , and

Corr,

Nabe, and Corr ( 2 0 0 0 ) . End-of-life issues involving death and deci-

in religious

sion making are complex in today's health care

(Koenig, Larson, 8c

setting, as technology allows for life to be sus-

Matthews, 1 9 9 9 ) . Imminent death brings with

tained in circumstances where in the past it

it a period o f spiritual reflection for many

would have ceased. Although every human

people. Questions such as " W h a t is the mean-

eventually must face his or her mortality, the

ing o f life" and " W h a t have I done with my

process of death and dying is unique to each

life?" are frequently asked (Tobin & Lindsey,

individual, and it is the health care professional

1 9 9 9 ) . Questioning one's existence and its

who can grant the older adult a sense of control

relation to a bigger picture or an afterlife is a

and help to make the process o f dying the indi-

normal concomitant o f contemplating death

vidual's own experience.

495

496

SPECIAL ISSUES SUMMARY AND CONCLUSIONS

Older adults are, by definition, closer to death than are younger adults due to age

and

This chapter has briefly presented information

increased risk of life-threatening diseases. Thus,

that a clinician likely would find helpful when

the health care professional must educate him-

providing psychological services to older adults

self or herself regarding the major medical and

in health care settings. M u c h of the information

financial decisions commonly faced by older

pertains to age-related issues ranging from sen-

adults and how to participate in the determina-

sory processes to the presentation of depres-

tion o f capacity to make these decisions.

sion. It is particularly important that the reader

Finally, because death is experienced more

appreciate the ways in which adults can change

often by older adults than by younger adults, it

as they age and how these changes can affect

is important that the health care professional

their experiences and presentations o f problems

obtain knowledge regarding end-of-life issues

and disorders. These changes, the presence o f

and how to contribute to the care of dying

multiple chronic diseases, the psychological

patients. As has been said before, " W e will not

correlates o f these diseases, and the adverse

get out o f this life alive." However, the health

responses to drugs used to treat them can pre-

care professional can assist others in making

sent an enigmatic collection o f behaviors that

that transition as physically and psychologically

may complicate assessment and intervention.

comfortable as possible.

REFERENCES Aarsland, D., Larsen, J . P., Cummings, J . L., & Laake, K. (1999). Prevalence and clinical correlates of psychotic symptoms in Parkinson's disease. Archives of Neurology, 56, 5 9 5 - 6 0 0 . Administration on Aging. (2001). A profile of older adults: 2001 [Online]. Retrieved January 2 0 , 2 0 0 3 , from www.aoa.gov/aoa/stats/profile/2001 American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Arfken, C. L., Lach, H. W., Birge, S. J . , & Miller, J . P. (1994). The prevalence and correlates of fear of falling in elderly persons living in the community. American Journal of Public Health, 84, 5 6 5 - 5 7 0 . Baez-Franceshi, D., & Morley, J . E. (1999). Causes of malnutrition in the elderly [Online]. Retrieved January 2 0 , 2 0 0 3 , from www.healthandage.com/html/min/ basel/content/publi02 .htm Benner, P. (2001). Death as a human passage: Compassionate care for persons dying in critical care units. American Journal of Critical Care, 10, 3 5 5 - 3 5 9 . Blazer, D., George, L. K., &c Landerman, R. (1986). The phenomenology of late-life depression. In P. E. Bebbington & R. Jacoby (Eds.), Psychiatric disorder in the elderly (pp. 1 4 3 - 1 5 1 ) . London: Springer. Bliwise, D. (1993). Sleep in normal aging and dementia. Sleep, 16, 4 0 - 8 1 . Boselli, M., Parrino, L., Smerieri, Α., & Terzano, M. G. (1998). Effects of age on EEG arousals in normal sleep. Sleep, 21, 3 5 1 - 3 5 7 . Bourgeois, M. S., Schulz, R., & Burgio, L. (1996). Interventions for caregivers of patients with Alzheimer's disease: A review and analysis of content, process, and outcomes. International Journal of Aging and Human Development, 43, 35-92.

Geriatric

Populations

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Slaughter, J . R., Jain, Α., Holmes, S., Reid, J . C , Bobo, W., & Sherrod, Ν. B . (2000). Panic disorder in hospitalized cancer patients. Psycho-Oncology, 9, 2 5 3 - 2 5 8 . Smith, C. M., & Reynard, A. M . (1992). Textbook of pharmacology. Philadelphia: W. B . Saunders. Stoehr, G. P., Ganguli, M., Seaberg, E. C., Echement, D. Α., & Belle, S. (1997). Over-the counter medication use in an older rural community: The Movies Project. Journal of the American Geriatrics Society, 45, 1 5 8 - 1 6 5 . Studenski, S., Duncan, P. W., Chandler, J . , Samsa, G., Prescott, B . , Hogue, C , & Bearon, L. B . (1994). Predicting falls: The role of mobility and nonphysical factors. Journal of the American Geriatrics Society, 42, 2 9 7 - 3 0 2 . Thomas, F. B., Mazzaferri, E. L., & Skillman, T. G. (1970). Apathetic thyrotoxicosis: A distinctive clinical and laboratory entity. Annals of Internal Medicine, 72, 6 7 9 - 6 8 5 . Thompson, R. F. (2000). The brain: A neuroscience primer (3rd ed.). New York: Worth. Tinetti, M . E., Baker, D. L, McAvay, G., Claus, Ε. B . , Garrett, P., Gottschalk, M., Koch, M . L., Trainor, K., &C Horwitz, R. I. (1994). A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine, 331, 8 2 1 - 8 2 7 . Tobin, D. R., & Lindsey, K. (1999). Peaceful dying. Cambridge, MA: Perseus Books. Vernon, M . (1989). Assessment of persons with hearing disabilities. In T. Hunt & C. J . Lindley (Eds.), Testing older adults: A reference guide for geropsychological assessments (pp. 1 5 0 - 1 6 2 ) . Austin, T X : Pro-Ed. Wade, D. T., Legh-Smith, J . , & Hewer, R. A. (1987). Depressed mood after stroke. British Journal of Psychiatry, 151, 2 0 0 - 2 0 5 . Wallace, M . (2001). Pain in older adults. Annals of Long-Term Care, 9, 5 0 - 5 8 . Whitbourne, S. (1996). The aging individual: Physical and psychological perspectives. New York: Springer. Wolinsky, F. D., Johnson, R. J . , & Fitzgerald, J . F. (1992). Falling, health status, and the use of health services by older adults: A prospective study. Medical Care, 30, 5 8 7 - 5 9 7 . Yellowlees, P. M., Alpers, J . H , Bowden, J . J . , Bryant, G. D., & Ruffin, R. E. (1987). Psychiatric morbidity in patients with chronic airflow obstruction. Medical Journal of Australia, 146, 3 0 5 - 3 0 7 . Yohannes, A. M., Baldwin, R. C , &C Connolly, M . J . (2000). Mood disorders in elderly patients with chronic pulmonary disease. Reviews in Clinical Gerontology, 10, 1 9 3 - 2 0 2 . Zarit, J . M., 8c Zarit, S. H. (1987). Molar aging: The physiology and psychology of normal aging. In L. Carstensen & B . Edelstein (Eds.), Handbook of clinical gerontology (pp. 1 8 - 3 2 ) . New York: Pergamon.

|

501

CHAPTER

Public Health

Approaches

Finding the Interface With Health JALIE A N D

A.

C A T H Y A.

A of

TUCKER,

10 26

JOSHUA

C.

Psychology

KLAPOW,

SIMPSON

fter decades o f delivering psychologi-

(Curry & Kim, 1 9 9 9 ; Pronk, Boucher, Gehling,

cal services primarily in the form o f

Boyle, & Jeffery, 2 0 0 2 ) . In clinical care, persons

psychotherapy, the settings and scope

w h o have developed problems seek help from

psychological practice have

expanded

professionals and receive treatments that are

into health care, w o r k site, organizational,

relatively intensive and effective but costly.

1999).

Treatment seekers, however, tend to be a small

Health psychology research and practice have

minority o f the larger population with prob-

been vital to this trend, and many o f the inno-

lems, and they tend to have more serious prob-

and

community

settings

(Tucker,

vations have been concerned with understand-

lems. In public health practice, populations or

ing and modifying relations among health,

at-risk groups are actively targeted with brief

disease, and behavior. Services that support

interventions that typically are more preventive

health behavior change n o w span interven-

than therapeutic in focus. Compared with clini-

tions that

cal care, public health interventions do not

vary in scope, intensity, cost-

effectiveness, target audience, and population

involve as much personal contact, can be deliv-

impact. Services range from individual clinical

ered by trained nonprofessionals, and are more

services to focused interventions for select risk

accessible; for example, they may involve writ-

groups to brief, low-intensity interventions for

ten or videotaped materials and can be deliv-

communities or populations.

ered by telephone, television, or via the Internet.

In other words, clinical care is increasingly

Although public health interventions typically

being supplemented by interventions that are

are less efficacious than clinical interventions,

more in line with a public health approach

they are less costly per person and can reach

A U T H O R S ' N O T E : Manuscript preparation was supported in part by National Institute on Alcohol Abuse and Aging Grant K 0 2 A A 0 0 0 2 0 9 to Jalie Tucker and by National Institute on Aging Grant K 2 3 A G 0 0 9 3 2 to J o s h u a Klapow.

502

Public Health

503

many more people. Thus, in the aggregate, the

with those o f public health, synergies should

overall impact on the health status of commu-

emerge that enhance the population impact of

nities or populations may be considerably

behavioral interventions to promote health and

greater from public health interventions than

to prevent and manage disease.

from clinical care.

This chapter provides

In combination, the two approaches can

an overview o f

the public health field for psychologists.

contribute to the development o f systems o f

Concepts, methods, and findings from epi-

care that span the conventional end points o f

demiology, behavioral epidemiology,

public health and clinical practice and that

health outcomes assessment are emphasized

and

include both preventive and therapeutic ser-

because they are likely points o f intersection

vices. T h e need for such coordinated systems

with health psychology. T h e chapter summa-

of care is widely recognized (e.g., Galea et al.,

rizes the history and key concepts in these

2 0 0 1 ; U.S. Department o f Health and H u m a n

areas, discusses educational opportunities in

Services, 1 9 9 9 ) , but implementation is chal-

public health generally, and then selectively

lenging and uncommon (e.g., Humphreys &

illustrates education and training in the field o f

Tucker, 2 0 0 2 ) . Psychologists have much to

health outcomes assessment, which is a natu-

contribute to such initiatives. But to partici-

ral connection for psychologists. T h e chapter

pate effectively, they would

ends with consideration o f differences in the

benefit

from

greater public health knowledge and skills,

"worldviews"

which are not routinely covered in graduate

health, discussed in the context o f mental

education

not

health research and practice. These differences

exhaustive, relevant content areas include

must be understood and respected if the disci-

(a) population distributions and dynamics o f

plines are to collaborate effectively.

in

health and

psychology.

Although

o f psychology and

public

behavioral health problems as

well as the nature o f relations between them; (b) organization and economics o f health care

H I S T O R I C A L ISSUES

systems,

AND KEY CONCEPTS

patterns

of

and

influences

on

service utilization, and cost-utility analysis; (c) research methods

suitable for

studying

populations and organizations rather

than

individuals; (d) intervention marketing

and

The

beginnings o f c o n t e m p o r a r y

public

health research and practice lie in the field of epidemiology,

which is the study o f the

dissemination to groups, communities, and

determinants o f disease in populations. T h e

organizations; and (e) health outcomes assess-

origins

ment and health policy research, including

to observational studies o f infectious disease

mental health policy.

transmission patterns during the m i d - 1 8 0 0 s

Psychologists, in turn, can offer

unique

of epidemiology

can

be

traced

such as J o h n Snow's classic analysis o f h o w

knowledge and skills that are fundamental to

cholera was transmitted

an effective merger of clinical and public health

drinking water in L o n d o n (Turnock, 1 9 9 7 ) .

by

contaminated

approaches to health promotion and disease

S n o w collected data on the frequency and

prevention and management. In addition to

distribution o f cholera deaths in L o n d o n as a

their strong research skills, psychologists have

function o f the decedents' source o f water.

comprehensive knowledge and skills concern-

F r o m these data, he was able to identify con-

ing mental health disorders, behavior change,

taminated water sources, thereby preventing

theory and measurement of behavior, and the

further exposure and cholera deaths.

role o f behavior in health and disease. By merg-

As Snow's research exemplifies, epidemiol-

ing the disciplinary strengths of psychology

ogy typically uses nonexperimental correlational

SPECIAL ISSUES

504

methods to assess the strength of association in

Raczynski, in press). Behavioral epidemiology

large samples between possible causes of disease

and health psychology share common goals of

and patterns o f disease onset, transmission,

understanding and modifying behavior and

morbidity, and mortality (Hennekens & Buring,

psychological factors involved in health and

1 9 8 7 ) . Key measures of association are inci-

disease but differ in the scope of application

dence and prevalence,

hicidence is a measure o f

and methods o f study. Research in behavioral

the rate of disease onset and represents the

epidemiology has been instrumental in identi-

number of new cases in a population over a

fying modifiable risk factors for disease that

given period o f time. Prevalence reflects the total

involve behavior and that are appropriate tar-

number of cases in a population either at a

gets for intervention. For example, diet, smok-

single point in time (i.e., "point" prevalence) or

ing, and inactivity have been established as risk

over a given time period (e.g., annual or lifetime

factors for coronary heart disease (National

prevalence). Lncidence and prevalence are inter-

Heart, Lung, and Blood Institute, 1 9 9 4 ) . Ln

related because prevalence is a function o f both

addition, increased risk o f coronary heart dis-

the rate of new cases (i.e., incidence) and the

ease has been associated with specific compo-

duration of disease.

nents o f "Type A " behavior patterns such as

Other central concepts in epidemiology are

hostility, reactivity, and time pressure (e.g.,

for disease (Fletcher,

Houston, Chesney, Black, Cates, & Hecker,

Fletcher, & Wagner, 1 9 9 6 ) . Risk is the likeli-

1 9 9 2 ; Krantz, 1 9 8 8 ) and with the presence o f

risk

and risk

factors

hood that persons who are exposed to a parti-

depressive

cular factor or who have a given characteristic

T y p e A behavior patterns (Frasure-Smith,

symptoms

in conjunction

with

will develop the disease o f interest. Risk factors

Lesperance, J u n e a u ,

are the characteristics, circumstances, or behav-

1 9 9 9 ) . As another example, several modifiable

iors that are associated with an increased risk o f

risk factors for human immunodeficiency virus

Talajic, 8c Bourassa,

disease occurrence. Because relations between

(HIV) infection have been identified, including

exposure to risk factors and disease are evalu-

drug o f choice, injection practices, and sexual

ated at the population level, the observed rela-

practices (Peterson, Dimeff, Tapert, Stern, &

tions do not necessarily hold for individuals

Gorman, 1 9 9 8 ) .

(Kaplan, 1 9 8 4 ) . M a n y persons who have a neg-

Another relevant subspecialty is health

out-

ative health outcome have no known risk fac-

comes

tors, even when a robust relationship between

including health outcomes assessment (Klapow,

research

(Clancy & Eisenberg, 1 9 9 8 ) ,

risk factors and disease has been established at

Kaplan, 6c Doctor, in press). Historically, the

the population level. Moreover, empirical sup-

primary outcome measures in epidemiology

port for risk factors typically comes from non-

were mortality and morbidity as represented

(e.g., case

by biological indicators o f disease. This focus,

experimental research methods

control studies) that fall short of the standards

however, does not represent many important

for causal inference as defined and investigated

functional domains that contribute to health

in experimental psychology.

and disease status. This limitation led to the

A recent development o f relevance to health

development of the "quality-adjusted life year"

psychologists is the emergence o f the subspe-

(QALY)

cialty o f behavioral

which

Weinstein 8c Stason, 1 9 7 7 ) . Q A L Y s reflect in

involves the application o f concepts and meth-

a single measure the benefits o f reduced mor-

ods from epidemiology to investigate the role

bidity and mortality, and it was an important

of behavior and psychological variables in

advance in the assessment o f health outcomes.

health and

epidemiology,

disease at a population

as an alternative measure

(e.g.,

level

The scope o f health outcomes assessment has

(Sexton, 1 9 7 9 ; Tucker, Phillips, Murphy, &

continued to expand to include a range o f

Public Health

505

monetary cost measures and measures of patient

level o f generality that is unattainable

functioning and satisfaction. Economic analyses

psychology. In comparison, psychology offers

in

(e.g., cost-effectiveness, cost-benefit analysis) are

a more intensive individual level o f analysis

becoming a standard part of evaluation research

that often is better grounded in theory and

on health outcomes (Drummond, O'Brien,

sound measurement practices. T o promote

Stoddart, & Torrence, 1 9 9 7 ) . This work has

interdisciplinary synergies, researchers

shown, for example, that including mental

practitioners in each discipline should acquire

health benefits in comprehensive health plans

a working knowledge o f the other's field.

and

tends to reduce the use and cost of medical ser-

Basic training and skills in public health for

vices (Cummings, O'Donohue, &

psychologists are described next.

Ferguson,

2 0 0 2 ) . This medical "cost offset" effect provides strong support for the economic utility of insuring mental health services.

SPECIALIZED T R A I N I N G

Expansion into the assessment o f patient

A N D SKILLS N E E D E D

functioning poses measurement challenges not present in pure economic evaluations. Health

This section provides an overview of graduate

status and health-related quality o f life are

education in public health and pathways for

functional constructs that encompass symp-

acquiring specialized training and skills in public

toms, behavior, and psychological and social

health for psychologists. This material is fol-

functioning. Operationalizing these constructs

lowed by a more detailed discussion of opportu-

and evaluating them are well within the exper-

nities and educational requirements in the area of

tise o f health psychologists. Skills in psycho-

health outcomes assessment, which exemplifies

metrics, behavioral assessment, and instrument

opportunities for psychologists in health services

development and validation are a cornerstone

research. The section ends with a description

o f their training. Given that definitions o f

of the joint clinical psychology-public health

health are shifting from a biomedical process

program

model (e.g., physiological markers of health) to

Birmingham (UAB), which shows how educa-

a patient-focused outcomes model (e.g., symp-

tion and training in the two fields can be inte-

toms, distress, functioning), so too must the

grated effectively at the predoctoral level.

at the University o f Alabama at

measurement o f health shift from a biomedical process to outcomes assessment. T h e process of defining and operationalizing a construct

Public Health Education Programs

(e.g., health, anger, pain, hostility), quantifying

Probably the most direct way for psycholo-

it through instrument development, validating

gists to gain knowledge about public health is

the instrument to ensure reliability and accu-

to enroll in courses or degree programs in

racy o f measurement, and interpreting data

graduate programs in public health. This sub-

obtained from such an instrument are com-

section describes graduate education in public

mon practices in health psychology (Klapow

health, including core content areas required

et al., in press).

for program accreditation by the Council on

In summary, public health and health psychology share many c o m m o n goals, but they

Education for Public Health ( C E P H ) . Much

like the American Psychological

have approached the study o f health, disease,

Association's Committee on Accreditation peri-

and the role o f the environment and behavior

odically reviews doctoral programs in psychol-

in different yet potentially

ogy, the C E P H serves this function for schools

complementary

ways. Public health brings a broad population

of public health and related academic pro-

perspective to bear on the issues and offers a

grams, including community health/preventive

506

SPECIAL ISSUES medicine programs and community

health

that involve direct patient interaction. This is

education programs. As of June 2 0 0 2 , C E P H -

the foundation of training for health psycholo-

accredited programs included 3 2 schools of

gists. T h e meso level consists of the organiza-

public health, 3 6 community health/preventive

tional entities that deliver health care services

medicine

programs,

and

14

community

and

their

associations

with

community

health education programs. T h e current list

resources. T h e macro level consists of policies

may be obtained from the C E P H W e b site

that create the parameters within which health

(www.ceph.org). In addition to serving a gen-

care organizations, communities, and providers

eral quality assurance function, C E P H accredi-

function. As noted in the W H O report, lines of

tation allows programs to be eligible for certain

demarcation between the levels are not always

federal funds such as research awards from the

clear. Nevertheless, when health care policies,

Centers for Disease Control and Prevention

organizations, communities, and interventions

(CDC). Linkages between public health pro-

align, the quality of health care services is likely

grams and the C D C are a unique feature not

to improve (cf. Humphreys & Tucker, 2 0 0 2 ) .

enjoyed by conventional doctoral psychology programs.

As discussed in Frank, Farmer, and Klapow (in press), as a profession o f behavioral scien-

All CEPH-accredited programs offer educa-

tists, health psychologists are potentially capa-

tional experiences leading to the master of

ble o f functioning at any o f these levels. Health

public health (M.P.H.) degree, which is a pro-

psychologists

fessional degree recognizing broad knowledge

education in the scientific method, research

of content and method relevant to the practice

methodology, statistics, psychometric theory,

of public health. Additional generalist and spe-

personality theory, learning theory, and behav-

receive

rigorous

graduate

cialist degrees may be offered, for example, the

ior change interventions. T o date, however, the

academically oriented M.S.P.H. degree and doc-

application o f this knowledge base has been

toral degrees that are professional (Dr.P.H.) or

limited primarily to the micro level of the

academic (Ph.D., Sci.D.) in nature. Five core

health care system. By offering educational

areas o f knowledge are required in M.P.H.

opportunities that convey the necessary exper-

programs: biostatistics, epidemiology, environ-

tise at the meso and macro levels, health psy-

mental health sciences, health services adminis-

chologists will be prepared to contribute across

tration, and social and behavioral sciences.

the multiple levels o f the system o f care.

These core areas often serve as the defining basis

Doing so, however, will require changes in

of departments in schools of public health,

psychology doctoral programs. Graduate pro-

although this arrangement is not a C E P H

grams

requirement per se.

more coursework and expand the curriculum

Educational Opportunities in Health Services Research and Practice

will continue to limit the contributions of health

understandably

hesitate to

require

(Elliott & Klapow, 1 9 9 7 ) , but failure to do so psychologists to the micro level of health care systems. A training model that blends core skills

The delivery o f health care services is a com-

in health psychology with a working knowledge

plex and dynamic process. As discussed in a

of the levels of the health care system will enable

report of the W o r l d Health

future psychologists to apply their skills in the

( W H O , 2 0 0 2 ) titled Innovative Chronic Action,

Conditions:

Building

Organization Care Blocks

for

dynamic health care system and to deal effec-

for

tively with future economic and organizational

health care systems can be divided into

three levels: micro,

and macro.

changes (Elliott & Klapow, 1 9 9 7 ) .

The

Although the possibilities for content are

micro level of health care consists of services

virtually endless when considering the study of

meso,

Public Health

507

health care systems, several core areas are

example, some psychologists (including the first

essential for a basic level of expertise: health

two chapter authors) have obtained knowledge

economics, health insurance, health policy,

and skills in public health through receipt of

quality improvement,

competitive Public Health Service career devel-

patient-based

program

outcomes

evaluation,

evaluation,

cost-

opment awards (i.e., "K-awards").

effectiveness analysis, and design and evaluation of clinical trials. It is important to note that these content areas are in addition to the foundation of training that health psychologists

Health Outcomes Assessment

now

Measurement is a cornerstone of psychol-

receive. Thus, it is assumed that health psychol-

ogy. T h e field o f health psychology has made

ogists who explore these content areas have req-

significant progress in transitioning the princi-

uisite skills in statistics, psychometric theory,

ples of psychometric theory into a variety o f

instrument development and validation, and

assessment applications in the field o f medicine.

research methods. With a health psychology

For the most part, however, measurement in

foundation and these additional content areas,

health psychology has focused on (a) identify-

health psychologists can pursue opportunities

ing psychological processes associated with

across the spectrum of health care. Without

health and illness, (b) evaluating psychological

such knowledge, they are limited in their ability

and social contextual variables and their rela-

to work within the meso (health care organiza-

tionship to biological markers o f health, and

tion) and macro (health policy) levels.

(c) assessing psychological distress as a primary

Although it is necessary for health psychol-

outcome (Klapow et al., in press; Pennebaker,

ogists to have an understanding o f the health

Kiecolt-Glaser, &

care system from the micro level to the macro

these are important contributions, the some-

Glaser, 1 9 8 8 ) .

Although

level, the method o f education can take several

what narrow focus has limited health psychol-

forms. Integration o f coursework and areas o f

ogy's role in health outcomes assessment.

concentration into doctoral programs, contin-

As discussed in Frank and colleagues (in

uing education opportunities, and additional

press), because chronic conditions are increasing

postgraduate degrees all are possible, depend-

as the U.S. population ages, effective medical

ing on the depth o f understanding desired. If

management of chronic conditions is growing in

comprehensive health services and outcomes

importance. Heretofore, biological markers

training programs are not available or feasi-

have been used as primary end points for disease

ble, psychologists can gain some understand-

assessment, but such measures are only mod-

ing

in

the

core

content

areas

through

estly correlated with health outcomes. L o w cor-

individual courses, independent reading, and

relations between biological measures of disease

continuing education classes.

process and

Psychologists also can acquire knowledge of

patient

outcomes

have

been

observed in many areas of medicine (Feinstein,

health policy and the political environment

1 9 9 4 ) . For example, rheumatologists often mea-

through fellowship programs. T h e R o b e r t

sure disease activity by sédimentation rates or

W o o d Johnson Foundation sponsors a health

the number o f swollen joints, but these measures

policy fellowship that supports the participation

are poorly correlated with patient disability and

of psychologists and other health professionals

capacity to function. Thus, biological measures

in the formulation o f national health policy in

serve only a limited role in predicting patient

the U.S. Congress. Similar programs are offered

outcomes. Functional disability and capacity to

by the American Psychological Association and

function (i.e., ability to carry out activities o f

Service (De Leon,

daily living) also are relevant measures, and

the U.S. Public Health

Hagglund, Ragusea, & Sammons, in press). For

measures

o f psychosocial

and

behavioral

508

SPECIAL ISSUES variables (e.g., stress levels, coping responses,

educational initiatives aimed at providing them

health behaviors, social networks) further con-

with the requisite knowledge and skills as part

tribute to the prediction of health outcomes

of their graduate education. One such program

(Kurki, 2 0 0 2 ; Tucker etal., in press). These

exists at UAB, a large urban university that

nonbiological variable classes fall within the

offers undergraduate, graduate, and profes-

domain of psychology and are important lines

sional degrees and is recognized for its excel-

of research for health psychologists to pursue.

lence in health-related research. Three schools at

hi general, definitions of health are shifting

UAB (Social and Behavioral Sciences, Public

that is based

Health, and Medicine) are collaborating to offer

on physiological markers of health and disease to

educational opportunities for psychologists to

a patient-focused

gain expertise in health services and outcomes

from a biomedical

process outcomes

model model

that encom-

passes symptoms, functioning, and

distress

(Kaplan 8c Anderson, 1 9 9 6 ; Kaplan, Anderson,

research at the predoctoral, postdoctoral, and professional levels of training.

8c Ganiats, 1 9 9 3 ) . Medicine is increasingly faced

The joint P L D . / M . S . P . H . (master o f science

with evaluating interventions for chronic condi-

in public health) program in Medical Clinical

tions, rationing health care based on improve-

Psychology and Health Outcomes and Policy

ments in health and quality of life, and viewing

Research is the most comprehensive program.

patients as consumers of care. These changes are

T h e program provides psychology doctoral

propelling the shift in models and measurement

students with coursework and research experi-

of health outcomes, and they pose challenges for

ences in outcomes and policy research that

the medical community, which is not well versed

complement their existing training in clinical

in the assessment of nonbiological outcomes.

health psychology. Students enrolled in the

Thus, psychologists have an opportunity

program complete basic coursework in clinical

to

apply their expertise in measurement across the

health psychology and then are permitted to

health care field in ways that should contribute

enroll in the Outcomes and Policy Research

to better conceptual and operational definitions

M.S.P.H. program in the School o f Public

of health and to sound assessment practices. The

Health. T h e curriculum for the program is pre-

process of defining and operationalizing a con-

sented in Table 2 6 . 1 . Students complete the

struct (e.g., health, anger, pain, hostility), quanti-

core content areas and two elective courses.

fying

T h e électives enable students to concentrate

it through

instrument

development,

validating the instrument to ensure reliability and

their efforts in health policy, advanced analyt-

accuracy, and collecting and interpreting data

ics, or clinical outcomes evaluation. Because of

using the instrument are common practices in

their foundation

health psychology. The requisite skills in psycho-

research design, the biostatistics requirements

metrics, behavioral assessment, and instrument

are waived. O n completion o f the coursework,

o f skills in statistics and

development and validation are cornerstones of

each student conducts an independent research

training in psychology. Thus, health psycholo-

project under the mentorship of a School of

gists are poised to become leaders in the evalua-

Public Health faculty member. T h e program

tion of health outcomes.

typically can be completed in 1 year and so adds an additional year to students' doctoral

Joint Training Programs in Psychology and Public Health: The UAB Example

training in psychology. Graduates of the joint degree program gain knowledge and skills necessary to investigate the effects o f medical and public health interventions on survival, quality

Growing opportunities for psychologists to

of life, and resource utilization. They are pre-

work in select areas of public health are nurturing

pared for careers in public health, health care

Public Health Table 2 6 . 1

Required Courses for the Coordinated Master of Science of Public Health (M.S.P.H.) and Doctor of Philosophy (Ph.D.) in Medical Psychology at the University of Alabama at Birmingham

M.S.P.H. core Biostatistics I (3 hours) Biostatistics II (3 hours) Principles of epidemiologic research (4 hours) Principles of epidemiologic research lab Outcomes research Design of clinical trials Health economics Patient-based outcomes measurement Social and ethical issues in public health Health insurance and managed care Cost-effectiveness analysis for public health and medicine Decision analysis for public health and medicine Approved électives Regression analysis Health program evaluation Applied logistic regression Clinical trials and survival analysis Survey research methods Public health policy Public health law Improving health care quality outcomes Aging policy Policy analysis: Modeling and simulation Special problems in policy analysis Research experience Master's-level research project NOTE: These requirements are in addition to the requirements of the Ph.D. program in psychology.

settings, and health services research such as

research programs. All projects address core

program evaluation, health outcomes assess-

outcomes and health services research topics

ment, and pharmacoeconomics.

such as quality improvement, cost-effectiveness

For those who have already completed

analyses, patient-centered outcomes evalua-

a Ph.D., the U A B Center for

Outcomes

tion, program evaluation, and clinical trials.

and Effectiveness Research and

Education

Fellows attend weekly research discussion

( C O E R E ) offers a 1- to 2-year postdoctoral fel-

groups and journal clubs, attend health ser-

lowship that provides research experiences in

vices methods workshops, and can enroll in

outcomes and health services research. During

the courses offered in the previously described

the fellowship, psychologists are exposed to a

M.S.P.H. program. T h e C O E R E fellowship

variety o f outcomes and

provides opportunities

health

services

to collaborate with

research projects, the content of which varies

other fellows from diverse disciplines, includ-

from year to year depending on

ing medicine, health economics, and health

faculty

509

510

SPECIAL ISSUES administration. Psychology fellows are jointly

health services research; health

supervised by the center directors and by a

psychiatry; public health; and medicine.

clinical psychologist (this chapter's second

education;

An overarching goal o f the meeting was to

author), who serves as a division director in the

explore barriers to collaboration between

COERE.

clinical and public health scientists. T h e following points emerged during the meeting:

CONCLUDING COMMENTS:

•

Basic and public health scientists place different values on many research activities and products, including individual investigator versus collaborative research, hypothesis testing versus applied research, research on interactions that support mediation/moderation of theoretically meaningful effects versus strong main effects with intervention implications, small versus large samples, and internal versus external validity and generalizability.

•

Because of these value differences, the criteria for tenure and promotion, publications, grants, and other career advancement opportunities often differ. Training opportunities in the "two worlds" of basic behavioral science and public health science are lacking. Several psychologists in attendance had acquired knowledge about public health through mid-career development K-awards. Creating educational opportunities at earlier (e.g., predoctoral) levels of training is essential to advancing the disciplinary interface.

DISCIPLINARY DIFFERENCES IN PERSPECTIVE A N D VALUES As the preceding discussion suggests, a fundamental feature o f public health that is new to many psychologists is its interdisciplinary and collaborative nature. In conventional psychology settings, psychologists often labor alone or in small teams with graduate students. This is uncommon in public health because the scale o f problems that are the subject o f research

and

practice

often

cannot

be

addressed unless multiple areas o f expertise are involved.

•

For example, in 1 9 9 9 , the surgeon general released a report

on mental health (U.S.

Department of Health and Human Services, 1 9 9 9 ) that highlighted the need to expand approaches to mental health research and practice beyond dominant clinical approaches to include population-based

public

health

approaches. T h e historical, but diminishing, dominance of psychiatry in the mental health

•

field had promoted a long-standing clinical approach to the neglect of a public health approach.

S o o n thereafter

(in N o v e m b e r

2 0 0 0 ) , the National Institute on Mental Health held a meeting in Rockville, Maryland, titled "Research on Mental Disorders: Overcoming Barriers to Collaborations Between Basic Behavioral

Scientists and

Public

Health

Scientists" that was attended by this chapter's first author. T h e following disciplines were represented at the meeting and exemplify the breadth

o f relevant expertise c o m m o n in

public health research: biostatistics; clinical, experimental, health, and social psychology; community health sciences; epidemiology; health communications; health economics;

•

Even among informed professionals, key terms often convey important and subtle differences in meaning in different disciplines. For example, scientists from disciplines other than epidemiology often do not recognize that incidence is a technical term that refers to a measure of rate with time in the denominator. Similarly, attitude is a wellresearched construct in psychology, but this body of work often is unfamiliar to nonpsychologists, who use the term in the vernacular. Considerable comorbidity exists between health problems and mental health problems. However, the issue is underresearched, and the extent of comorbidity is underdiagnosed and undertreated in practice settings, in part because of historical lines drawn among the pertinent disciplines.

Public

Health

These points are instructive about the chal-

Psychologists have much to contribute in

lenges involved in moving across the disci-

these areas of application, but relatively few

plinary boundaries of psychology and public

have acquired the "hybridized"

health. But many opportunities exist as well.

knowledge needed to work effectively in an

As noted earlier, psychologists have research

interdisciplinary health care or research envi-

skills that would enhance the quality of evalua-

ronment. As discussed in this chapter, there are

tion research on public health behavioral inter-

a number o f paths to acquiring essential knowl-

ventions. They also are knowledgeable about

edge and skills, and joint psychology-public

etiology and conceptual issues in abnormal

health programs are likely to become more

behavior and human change processes. In this

common in response to the need for behavioral

skills and

regard, helping the public health field to move

scientists with the necessary breadth of knowl-

beyond its reliance on the health belief and

edge and skills. Interdisciplinary approaches are

transtheoretical models was noted as a concep-

essential to finding satisfactory solutions to

tual issue that would benefit from input by

many contemporary health-related challenges,

psychologists.

including expanding prevention

In the arena

o f practice and

research, promoting

adherence to

programs,

applied

improving health care access and effectiveness,

health-

reducing health disparities, and

related programs was identified as a critical

containing

costs without reducing the quality o f care.

issue that must be tied more closely to techno-

Psychologists have been underrepresented

logical and pharmaceutical innovations in

in these endeavors, probably due in part to

care. In addition, because primary health care

their historical efforts to practice indepen-

professionals are overburdened,

calling on

dently without medical supervision and to the

them to do more in the behavioral health arena

corresponding applied research agenda that

was viewed as unrealistic. Helping to refine

emphasized comparative outcome evaluations

their focus and increasing the efficiency of

of different types of psychotherapy. These ini-

what

of

tiatives were successful, but the struggle for

"physician extenders," and increasing direct

they

do,

making

greater

use

professional independence may have inadver-

patient access to assessment and intervention

tently deterred the participation o f psycholo-

options were recommended as alternatives. It

gists in interdisciplinary teams that are the

was further recommended that, in nonspecial-

hallmark of public health research and prac-

ized health care settings, mental health services

tice. T h e expertise of psychologists is needed,

should be "bundled" with other behavioral

and they will almost certainly find the colle-

health services to increase efficiency and to

giality and respectfulness that are characteristic

decrease the stigma o f mental illness. T h e tim-

of public health collaborations to be more pro-

ing o f delivery of such services to optimize

ductive and satisfying than the medical hierar-

access, utilization, and outcomes

chy model that dominated the early years o f

remains

poorly understood and underresearched.

psychology's professional development.

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CHAPTER

10 27

Practical Research in a Medical Setting Is Good Medicine K A T H L E E N

PALM, JACK

M.

A N T O N U C C I O ,

C

L.-M.

A N D E L I Z A B E T H

important

is

becoming

increasingly

in the behavioral

DAVID

O.

V . GlFFORD

onducting clinical research in medical

settings

MUTNICK,

health

There

are m a n y

advantages

to

doing

research in medical clinics. F o r example, researchers can contact more patients, observe

care field. In the w a k e o f managed care, the

a greater range o f complaints, and interact

role o f the behavioral health care provider is

with multidisciplinary teams. Perhaps most

shifting.

the

important, researchers can study treatment

session will eventually

and treatment outcomes as they occur in

S o m e experts speculate that

50-minute therapy

become extinct (Cummings, 2 0 0 0 ;

Hayes,

Barlow, & Nelson-Gray, 1 9 9 9 ) . Behavioral

"real-world"

treatment

settings.

Before

beginning a research program in these set-

health care specialists will increasingly need

tings, however, there are special issues to

to function within different contexts.

consider. T h i s c h a p t e r

describes a

brief

As the practice o f behavioral care special-

history o f research in medical settings and

ists shifts, so must the focus o f research. There

then details institutional and research consid-

is a growing need to assess the effectiveness o f

erations. C o m m o n roadblocks are discussed,

psychological treatments outside o f controlled

and practical advice is provided. A case study

laboratory settings. Controlled studies assess

illustrates h o w

the efficacy o f treatments by testing whether

blocks can be addressed.

different

issues and

road-

interventions w o r k under ideal circumstances. Typical medical settings, however,

include

numerous factors that cannot be controlled

CASE

STUDY

and are hardly ideal. Because this is where many interventions will be delivered, this is

Throughout this chapter, the authors draw

where the research needs to be conducted.

on a specific real-world example of clinical

A U T H O R S ' N O T E : This research was supported by National Institute on Drug Abuse Grant 1 R 0 1 D A 0 1 3 1 0 6 - 0 3 .

514

Practical

Research

in a Medical

Setting

research in a medical setting. T h e investigators

where the focus was more on advancing science

of this study sought to examine the impact on

for the sake o f knowing rather than for the sake

smoking cessation o f bupropion

of healing human suffering. Examples from the

sustained

release (SR) versus bupropion S R plus behav-

19th and early 2 0 t h centuries illustrate how the

ior therapy. Approximately 3 0 0 patients par-

burden o f serving as research participants fell

ticipated and were treated at the local Veterans

largely on poor ward patients, whereas the

Affairs (VA) hospital, a family medicine clinic,

luxury of improved medical care went primarily

or the psychiatry clinic at the University o f

to private and wealthier patients. One example

School o f Medicine. All patients

of maltreatment of research participants is the

received a 10-week course o f bupropion S R

exploitation of unwilling prisoners as partici-

and were given the standard instructions for

pants in Nazi concentration camps (Shuster,

Nevada

taking the medication. Participants were ran-

1 9 9 7 ) . In the United States during the 1940s,

domly assigned to one o f three groups: medi-

the Tuskegee Syphilis Study used disadvan-

cation only, medication plus assessment, or

taged, rural, African American men to study the

medication plus assessment plus

untreated course of a disease that was by no

behavior

therapy. Behavior therapy involved 1 0 weeks

means confined solely to that

of individual and group treatment. Assessment

(Fairchild & Bayer, 1 9 9 9 ) . T o avoid interrup-

was conducted at intake, W e e k 3, W e e k 7,

tions in the study, these individuals

posttreatment,

deprived o f demonstrably effective treatment

6-month

follow-up,

and

population were

12-month follow-up. Although the research

long after such treatment became available to

design and outcomes from this study were

the general public (Fairchild & Bayer, 1 9 9 9 ) .

enlightening, the locations in which this study took place perhaps presented more information and challenging questions than did the initial research hypotheses. As different parts o f this chapter are highlighted, brief examples from this study are provided to illustrate how the investigators addressed the challenges o f working within these medical clinics.

It is against this historical background that the concepts of justice and ethical practice being relevant to research involving human participants (Francis, 2 0 0 1 ) is painfully clear. And it is for these reasons that the selection o f research participants needs to be scrutinized to ensure that particular groups o f people are not being selected simply because o f availability, c o m p r o m i s e d position, or

manipulability.

Rather, participants should be selected for H I S T O R I C A L A N D E T H I C A L ISSUES

reasons related to the problems being studied. Ultimately, when research supported by public

Before commencing a program o f research

funds leads to the development o f new thera-

within a medical setting, it is useful to con-

pies and procedures, ethical guidelines demand

sider the historical context. T w o important

that these treatments not provide advantages

historical angles are the history o f research in

only to those who can afford them and that

medical practice and the history o f the inte-

such research should not unduly involve

gration o f psychological interventions with

persons from groups unlikely to be among the

traditional medical practice. Investigators are

beneficiaries o f subsequent applications of that

also encouraged to become familiar with the

research.

tradition

o f research within

the specific

clinics in which they will be working. One historical issue to consider is the treatment o f research participants

in medical

research. There is a history in medical research

Three basic ethical principles are particularly relevant to the ethics o f research involving human

participants:

"beneficence," and

"respect o f persons," "justice" (U.S. National

Commission for the Protection of Human

515

516

SPECIAL ISSUES Subjects

of

Biomedical

and

Behavioral

alternatives to the proposed

intervention;

Research, 1 9 7 9 ) . Respect for persons incorpo-

(d) an account o f the relevant risks, benefits,

rates at least two ethical convictions, namely,

and uncertainties related to each alternative;

that

(a) individuals

should

be

treated

as

and (e) reassurance that personally identifi-

autonomous agents and (b) persons with dimin-

able private information will be held in strict

ished autonomy are entitled to protection.

confidence (Ashford, Scollay, & Harrington,

Beneficence requires that participants be treated

2 0 0 2 ) . O n e must remember that informed

in an ethical manner not only by respecting their

consent originates from the research partici-

decisions and protecting them from harm but

pants' legal and ethical right to direct what

also by making efforts to secure their well-being.

happens to their bodies and from the ethical

T w o general rules have been devised as corre-

duty o f the research team to involve the

sponding expressions o f beneficent actions,

participants in the decision-making process.

namely, to (a) do no harm and (b) maximize

In the medical industry, there often seems

possible benefits and minimize possible harms

to be a distinction made between research

(Reitsma 8c Moreno, 2 0 0 2 ) . T h e final basic

and practice. Research

ethical principle widely accepted in research is

data, whereas the term practice

is thought to focus o n connotes a

that of justice. In delving into this expansive

focus on healing. O n e o f the biggest distin-

topic, one needs to consider the question of who

guishing

should receive the benefits of research and who

within medical settings is the need to interact

should bear its burdens. This is a question of

effectively with an existing system that typi-

factors

o f research

justice in the sense of "fairness in distribution"

cally

or "what is deserved."

research demands.

prioritizes

clinical

conducted

practice

above

M a n y medical clinics

A very important topic that may be under-

have not experienced the effective integration

emphasized is "informed consent." Informed

o f research and practice. This chapter out-

consent is a process, not just a form to be

lines h o w t o develop a research program that

signed. It is necessary for the researcher to pre-

will w o r k within these settings.

sent all of the pertinent information to the participants to enable these individuals

to

voluntarily decide whether or not to partici-

DEFINING A RESEARCH QUESTION

pate. It is fundamental to ensure respect for persons through provision o f thoughtful con-

W h e n working within a fast-paced setting

sent for a voluntary act (Casari 8c Massimo,

with limited time and staff resources, it is

2 0 0 2 ) . T h e procedures

obtaining

important to pose a question in the most effi-

informed consent should be designed to edu-

used in

cient way possible. In other words, consider

cate the participants in terms that they can

posing the question in a way such that the

comprehend. Therefore, the language and doc-

findings add the most information to the

umentation must be written in terms that are

current state o f knowledge in the field. For

understandable to the people being asked to

example, investigating the question

participate.

Treatment X w o r k ? " may be interesting, but

T h e essential c o m p o n e n t s that be included

when

attempting

to

"Does

should

one can gather more informative data if the

obtain

question is posed in such a way that health

informed consent from research participants

care providers can determine which

are as follows: (a) a description o f the overall

is best for which

treatment

experience that participants can expect; (b) a

tions (Paul, 1 9 6 7 ) . Therefore, studying multi-

people under which

condi-

description o f the benefits that participants

ple factors that may influence the effects of

may

treatment will provide more information than

reasonably

expect;

(c) r e a s o n a b l e

Practical simply inquiring whether or not

Research

in a Medical

Setting

517

treatment

There are several steps researchers can take

works. Furthermore, investigating the mecha-

to facilitate the adoption o f new ideas in med-

nism o f change in addition to outcomes might

ical settings (Strosahl, 2 0 0 1 ) . First, researchers

better inform treatment development (Follette,

should attain the support o f the administra-

1 9 9 5 ) . Researchers can also maximize effi-

tion (e.g., chief executive officers, directors o f

ciency by exploring alternative explanations

units). They should ask these people whether

to the investigated problem. For instance, in

they would be willing to help pitch the idea to

the described case study, the

investigators

the rest o f the clinic. Second, if possible,

hypothesized that treating emotional avoid-

researchers should try to attend staff and/or

ance would

function

to reduce

smoking. They also investigated

cigarette alternative

residents

meetings. Getting to k n o w

the

people within the clinic can be helpful in try-

mechanisms o f change for smoking cessation,

ing

including social support, stage o f readiness,

Having others' support will help to facilitate

and the taste o f cigarettes after taking the

assessment and

medication. By assessing various

increase the likelihood o f obtaining

possible

to

advance

project treatment

implementation. and

may

also more

mediating variables, the investigators could

referrals. A related strategy involves enlisting

identify which mechanisms accounted for the

an employee o f the institution as a collabora-

largest degree o f change in outcomes.

tor or consultant on the study. In the case study, physicians from the various clinic sites were invited to be consultants on the study. T h e investigators

SELLING T H E RESEARCH IDEA

also attended

meetings to educate

residency

the residents

about

Despite the most exciting research ideas, one

bupropion S R , describe the research goals,

o f the main obstacles to confront is selling

and enlist the support o f the medical staff.

the ideas to staff at the medical

facility.

Third, researchers should find out whether

Depending on the size o f the medical setting

there is specific information o f interest to clinic

and the size o f the project, it will be more or

staff. Some information can be easily collected

less feasible to pitch research ideas to the

along with other data. Being open to gathering

administration and staff. Research may be

information relevant to the practice setting

an integral part o f some medical settings,

increases the chance that the clinic will accept

whereas other facilities have never partici-

the research idea. Also, when presenting the

pated in research projects. Before pitching the

idea, researchers should try to have as much

research idea, it would be helpful to assess

detail formulated as possible while maintaining

h o w supportive the clinic or hospital is o f

a degree o f openness to change. Providing a

research. If it has supported research in the

clearly explicated project will bolster confi-

past, it would be ideal to talk to investigators

dence in the competence o f the investigators.

working in that setting so as to anticipate

At the same time, maintaining a degree of flex-

possible institutional barriers that might arise.

ibility will also increase the likelihood o f

F o r example, one practical consideration to

success in these settings.

anticipate may be related to the increased

In addition to information, the medical

security measures that have developed in hos-

clinic or clinic staff may be in need o f services

pitals and clinics during recent years. It may

that the researchers can provide. For instance,

be important to show the staff and adminis-

the investigators in the case study provided

tration that the researchers share their con-

instruction on using the Internet to clinic

cerns about security and will make every

nurses at one site and permitted use o f the

effort to w o r k within their regulations.

assessment computers when these computers

518

SPECIAL ISSUES were not being used by research participants.

nonresponse t o treatment.

In exchange for the use o f these resources, the

medical facilities may insist on additional exclu-

clinic provided

the researchers with

In fact, some

office

sion criteria based on institutional concerns

space and referrals to the smoking cessation

about appropriate candidates for treatment.

program.

Researchers should work collaboratively with

Researchers should try, to the extent pos-

the medical setting staff to develop the safest,

sible, t o incorporate data collection into the

most efficient, and strongest research design

normal routine of treatment. In the case

possible given the requirements of the setting.

study, the investigators simply set up

an

In addition to ethical issues, investigators

adjunctive smoking cessation clinic in the V A

often will need to negotiate more practical

Mental

site.

concerns. T h e issue o f office space is fre-

Participation by veterans in these adjunctive

Health

Clinic

at

another

quently a dilemma. Researchers may have

clinics was counted as use o f V A services.

limited space, if any at all, within which to work. Although having an office for the investigators may be ideal, researchers might

INSTITUTIONAL CONSIDERATIONS

not have any office space available and will have to work quickly in the hallways between

Medical settings use written and unwritten

seeing patients. F o r this reason, it is impor-

policies that include, but are n o t limited to,

tant to have organized assessments that are

regulations,

easily accessible and include clear instruc-

particular guidelines and protocols o f the

tions. Practical issues regarding the everyday

institutional

review

board

medical setting, and other research review

operation o f a research study might seem

procedures. It is important to investigate and

inconsequential at first. However, these prob-

address these institutional policies to facili-

lems can potentially interfere with the flow o f

tate cooperation within the clinic. T h e r e are

research and possibly the eventual completion

two policy matters to which researchers must

of the project. Therefore, it is important to

attend (a) the ethics o f the proposed research

carefully plan h o w treatment and assessments

study and (b) practical concerns related to

will be conducted. In addition to space con-

the logistics o f conducting the study.

cerns, researchers should clearly outline the

Researchers should be aware o f the ethical

format of assessments (e.g., paper and pencil,

guidelines followed by the medical facility.

c o m p u t e r ) , where patients

Although most adhere to standard guidelines,

assessments, where data will be stored, w h o

will complete

some facilities may incorporate additional con-

will have access t o the data, and

siderations. For example, investigators should

personnel will be collecting the data.

which

become familiar with the institutional protocol for adverse events. If none is specified, procedures should be created indicating w h o should

RESEARCH DESIGN

be contacted in an emergency, what reports need to be written in such a case, who should

T h e r e are a variety o f design options to use

receive copies o f the reports, and what needs to

when conducting research in a medical set-

be done in response to specific adverse events.

ting. These designs range from single-case

In addition, some medical settings may have

methodology to large randomized

special policies related to patients' response, or

trials. Although a review o f research designs

lack o f response, to treatment. Patients should

is beyond the scope o f this chapter, the

always be adequately informed

reader is referred to B a r l o w and

of poten-

tial risks, including iatrogenic effects

and

control

Hersen

( 1 9 8 4 ) for single-case methodology and to

Practical Kazdin ( 1 9 9 8 a , 1 9 9 8 b ) for group

design

methodology. The context o f the medical setting introduces special issues that might not apply in

Research

in a Medical

Setting

have large enough variability in

symptom

severity to detect differences? Are the assessments sensitive enough to detect changes over the duration o f the study?

other settings. For example, hospitals may

Another issue that should be addressed is

differ in their views of what types of control

attrition. Some patients might leave the study

conditions are acceptable. Although ethical

before they have completed their participation.

guidelines provide a framework from which to

Although

work, some hospitals or clinics may have more

received the full treatment, information about

stringent policies. Again, researchers need to

these individuals can be very useful. Collecting

these patients

might

not

have

become knowledgeable about local policies and

information about why the patients quit treat-

how to best structure research projects in ways

ment can inform providers

that work within these systems. It is important

patients are more likely to adhere to the treat-

about

which

to find the best balance between workability

ment in the future. If participants do not agree

within the hospital system and strength o f the

to complete the assessment portion o f the

conclusions that can be drawn from the study.

study, using a brief telephone follow-up ques-

Ideally, researchers should identify extraneous

tionnaire or mailing a brief assessment packet

variables and implement procedures that will

can be invaluable. In the case study, the inves-

best control for them. In the case study, the

tigators decided to use a brief, 5-minute tele-

investigators speculated that contact with

phone follow-up format to collect information

assessment staff during the course o f treatment

about smoking status, participation in other

might affect the outcome. Consequently, an

treatments, hypothesized mediating variables

additional condition was added in which par-

(e.g., avoidance, social support), and

ticipants continued to receive medication but

patients were choosing to quit the study at that

why

had limited contact with assessment staff

time. This procedure allowed the researchers

during the treatment phase of the study.

to gather minimal outcome data and prelimi-

In many medical clinics, multiple health care providers see one patient. Within one

nary data about which individuals were not as likely to benefit from the intervention.

clinic, it is not uncommon for a patient to be

It is also important to track and report

involved in an anger management group, indi-

information regarding participants w h o were

vidual therapy for posttraumatic stress disor-

excluded from the study. Often, there are

der, and treatment for diabetes. It is possible

treatment options that are proscribed given

that treatments other than the one under inves-

certain conditions. F o r example, in the smok-

tigation might influence outcomes. In other

ing cessation study, the investigators found

words, outcomes may be due to changes that

that bupropion S R was contraindicated for

are occurring in another treatment domain. It

people w h o , among other things, were taking

is also plausible that an intervention targeted at

selective serotonin reuptake inhibitors or had

another problem is dampening the impact that

a history o f seizures. Given these precau-

the treatment under investigation may have.

tions, many veterans were unable to partici-

Tracking a patient's participation across health

pate in the study due to medical exclusions

services can help to identify the impact o f other

(Kohlenberg, Antonuccio, Hayes, Gifford, &

treatments on patient outcome. Some other

Piasecki, 2 0 0 2 ) . These data provided useful

questions to ask include the following: Has the

information regarding the effectiveness o f

patient already participated in identical or

using this treatment option within the V A

similar treatments such that little improvement

clinic. Identifying

can be expected? Does the patient population

treatments are not suitable is as important as

populations

for

whom

519

520

SPECIAL ISSUES identifying those for w h o m treatments are effective.

In

conducting

good

assessment,

it

is

important t o collect meaningful and efficient measures. Documentation and referrals should be easy (Hollis et al.,

2000), especially if clinic

RECRUITMENT

personnel are collecting data as part o f the

Before recruiting participants for a study, it is

the time demands of busy practice environ-

important to define what the inclusion and

ments. In addition, investigators should care-

research program. It is imperative t o consider

exclusion criteria will be. As described previ-

fully research the most persuasive data. For

ously, patients may have medical or psychi-

example, is self-report o f cigarettes smoked

atric conditions that would preclude their

better than carbon monoxide reading? In addi-

participation. It is useful to have a script and a

tion, researchers should consider the length o f

standardized screening assessment for staff so

time for which data are being collected and

that all participants receive the same informa-

whether it is possible t o see a change in these

tion during the initial phone screen. T h e script

data during that amount o f time.

should include a thorough discussion o f the

Finally, it is important for investigators to

expectations o f study participants. Although

constantly attend to the morale o f the people

patients will be presented with informed con-

involved in the project as well as t o the rela-

sent documents when they enter the study, in

tionship between research assistants and the

the chapter authors' experience, patients seem

medical facility staff. T h e number o f obstacles

t o participate more fully in the program when

that can be encountered during a research

informed consent and commitment-enhancing

study c a n be demoralizing. Barriers may

procedures are implemented during the first

range from dealing with institutional politics

contact with the patients.

to trying to get patients to adhere to treatment and complete assessments. Within this context, treatment and assessment staff may become less committed to the project, drift in

ASSESSMENT

their delivery o f services, and not be as attenbe

tive to maintaining respectful and effective

considered before assessment systems are put

relationships with coworkers. Investigators

There

are several issues that

should

into place. First, investigators should iden-

can plan ongoing training opportunities, hold

tify whether or not reactivity to assessments

regular meetings, and provide a great deal o f

might be a concern. F o r example, researchers

encouragement to everyone involved in the

have found that people can change behavior

study t o maintain healthy relationships and

and their physiology when they have access to

morale. As the investigators found in the case

physiological measures (Abueg, Colletti, 8c

study, food nearly always works.

Kopel, 1 9 8 5 ; M c D o w e l l et al., 1 9 9 9 ; Scharff, Marcus,

8c M a s e k , 2002). In the case study,

researchers were measuring carbon monoxide

TREATMENT

readings from smoking patients and decided to ensure that patients did not see their ratings

Before interventions are implemented, there are

until after the study was completed. Providing

a few steps that researchers can take t o assist in

an attractive graph o f the patients' readings

the flow of the project. T o begin, researchers

only at the end of the study reduced the possi-

should design protocols that explicate the roles

ble effects o f reactivity to this measure and

of the staff that are involved in the study.

gave patients something additional to take

Research and medical staff should be trained on

away from their participation in the study.

what is and is not expected of each. These

Practical

Research

in a Medical Setting

\

protocols should also outline who should be

patients actually received the treatment in

contacted for psychiatric and/or medical emer-

totality. For example, if patients were taking

gencies. Additional

be

an antidepressant, did they take the indicated

addressed in the protocols might include the

number o f pills per day? O r , if they were

training of treatment providers and the moni-

using a nicotine patch, did they use the patch

toring o f treatment adherence.

as indicated? T o measure their adherence,

items that

should

Also, staff roles should fit efficiently into

patients could record whether or not they

office flow (Hollis et al., 2 0 0 0 ) . It is important

receive treatment each day o f the week. T h e

to have a steady flow and good communica-

problem with this procedure, however, is that

tion between health providers and research

self-monitoring has been found to be an effec-

assistants. For example, in the smoking cessa-

tive treatment in and o f itself (Abueg et al.,

tion study, research assistants conducted the

1 9 8 5 ; Gillmore et al., 2 0 0 1 ) . Therefore, it

screening and initial assessments and then pro-

would be difficult to tease apart the effects o f

vided physicians with a summary o f this infor-

the self-monitoring versus the treatment being

mation so as to work more efficiently with the

studied.

doctor. T o avoid losing possible participants,

adherence to treatment might be to use a ver-

investigators should also plan on minimizing

sion o f the time line follow-back procedure

the time between obtaining a referral, conduct-

(Sobell, Brown, L e o , & Sobell, 1 9 9 6 ) . In this

ing the phone screen, and starting treatment.

procedure, the research assistant reviews a

Training o f treatment providers will vary depending on w h o will be delivering treatment. I f the research team is providing the clinicians, investigators often have the luxury o f time and resources to spend on training. However, if the clinicians are current staff

An alternative w a y

o f assessing

calendar with the patients, w h o indicate the days on which they complied with the treatment protocol. Researchers should

always

consider h o w the delivery and monitoring o f treatment affects outcomes. In

the

smoking

cessation

study,

the

from within the medical setting, researchers

researchers specified how many therapy sessions

will need to develop a quick and efficient

a patient had to attend to be considered some-

training program for the clinicians. Providing

one who completed the treatment. Likewise,

manuals, videotapes, C D - R O M s , one-time

they needed to specify the definition of adher-

training meetings, or some combination o f

ence to the study medication. These decisions

these options may be the best approach to

should be made before treatment begins.

training. T o monitor any drift in treatment delivery and to ensure that treatment is being provided as it should be, researchers should

C O N F L I C T O F I N T E R E S T ISSUES

periodically monitor adherence to treatment protocols while the treatment phase is in

Conducting research within medical settings is

progress (Elkin, 1 9 9 9 ) . F o r example, adher-

influenced by factors that lie inside and outside

ence can be assessed through coding tapes o f

of the actual clinics. It is not uncommon for

clinicians w h o are providing the interven-

these factors to interfere with

tion. Periodic monitoring o f treatment deliv-

research

ery during the treatment phase o f the study

researchers have a moral and ethical obligation

can provide opportunities to give feedback to

to address these difficult issues and to make

treatment providers.

sure that important information is dissemi-

Investigators should also define what they

and

clinical practice.

appropriate However,

nated. Some o f these dilemmas include finan-

consider to be a treatment "completer." T o

cial conflicts o f interests and

conclude whether or not treatment was effec-

biases. These factors are especially complicated

publication

tive, researchers must be able to show that

to address when medications are included in

522

SPECIAL ISSUES the study. For example, it is difficult to think o f

results of their studies, no matter whose o x is

any arena involving information about medi-

gored. The integrity of medical research is at

cations that does not have significant industry

stake and is worth fighting for.

financial or marketing influences. Industry financial influences extend to federal regulatory agencies, professional organizations and

CONCLUSIONS

their journals, continuing medical education, scientific researchers, media experts, and con-

Conducting

sumer advocacy organizations (Antonuccio,

presents challenges that are typically not

Burns, & Danton, 2 0 0 2 ) . Respected psychi-

encountered in more traditional

atric researchers such as M a r k s (Marks et al.,

research environments. Investigators

1 9 9 3 ) and Fava ( 1 9 9 8 ) have warned that such

must study politics and persuasion nearly as

research

in medical

settings

behavioral often

widespread corporate interests may result in

much as they study their research question.

self-selecting academic oligarchies influencing

Although these added pressures can be daunt-

clinical and scientific information. In fact,

ing, the rewards of doing this work far surpass

those who produce data contrary to industry

the costs. Within 15 months, the researchers in

interests may find themselves vulnerable to

the case study helped approximately 3 0 0

legal, professional, or even personal attack,

patients to quit smoking. M a n y o f these

either directly or indirectly financed by the

patients would not have had the opportunity to

industry (Antonuccio et al., 2 0 0 2 ) .

join this program if it had been located outside

Furthermore, there are widely acknowledged

of their medical clinics. Although it took time

publication biases, often related to conflicts of

and patience to conduct this project, prelimi-

interest, that favor pharmaceutical industry

nary analyses indicate that 2 7 % o f those

products (Antonuccio et al., 2 0 0 2 ) . In fact, these

patients who could be contacted for assessment

biases have so eroded the credibility o f the med-

6 months after treatment remained smoke free.

ical literature (Quick, 2 0 0 1 ) that new proposals

The ultimate goal in health care is to develop

call for stringent accountability guidelines (e.g.,

and provide the best treatments possible for

Davidoff et al., 2 0 0 1 ; Moses & Martin, 2 0 0 1 )

those individuals who need them, implementing

aimed at ensuring researcher independence in

research programs within medical settings helps

study design, access to data, and right to pub-

to accomplish this goal in several ways. First, this

lish. It remains to be seen whether these new

practice can foster the dissemination of effective

guidelines will have the desired effect of improv-

treatments. Second, it can force researchers to

ing the quality and credibility o f the literature.

develop treatments that are more acceptable

The bottom line is that researchers in a medical

within these environments. Most important, by

setting have a moral and ethical obligation to

moving into medical clinics, patients who need

their human participants to

care will have access to a greater number of

independently

design, implement, analyze, and publish the

opportunities to decrease their suffering.

REFERENCES Abueg, F. R., Colletti, G., & Kopel, S. A. (1985). A study of reactivity: The effects of increased relevance and saliency of self-monitored smoking through enhanced carbon monoxide feedback. Cognitive Therapy & Research, 9, 3 2 1 - 3 3 3 . Antonuccio, D. O., Burns, D. D., & Danton, W. G. (2002). Antidepressants: A triumph of marketing over science? Prevention and Treatment, 5, Article 2 5 . [Online]. Retrieved January 2 0 , 2003, from http://journals.apa.org/prevention/volume5/ pre0050025c.html

Practical

Research

in a Medical

Ashford, R. U., Scollay, J . , 8c Harrington, P. (2002). Obtaining informed consent. Hospital Medicine, 63, 3 7 4 . Barlow, D. H., 8c Hersen, M. (1984). Single case experimental designs: Strategies for studying behavior change. New York: Pergamon. Casari, Ε. E , & Massimo, L. M . (2002). From informed to shared: The developing process of consent. Minerva Pediatrica, 54, 2 1 1 - 2 1 6 . Cummings, N. A. (2000). A psychologist's proactive guide to managed care: New roles and opportunities. In A. J . Kent S i M . Hersen (Eds.), A psychologist's proactive guide to managed mental health care (pp. 1 4 1 - 1 6 1 ) . Mahwah, NJ: Lawrence Erlbaum. Davidoff, F., DeAngerlis, C. D., Drazen, J . M., Nicfiolls, M. G., Hoey, J . , Hoigaard, L., Horton, R., Kotzin, S., Nicholls, M. G., Nylenna, M., Overbeke, A. J . P. M., Sox, H. C , Van der Weyden, M. B., Sc Wilkes, M. S. (2001). Sponsorship, authorship, and accountability. New England journal of Medicine, 345, 825-827. Elkin, I. ( 1 9 9 9 ) . A major dilemma in psychotherapy outcome research: Disentangling therapists from therapies. Clinical Psychology: Science & Practice, 6, 1 0 - 3 2 . Fairchild, A. L., 8c Bayer, R. (1999). Uses and abuses of Tuskegee. Science, 284, 9 1 9 - 9 2 1 . Fava, G. A. (1998). All our dreams are sold. Psychotherapy and Psychosomatics, 67, 1 9 1 - 1 9 3 . Follette, W. C. (1995). Correcting methodological weaknesses in the knowledge base used to derive practice standards. In S. C. Hayes, V. M . Follette, R. M . Dawes, Sc Κ. E. Grady (Eds.), Scientific standards of psychological practice: Issues and recommendations (pp. 2 2 9 - 2 4 7 ) . Reno, NV: Context Press. Francis, C. K. (2001). The medical ethos and social responsibility in clinical medicine. Journal of the National Medical Association, 93, 5 7 - 6 9 . Gillmore, M . R., Gaylord, J . , Hartway, J . , Hoppe, M. J . , Morrison, D. M., Leigh, B. C , Se Rainey, D. T. (2001). Daily data collection of sexual and other healthrelated behaviors. Journal of Sex Research, 38, 3 5 - 4 2 . Hayes, S. C , Barlow, D. H., Sc Nelson-Gray, R. O. (1999). The scientist practitioner: Research and accountability in the age of managed care (2nd ed.). Needham Heights, MA: Allyn Sc Bacon. Hollis, J . F., Bills, R., Whitlock, E., Stevens, J . J . , Mullooly, J . , Sc Lichtenstein, E. (2000). Implementing tobacco interventions in the real world of managed care. Tobacco Control, 9, 1 8 - 2 1 . Kazdin, A. E. (1998a). Methodological issues and strategies in clinical research (2nd ed.). Washington, DC: American Psychological Association. Kazdin, A. E. (1998b). Research design in clinical psychology (3rd ed.). Needham Heights, MA: Allyn Sc Bacon. Kohlenberg, B. S., Antonuccio, D. O., Hayes, S. C , Gifford, Ε. V., Sc Piasecki, M. P. (2002). Bupropion SR for nicotine dependent smokers: Limited applicability? Unpublished manuscript, University of Nevada School of Medicine. Marks, L M., Swinson, R. P., Basoglu, M., Kuch, K., Noshirvani, H., O'Sullivan, G., Lelliott, P. T., Kirby, M., McNamee, G., Sengun, S., Sc Wickwire, K. (1993). Alprazolam and exposure alone and combined in panic disorder with agoraphobia: A controlled study in London and Toronto. British Journal of Psychiatry, 162, 7 7 6 - 7 8 7 . McDowell, B . J . , Engberg, S., Sereika, S., Donovan, N., Jubeck, M . E., Weber, E., 8c Engberg, R. (1999). Effectiveness of behavioral therapy to treat incontinence in homebound older adults. Journal of the American Geriatrics Society, 47, 309-318. Moses, H., 8c Martin, J . B . (2001). Academic relationships with industry: A new Association, model for biomedical research. Journal of the American Medical 285, 9 3 3 - 9 3 5 .

Setting

524

SPECIAL ISSUES Paul, G. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting and Clinical Psychology, 31, 1 0 9 - 1 1 8 . Quick, J . (2001). Maintaining the integrity of the clinical evidence base. Bulletin of the World Health Organization, 79, 1 0 9 3 . Reitsma, A. M., & Moreno, J . D. (2002). Ethical regulations for innovative surgery: The last frontier. Journal of the American College of Surgery, 184, 7 9 2 - 8 0 1 . Scharff, L., Marcus, D. Α., &C Masek, B . J . (2002). A controlled study of minimalcontact thermal biofeedback treatment in children with migraine. Journal of Pediatric Psychology, 27, 1 0 9 - 1 1 9 . Shuster, E. (1997). Fifty years later: The significance of the Nuremberg Code. New England Journal of Medicine, 337, 1 4 3 6 - 1 4 4 0 . Sobell, L. C , Brown, J . , Leo, G. I., & Sobell, M . B . (1996). The reliability of the Alcohol Timeline Followback when administered by telephone and by computer. Drug & Alcohol Dependence, 42, 4 9 - 5 4 . Strosahl, K. (2001). The integration of primary care and behavioral health: Type II changes in the era of managed care. In N. A. Cummings, W. O'Donohue, S. C. Hayes, & V. M . Follette (Eds.), Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice (pp. 4 5 - 6 9 ) . San Diego: Academic Press. U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont Report: Ethical principles and guidelines for the protection of human subjects of research. [Online]. Retrieved July 15, 2 0 0 2 , from http://ohsr.od.nih.gov/mpa/belmont.php3

CHAPTER

10 28

Evaluating Outcomes in Health Care Settings JOAQUIN WILLIAM

D

B O R R E G O , JR., C.

A N D

FOLLETTE

uring this era o f managed care and

examining the effectiveness o f a specific

increased consumer awareness, there

treatment for diabetes for a particular individual

is an ever-increasing demand from dif-

to assessing for client satisfaction with the

ferent entities (e.g., federal agencies, third-

services received at a community outpatient

party reimbursements, consumer

advocate

clinic. Along with measuring intervention effec-

groups) to ask for evidence o f professional ser-

tiveness, there is also an increasing focus on

vice effectiveness. This demand is amplified by

evaluating prevention efforts in health-related

the dramatic cost increases in providing quality

problems such as substance abuse (Hansen,

health care (Relman, 1 9 8 8 ) . In turn, public and

2 0 0 2 ) . Evaluation of existing programs can

private organizations are beginning to incorpo-

focus on both process and overall program

rate evaluation components into different ser-

effectiveness (Kelley, V a n Horn, & De M a s o ,

vice delivery programs (Brown & Reed, 2 0 0 2 ) .

2 0 0 1 ) . This flexibility allows professionals to

This change is especially evident in health care

answer a multitude o f questions in different

settings that serve a wide range o f populations

practice settings (Posavac & Carey, 1 9 9 7 ) .

with different health problems (Fink, 1 9 9 3 ) .

Program evaluation is defined as a system-

One way o f directly addressing professional

atic methodology that allows professionals to

accountability is through the systematic evalua-

(a) document whether the treatment was imple-

tion of the services delivered. This systematic

mented as intended, (b) choose appropriate

evaluation of different service components is

measures that are sensitive to behavior change,

called program

T h e goal o f pro-

(c) demonstrate treatment effectiveness, and (d)

gram evaluation is the collection, analysis, and

demonstrate how a particular intervention pro-

evaluation.

interpretation o f data pertaining to intervention

duces change (if desired). T h e ideas set forth in

efforts (Rossi & Freeman, 1 9 9 3 ) . With pro-

this chapter are meant to be broad enough so

gram evaluation, a multitude o f service delivery

that the concepts covered can be implemented

practices can be evaluated, ranging

in multiple settings (e.g., private practice,

from

525

526

SPECIAL ISSUES medical centers) targeting different

services

STEPS IN P R O G R A M EVALUATION

(e.g., individual vs. group treatment, case management, consultation).

There are several steps involved in conducting

Program evaluation can be applied

to

a thorough program evaluation. T h e first step

address a host of physical (e.g., obesity, dia-

in program evaluation is defining the specific

betes) and psychological (e.g., depression,

targets or questions that the clinician is inter-

anxiety) problems encountered in health care

ested in addressing in the evaluation. As an

settings. Questions addressed

example, a clinician in private practice might

by

program

evaluation strategies can range from simple

be interested in evaluating the effectiveness o f

objective questions (e.g., " D o e s Intervention

cognitive-behavioral group treatment with an

X w o r k with Population Y ? " ) to more c o m -

obese population. In contrast, a clinician in a

plex and

"Are

rural community setting might be interested

are

in conducting a systemwide program evalua-

subjective questions

(e.g.,

clients satisfied with the services that

offered in a community clinic and w h y ? " ) . Although it is beyond the scope of the chap-

tion and so would prefer to assess treatment accessibility, treatment

acceptability, and

ter to outline the technical details of all aspects

treatment

of program evaluation, there is one distinction

community catchment area.

satisfaction within

a

particular

to keep in mind: the distinction is between a

Once the question (or set of questions) and

cost-benefit analysis and a cost-effectiveness

hypotheses have been identified, the next step

analysis. Cost-benefit analyses are procedures

is to identify the population to be involved in

used to measure programs and outcomes on the

the program evaluation. T h e target population

same metric, namely dollars. Program costs are

can range from being broad in nature (e.g.,

determined

(e.g., costs per employee in an

assessing for satisfaction in services received in

employee assistance program) and benefits are

a multipurpose clinic) to addressing clinically

measured in terms of dollars saved in medical

related questions with a specific population

services use or dollars saved in employee

(e.g., asking whether Treatment Ζ would work

replacement costs. Often, companies or policy-

with diabetes patients). With the former ques-

makers contracting for or funding services are

tion, clinicians are accessing all clients who use

interested in these kinds of program evaluations.

services that are offered in the clinic, whereas

Individual providers and clients are fre-

the latter question might focus on only a sub-

quently more interested in cost-effectiveness

set o f the clinic population

data. In this type of analysis, costs are still gen-

patients).

(e.g., diabetic

erally computed in dollars, whereas outcomes

O n c e the target population has been identi-

are measured in terms of specific effects. For

fied, the next step involves identifying the

example, it might cost $ 4 0 0 to add an addi-

independent and dependent variables that are

tional harm reduction treatment module to a

going to be used in the program evaluation.

substance abuse intervention to produce a spe-

T h e independent variables that are going to be

cific effect such as a demonstrable increase in

identified are related to the treatment the clin-

employer satisfaction. Details o f the differences

ician is interested in evaluating. T h e key to this

between these two strategies and technical

process is selecting variables that are specific.

details o f how to conduct each can be found

Instead o f asking "Does my antidepression

elsewhere (e.g., Yates, 1 9 9 6 ) . Instead, this

treatment

chapter provides the reader with an overview

clients?," one can develop a more precise

of issues to consider when developing and

question such as " H o w does each component

program

work

with

depressed

implementing a program evaluation compo-

of an antidepressant treatment program con-

nent into one's practice setting.

tribute to the o u t c o m e ? " or "Does the level of

Evaluating

j

Outcomes

training in a particular therapy modality affect

rather than vague. As an example, instructing

the outcome in this clinic?" O n the outcome

a client to "eat better" can be improved by

or dependent variable side o f the evaluation, it

specifying the actual behaviors that the clini-

is again useful to identify maximally useful

cian is interested in modifying: eating two or

measures. Although one might be interested in

three servings o f vegetables per day, decreasing

the question "Are clients satisfied with treat-

fatty food intake by 3 0 fat grams per day,

ment?," it may be much more informative to

drinking 6 4 ounces o f water per day, and so

ask "Does a particular antidepression

pro-

on. As another example, a direction to "exer-

gram lead to a decrease in Beck Depression

cise m o r e " can be improved by making specific

Inventory scores and an improvement in life

recommendations: stretching for 1 0 minutes

satisfaction, and does that lead to increased

per day, walking for 2 0 minutes per day/four

client satisfaction with services, session atten-

times per week, and so on.

dance, and even fee remittance?" This latter

Meeting the criteria for choosing observable

version o f the specification o f the dependent

and specific target behaviors makes it easier for

variable gives a glimpse o f the potential power

clinicians to measure outcomes. It is much

o f program evaluation in that processes that

easier to measure behaviors that are observable

serve the program and the clients alike can be

and specific (e.g., monitoring the frequency

highlighted.

with which a person smokes per day) than to measure events that are unobservable

and

vague (e.g., "thinking patterns" that may or

Identifying and Defining Behaviors of Interest

may not be highly correlated with the actual treatment goals). Appealing to hypothetical

Before a treatment is implemented and eval-

constructs (e.g., the mind, the subconscious)

uated, the clinician should define what behav-

makes it difficult to monitor and document the

iors he or she is interested in changing given the

behaviors, and so they are not as amenable to

target population (e.g., decreasing smoking in

change through standard clinical practices. In

smokers if abstinence is the goal vs. decreasing

contrast, measuring behavior change involving

o f cigarettes smoked if harm

observable and specific behaviors makes it

reduction is the goal). This selection process

easier for clients to follow directions and increa-

and

ses the likelihood o f compliance. It may be

should occur early in the assessment process

helpful to make use o f simple instrumentation

(Hawkins, 1 9 8 6 ) . Three criteria for identify-

in some cases. Walking can be monitored using

the number

involves identifying

target

behaviors

ing, defining, and choosing target behaviors

a pedometer. Medication can be monitored

are that they must be observable, specific, and

with pill counts or with more expensive devices

measurable. Although private events (e.g., cog-

that can record when and how often a pill

nitions) can be measured, it is easier for clini-

bottle is opened.

cians and clients to measure observable events. As an example, although the clinician can assign a homework assignment to monitor the number o f times a person "thinks" about hav-

Other Types of Assessment Methods

ing a cigarette, it might be more beneficial to

Several assessment methods are available to

have the patient monitor the number of times

the clinician in documenting and demonstrat-

he or she smokes during a specified time period

ing behavior change. Some o f these methods

(e.g., each day, each week).

include interviews, self-report measures (e.g.,

T h e second criterion involves choosing a

rating scales), and direct observation in analog

behavior or a set o f behaviors that is specific

(i.e., clinic) and natural settings. Although

527

528

SPECIAL ISSUES interviews are considered to be qualitative in

Given the target behavior in question, some

nature, they are nonetheless important because

instruments will be more applicable than others.

they provide the clinician with information

Choosing instruments that are sensitive to

from the client's perspective about his or her

change is important because not all instruments

history and current environmental situation.

display the same level of sensitivity. As with the

Methods

line follow-back

previous example, some measures might be

(Sobell & Sobell, 1 9 9 6 ) can be reliable and

more applicable in measuring changes in global

useful ways in which to gather baseline data.

distress patterns over a longer period of time

such

as time

Self-report measures are also important

in

(e.g., 4 months), whereas other instruments

helping to choose target behaviors to change.

might be more suitable for detecting subtle

When available, staff trained to a high level of

changes in client behavior on a shorter time

reliability should be used to conduct behav-

basis (e.g., daily, weekly). If clinicians are inter-

ioral observations o f specific client behaviors

ested in tracking subtle changes but choose an

using instruments validated in the literature. A

instrument that is designed to detect global

highly structured environment (e.g., medical

changes, actual changes in client behavior will

center setting) can facilitate the process o f mak-

not be detected.

ing systematic observations but might lack ecological validity. Natural environments can pose problems o f their own, although time sampling using audiotapes may provide useful data if the clinician is evaluating communication training in a family therapy intervention. Institutional settings provide unique data-gathering opportunities o f their own (for a particularly creative reference to program evaluation in institu-

Other Issues Related to the Selection of Assessment Strategies Program evaluation can have a variety of goals and occurs in many types of settings. One goal may be to assess for the presence or absence o f a diagnostic label before and after an intervention. Such assessments will have certain

tional settings, see Paul & Menditto, 1 9 9 2 ) .

characteristics (Silva, 1 9 9 3 a , 1 9 9 3 b ) . If a pro-

Choosing Appropriate and Sensitive Measures

problem, or if the program is designed to

gram assumes a unitary cause for a particular

Choosing appropriate measures will also

deliver a structured, standardized, comprehensive treatment for a problem, reliable standardized assessments o f client problem changes and

assist clinicians in determining what and when

treatment

integrity may be sufficient (cf.

to measure. As stated previously, clinicians

Follette, Naugle, & Linnerooth, 2 0 0 0 ; Haynes,

should choose variables of interest that are clin-

1 9 9 2 ; Haynes, Leisen, & Blaine, 1 9 9 7 ) .

ically meaningful (Biskupiak, 2 0 0 1 ) . Given the

However, some programs and many prac-

question that is asked and the independent and

tices allow treatment staff to vary treatment

dependent variables that are chosen, measures

depending on client characteristics. In this case,

should be chosen that are suitable for the pro-

the service providers in a program ought to

ject. In program evaluation, it is important to

attend to the selection of assessment procedures

choose a measure or a set o f measures that is

that demonstrate

appropriate

and sensitive enough to detect

Nelson, & Jarrett, 1 9 8 7 ; Silva, 1993b). Treat-

changes for the evaluation of targeted behaviors.

ment utility of assessment is the degree to which

When appropriate, clinicians should choose instruments that are suitable for measuring the behavior change being monitored (e.g., changes in distress as a result of decreasing food intake).

treatment

utility

(Hayes,

information derived from an assessment procedure would lead a therapist to alter an intervention in a way that would affect outcome. For example, an assessment of a client's activity level

Evaluating

Outcomes

\

might lead a therapist to include a behavioral

allows for the systematic examination o f

activation component to treatment for depres-

progress (or lack thereof) when dealing with

sion. If decisions based on such an assessment

individual

clients (Hawkins

8c M a t h e w s ,

lead to improved outcomes, the assessment

1 9 9 9 ) . Although statistical analytic procedures

procedure has treatment utility. However, not all

are available for analyzing single-case designs,

programs aEow such flexibility.

visual analysis is frequently appropriate when working with individuals. As recommended by Franklin, Allison, and Gorman ( 1 9 9 6 ) , com-

Levels of Analysis Affecting Design Considerations

parison of the dependent measure across treatment conditions can provide objective data

Program evaluation can occur at many

from which to infer clinical significance.

levels, including the individual client level (i.e., the efficacy o f a type o f intervention for

Group

Designs.

An often-neglected step

a type o f client), the clinic level, or even the

involved in program evaluation is checking to

institutional level. F o r simplicity, the follow-

see whether the treatment was implemented as

ing discussion is limited to the first two cases.

intended. T h e process o f evaluating the degree to which the treatment was delivered as

Single-Case

Designs.

For

single-case

intended is called treatment

(Kazdin,

integrity

designs, multiple baseline data points can be

1 9 9 2 ) . Checking for treatment integrity allows

collected before starting treatment. Gathering

clinicians to check whether the independent

multiple data points during baseline helps to

variable (i.e., the delivered treatment) was suc-

guard against reactivity to measures, lack o f

cessfully manipulated (Follette &

reliability o f a single measurement point, and

1 9 9 9 ) . Figure 2 8 . 2 highlights the four possible

Compton,

regression to the mean artifacts. Multiple data

outcomes involved in conducting a manipula-

points also help in determining the trend and

tion check. In Quadrant I, the independent

level o f the problem being assessed. A single-

variable has been successfully implemented,

case design allows for the use o f repeated

and there was an observed change in the

measurement o f changing client behaviors,

dependent variable. Clinically, this is the best

allowing clinicians (or other evaluators) to

possible outcome because there is a level of cer-

track behavior on an individual basis and to

tainty that the observed change in targeted

tailor the measurement to fit their clinical

behavior is due to the introduction o f treat-

needs (e.g., daily monitoring, weekly therapy

ment. In Quadrant II, the treatment was suc-

session change, within-session change).

cessfully

For individual cases, a strategy that offers

implemented,

but there was

no

observed change in behavior (i.e., no change in

clinical utility is that o f graphing data for

the dependent

clients (Figure 2 8 . 1 ) . Graphing data creates a

research is being conducted, one possible

variable). I f group

design

visual analysis for clinicians that can be shared

explanation is that the treatment did not work

directly with clients. In turn, the graphed data

in accomplishing the clinically relevant goals

(Hawkins,

(assuming that there was sufficient statistical

Mathews, & Hamdan, 1 9 9 9 ) . M o r e impor-

power). In Quadrant III, the treatment was

can lead to therapeutic

gains

tant, if a reliable coding system is in place for

not

the coding of different behaviors, the graphed

was still an observed change in the desired

successfully

implemented,

but

there

data can serve as an objective measure o f client

outcome (e.g., decrease in smoking frequency).

progress during the intervention (Hawkins et

Unfortunately, the change in the dependent

al., 1 9 9 9 ) . This is important information for

variable cannot be attributed to the imple-

both clinicians and clients. For clinicians, it

mented treatment. T h e observed change might

529

530

j

SPECIAL ISSUES Baseline 1

Intervention

•A/V A

.

.

V\ ν

1

1

2

1

3

,

4

NY

4

A

\/V\

V

'

5

ι

6

7

8

9

Intervention

*

.

1

Baseline 2

1

,

,

1

1

1

1

i

\

Λ

1 0 11 12 1 3 1 4 1 5 1 6 17 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5 3 6

Days

Figure 28,1

Individual Monitoring of Behavior Change

be due to non-treatment-related events (e.g.,

checklists that are specific to the treatment o f

new medical information

interest (for a detailed discussion on treat-

received from

a

physician during the course o f treatment) or to

ment integrity checklists, see W a l t z , Addis,

threats to internal validity (e.g., changes due to

Koerner, & J a c o b s o n , 1 9 9 3 ) .

history and maturation) (Follette & Compton, 1 9 9 9 ; Kazdin, 1 9 9 2 ) . In Quadrant IV, the treatment was not successfully implemented,

ANALYSIS O F O U T C O M E

and there was no observed change in the tar-

EVALUATION

geted behavior. From a program evaluation perspective, this result would highlight the

If clinicians are interested in evaluating out-

need to implement better therapy training or to

comes for groups of individuals, there are a

identify another therapy that might be easier to

variety o f analytic techniques that are avail-

deliver for the population being evaluated.

able. Using conventional inferential statistical

In summary, the best clinical condition to

analyses targeting groups, clinicians can com-

have is that in Quadrant I, where clinicians

pare (a) one treatment condition with another

have a level o f certainty that a change in a

or (b) a specific treatment with a placebo or

client's behavior (e.g., decrease in weight) is

"wait list" group or some "treatment as usual"

due to the treatment delivered (e.g., targeting

condition (i.e., control group) (Figure 2 8 . 3 ) .

weight loss). F o r clinicians w h o use treat-

There is a growing literature that provides

ment manuals as a means o f delivering treat-

an alternative to traditional null hypothesis

ment,

testing in the form o f model fitting (Bakeman

treatment

protocol

checklists

are

available in many o f the treatment manuals.

&

If treatment manuals are not available, it

test a priori models o f processes that might

is possible to develop treatment

explain change. T h e notion in model fitting is

integrity

Gottman, 1 9 9 7 ) . Model-fitting strategies

Evaluating Changes in Dependent Variable (DV) Yes

Change in D V ( + )

Change in IV (+) No Change in D V (-)

Yes I

II

No Change in IV (-) No

Change in DV ( + )

No Change in IV (-) No Change in D V (-)

III

Figure 2 8 . 2

\

No

Change in IV ( + )

Manipulation of Independent Variable (IV)

Outcomes

IV

T r e a t m e n t Integrity Q u a d r a n t

N O T E : IV = independent variable; D V = dependent variable.

that clinicians can posit those factors that

First, clinicians can summarize program

account for change and then test the goodness

effects in terms o f Cohen's effect size statistics

of fit o f the proposed model to the actual data.

(Cohen, 1 9 8 8 ) that are often used in meta-

Clinicians can identify sources o f change that

analyses (Rosenthal &

DiMatteo, 2001).

are not modeled to refine their understanding

Rather than showing only that a program

of the change process. These techniques are

produces a change larger than zero, effect size

somewhat more demanding in terms o f soft-

statistics suggest h o w large a program change

ware and numbers o f subjects required for

is compared with similar programs if such

analysis, but they can produce data that guide

summary data exist. Regardless o f the avail-

theory and treatment development in ways

ability o f comparison data, effect sizes and

that conventional statistics cannot.

confidence intervals give some indication o f the magnitude of change a program produces.

Methods of Describing Change Although most conventional group statistical approaches to summarizing outcomes

A second approach gaining acceptance is that

o f normative

comparisons (Kendall,

Marrs-Garcia, Nath,

&

Sheldrick, 1 9 9 9 ;

Rogers, Howard, & Vessey, 1 9 9 3 ) . In this

make use o f reporting the mean change aver-

strategy, if normative data on nonclinical sam-

aged across all participants, many researchers

ples exist, the posttreatment means are tested

looking for ways in which to better describe

to see whether those treated for a problem are

the meaningfulness o f change have proposed

improved to a degree that is equivalent to a

alternatives to merely reporting mean changes

nonclinical normative sample. For example, if

between treatment or program conditions.

a program is designed to address problems o f

Three strategies deserve some mention here

child externalizing behavior (i.e., acting out),

(see also Follette & Callaghan, 2 0 0 1 ) .

two analytic steps would occur. First, the

531

532

SPECIAL ISSUES

Little change observed in control group

High Stress Levels Medium

Low

C h a n g e observed in experimental group

Pre-Treatment

Figure 28.3

Post-Treatment

Traditional Monitoring of Behavior Change

change from pretreatment to

posttreatment

it allows evaluators to categorize program

would be assessed statistically. If the change

results in terms o f what proportion o f individ-

was significant, the posttest level o f externaliz-

ual clients actually significantly improved to

ing behavior would be compared with the

become indistinguishable from normal con-

norms for a nonclinical sample to see whether

trols, what proportion improved but still dif-

the program returned participants to a normal

fered from controls, what proportion did not

level of functioning. These kinds o f data are

improve, and what proportion deteriorated as

useful

a result o f treatment.

in providing

consumers

and

pro-

gram designers with information about the

These three methods o f describing change

practical magnitude o f change an intervention

produced by a program are clinically relevant

produces.

to clients and providers alike, whereas cost-

Although equivalence or normative testing

benefit analyses and even cost-effectiveness

is useful, it assesses average changes at the level

analyses may be more meaningful to policy-

of the group. T h e third alternative for summa-

makers or those w h o contract for services.

rizing data is done at the level of the individual. In an approach similar to equivalence testing, each individual's result is tested to see whether the program both produced a reliable change

Assessment of Social Validity An often-neglected aspect o f program evalu-

and returned the client to a normal level of

ation is assessing what clients find to be accept-

functioning (Jacobson, Follette, & Revenstorf,

able treatment and their satisfaction with the

1 9 8 4 ; J a c o b s o n & T r u a x , 1 9 9 1 ) . Like equiva-

treatment process and outcome. Assessing for

lence testing, this approach requires the exis-

these two components involves assessment of

tence of good normative data on nonclinical

social validity. W o l f

participants

The

important issue o f assessing for social validity in

advantage o f this approach over others is that

the context o f services offered with respect to

for dependent measures.

( 1 9 7 8 ) addressed

the

Evaluating

Outcomes

|

three criteria. T h e first criterion for social

clients what they thought o f or h o w they

validity is assessing for the social significance of

perceived the treatment process and whether

the identified target behaviors and treatment

they were satisfied with the

goals. If clinicians were to identify treatment

Because of the subjective nature of clients'

goals, would clients find the target behaviors

responses, assessing for treatment satisfaction is

and treatment goals to be acceptable? It is very

often omitted in the scientific evaluation o f

important for clients to have input on the target

treatment programs. Although there is a sub-

behaviors given that not agreeing on the same

jective component to assessing for social valid-

target behaviors can interfere with and impede

ity, it is nonetheless an important variable to

treatment progress. As an example, if a clinician

assess for because it can provide valuable clini-

is working with a Mexican American woman

cal information. Information that assesses for

with diabetes, the target goal of decreasing

client acceptability of the treatment process and

intervention.

her intake of fat and sugar and increasing her

client satisfaction with the treatment should be

intake of steamed vegetables (e.g., broccoli)

considered as important as objective indexes o f

would probably fail given that the client has

behavior change (e.g., reported change on a

a history of eating different kinds o f food that

psychometrically sound rating scale). T h e like-

are prepared and cooked differently

(i.e.,

lihood of sustained change observed in treat-

Mexican diet). T h e second criterion to address

ment may be affected by clients' acceptability o f

is the social appropriateness of the treatment

the treatment and their satisfaction with the

procedures. It is important to assess whether

treatment and services offered.

clients find a specific treatment to be acceptable. T h e assumption is that clients who find a treatment more acceptable are more likely to participate in treatment than are those who do not find the treatment to be acceptable. Finally, the third criterion to address is the social importance of the treatment effects. This is the "consumer

satisfaction" c o m p o n e n t

o f social

validity in that it informs clinicians as to whether clients were satisfied with the services offered. Assessing for consumer satisfaction can be tailored to fit the clinician's or agency's needs. As an example, consumer satisfaction can vary from assessing a client's satisfaction with the actual treatment to assessing his or her satisfaction with administrative services and the like. Unfortunately,

CONCLUSIONS This chapter has attempted to make an argument for the systematic method o f conducting program evaluations that can be adapted for different types o f practice settings. Different contingencies

(e.g., third-party

reimburse-

ments) have placed an even greater emphasis on professionals becoming active participants in the continuous evaluation of their services. Implementing a program evaluation component forces professionals to focus on the question of " W h a t should be measured and why?" This measurement question can range from evaluating patients' quality o f life to gauging

social

validity

as

an

their satisfaction with clinical services. Without

assessment component has historically been

outcome

neglected, as is apparent by the low percentage

determine the impact o f the intervention, nor

of published material that assesses for social

can they optimize care (Toscani 8c Pizzi, 2 0 0 1 ) .

validity (Carr, Austin, Britton, Kellum, 8c Bailey, 1 9 9 9 ) . Neglect in the assessment for

measurements,

clinicians cannot

In spite o f noted methodological weaknesses

and

challenges

(e.g., el-Guebaly, 2002;

social validity might be due to the "subjectiv-

Hodgins, Armstrong, 8c Addington,

ity" involved. Social validity is considered to be

Ellingstad, Sobell, Sobell, 8c Planthara, 2 0 0 2 ;

subjective in the sense that clinicians are asking

Follette, 1 9 9 5 ) , professionals can incorporate

533

534

SPECIAL ISSUES evaluation

ranging from individual or group therapy to

component that would enhance the quality o f

case management, can be monitored for their

services offered. Program evaluation is a rela-

efficiency and effectiveness. W h a t may be

into their practice a program

tively easy process, with the numerous benefits

more challenging for clinicians is choosing

including maintaining high ethical and practice

treatments that

standards, monitoring program efficiency and

and that specify the mechanisms o f behavior

effectiveness, and providing important finan-

change. Theoretically, the chosen interven-

cial information (Cone, 2 0 0 0 ) . Although pro-

tion should include a strong rationale for why

are conceptually coherent

gram evaluation seems like a daunting task for

specific treatment components are included

clinicians, it is hoped that the recommenda-

and what they are intended to change.

tions offered in this chapter make clinicians

Continuous evaluation o f one's practice

appreciate the benefits of conducting program

should be as much part of a professional's

evaluations whether in private practice or in a

repertoire as is being ethically responsible.

medical center. T h e data gathered should lead

Program evaluation data should also lead to

clinicians to ask further questions regarding

the dissemination o f more effective standards

what they practice and the way in which they

of practice. In turn, better developed stan-

practice. T h e data obtained from

program

dards o f practice can lead to more effective

evaluations can lead to future needs assess-

ways in which clinicians actually practice

ments and the development, refinement, and

(Dawes, 1 9 9 5 ) . As managed care continues to

implementation o f practice standards.

The

change the landscape and manner in which

results from a well-planned program evalua-

clinicians practice, it is becoming increasingly

tion can place a practitioner or an agency at a

important to demonstrate the effectiveness o f

competitive advantage when asked to justify

their interventions. As the commitment to the

costs, resources, and growth of services. Program evaluation

is

flexible

enough

in its methodology that different services,

systematic evaluation o f programs continues to grow, treatment efficiency and effectiveness will also continue to improve.

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Evaluating el-Guebaly, N., Hodgins, D. C , Armstrong, S., & Addington, J . (2002). Methodological and clinical challenges in evaluating treatment outcome of substance-related disorders and comorbidity. Canadian Journal of Psychiatry, 44, 2 6 4 - 2 7 0 . Ellingstad, T. P., Sobell, L. C , Sobell, M . B . , & Planthara, P. (2002). Drug treatment outcome methodology ( 1 9 9 3 - 1 9 9 7 ) : Strengths, weaknesses, and a comparison to the alcohol field. Addictive Behaviors, 27, 3 1 9 - 3 3 0 . Fink, A. (1993). Evaluation fundamentals: Guiding health programs, research, and policy. Newbury Park, CA: Sage. Follette, W. C. (1995). Correcting methodological weaknesses in the knowledge base used to derive practice standards. In S. C. Hayes, V. M . Follette, R. M . Dawes, &C Κ. E. Grady (Eds.), Scientific standards of psychological practice (pp. 2 2 9 - 2 4 7 ) . Reno, NV: Context Press. Follette, W. C , &C Callaghan, G. M . (2001). The evolution of clinical significance. Clinical Psychology: Science and Practice, 8, 4 3 1 - 4 3 5 . Follette, W. C. & Compton, S. (1999). Correcting methodological weaknesses in traditional psychotherapy outcome research. Unpublished manuscript, University of Nevada, Reno. Follette, W. C , Naugle, A. E., & Linnerooth, P. J . (2000). Functional alternatives to traditional assessment and diagnosis. In M. J . Dougher (Ed.), Clinical behavior analysis (pp. 9 9 - 1 2 5 ) . Reno, NV: Context Press. Franklin, R. D., Allison, D., & Gorman, B . S. (1996). Design and analysis of singlecase research. Mahwah, NJ: Lawrence Erlbaum. Hansen, W. B . (2002). Program evaluation strategies for substance abuse prevention. Journal of Primary Prevention, 22, 4 0 9 - 4 3 6 . Hawkins, R. P. (1986). Selection of target behaviors. In R. O. Nelson 8c S. C. Hayes (Eds.), Conceptual foundations of behavioral assessment (pp. 3 3 1 - 3 8 6 ) . New York: Guilford. Hawkins, R. P., & Mathews, J . R. (1999). Frequent monitoring of clinical outcomes: Research and accountability for clinical practice. Education & Treatment of Children, 22, 1 1 7 - 1 3 5 . Hawkins, R. P., Mathews, J . R., δί Hamdan, L. (1999). Measuring behavioral health outcome: A practical guide. Dordrecht, Netherlands: Kluwer Academic. Hayes, S. C , Nelson, R. O., & Jarrett, R. B . (1987). The treatment utility of assessment: A functional approach to evaluating assessment quality. American Psychologist, 42, 9 6 3 - 9 7 4 . Haynes, S. N. (1992). Models of causality in psychopathology: Toward synthetic, dynamic, and nonlinear models of causality in psychopathology. Needham Heights, MA: Allyn & Bacon. Haynes, S. N., Leisen, M . B . , & Blaine, D. D. (1997). Design of individualized behavioral treatment programs using functional analytic clinical case models. Psychological Assessment, 9, 3 3 4 - 3 4 8 . Jacobson, N. S., Follette, W. C , & Revenstorf, D. (1984). Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance. Behavior Therapy, 15, 3 3 6 - 3 5 2 . Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 1 2 - 1 9 . Kazdin, A. E. (1992). Research design in clinical psychology (2nd ed.). New York: Macmillan. Kelley, S. D., Van Horn, M., &c De Maso, D. R. (2001). Using process evaluation to describe a hospital-based clinic for children coping with medical stressors. Journal of Pediatric Psychology, 26, 4 0 7 - 4 1 5 .

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SPECIAL ISSUES Kendall, P. C , Marrs-Garcia, Α., Nath, S. R., Sc Sheldrick, R. C. (1999). Normative comparisons for the evaluation of clinical significance, journal of Consulting and Clinical Psychology, 67, 2 8 5 - 2 9 9 . Paul, G. L., & Menditto, A. A. (1992). Effectiveness of inpatient treatment programs for mentally ill adults in public psychiatric facilities. Applied & Preventive Psychology, 1, 4 1 - 6 3 . Posavac, E. J . , Sc Carey, R. G. (1997). Program evaluation: Methods and case studies (5th ed.). Upper Saddle River, NJ: Prentice Hall. Relman, A. S. (1988). Assessment and accountability: The third revolution in medical care. New England Journal of Medicine, 319, 1 2 2 0 - 1 2 2 2 . Rogers, L. K., Howard, Κ. I., Sc Vessey, J . T. (1993). Using significance tests to evaluate equivalence between two experimental groups. Psychological Bulletin, 113, 5 5 3 - 5 6 5 . Rosenthal, R., Se DiMatteo, M . R. (2001). Meta-analysis: Recent developments in quantitative methods for literature reviews. Annual Review of Psychology, 52, 59-82. Rossi, P. H., Sc Freeman, Η. E. (1993). Evaluation: A systematic approach. Newbury Park, CA: Sage. Silva, F. (1993a). Psychometric foundations and behavioral assessment. Newbury Park, CA: Sage. Silva, F. ( 1 9 9 3 b ) . Treatment utility: A reappraisal. European Journal of Psychological Assessment, 9, 2 2 2 - 2 2 6 . Sobell, L. C , Sc Sobell, M . B. (1996). Alcohol timeline follow-back (TLFB) users' manual. Toronto: Addiction Research Foundation. Toscani, M . R., Se Pizzi, L. T. (2001). Measuring and improving the intervention. outcomes in In R. Patterson (Ed.), Changing patient behavior: Improving health and disease management (pp. 1 7 7 - 2 0 0 ) . San Francisco: Jossey-Bass. Waltz, J . , Addis, M . E., Koerner, K., Sc Jacobson, N. S. (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61, 6 2 0 - 6 3 0 . Wolf, M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 2 0 3 - 2 1 4 . Yates, Β. T. (1996). Analyzing costs, procedures, processes, and outcomes in human services. London: Sage.

Name

Index

Aaronson, Ν. K., 3 3 2 , 3 4 2 Aarsland, D . , 4 8 7 Abarbanel, Α., 366 Abeloff, M . , 3 3 4 Abrams, D. B., 6 1 , 6 2 , 110 Abueg, F. R., 5 2 0 , 521 Abuzzahab, F., 3 6 9 Acerbi, Α., 21 Achmon, J., 2 6 2 Ackerman, B. J., 2 8 9 Ackerson, L . , 4 6 1 Adams-Campbell, L. L . , 3 1 0 A d a m s , D. P., 114 Adams, Η. E., 367 A d a m s , P. F., 3 9 7 Addington, J., 533 Addis, M . E . , 5 3 0 Addy, C . L . , 128 Adkins, D., 106 Adlercreutz, H . , 2 5 5 Administration on Aging, 4 8 5 , 4 9 0 Adunsky, Α., 2 1 Afari, N . , 4 4 Affleck, G., 2 3 2 Aghabeigi, B., 2 3 4 Agras, W. S., 2 6 2 Agurs-Collins, T. D . , 3 1 0 Ahern, D. K., 2 4 3 Ahlbom, Α., 4 7 3 Ahlgren, P., 4 8 9 Ahluwalia, J. S., 2 6 5 Ahmedzai, S., 3 3 2 Ahonen, Α., 87 Aikens, J., 24 Ainsworth, Β. E . , 128 Ajzen, I., 2 1 1 , 388 al'Absi, M . , 113, 2 5 3 , 2 5 4 , 2 5 5 Albanes, D., 156 Albarede, A. L . , 4 9 2 Albert, M . , 4 5 9 Alberti, R. E . , 2 9 3 Albini, F., 2 5 7 Alerman, M . H . , 2 6 5 Alexander, C. J . , 3 6 0

Alexander, F., 253 Alexander, M . J., 4 7 0 Algor, R., 3 2 7 , 3 3 2 , 3 3 7 Allard, P., 4 8 9 Allen, J . P., 199 Allen, M . T., 253 Allen, R . , 2 8 0 Allen, T. W., 2 6 2 Allison, D . , 5 2 9 Allison, D. B., 126, 129, 1 3 1 , 1 3 5 , 1 3 7 Allison, T. G., 2 8 2 , 2 9 2 Almy, T. P., 4 0 2 Aionso, C , 4 7 7 Alpers, J. H . , 4 8 8 Alpert, Μ . Α., 258 Alpert, S. G., 3 0 6 Alrakawi, Α., 308 Altabe, M . N., 1 2 7 Alter, C . L . , 341 Alterman, A. I., 86 Althof, S. E . , 369 Alto, W. Α., 2 1 3 , 438 Altwein, J . E . , 368 American Association of Cardiovascular and Pulmonary Rehabilitation, 150 American Cancer Society, 4 5 7 American College of Sports Medicine, 147 American Diabetes Association (ADA), 3 0 4 , 310, 311, 312 American Medical Association (ΑΜΑ), 1 1 , 189, 197, 2 1 5 , 4 4 7 American Psychiatric Association, 5, 6, 2 3 , 80, 1 0 2 , 126, 176, 2 3 3 , 2 3 4 , 2 3 5 , 2 8 7 , 3 4 3 , 359, 362, 365, 366, 367, 369, 386, 387, 388, 392, 393, 395, 4 1 1 , 426, 487, 492 American Psychological Association (ΑΡΑ), 4 4 3 , 444, 445, 447, 449, 4 5 1 , 453 A m m e r m a n , A. S., 2 1 6 Amodei, N., 4 7 7 Amundson, G. M . , 2 3 7 Andersen, B. L . , 61 Andersen, R., 161 Andersen, R. E . , 133 Anderson, B. J., 5 9 , 6 7

537

538

T H E HEALTH P S Y C H O L O G Y HANDBOOK Anderson, D. Α., 127 Anderson, J . P., 508 Anderson, J . R., 66 Anderson, J . S., 2 3 7 Anderson, Ν. B., 2 6 2 Anderson, R. J . , 3 0 3 , 3 0 7 , 308 Anderson, R. M . , 66, 3 1 3 , 3 1 5 Andreasen, N . C , 3 4 0 Andreski, P., 229 Andrews, G., 34, 4 0 0 Andrews, K., 4 9 1 Andrulonis, P. Α., 3 9 9 Andrykowski, Μ . Α., 328 Angold, Α., 4 7 5 Angst, J . , 4 7 2 Anthenelli, R. M . , 83 Antoni, M . H . , 64 Antonuccio, D. O., 5 1 9 , 5 2 2 Appel, L. J . , 2 5 8 , 2 5 9 , 2 6 1 Appelbaum, M . , 152, 2 6 1 Apt, C , 3 6 5 Arber, S., 4 7 4 Arfken, C. L., 4 9 1 Arkowitz, H . , 4 5 Armstrong, S., 533 Arnett, D. K., 2 5 4 Arnold, S. E . , 1 7 7 Arrol, B., 2 6 1 Ascanio, R., 4 6 0 Ashford, R. U., 516 Ashley, M . J . , 2 6 0 Asmundson, G. J . G., 2 3 9 Atan, Α., 368 Atkinson, J . , 3 9 2 Attanasio, V., 243 Audet, J . , 309 Augustini, K. F., 3 3 1 Austin, J . L . , 533 Australian Department of Health and Aged Care, 28 Australian Psychological Society, 31 Aversa, Α., 368 Avina, C , 360 Avis, Ν. E . , 4 7 1 Axelrod, Β. N . , 2 2 Ayers, S., 3 0 5 Babyak, M . , 158 Bacak, S. J . , 162 B a c k , A. L . , 3 2 9 Badcock, C. Α., 4 0 5 Baez-Franceshi, D . , 4 9 2 Bailey, D., 29 Bailey, J . S., 533 Bakeman, R., 5 3 0 Baker, D., 473 Baker, M . D., 4 8 7 Baker, R. W., 343 Baker, S., 90 Baker, T. B., 103, 106, 107, 110

Baldwin, R. C , 488 Balfour, D . J . , 1 0 2 Ballinger, C , 4 7 2 Balon, R., 2 9 Baiter, M . B., 4 2 5 Bancroft, J . , 359, 366 Bandura, Α., 88 Bandura, A. J . , 2 1 0 , 2 1 1 , 406 Banerjee, K . , 4 6 1 Banikarim, C , 4 7 7 Banks, S. M . , 2 4 0 Bar, J . L . , 80 Barach, P., 32 Baranowski, T., 44 Barbaree, H . E . , 2 3 1 , 2 3 9 , 243 Barbarotto, R., 2 1 Barclay, G., 104 Barlow, D. H . , 3 6 0 , 364, 3 6 9 , 4 0 5 , 4 1 1 , 5 1 4 , 518 Barnes, D., 2 9 Barnes, P. M . , 147 Barnett, M . C , 2 8 2 Barnett, P. Α., 2 6 2 Barnett, R. C , 473 Barnhill, R. L . , 3 3 0 Barnoya, J . , 126 Baron-Faust, R., 4 2 9 Barr, H . , 3 7 Barraclough, J . , 334 Barreioro, Μ . Α., 4 0 6 Barrett, C . L . , 2 4 0 Barrios, B., 2 8 5 Barry, R. E . , 4 1 4 Barsky, Α., 51 Barsky, A. J . , 2 8 2 Bartlik, B., 3 6 0 Baruch, G. K., 4 7 3 Basar, M . , 368 Bassett, D. R., 148 Bates, M . S., 4 5 7 Batey, D. M . , 2 6 2 Baum, Α., 3 4 4 B a u m , F. E . , 4 2 6 Baxter, J . , 3 1 0 Bayer, R., 5 1 5 Bazzacchi, G., 4 0 1 Beaglehole, R., 2 6 1 Beaulieu, C . L . , 2 3 9 Beck, A. T., 2 3 , 64, 90, 177, 1 8 1 , 2 3 1 , 4 1 1 Beck, J . G., 3 6 9 Beck, J . S., 2 4 3 Becker, B. ML, 111 Becker, D. M . , 4 6 0 Becker, M . H . , 2 1 2 , 3 3 0 Beckham, J . C , 108, 2 3 9 Beebe, G. W., 3 3 2 Beena, M . B., 24 Beevers, D. G., 2 6 0 Begg, C , 3 3 0 Begleiter, H . , 86

Begura, S., 86 Beitman, B. D., 2 3 4 Bélanger, Α., 309 Belar, C . D., 4, 5, 6, 8, 9, 10, 12, 3 0 , 3 2 , 3 3 , 36, 6 7 , 6 8 , 4 4 4 , 4 4 5 , 4 4 9 , 4 5 4 Belcher, M . , 103 Bell, Α., 44 Bell, R., 368 Belle, S., 4 9 0 Belle, S. H . , 3 3 5 , 4 8 9 Bellg, A. J . , 6, 7 Belluzzi, J . D., 104 Belsky, J . , 4 7 0 Benazon, N . , 4 7 8 Benedict, R. H . B., 2 0 Benhamou, Y., 4 1 2 Benkert, O., 368 Benner, P., 4 9 5 Bennet, E. J . , 4 0 5 Benotsch, E . , 388 Benowitz, N . L . , 1 0 2 , 103 Benson, D. F., 4 9 2 Benson, V., 3 9 7 Berber, Α., 136 Berg, R. Α., 19, 2 0 Berghammer, R., 4 7 7 Bergman, B., 3 3 2 Berkman, L . , 4 5 9 Berkowitz, R. I., 129, 258 Berlin, J . Α., 150 Berlowitz, D. R., 2 6 4 Bernbaum, M . , 306 Bernstein, D. Α., 179 Bernstein, I. H . , 2 1 9 Bernstein, M . , 149 Bernstein, S. L . , I l l Berridge, K. C , 8 5 , 103, 104, 1 0 5 , 107 Berry, M . J . , 153 Bertelson, A. D., 4 3 2 Bertrand, C , 2 3 4 Berube-Parent, S., 136 Berwick, M . , 330 Best, C . L . , 4 7 9 Beutel, M . , 336 Beutler, L . , 5 Bhandari, S., 24 Bhugra, D., 3 6 0 Bidzan, L . , 2 1 Bidzan, M . , 2 1 Biener, L . , 110 Biering-Sorensen, F., 368 Billig, N., 4 9 2 Binik, Y. M . , 366 Birch, L . , 129 Birge, S. J . , 4 9 1 Birk, L . , 361 Bishop, S., 2 3 2 Bishop, S. R., 2 3 9 Biskupiak, J . E . , 528 Biswas, Α., 3 3 6

Bitschnau, M . , 4 7 1 Bixler, E . O., 172 Black, D. R., 63 Black, G. W., 2 6 2 , 5 0 4 Black, J . L . , 2 8 2 , 2 9 2 Blackwell, B., 4 0 6 Blaine, D. D., 528 Blair, S., 147 Blair, S. M . , 156 Blair, S. N . , 1 6 1 , 1 6 2 Biais, L . M . , 3 3 0 Blake, F., 4 7 6 Blake, J . , 2 5 3 Blalock, A. C . , 3 9 1 , 3 9 2 , 393 Blanchard, Ε. B., 4 0 4 , 4 0 5 , 4 0 9 , 4 1 1 , 4 1 4 Blank, K., 23 Blazer, D., 4 9 3 Blewett, Α., 4 0 5 Bliss, J . M . , 3 3 2 Bliwise, D., 4 9 1 Block, A. R., 2 4 0 , 2 4 1 Block, S., 336 Bloom, F. R., 389 Bloom, J . D., 192 Bloom, J . R., 6 5 , 6 7 , 336 Blum, K., 84, 85 Blume, A. W., 4 4 Blumenthal, J . Α., 6 1 , 6 2 , 1 5 2 , 158, 2 6 1 , 281, 286, 292 Blyth, F. M . , 2 2 9 Bock, B., 14 Bock, B. C . , 154 Boer, K . , 4 7 1 Bogart, L . , 388 Bogdale, N . , 2 2 9 Boland, F. J . , 2 5 8 Bolland, J . M . , 177 Bollerud, K . , 4 7 4 Bonadonna, R. C . , 3 0 4 Bonato, D. P., 258 Bond, M . J . , 2 4 , 368 Bonke, B., 343 Bono, J . E . , 32 Booth-Kewley, S., 2 8 8 Boothby, J . L . , 2 3 0 , 2 3 1 , 2 3 2 , 2 3 9 Boraz, M . Α., 2 5 8 Borg, G., 343 Borgioni, C . , 2 5 7 Borkovec, T. D., 179 Bornstein, G., 3 3 4 Borrelli, B., 103, 106 Boscaro, M . , 2 5 4 Boselli, M . , 4 9 1 Bosley, F., 2 6 2 Bosmajian, L . , 4 0 5 Botelho, R. J . , 213 Bottomley, Α., 66, 6 7 Bouchard, C . , 129, 154 Boucher, J . L . , 5 0 2 Boulard, Ν. E . , 4 7 6

540

T H E HEALTH P S Y C H O L O G Y HANDBOOK Boulware, L. E . , 2 6 6 Bourassa, M . G., 504 Bourgault, C , 24 Bourgeois, M . S., 4 9 2 Bourjeily, G., 153 Bovbjerg, D., 3 3 9 , 340 Bovbjerg, D. H . , 83 Bowden, J . J . , 4 8 8 B o w m a n , Β. Α., 126, 127 Boxer, A. W., 4 7 8 Boyce, P., 4 0 0 Boyd-Wickizer, J . , 24 Boyle, J . P., 303 Boyle, R. G., 502 Brackett, J . , 59 Bradbeer, M . , 4 9 3 Bradley, Κ. Α., 24 Bradley, W. E . , 3 6 9 Bradshaw, C , 3 3 2 Braith, R. W., 2 6 1 Brand, M . B., 2 5 9 Brandon, T. H . , 1 0 1 , 110 Brandt, J . , 2 0 Brandt, Κ. M . , 86 Brannick, M . , 88 Braverman, B., 2 4 0 Bray, G. Α., 136 Bray, J . H . , 34, 2 4 4 Breaux, C , 458 Brecher, Ε. M . , 82 Breitbart, W., 3 4 1 , 343 Brennan, A. F., 2 4 0 Brennan, P. Α., 87 Brent, D., 306 Breslau, N . , 106, 2 2 9 , 2 3 5 Brewer, G., 138 Brigham, J . , 112 Brighton, L. Α., 156 Britt, D. M . , 113 Brittain, E . , 2 5 2 Britton, J . Α., 156 Britton, L. N., 533 Brocker, P., 4 9 1 Broekhuijsen, Μ . Α., 334 Brooks-Gunn, J . , 4 7 0 Brown, G. K . , 177, 2 3 9 Brown, G. W., 173, 177 Brown, J . , 5 2 1 Brown, J . M . , 2 3 1 Brown, L . , 2 2 Brown, L. L . , 331 Brown, M . D., 152, 2 6 1 Brown, R. E . , 5 2 5 Brown, S. Α., 105 Brown, S. E . , 4 7 8 Brown, Τ. Α., 360 Brownell, K. D., 62, 128, 137, 153, 2 1 0 Brownson, R. C . , 162 Bruce, D. G., 3 1 5 Bruehl, S., 2 3 7

Brunner, E . , 2 5 9 Brunner, R., 4 7 9 Bryant, G. D., 4 8 8 Brymer, J . , 2 9 0 Buchanan, R. G., 199 Buchanan, T., 254 Buchsbaum, D. G., 199 Buckloh, L. M . , 304, 313 Budd, Μ . Α., 34 Buddeberg, C , 3 3 1 Budzynski, T. H . , 179 Buffington, V. E . , 80 Bukofzer, S., 368 Bulik, C . M . , 127 Bullinger, M . , 332 Bunag, R. D., 2 5 5 Burchardt, M . , 368 Burg, Μ . Α., 3 3 0 Burger, H., 360 Burgio, L . , 4 9 2 Buring, J . E . , 2 8 0 , 504 Burish, T. G., 334 Burke, B. L . , 4 5 Burke, G., 3 9 9 Burke, L. E . , 2 1 0 , 294 Burkovec, T . D., 2 3 1 Burleson, M . H . , 59 Burls, Α., 368 Burman, B., 3 3 5 Burman, D., 4 9 3 Burman, M . L . , 24 Burmeister, L. Α., 4 8 9 Burnett, C. K., 398 Burns, B. J . , 458 Burns, D. D . , 5 2 2 Burns, D. M . , 104 Burns, S., 62 Burrows, G., 33 Burrows, L . , 59 Burstein, R., 157 Burt, V. L . , 253 Busby, Κ. Α., 4 9 1 Butler, C . , 44 Butler, R. W., 2 3 2 , 2 3 9 Butler, W. M . , 3 6 0 Buyesse, D. J . , 4 2 6 Byrd-Holt, D. D., 310 Byrne, T., 189 Cadoret, R. J . , 84 Calarco, M . M . , 30 Callaghan, G. M . , 5 3 1 Callahan, L. F., 156 Cameron, O. G., 158 Camic, P. M . , 7 Camilleri, M . , 398 Campbell, Ε. H . , 3 6 7 Campbell, N . R., 2 6 0 Campbell, P. C , 326, 341 Campbell, T. L . , 34, 3 5 , 3 7

Name Index C a m p i a , U., 2 5 7 C a n a d a , A. L . , 3 3 1 Cannon, W., 172 Cannuscio, C . C , 156 Capatani, E . , 21 Capozolli, K., 343 Cardillo, C , 2 5 7 Carey, M . P., 4 4 , 2 1 3 , 3 5 9 , 3 6 0 , 3 6 2 , 3 6 5 , 369 Carey, R. G., 5 2 5 Carlson, C. R., 179, 183 Carlson, L . , 3 5 Carlson, N . R., 172 Carlson, R. W., 3 3 6 C a r m o d y , T. P., 103, 106 Carnahan, J . E . , 2 1 0 Carney, R., 4 Carney, R. M . , 2 3 4 , 2 8 8 , 2 9 2 Carnike, C . L. M . , J r . , 24 Carpenter, C , 388 Carpenter, J . , 29 Carpenter, Κ. M . , 126 Carr, D. B., 4 0 3 Carr, J . E . , 533 Carrier, S., 368 Carrington, P., 180 Carrion, H . M . , 368 Carroll, B. T., 3 4 1 Carruthers, S. G., 2 6 0 Carter, J . S., 4 5 7 Carter, L. C , 113 Carter-Pokras, O., 161 Carver, C . S., 331 Casari, E. F., 5 1 6 Casebeer, L . , 2 1 3 Casper, R. F., 478 Caspersen, C . J . , 147, 148 Caspi, Α., 4 7 0 Cassem Ν . H . , 2 8 8 Cassidy, T., 173 Cassileth, B. R., 3 3 1 , 3 3 5 Cates, D. S., 5 0 4 Cattarin, J . , 127 Catz, S. L . , 3 8 8 , 3 8 9 , 3 9 0 Caudill, Μ . Α., 2 3 7 Cavallini, M . C , 2 5 7 Cella, D. F., 3 4 2 Center for the Advancement of Health, 2 1 5 Centers for Disease Control and Prevention ( C D C ) , 56, 1 0 1 , 104, 107, 1 2 5 , 126, 146, 150, 3 8 3 , 384, 3 8 7 , 388 Centor, R., 213 Centor, R. M . , 199 Cerri, M . , 2 1 Cervero, F., 4 0 2 , 4 0 3 Cesana, G., 151 Chacko, M . R., 4 7 7 C h a c k o , R. C , 21 Chaitchik, S., 3 2 6 , 3 2 7 , 3 2 8 , 3 3 0 , 3 3 1 , 3 3 2 , 334, 3 3 7 Chakour, M . C , 4 9 3

Chamberlain, K., 32 Chamberlin, C. L . , 106 Chambers, L . , 64, 1 5 1 , 2 6 2 , 2 9 2 Chambless, D. L . , 34 Chambless, L . E . , 2 6 0 Champion, D., 2 4 2 Chan, J . K . , 303 C h a p m a n , C. R., 2 4 0 , 3 2 9 Charles, Μ . Α., 129 Charleston, J . , 2 5 9 Charuzi, I., 157 Chaturvedi, S. K . , 24 Chaves, J . F., 2 3 1 Chen, M . S., 4 6 0 Cheng, Y., 155, 161 Cherny, Ν. I., 329 Cheskin, L. J . , 131 Chesney, M . , 2 1 5 Chesney, Μ . Α., 2 6 2 , 5 0 4 Chesson, A. L . , 4 3 6 Cheung, F. K., 4 5 8 Chevron, E. S., 65 Chisholm, D. J . , 3 1 5 Chochinov, Η. M . , 3 2 9 Choi, Η. K . , 3 6 8 , 3 7 5 Chorlian, D . B., 86 Chou, F. F., 368 Chrisman, N . J . , 2 1 5 Christensen, A. J . , 2 3 9 , 2 6 6 Christiansen, C. L . , 2 8 2 Christie-Seely, J . , 7 Christos, P. J . , 156 Chrousos, G. P., 4 0 8 Chudzik, G., 7 Ciliska, D., 137 Cinciripini, P., 3 2 9 , 3 3 0 Ciucci, Α., 2 5 7 C l a m o n, G. H . , 3 4 1 Clancy, C. M . , 5 0 4 Clark, Α., 3 2 7 Clark, D . B., 4 7 0 Clark, J . D., 2 2 9 Clark, M . , 14, 258 Clark, M . S., 2 4 Clark, W., 368 Clarke, C , 29 Clarke, P. B., 104 Clarridge, B. R., 329 Clauw, D . J . , 4 0 8 Cleary, P. D., 2 8 2 Cleeland, C . S., 343 Clement, S., 313 Clements, K. L . , 2 3 2 Clementy, J . , 2 5 7 Clenney, T . L . , 368 Clerici, M . , 2 6 2 Cleroux, J . , 2 6 1 Clifford, P. Α., 2 6 6 Clinch, J . J . , 329 Cloninger, C . R., 79, 87, 108

541

542

T H E HEALTH P S Y C H O L O G Y HANDBOOK Clouse, R. E . , 64, 3 0 3 , 3 0 8 , 3 1 6 , 4 0 4 , 4 8 8 Coats, Α., 2 5 6 Cochrane, C , 3 0 7 Coderre, T. J . , 4 0 3 Cody, Η . Α., 4 9 4 Cody, M . , 3 3 1 C o e , C. L . , 4 7 7 C o g g o n , D . , 155 Cohen, D . , 3 6 6 Cohen, H . , 2 6 5 Cohen, J . , 5 3 1 Cohen, L . , 344 Cohen, L. M . , 103, 105, 113 Cohen, L . S., 2 1 0 , 4 7 1 Cohen-Mansfield, J . , 4 9 2 Cohen, P. T., 3 8 4 , 3 8 7 Cohen, S., 5 9 , 6 2 , 64, 66, 176, 3 4 5 , 4 0 5 Col, N., 4 9 0 Colditz, G . Α., 126, 150, 156 Cole, J . , 3 6 9 Coleman, H . , 51 Colletti, G., 110, 5 2 0 Collins, F. L . , 102, 103, 179, 183 Collins, F. L . , J r . , 109, 113 Collins, F. S., 15 Collins, R., 152 Collins, S. M . , 4 0 2 C o m p a s , Β. Ε., 62, 66 C o m p t o n , S., 5 2 9 , 5 3 0 Comstock, G. W., 108, 3 3 2 Comuzzie, A. G., 129 C o n , Α. Η., 2 6 2 Cone, J . D., 5 3 4 Conger, J . J . , 83 C o n l e y . J . J . , 86 Connell, C . M . , 3 0 9 , 4 6 0 Connelly, J . E . , 9 Connolly, M . J . , 4 8 8 Conry, M . , 4 9 0 Conti, J . B., 2 8 2 Contrada, R. J . , 66, 4 5 9 C o o k , E . W., 3 9 8 C o o k , G., 2 9 , 30 C o o k , N . R., 2 6 0 C o o k , U., 4 0 2 C o o k e , D. J . , 4 7 1 C o o k e , R. D., 4 2 6 Cooper, A. R., 261 Cooper, C , 155 Cooper, H . , 4 7 5 Cooper, J . R., 193 Cooper, R., 4 5 7 Cooper, S. E . , 3 6 9 Cooper, Z . , 138 Coovert, M . 127 Copeland, A. L . , 110 Coppola, K., 495 Corazziari, E . , 4 0 0 , 4 0 9 Corbett, S., 3 0 5 C o r d o v a , M . J . , 341 (

Corr, C , 4 9 5 Corr, D . , 4 9 5 Corrigan, S. Α., 2 5 9 Cortinas, L., 136 Coscarelli, Α., 3 3 2 Coscarelli Schag, C. Α., 343 C o s t a , P. T., 3 3 5 , 4 0 5 Council on Scientific Affairs, 197, 198 Courtney, J . G., 3 3 2 Covey, L. S., 114 Cowie, C . C , 3 1 0 C o x , D. J . , 60, 2 9 2 , 316 C o x , T., 32 Coyne, J . C , 59, 6 2 , 64, 177 Craig, T., 4 0 5 Cramer, J . Α., 2 1 7 Cranley, M . S., 4 7 0 Craven, J . L . , 3 0 9 Crawford, S. L . , 4 7 1 Creed, F., 4 0 5 Crespo, C . J . , 161 Crettenden, I., 4 2 6 Crits-Christoph, P., 3 1 6 , 318 Croft, P. R., 3 6 8 , 3 9 7 C r o g h a n , T. W., 2 1 5 Crombez, G., 2 3 2 Crombie, I. K., 3 9 7 Crosby, J . R., 36 Crouch, M . , 7 Cryer, P. E . , 4 8 8 C u b a , S. L . , 4 5 7 Cull, Α., 3 3 2 Cummings, J . L . , 4 8 7 , 4 9 2 Cummings, Ν. Α., 5 0 5 , 514 Cunningham, A. C , 2 3 9 Cunningham, J . Α., 3 4 6 Currie, L . , 4 8 7 Currie, S. R., 44 Curry, S. J . , 4 4 , 6 1 , 5 0 2 Cushman, W. C , 2 6 0 , 2 6 1 Cutler, J . , 2 5 2 Cutler, R. B., 2 4 4 Cycowicz, Y. M . , 87 Czechowicz, D. J . , 193 Dahlgren, L. Α., 108 Dahlof, P., 2 9 0 Dalton, C , 3 9 9 Daltroy, L. H . , 2 1 4 Dam, H., 489 Damarin, F. L . , 2 3 9 D'Angelo, T., 3 3 5 Dani, J . Α., 105 Daniels, E. R., 329 Danton, W. G., 5 2 2 Darke, L. L . , 4 7 7 Darwin, C . R., 88 Daut, R. L . , 343 Davey, S. G., 2 5 9 Davida, F. K., 308

Name Index Davidoff, F., 5 2 2 Davidson, J . , 3 3 2 Davidson, K. W., 2 8 2 Davidson, M . B., 2 1 6 Davidson, M . H . , 136 Davies, A. O., 2 5 4 Davis, D. Α., 2 1 0 Davis, G. C . , 2 2 9 Davis, M . H . , 36 Davis, M . S., 2 1 5 Davis, P. M . , 3 9 9 Davis, R. C , 361 Davis, S., 360 Davis, V. E . , 85 Davis, W. K . , 3 0 9 Dawes, R. M . , 9 0 , 5 3 4 D a w s o n , Α. Α., 334 Day, Α., 4 7 6 D e Felice, F., 2 5 7 de Groot, M . , 3 1 0 de H a e s , J . , 3 3 2 de Haes, J . C . J . M . , 343 de Jongste, M . J . L . , 2 4 2 de Leon, J . D., 108 De Leon, P. H . , 5 0 7 De M a s o , D. R., 5 2 5 De Yonge, J . , 32 Dean, C . , 3 3 5 Deardorff, W. W., 4, 5, 8, 9, 10, 3 0 , 6 7 , 444, 445, 449, 454 DeBeurs, E . , 4 9 3 DeBusk, R. F., 2 1 0 , 2 1 4 , 2 1 6 Deeg, D. J . H . , 4 8 7 DeFlorio, M . , 340 DeFronzo, R. Α., 3 0 4 D e G o o d , D. E . , 2 3 8 , 2 3 9 DeKosky, S. T., 4 8 9 Delgado, P., 360 Dellapietra, L . , 23 Dement, W. C . , 4 2 5 , 4 3 8 Demmers, R. Y., 3 0 7 Demming, B., 91 D e M u t h , N . M . , 61 Dengel, D. R., 2 6 1 Dennerstein, L . , 3 6 0 , 4 7 1 Denney, M . W., 3 6 4 Denton, M . , 4 7 4 Derogatis, J . R., 3 4 2 Derogatis, L. R., 2 3 , 177, 3 3 4 , 3 4 0 , 4 1 1 D e r o o , L . , 4 2 , 62 Derry, P. S., 4 7 1 DeRubeis, R. J . , 3 1 6 , 318 DeSoto, C . B., 24 DeSoto, J . L . , 24 Devereux, R. B., 2 5 3 Devins, G. M . , 3 0 9 DeVries, H . , 6 2 Dew, M . Α., 3 9 2 Dey, J . , 368 Di Chiara, G., 104

Diabetes Prevention Program Research G r o u p (DPPRG), 3 0 5 , 311 D i a m o n d , S., 59, 3 4 5 Diana, M . , 105 DiCesare, J . , 4 1 1 DiCicco, L . , 43 Dickel, M . J . , 428 Dickey, F., 7 DiClemente, C . C , 4 3 , 92, 110, 2 1 1 , 2 1 2 Dieppe, P., 155 Dietz, W., 126 Dietz, W. H., 127, 129 Dill, P. L . , 136 D i ! l e y , J . W., 3 9 2 D i M a t t e o , M . R., 2 1 5 , 2 1 6 , 2 1 7 , 4 7 0 , 5 3 1 Dimeff, L. Α., 5 0 4 D i N a r d o , P. Α., 4 1 1 Ding, Y., 2 6 2 DiNicola, D. D., 2 1 6 , 2 1 7 DiPlacido, J . , 3 3 0 D i x o n , H . Α., 4 9 0 Doctor, J . , 5 0 4 Doddi, S., 4 8 8 Dodding, C . J . , 191 Doleys, D. M . , 4 5 7 Dollard, M . , 32 Donnay, Α., 2 3 7 Donnelly, G., 109 Donner, A. P., 3 3 5 D o r a n , T., 3 1 0 Dorhofer, D. M . , 4 7 6 Doucet, E., 136 Dovetail, G., 4 0 0 D o w d a , M . , 128 D o w n s , A. D., 2 8 9 Downton, J . H . , 4 9 1 Dowzer, C , 4 1 4 Doyle, D. V., 155 Droppelman, L . F., 3 4 2 D r o s s m a n , D. Α., 3 9 7 , 3 9 8 , 3 9 9 , 4 0 0 , 4 0 1 , 4 0 5 , 4 0 6 , 407, 409, 410, 411 Drozdick, L . W., 4 9 1 D r u m m o n d , M . F., 505 Dubbert, P. M . , 6 1 , 6 2 , 147, 150, 1 5 2 , 158, 162, 2 6 1 Ducharme, S., 3 6 0 Duckro, P. N . , 306 Duckworth, W. C , 157 Dudgeon, D . , 3 2 9 Dudley, E . , 3 6 0 Dudley, W., 4 4 Duffy, L. S., 4 8 9 Dugoni, B. L . , 128 Dunbar-Jacob, J . , 210 Dunbar-Jacobs, J . M., 294 Dunkel-Schetter, C , 336 Dunn, C , 4 2 , 4 4 , 4 5 , 4 9 , 5 1 , 52, 62 Dunn, K . M . , 368 Dunne, F. J . , 4 7 5 D u p k e , C. Α., 3 6 4 Durand, D., 3 6 0

543

544

THE HEALTH PSYCHOLOGY HANDBOOK Durandet, P., 2 5 7 Dusseldorp, E . , 63, 2 8 8 , 2 9 2 Dziegielewski, S. F., 113 Eakin, E. G., 162 Earleywine, M . , 83, 86, 87, 88 Earp, J . Α., 4 6 1 Eater, J . Α., 113 Ebrahim, S., 2 5 9 Eccleston, C , 2 3 2 Echement, D. Α., 4 9 0 Eddy, Ν. B., 83 Edelstein, B., 4 8 6 , 4 9 4 Edelstein, Β. Α., 4 9 1 , 493 Eder, H . , 4 7 1 Edmonds, A. L . , 368 Edmonds, C . V. I., 346 Edwards, J . R., 332 Edwards, Ν. B., 2 8 9 Edwards, R. R., 4 5 7 Edwards, W. T., 4 5 7 Effron, M . B., 2 6 1 Egan, Β. M . , 4 6 0 Egede, L. E . , 307, 308 Egger, P , 155 Ehrlich, M . H . , 2 6 5 Ehsani, Α. Α., 2 6 1 Eisen, S., 4 Eisen, S. Α., 288 Eisenberg, D. M . , 2 6 2 Eisenberg, J . M . , 5 0 4 Eissenberg, T., 114 Eizenman, D. R., 4 5 9 Ejnell, H . , 2 9 0 el-Guebaly, N . , 4 4 , 533 EI-Halwagy, H . E . , 4 7 7 Elash, C . , 103 Elbert, K., 3 0 7 Elder, J . P., 4 6 0 Elkin, I., 5 2 1 Ell, K . , 335 Ellery, D., 2 3 9 Ellingstad, T. P., 533 Elliot, Α., 3 9 0 , 391 Elliott, P., 259 Elliott, T. E . , 5 0 6 Elliott, T. R., 2 4 0 Ellis, A, 3 1 5 Elwood, J . M . , 326 Emanuel, E. J . , 3 2 9 Emery, C . F., 153 Emery, G., 64, 2 3 1 , 4 1 1 Emmons, Κ. M . , 104 Emmons, M . L . , 293 Engel, B. T., 4 0 1 Engel, G. L . , 4, 5 5 , 56, 194 Engel, R. J . , 4 9 3 Engelgau, M . , 63 Engelgau, M . M . , 314 Engelhardt, P., 368

Enright, P. L . , 4 9 1 Ensink, B., 3 6 0 Epping-Jordan, M . P., 105 Epstein, L . H . , 5 9 , 63 Epstein, N . , 3 6 0 Epstein, Y., 157 Erblich, B., 83, 88 Erblich, J . , 83, 84, 86, 88 Ericsson, M . , 136 Erikssen, J . , 2 5 2 Ernst, D . , 3 3 5 Etscheidt, Μ . Α., 2 4 0 Ettinger, W. H . , J r . , 156 Evans, D. Α., 2 6 0 Evans, R. W., 398 Everson, S., 2 5 4 Everson, S. Α., 2 5 3 , 2 5 4 Ewart, C . K . , 2 6 2 Ewing, J . Α., 24 F. A. Davis, 2 3 8 Fagard, R. H . , 2 6 1 Fagelman, Α., 368 Fagelman, E . , 368 Fagerstrom, K. O., 109, 110 Fairburn, C. G., 138 Fairchild, A. L . , 5 1 5 Fairclough, C . L . , 3 2 9 Faith, M . S., 126, 129, 1 3 1 , 134, 135, 137 Fallo, F., 2 5 4 Fallowfield, L . , 4 8 9 Fallowfield, L. J . , 3 2 7 Fallsberg, M . B., 36 Fanale, J . E . , 4 9 0 Fanghanel, G., 136 Fant, R. V., 102 Faragher, Ε. B., 4 1 4 Farmer, J . Α., 2 8 1 Farmer, J . E . , 506 Farmer, K. C . , 2 1 7 Farmer, R., 4 0 5 Fasanmade, Α. Α., 399 Faucett, J . , 4 5 7 Fava, G. Α., 5 2 2 Fawzy, F. I., 3 3 1 , 3 4 5 , 3 4 6 , 348 Fawzy, N . W., 3 3 1 , 3 4 5 , 3 4 6 Fearn, P. Α., 368 Featherman, D. L . , 4 5 9 Fedoravicius, A. S., 4 0 6 Feinglos, M . N., 3 0 7 , 3 1 5 Feinmann, C . , 2 3 4 Feinstein, A. R., 5 0 7 Feldman, Η. Α., 3 6 7 Feldman, R. D . , 2 6 1 Feldt, K. S., 4 9 3 Felton, B. J . , 3 3 1 Fenske, M . M . , 308 Fentem, P., 155 Ferell, B. R., 4 9 2 Ferguson, Κ. E . , 5 0 5

Name Index Fernandez, E . , 2 4 0 Fernandez, M . , 4 6 1 Ferrando, S. J . , 3 9 2 Ferrannini, E . , 3 0 4 Ferrans, C . E . , 2 3 7 Ferraro, M . G., 4 8 9 Ferrell, Β. Α., 4 9 2 Ferrell, R. E . , 2 6 1 Ferster, C . B., 134 Fett, S. L . , 4 1 4 Fetting, J . H . , 343 Field, A. E . , 126 Field, B. J . , 3 0 7 Field-Gass, M . , 61 Field, J . K., 3 6 4 Field, L . , 2 6 5 Fields, H . , 4 0 4 Figer, Α., 334 File, S. Ε . , 106 Fillingim, R. Β., 4 5 7 Finch, J . , 197, 198 Fine, J . Α., 330 Fink, Α., 5 2 5 Finn, O. J . , 339, 3 4 4 Finn, P. R., 86, 87 Fiore, M . , 61 Fiore, M . C . , 103, 107, 1 1 1 , 112, 113, 114 First, M . B., 110, 4 1 1 Fischer, G., 4 7 1 Fischer, M . E . , 151 Fishbach, R. L . , 4 7 9 Fishbain, D. Α., 2 3 4 , 2 4 1 Fishbein, M . , 2 1 1 , 388 Fisher, Ε. B., 162 Fisher, J . Α., 129 F i s h e r , } . D., 2 1 1 , 2 1 3 , 388 Fisher, J . E . , 3 6 0 F i s h e r , ] . L . , 105 Fisher, W. Α., 2 1 1 , 2 1 3 , 388 Fishman, B., 392 Fiske, Α., 4 9 3 Fitzgerald, F., 2 8 1 , 2 8 2 , 2 9 2 Fitzgerald, J . F., 4 9 0 Fitzgibbon, D., 329 Flanery, R. C . , 343 Fleishman, S. B., 3 4 1 Flessig, Y., 2 1 Fletcher, R. H . , 5 0 4 Fletcher, S. W., 5 0 4 Flor, H . , 2 4 4 Fodor, I. G., 4 7 1 Fodor, J . G., 2 5 9 Foege, W., 3 Foley, Κ. M . , 2 4 1 Folkman, S., 170, 174, 2 3 0 , 2 9 1 , 3 3 0 , 4 7 2 Follette, W. C . , 5 1 7 , 5 2 8 , 5 2 9 , 5 3 0 , 5 3 1 , 5 3 2 , 533 Folli, G., 2 5 7 Follick, M . J . , 243 Folstein, M . E . , 21

Folstein, M . F., 343 Folstein, S. E . , 2 1 Fontaine, K. R., 1 2 6 , 131 Ford, D. E . , 4 2 6 Ford, E. S., 126, 127 Ford, S., 4 8 9 Fordyce, M . , 4 9 4 , 4 9 5 Fordyce, W. E . , 5 6 , 2 4 3 Foreyt, J . P., 106, 130, 134, 136 Forsyth, A. D., 2 1 3 Forsyth, L. H . , 154 Fortmann, S. P., 103, 111 Fortrat, J . O., 2 5 7 Foster, D., 3 3 1 Foster, D. W., 2 5 4 Foster, G. D., 62, 1 3 1 , 134, 137, 138, 153 Fox, Β. H . , 3 3 1 , 3 3 3 , 334, 3 3 6 , 3 4 6 Fox, B. J . , 107 Francis, C . K., 2 6 5 , 5 1 5 Frank, R. G., 1 1 , 5 0 6 , 5 0 7 Franklin, G. M . , 3 1 0 Franklin, R. D., 5 2 9 Franks, V., 471 Franzen, Α., 157 Franzen, M . D . , 19 Frasure-Smith, N . , 4, 64, 2 8 2 , 2 8 8 , 2 9 2 , 5 0 4 Frazer, D . W., 4 8 7 , 4 8 8 , 4 8 9 , 4 9 0 Frazier, A. L . , 156 Frecker, R. C . , 110 Frederick, I. O., 4 1 1 Fredericks, L . , 4 6 1 Freeborn, D. K . , 88 Freedland, K . , 4 Freedland, Κ. E . , 2 3 4 , 2 8 0 , 2 8 8 Freedman, M . , 2 1 Freedson, P. S., 147, 148, 149 Freeland, Κ. E . , 3 0 3 , 316 Freeman, E . L . , 36, 67, 68 Freeman, E. W., 4 7 7 , 4 7 8 Freeman, Η. E . , 5 2 5 Freeth, D . , 3 7 French, S. Α., 128 Freud, S., 88 Freudenheim, J . L . 2 1 7 Fried, L . , 4 9 1 Friedberg, F., 2 3 6 Friedenreich, C. M . , 156 Friedman, D., 8 7 Friedman, G. D . , 2 6 0 Friedman, H . S., 2 8 8 Friedman, J . M . , 3 6 5 Friedman, L. S., 3 9 7 Friedman, M . , 64, 2 7 9 , 2 8 8 , 2 9 2 , 2 9 3 Friedman, Μ . Α., 137 Friedman, P. Α., 2 8 2 Frohlich, P. F., 3 6 0 Frost, S., 102 Fuchs, F. D., 2 6 0 Fudala, P. J . , 107 Fujisawa, Α., 2 5 7 (

545

546

THE HEALTH P S Y C H O L O G Y HANDBOOK Fukuda, K., 2 3 7 Fydrich, T., 2 4 4 Gabriel, B., 345 Gabriel, S. E . , 398, 399 Gaeta, H . , 87 Gagnon, J . H . , 359, 362 G a g n o n , P., 3 2 9 , 4 8 9 Gaither, G. Α., 360 Galatopoulos, C , 4 7 5 Galea, S., 503 Gallacher, J . E. J . , 2 9 2 Gallant, M . P., 3 0 9 Gallant, S. J . , 471 Gallup, G., J r . , 4 9 5 Gallup Organization, 4 2 5 Galovski, T. E . , 4 1 4 G a m m a , Α., 4 7 2 G a m m o n , M . D . , 156 G a n g a d h a r a p p a , N., 86 Ganguli, M . , 4 8 9 , 4 9 0 Ganiats, T. G., 508 Ganz, P., 3 3 2 , 343 Garay-Sevilla, M . E . , 308 G a r c i a - M u n o z , M . , 105 Garcy, P., 2 4 0 Gardner, E . , 303 Garfinkel, J . , 3 2 5 Garretson, H . D., 2 4 0 Garrod, Α., 4 7 6 Garron, L. Α., 333 Garrow, J . S., 125 Garssen, B., 3 3 9 , 343 Gaskin, M . E . , 2 4 0 Gatchel, R. J . , 2 3 9 , 2 4 0 G a t h , D., 3 6 6 , 4 7 6 Gatz, M . , 4 8 5 , 4 9 3 G a u , G. T., 2 8 2 Gaule, D., 188, 194, 198, 199 Gauvin, L . , 158 Gavard, J . Α., 316 Gayet, C , 2 5 7 Gaztambide, S., 23 Gebhardt, M . C , 3 4 1 Gehl, Κ. Α., 155 Gehling, E . , 502 Geisser, M . , 6 Geisser, M . E . , 2 3 1 , 2 3 2 , 2 3 9 , 2 4 0 , 2 4 3 Gelbaya, Τ. Α., 4 7 7 Gelenberg, A. J . , 3 0 8 , 360, 368 Geliebter, Α., 135 Gellert, G. Α., Maxwell, R. M . , 336 Gelmon, S. B., 3 5 George, L. K., 4 9 3 George, M . , 368 Georgiades, Α., 6 1 , 152 Gerard, M . J . , 2 6 0 Gerhardsson de Verdier, M . , 332 Geronimus, A. T., 4 5 9 Gerrish, K., 2 9

Gershon, M . , 4 0 7 Gerstley, L. J . , 86 Geyer, S., 332 Gharib, C , 2 5 7 Giancola, P. R., 85 Gibbon, M . , 1 1 0 , 4 1 1 Gibson, G., 2 6 5 Gibson, S., 493 Gibson, S. J . , 4 9 3 Gifford, Ε. V., 5 1 9 Gil, Κ. M . , 2 3 9 , 2 4 1 Gilbert, B. O., 103, 104, 106, 108 Gilbert, D . G., 103, 104, 106, 108 Gilbert, J . H . V., 30, 3 5 , 36 Gilbert, P., 4 7 1 Giles, D. E . , 4 2 6 Gilkson, M . , 2 8 2 Giller, E. L . , 341 Gillmore, M . R., 5 2 1 Oilman, M . W., 2 6 0 Gingras, J . , 309 Gipson, M . , 3 6 5 Gittelman, D. F., 4 7 7 Gittelsohn, J . , 4 6 0 Giuliano, F., 368 Gladsjo, J . Α., 108 Glaser, R., 66, 172, 3 3 9 , 5 0 7 Glasgow, R. E . , 64, 162, 2 1 5 , 2 1 6 , 304, 314, 3 1 5 , 316 Glassman, A. H . , 114, 2 8 8 Glatt, A. E . , 3 6 6 Gleser, L . J . , 63 Glover, E. D., 113 Glover, P. N., 113 G o d a , Y., 105 Godin, G., 2 1 4 Goetsch, V. L., 3 0 7 Gold, Α., 2 6 2 Gold, L . , 368 Gold, M . S., 83, 192 Goldberg, A. D . , 2 8 0 Goldberg, D. E . , 2 5 4 Goldberg, E. L . , 364 Goldberg, I. D., 332 Goldberg, M . , 2 3 4 Goldberg, R. T., 4 7 9 Golden, A. G., 4 9 0 Goldfried, M . R., 2 8 5 Goldman, M . S., 88 Goldsmith, R. J . , 30 Goldstein, G., 86 Goldstein, I., 3 6 7 Goldstein, M . G., I l l Goldstein, M . Z . , 3 6 0 Goldstone, S. E . , 3 6 9 Golomb, M., 262 Gomberg, E . S., 4 7 5 Gonder-Frederick, L . , 2 9 2 Gonder-Frederick, L. Α., 6 0 , 6 1 , 66, 316, 3 1 9 Gonzalez-Fernandes, R. Α., 2 6 5

Goode, Ε., 31 Goodie, J . , 4 8 6 Goodkin, K., 6 5 , 339 Goodrick, G. K., 130, 134 Goodwin, J . S., 3 3 5 Goodwin, P. J . , 6 5 , 67, 3 3 6 , 346 Goorin, Α., 341 Gordon, J . Α., 3 6 9 G o r d o n , J . R., 89, 9 1 , 2 1 4 , 2 1 9 , 3 0 7 Gordon, L. K . , 4 0 5 Gordon, N., 4 5 7 Gordon, T., 2 9 3 Gorman, B. S., 529 Gorman, L. L., 67 Gorman, M., 504 Gorrell, C . , 3 6 5 Gorsuch, R. L . , 177, 2 6 6 Gortmaker, S. L., 1 2 7 Gosse, P., 2 5 7 Gotay, C. C . , 4 6 1 Gottheil, E . , 65 Gottman, J . M . , 5 3 0 Gotto, A. M . , 2 8 1 Goubert, L . , 2 3 2 Gould, J . W., 23 Graber, J . Α., 4 7 0 Graettinger, W. F., 2 5 7 Graf-Morgenstern, M . , 368 Grafton-Becker, V., 3 6 5 Gramling, S. E . , 2 8 5 Granek, M . , 2 6 2 Grange, T., 4 9 2 Granot, M . , 4 7 7 Grant, I., 153, 3 9 2 , 393 Grant, P. J . , 44 Grant, W., 3 0 7 Graves, J . E . , 2 6 1 Gray, R., 105 Green, C. Α., 88 Green, G. F., 368 Green, L. W., 6 1 , 2 1 7 , 326 Greenberg, D. B., 3 4 1 , 4 8 9 Greenberg, P. E . , 34 Greene, A. F., 2 4 0 Greene, J . G., 4 7 1 Greenfield, D. P., 188 Greenhouse, J . , 343 Greer, S., 3 3 1 , 3 3 2 Greil, A. L . , 478 Gries, F. Α., 157 Griffith, L. S., 64, 3 0 7 , 3 1 6 , 4 8 8 Griffiths, Α., 32 Grigoletto, F., 21 Grilly, D. M . , 82 Gritz, E . , 62 Gritz, E. R., 104, 3 4 0 Groessl, E . J . , 56 Gronsman, K. J . , 3 0 7 Gross, R. T., 24, 2 3 9 Grossarth-Maticek, R., 3 3 4

G r o s s m a n , L. M . , 83 Grottos, L. C . , 61 Groves, P. M . , 105 G r u m a n , C . , 23 Grunberg, Ν. E . , 107 Grundy, S. M . , 154 Guidice, L . , 4 7 8 Gulbinat, W., 3 3 3 Gullette, E. C . D., 6 1 , 152 Gulliver, S. B., 108 Gunary, R. M . , 4 1 4 G u p t a , A. K., 4 2 6 G u p t a , Μ . Α., 4 2 6 Gupta, O. P., 398 Gust, S. W., 103 Gutterman, J . , 341 Guttmacher, A. E . , 15 Guyatt, G. H . , 151 Guyon, L . , 24 Guys, M . , 103 Gwee, Κ. Α., 3 9 9 H a a g a , D. Α., 62 H a b e r m a n , H . F., 4 2 6 Hackett, G. I., 368 Hackett, T. P., 288 H a d d o c k , C. K., 136 H a g b e r g , J . M . , 152, 2 6 1 Hagglund, K. J . , 5 0 7 H a h n , Β. Α., 3 9 8 , 4 1 1 H a h n , M . B., 2 4 0 H a i m o v , I., 4 9 1 Hajek, P., 103 Halbach, H . , 83 Halbert, J . Α., 152 Hall, A. C . , 155 Hall, Ε. M . , 32 Hall, J . Α., 2 1 5 Hall, J . E . , 2 5 7 Hall, R. C . W., 4 8 9 Hall, S. M . , 103, 106, 108, 2 9 2 Hall, W., 34, 80 Hallstrom, T., 2 9 0 Halvorsen, J . G., 3 6 5 H a m a n n , Η. Α., 5 7 Hamdan, L., 529 Hamilton, S., 4 1 4 H a m m a n , R. F., 3 1 0 H a m m a r , M . , 36 H a m m i c k , M . , 37 Hamovitch, M . , 3 3 5 H a m p s o n , J . P., 368 H a m p s o n , S. E . , 3 1 5 H a n n , D. M . , 3 4 5 , 3 4 6 Hannent, I., 2 3 9 Hansen, S. W., 341 Hansen, W. B., 5 2 5 H a p o n i k , E . F., 4 9 1 Harden, R. M . , 36 Harden, R. N., 2 3 7

548

T H E HEALTH P S Y C H O L O G Y HANDBOOK Hardin, Κ. N . , 7 Hargrove, D. S., 36, 6 7 , 68 Harley, R. M . , 80 H a r m a n , M . , 398 Harmsen, W. S., 398 Harper, R. G., 21 Harrell, L. E . , 4 9 4 Harrington, P., 5 1 6 Harris, M . , 2 3 4 Harris, M . I., 3 0 3 , 3 0 5 , 3 1 0 Harris-Reid, M . , 4 5 6 Harris, T. O., 173, 1 7 7 Harrison, P. Α., 86 Hart, D. J . , 155 Hart, J . , 2 6 2 Hàrter, M . , 336 Harvey, J . N., 368 Harvey, R. F., 4 1 4 Hashimi, M . W., 258 Hasin, D. S., 126 Hastings Center, 4 9 4 , 4 9 5 H a t s u k a m i , D. K., 1 0 2 , 103, 1 0 5 , 108, 110, 113, 114 Hattersley, Α., 3 0 5 Hatzichristou, D. G., 3 6 7 H a u c k , E. R., 153 Hauri, P., 4 2 5 , 4 2 6 , 4 2 8 Hautanen, Α., 2 5 5 Haviland, J . S., 3 3 2 Hawkins, D. R., 4 2 6 Hawkins, R. P., 5 2 7 , 5 2 9 Hawryluk, G., 153 H a w t o n , K., 366 Hayashida, M . , 85 Haybittle, J . L . , 3 3 2 Hayes, S. C , 5 1 4 , 5 1 9 , 528 Haynes, R. B., 2 0 9 , 2 1 0 , 2 1 4 , 2 1 6 , 2 6 6 Haynes, S. N., 528 H a y s , R. D., 368 Hdner, J . , 2 9 0 He, J . , 259 Headache Classification Committee of the International Headache Society, 2 3 6 Hearn, M . T., 4 7 8 Heather, N., 4 4 Heatherton, T. F., 110 Heaton, K . W., 4 0 0 Hébert, P. R., 4 6 0 Hecht, M . J . , 368 Heckemeyer, C . M . , 44 Hecker, M . H . , 5 0 4 Hecth, F. M . , 3 8 9 Hedahl, K. J . , 4 7 0 Heim, E . , 3 3 1 Heiman, J . R., 3 6 1 , 3 6 2 , 3 6 4 , 3 6 5 Heinberg, L . J . , 127 Heishman, S. J . , 102 Heiss, G., 2 6 0 Helge, T. D . , 4 3 3 Helgeson, V. S., 5 9 , 66, 6 7 , 3 4 5 , 4 7 2 Helme, R., 493

Helme, R. D., 4 9 3 Helmick, C . G., 155, 156 Helsing, K . J . , 3 3 2 Henderson, S., 34 Hening, W., 4 2 8 , 4 3 5 Hennekens, C. H . , 2 6 0 , 2 8 0 , 504 Henningfield, J . E . , 102, 1 1 2 , 114 Henrich, G., 3 3 6 Henry, J . L . , 3 1 5 Henry, J . P., 253 Henson, C . D., 2 3 2 Herberman, R. B., 3 3 5 Herbert, B., 4 7 9 Herbert, J . , 3 5 9 Herbison, G. P., 4 7 9 Herman, C . P., 137 Hernandez, J . T., 4 7 7 Herrman, C , 2 8 4 Herrman, H . , 2 8 , 3 0 Hersen, M . , 518 Hesselbrock, M . N . , 87 Hesselbrock, V. M . , 8 7 Hetzel, L . , 4 8 5 Hewer, R. Α., 4 8 9 Heymsfield, S. B., 1 2 5 , 136 H e y w o o d , E . , 84 Hiatt, R. Α., 4 6 1 H i c k a m , D. H . , 188 Higgins, E . T., 4 7 0 Higgins, M . , 2 5 2 Higgins, P., 2 3 2 Higgins, S. T., 102 Higuchi, S., 85 Hill, J . O., 128 Hill, M . , 2 1 4 , 2 6 5 Hill, M . N., 2 9 4 Hill, R. W., 2 3 8 Hillenberg, J . B., 179 Hillier, Τ. Α., 3 0 5 Hilton, R., 3 5 , 36 Hiltz, M . J . , 368 Himeno, E . , 2 5 8 Himmelfarb, S., 493 Hinken, C , 393 Hinton, R. Α., 4 1 4 Hirji, K . , 3 4 1 , 343 Hislop, T. G., 3 3 5 , 4 0 4 Hitsman, B., 106, 108 H o , J . , 59 H o b s o n , M . L . , 158 H o c k e , V., 4 7 9 H o d g e , F. S., 4 6 1 Hodgins, D. C , 4 4 , 533 Hoehler, F., 4 0 4 Hoenk, P. R., 340 Hoffman, N . G., 86 H o g a n , Β. E . , 60, 66, 2 5 6 Hogerzeil, Η . V., 4 7 1 Hohagen, F., 4 9 1 Hoick, P., 4 6 1

Holder, J . S., 161 Holland, J . , 3 2 9 Holland, J . C , 3 3 4 , 3 4 5 Hollis, J . F., 3 3 5 , 5 2 0 , 5 2 1 Hollnagel, H . , 4 7 2 Hollon, S. D., 34 Holloway, R. L . , 2 4 4 Holmes, T. H . , 173 Holmlund, U., 4 7 7 Holroyd, C , 4 8 7 Holroyd, Κ. Α., 66, 2 4 2 Holt, C . S., 341 Hontela, S., 4 8 8 Hoogendijk, W. J . G., 4 8 7 Horan, M . J . , 252 Horgen, Κ. B., 128 H o m e , D. J . d e L . , 30 Horwitz, R. I., 4 5 9 Hosking, D. J . , 3 0 6 Hospers, H . J . , 388 H o u s e , Α., 4 4 , 4 8 9 Houston, Β. K., 2 6 2 , 504 Houston-Miller, N., 2 1 4 H o w a r d , Κ. I., 531 Howland, J . , 491 Hoyert, D. L . , 325 Hoyt, M . F., 2 9 4 H u , L . , 458 Hubinger, Α., 157 Hiibner, W. Α., 368 H u d s o n , A. M . , 155 H u d s o n , B., 2 8 - 2 9 H u d s o n , C . J . , 158 Hughes, J . R., 102, 103, 105, 107, 108, 110 Hughes, M . , 4 5 6 Hulka, J . F., 4 7 7 Humphreys, K., 5 0 3 , 5 0 6 Hunsley, J . , 3 0 9 Hunt, C . , 2 3 9 Hunt, W. C . , 3 3 5 Hurlbert, D. F., 3 6 5 , 366 Hurt, R. D., 114 Hvas, L., 4 7 1 , 472 H w a n g , W. C , 4 5 9 , 4 6 1 H y a m s , J . S., 399 Hyde, R. T., 2 6 1 Hyman, D. J . , 2 6 4 Hypertension Detection and Follow-up Program Cooperative G r o u p , 2 1 6 Iconomou, G., 66 Ikeda, M . , 2 5 8 Imboden, J . B., 2 3 5 Impériale, T., 408 Inbar, M . , 3 3 4 , 348 Incrocci, L . , 368 Ingelfinger, F. J . , 326 Ingram, Κ. K . , 4 9 4 Institute for the Future, 2 0 9 - 2 1 0 Institute of Medicine, 2 1 0 , 2 1 2

Ironson, G., 64 Irvin, J . E . , 101 Isbell, H . , 83 Isgar, B., 398 Ishibashi, K., 2 5 9 Ishii, N., 368 Ives, D. G., 133 I w a m a s a , G. Y., 4 5 1 Iwamoto, E. T., 107 Iwamoto, T . , 368 J a b e r , L. Α., 3 0 7 J a c k , L. M . , 106 J a c k s o n , Α., 44, 2 6 5 Jackson, J . , 412 Jackson, J . C , 461 J a c k s o n , W. T., 2 4 0 J a c o b , P., Ill, 103 J a c o b , R. G., 2 6 2 J a c o b s , G. Α., 108, 177 J a c o b s , J . , 336 J a c o b s , J . R., 4 3 3 J a c o b s , J . W., 343 Jacobsberg, L. B., 3 9 2 Jacobsen, P. B., 2 3 2 , 3 4 5 , 346 Jacobsen, S. J . , 3 9 9 J a c o b s o n , A. M . , 3 0 6 , 3 1 0 J a c o b s o n , E . , 178 J a c o b s o n , N . S., 5 3 0 , 5 3 2 Jaffe, Α., 4 Jaffe, A. S., 2 3 4 , 2 8 8 Jailwala, J . , 4 0 8 , 4 1 2 J a i n , A. P., 398 J a j o o , U. N., 398 J a k o b , U., 336 J a m i s o n , R. N., 2 4 1 , 334 Janis, I. L . , 56, 2 1 0 J a n z , Ν. K . , 3 3 0 Jarrett, R. B., 4 7 7 , 528 Jarvis, M . , 113, 114 Jarvis, Μ . A. E . , 4 7 1 J a s o n , L. Α., 2 3 6 , 2 3 7 J e b b , S. Α., 154 Jee, S., 2 6 1 Jeffery, R. W., 128, 154, 5 0 2 Jeffrey, T., 12 Jeffrey, W. R., 5 9 , 63 Jennings, G. L . , 2 6 1 Jennings, J . R., 2 8 9 Jennings, S. G., 2 5 9 Jensen, J . , 4 9 3 Jensen, M . P., 2 3 2 , 2 3 9 Jensen, M . R., 3 3 1 Jeste, D. V., 108, 4 9 3 Jimenez-Genchi, Α., 106 Jin, C . B., 2 5 5 Joffe, H . , 4 7 1 Joffres, M . , 3 3 2 J o h n , Ε. M . , 156 Johnsen, S. K . , 2 2

550

THE HEALTH PSYCHOLOGY HANDBOOK Johnson, B., 189 Johnson, B. T., 2 1 3 Johnson, C . C , 4 6 0 Johnson, G., 342 Johnson, J . Α., 266 Johnson, J . H., 177 Johnson, J . V., 32 Johnson, R. J . , 4 9 0 Johnson, S., 127 Johnson, S. L . , 129 Johnson, V. E., 359, 360 Johnson, W. G., 127 Johnston, Α., 114 Johnston, D. W., 2 6 2 Johnston, S., 2 3 2 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure ( J N C ) , 1 5 1 , 2 5 3 , 2 5 8 , 2 6 1 , 2 6 5 , 266 Jones, B. T., 88 Jones, J . C , 364 Jones, J . W., 32 Jones, K. R., 399 Jones, M . , 28, 36, 37 Jones, N. L . , 2 1 4 Jones, T. G., 21 J o r d a n , C , 32 J o r d a n , M . C , 399 Jorgensen, P., 333 Jorgensen, R. S., 2 6 2 Josephs, R. Α., 83 Jowsey, S., 14 Judge, Τ. Α., 32 Julius, S., 2 5 5 , 2 5 7 Juneau, M . , 504 J u n g , D. L . , 261 J u p p , J . J , 360 Justice, Α., 332 Kagawa-Singer, M . , 4 5 9 K a h a n a , B., 341 Kahn, B., 343 Kahn, L . B., 310 Kahn, R. L . , 4 8 5 Kalauokalani, D., 243 Kales, Α., 172 Kalichman, S. C , 62, 2 1 3 , 386, 388 Kalucy, E. C , 4 2 6 Kalucy, R. S., 426 Kamarck, T. W., 2 8 1 , 2 8 9 Kamerow, D. B., 4 2 6 Karnes, L. D., 4 7 7 Kammeier, M . L . , 86 Kan, L., 335 Kanani, R., 2 1 4 Kanazir, D. T , 334 Kane, V., 30 Kanner, A. D., 1 7 7 Kaplan, G. Α., 2 5 4 , 3 3 5 Kaplan, Η. I., 4 7 5

Kaplan, H . S., 360, 364, 366 Kaplan, J . , 286 Kaplan, Ν. M . , 254, 2 6 5 Kaplan, N. W., 151 Kaplan, R., 3, 504 Kaplan, R. M . , 56, 2 0 9 , 504, 508 Kaprio, J . , 332 Karajgi, B., 4 8 8 Karasek, R., 4 7 3 , 4 7 4 Karasic, D. H., 392 Kardia, S. L. R., 107 Karel, M . J . , 4 8 5 Karnieli, E., 157 Kash, Κ. M . , 338 Kasl-Godley, J . E., 4 8 5 , 4 9 3 Kassel, J . D., 103 Kathol, R. G., 3 4 1 Katon, W., 64 Katsikitis, M . , 24 Kattan, M . W., 368 Katz, I. R., 4 9 0 Katz, J . , 403 Katz, N . P., 2 4 1 Katz, N . R., 2 1 5 Katz, R. C , 3 6 5 Katzoff, J . , 192 Kaufer, D. I., 4 9 2 Kaufert, P. Α., 4 7 1 Kaufman, P. G., 2 6 2 Kawachi, I., 104, 2 8 9 Kawanishi, Y., 368 Kay, A. D., 4 9 0 Kay, J . Α., 183 Kaye, M . D., 398 Kazdin, A. E., 5 1 9 , 5 2 9 , 530 Keane, T. M . , 88 Keck, P. E., J r . , 2 3 5 Keefe, F. J . , 5 5 , 59, 62, 66, 67, 2 2 9 , 232, 238, 239, 410 Keehn, R. J . , 332 Keenan, R. M . , 103 Keith, P. M . , 59 Keith-Spiegel, P., 4 4 5 , 4 5 3 Kelder, S. H., 4 7 7 Kelemen, M . H., 2 6 1 Keller, K. L . , 129 Keller, M . , 336 Kelley, G. Α., 152 Kelley, K. S., 152 Kelley, S. D., 5 2 5 Kellogg, C. E., 2 2 Kellow, J . E., 4 0 2 , 4 0 5 Kellum, Κ. K., 533 Kelly, G., 261 Kelly, J . Α., 62, 63, 67, 3 8 8 , 389 Kelly, J . J . , 4 6 1 Kelly, M . P., 366 Keltikangas-Jarvinen, L . , 2 5 5 Kemper, H . C. G., 148 Kempthorne-Rawson, J . , 333

Name Index Kendall, D., 2 4 0 Kendall, P. C , 5 5 , 531 Kendler, K. S., 1 2 7 Kenny, P. J . , 106 Kentish, J . , 2 6 2 Kenyon, L. W., 2 9 0 Keogh, E . , 2 3 9 Keppel, K. G., 4 5 6 Kern, Ε. E . , 3 0 Kern, F. J . , 4 0 2 Kern, J . M . , 3 6 0 Kerns, R. D., 2 3 8 , 2 4 0 Kessler, R., 473 Kessler, R. C , 4 0 5 Ketterer, M . W., 2 8 0 , 2 8 1 , 2 8 2 , 284, 2 8 5 , 289, 290, 2 9 1 , 292 Keuler, F. U., 368 Keuning, J . , 3 3 4 Key, C . R., 335 Khalife, S., 366 Khlat, R., 4 7 4 Khoury, A. J . , 4 6 9 Kiecolt-Glaser, J . , 5 0 7 Kiecolt-Glaser, J . K., 66, 172, 3 3 9 Kiernan, R. J . , 343 Kiesewetter, F., 368 Killen, J . D., 103, 1 1 1 , 2 1 4 Kilpatrick, D. G., 4 7 9 Kim, E. L . , 5 0 2 K i m , H . F. S., 488 Kimble, D. L . , 2 1 1 Kincade, J . E . , 3 3 5 Kington, R. S., 4 5 6 Kinsey, W., 189 Kirby, H . B., 21 Kircher, J . R., 3 6 6 Kirkpatrick, D. R., 4 9 3 Kirschenbaum, D. S., 130, 134 Kissane, D. W., 3 3 6 Kissel, S. S., 64, 316 Kivela, S. L . , 4 9 1 Klag, M . J . , 2 5 9 K l a p o w , J . , 2 1 3 , 504, 5 0 5 Klapow, J . C., 506, 507 Klatsky, A. L . , 2 6 0 Klein, K . , 4 1 2 Klein, R., 3 1 0 Kleinplatz, P. J . , 3 7 5 Klerman, G. L . , 65 Klesges, L. M . , 108 Klesges, R. C , 103, 108 Klinkman, M . S., 64 Knight, B. G., 4 9 0 Knight, E. L . , 2 6 4 , 2 6 5 Knight, S. J . , 7 Knowler, W. C . , 129 Koch, U., 3 3 6 Kochanek, K. D., 3 2 5 Koenig, H . G., 4 9 5 Koerner, K., 5 3 0

Koffman, D. M . , 4 6 0 Kofoed, L . , 1 9 2 , 193, 197 K o g a n , J . N., 493 K o g o n , M . M . , 3 3 6 , 346 Kohlenberg, B. S., 5 1 9 Kojima, S., 2 5 9 K o k , G. J . , 62 Kokkinos, P. F., 152 Kolli, R., 4 8 8 Konen, J . C . , 368 K o o b , G. F., 104, 105 Koocher, G., 331 Koocher, G. P., 4 4 5 , 4 5 3 Kooyers, K. J . , 63 Kopel, S. Α., 5 2 0 Koplan, J . P., 127 K o p p , M . S., 4 7 0 , 4 7 5 , 4 7 7 Koppel, I., 3 7 Koren, M . J . , 2 5 3 Kornblith, A. B., 3 4 0 Koskenvuo, M . , 3 3 2 Koski, K . , 4 9 1 Kotik-Harper, D., 2 1 Kottke, T., 3, 62, 2 1 4 , 2 6 5 Kouyanou, K., 2 3 5 Kovacs, M . , 306 Koven, L . , 4 8 6 Kovner, F., 3 2 8 , 3 3 7 Kozlowski, L . T., 110, 112 Koznar, J . , 369 K r a a i j , V., 6 3 , 2 8 8 Kraemer, H. C . , 6 5 , 2 6 2 Kraft, P., 2 9 0 Krahn, D. D., 4 8 8 Krailo, M . , 3 3 5 Krane, R. J . , 3 6 7 Krantz, D. S., 2 8 1 , 504 Kratt, P. P., 44 Krause, J . , 136 K r a u s s , D. J . , 369 Krege, B., 4 5 Kreitler, H . , 3 2 6 , 3 3 0 , 3 3 1 , 3 3 2 , 334, 3 3 7 , 3 4 6 , 348 Kreitler, S., 326, 3 2 7 , 3 2 8 , 3 3 0 , 3 3 1 , 3 3 2 , 334, 3 3 5 , 3 3 7 , 3 4 1 , 3 4 6 , 348 Kremer, J . , 4 8 7 Kreutzer, J . , 88 Kriska, A. M . , 148, 156, 157 Kristeller, J . L . , 104, 109 Kroenke, K . , 9, 4 0 8 Kronholm, P., 4 9 0 Kruis, W., 4 0 0 Kubler-Ross, E . , 329 Kubzansky, L. D., 2 8 9 Kuhn, C . M . , 3 0 7 Kulas, J . F., 2 2 Kulich, R. J . , 2 3 4 Kuller, L. H . , 133, 258 Kumanyika, S. K., 3 1 0 , 4 5 9 , 4 6 0 K u m a r , D., 399 Kummel, E . , 238

551

552

THE HEALTH PSYCHOLOGY HANDBOOK Kunen, S., 2 2 K u o , H-S., 4 5 8 Kupfer, D. J . , 4 2 6 K u r a m o t o , K., 2 5 7 Kurki, T. S., 5 0 8 Kuroiwa, Α., 258 Kurzrock, R., 3 4 1 Kushner, R., 2 5 7 , 258 Kuwajima, I., 2 5 7 Laake, K., 4 8 7 Laçasse, Y., 153 Lach, H . W., 4 9 1 Lackner, J . M . , 4 1 4 Lacks, P., 4 3 2 Lacourciere, Y., 2 6 0 Lacro, J . P., 108 Laffel, L . M . , 59 Lahita, R. G., 238 Laine, T. P., 87 Laippala, P., 4 9 1 Laird, J . M . , 4 0 2 , 403 Lalumiere, M . L . , 3 6 0 Lammers, C. Α., 3 1 5 Lamont, J . Α., 3 6 7 Landerman, R., 493 L a n d o , H . , 113, 114 Landsverk, J . Α., 3 4 0 Lane, D. S., 330 Langford, H . G., 2 5 9 Langston, J . W., 343 Lanier, A. P., 4 6 1 Lantelme, P., 2 5 7 Laqueur, T., 3 6 0 Laragh, J . F., 253 L a R o c c o , S. Α., 4 7 1 Larochelle, P., 2 5 9 Larsen, J . P., 4 8 7 Larson, D . B., 4 9 5 Latimer, P. R., 404 Lattika, P., 156 L a u , J . , 63 L a u m a n n , E. O., 3 5 9 , 3 6 2 , 365 Lawton, M . J . , 199 Lawton, M . P., 4 9 0 Layfield, M . , 2 4 0 Lazarus, R. S., 170, 174, 177, 1 8 1 , 2 3 0 , 2 4 0 , 2 9 1 , 330, 472 Le M o a l , M . , 104 Le Pape, Α., 474 Leaf, P. J . , 4 5 8 Lederberg, M . , 336 Lee, C., 4 7 2 Lee, J . , 335 Lee, J . Y., 2 6 5 Lee, P., 310 Leenen, F., 2 5 9 Lefebvre, J . C., 2 3 2 Lefebvre, M . F., 2 3 9 Lefkowitz, R. J . , 2 5 4

Legh-Smith, J . , 4 8 9 Legler, J . , 4 6 1 Lehrer, P. M . , 173, 177 Leibel, S. Α., 3 6 8 Leiblum, S. R., 3 6 2 , 3 6 5 , 3 6 7 , 3 6 9 Leicht, M . L . , 4 8 7 Leisen, M . B., 528 Leitenberg, FL, 62 LeMaster, P. L . , 4 6 0 Lenz, J . W., 2 6 2 Leo, G. I., 5 2 1 Leon, A. S., 150 Lepper, H . S., 2 1 5 LeResche, L . , 2 2 9 , 3 9 7 Lerman, C., 107, 3 3 8 Lesermann, J . , 4 0 6 L e s k o , L. M . , 3 4 1 , 3 4 2 , 348 Leslie, B., 34 Lesniak, K. T., 152 Lesperance, F., 4, 64, 2 8 2 , 2 8 8 , 2 9 2 , 504 Lessard, R. J . , 86 Lessmeier, T . J . , 283 Letizia, Κ. Α., 131 Leung, R. W., 2 6 1 Levav, I., 3 3 3 , 334 Levavi, H . , 3 3 4 Levendag, P. C., 368 Levenkrohn, S., 21 Levenson, R. W., 83 Leventhal, Ε. Α., 66 Levin, D. C., 153 Levin, E. D., 104, 107 Levin, W. C., 4 9 1 Levine, A. M . , 3 3 5 Levine, D . M . , 6 1 , 2 1 7 Levine, J . , 4 5 7 Levitt, Ε. E . , 134 Levy, S. M . , 335 Lewin, B., 2 8 1 , 2 9 2 Lewinsohn, P. W., 4 9 3 Lewis, D. Α., 4 7 6 Lewis, P., 188, 194, 198, 199 Lewis, S., 4 8 9 Lewis, T. S., 2 8 2 Lewis, T. T., 4 5 9 Lex, B. W., 4 5 9 Li, T. C., 4 7 8 Li, Z . , 4 0 5 , 4 1 0 Lichtenberg, P. Α., 4 8 5 Lichtenstein, E . , 113 Liddell, Α., 4 9 3 Lie, H . , 2 5 2 Lief, J . H . , 3 6 0 Liese, B. S., 90 Light, K. C., 253 Limacher, M . C., 261 Lindamer, L . Α., 108 Linde, S., 4 2 5 , 4 2 6 , 4 2 8 Linden, W., 6 0 , 6 3 , 64, 1 5 1 , 179, 2 5 6 , 2 6 2 , 2 9 2 Lindsey, K., 4 9 5

Name Index Linkins, R. W., 108 Linnerooth, P. J . , 528 Linton, S. J . , 2 3 1 , 3 9 7 Lipman, R. L , , 157 Lipowski, Z . J . , 3 0 Lippman, M . , 3 3 5 Lisman, S. Α., 88 Litchfield, W. R., 2 5 4 Littlefield, C . H . , 309 Litwin, M . S., 368 Livingston, E. G., 3 0 7 L o b o , Α., 343 Lock, M . , 4 7 1 Locker, D., 493 L o c k w o o d , G. Α., 346 Longnecker, M . P., 332 L o n g o , J . P., 189, 192, 195, 196, 197 LoPiccolo, J . , 3 6 1 , 3 6 5 , 366 Lorr, M . , 3 4 2 Louie, D., 61 Lovallo, W. R., 172, 173, 254 Lowenthal, D. T., 2 6 1 Lowery, D., 4 5 7 Luciano, D. S., 254 Lucini, D . , 2 6 2 Lucock, M . P., 24 L u d b r o o k , P. Α., 234 L u d m a n , E. J . , 44 Ludwig, W. W., 2 1 4 Luftey, K . , 2 1 5 Lumry, A. E., 86 Lushene, R., 177 Lusignolo T . M . , 4 5 9 Lusk, E. J . , 3 3 1 , 3 3 5 Lustman, P. J . , 64, 2 1 5 , 3 0 3 , 3 0 7 , 3 0 8 , 316, 3 1 8 , 4 8 8 Lutgendorf, S. K . , 66 Luukinen, H . , 4 9 1 Luzzatto, P., 3 4 5 Lynn, R. B., 3 9 7 Lyons, M . J . , 80 M a c A n d r e w , C . , 86 M a c é r a , C . , 155 Maciewicz, R., 2 3 4 Maclntyre, N . R., 153 M a c k , J . E . , 43 M a c L e o d , B. D., 193, 194, 198 M a c M a h o n , S., 1 5 1 , 2 5 2 M a d d e n , P. A. F., 103, 1 0 7 M a d h a v e n , S., 2 6 5 M a e s , M . , 106 M a e s , S., 6 3 , 2 8 8 M a g g i , S., 4 9 1 M a g g i o , C. Α., 305 Magnus, M . H., 460 Mahoney, M . J . , 2 1 0 , 2 1 4 M a i m a n , L. Α., 2 1 2 Malahey, B., 2 1 9 M a l a m o o d , H . S., 4 0 9

Malarkey, W. B., 172 M a l a s p i n a , D., 2 5 7 M a l a v a u d , B., 3 6 0 Malec, J . , 7 M a l g a d y , R. G., 110 Mallion, J . M . , 2 5 6 Malloy, T. E . , 2 1 1 Malterud, K . , 4 7 2 Mancia, G., 1 5 1 , 256, 2 5 7 Mancini, T., 2 8 5 Mandel, F. S., 4 7 9 Mandin, H . , 3 0 9 Mangelsdorff, A. D . , 9 M a n o l i o , Τ. Α., 4 9 1 Manson, J . , 305 M a n s o n , J . E . , 126 Mansvelder, H. D., 105 Mantell, J . , 335 M a r c u s , Β. H . , 154, 155 M a r c u s , D. Α., 5 2 0 Margolin, G., 3 3 5 M a r k , M . M . , 66 Markides, K. S., 4 5 9 M a r k o u , Α., 104, 105 Markovitz, J . H . , 172, 2 8 0 M a r k s , I. M . , 522 M a r k s , J . L . , 103 M a r k s , J . S., 127 M a r i a i t , G. Α., 89, 9 1 , 2 1 4 , 2 1 9 , 3 0 7 M a r o n d e , R. F., 192 M a r r s - G a r c i a , Α., 5 3 1 Marsh, L., 487 Marshall, J . Α., 3 1 0 M a r s o n , D. C . , 494 Martin, Α., 393 Martin, D . C . , 80 Martin, J . B., 5 2 2 Martin, J . E . , 150, 2 6 1 Martin, R., 4 8 6 Martin, W. H., 2 6 1 M a r u c h a , P. T . , 172 M a r u m o , K., 3 6 7 M a r x e r , F., 473 M a s e k , B. J . , 5 2 0 M a s o n , D. Α., 44 M a s o n , P., 44 M a s s e , B., 4 8 9 Massie, J . J . , 3 4 0 Massie, J . M . , 341 Massie, M . , 3 2 9 Massie, M . J . , 3 4 1 , 3 4 5 , 3 4 8 M a s s i m o , L. M . , 5 1 6 Masters, W. H . , 3 5 9 , 3 6 0 , 3 6 5 Mastroianni, L . , 4 7 8 Matarazzo, J . D., 210 M a t h e w s , J . R., 5 2 9 Matsui, D., 2 1 7 M a t s u m o t o , M., 2 5 3 M a t s u o k a , J . K., 458 Matsushita, S., 85

553

554

T H E HEALTH PSYCHOLOGY HANDBOOK Matt, K . S., 59 Mattar, M . , 7 Matthews, A. K., 4 5 7 Matthews, D. Α., 4 9 5 Matthews, K., 4 7 1 Matthews, Κ. Α., 172, 253 M a t t s o n , R. H . , 2 1 7 M a x t o n , D. G., 398 Maxwell, P. R., 399 Mayberry, D., 177 Mayer-Davis, E. J . 3 1 0 Mayer, Ε. Α., 4 0 2 , 4 1 1 Mayer, T. G., 2 3 9 , 2 4 0 Mazzaferri, E. L . , 4 8 9 Mazzuca, S. Α., 213 M c A d o o , W. G., 2 1 4 McAlindon, T., 155 McAuliffe, T., 388 McBride, C . , 61 McCabe, M., 360 M c C a l l u m , D. M . , 177 McCarter, R., 108 McCarthy, B. W., 3 6 9 McCarthy, D . M . , 105 McCaskill, C . C , 3 1 5 McCauley, C , 3 6 4 (

M c C h a r g u e , D. E . , 102, 103, 106, 108, 109, 113, 114 McClellan, P., 2 6 1 McClelland, D. C , 34 M c C o r m a c k , W. M . , 3 6 6 M c C r a c k e n , L . M . , 24, 2 3 9 , 4 5 7 M c C r a d y , B. S., 89 M c C r a e , R. R., 335 M c C u b b i n , J . Α., 3 0 7 McCulloch, D. K., 306 McCulloch, J . Α., 2 3 8 McCullough, A. R., 368 McCurley, I., 59 McDaniel, J . S., 339 McDaniel, K. L . , 88 McDaniel, S. H . , 34, 3 5 , 36, 3 7 , 67, 6 8 , 69, 3 9 1 , 3 9 2 , 393 M c D o n o u g h , P., 4 7 4 M c D o w a l l , A. C , 3 3 6 McDowell, A. J . , 368 McDowell, B. J . , 5 2 0 M c E w a n , B. S., 170 McEwen, B. S., 4 5 9 McGehee, D. S., 105 McGinness, J . , 3 McGovern, Κ. B., 366 M c G u i g a n , F. J . , 178 McGuire, L . , 66 McHorney, C. Α., 3 3 2 , 3 4 2 , 343 M c H u g h , P. R., 21 M c K a y , D. W., 2 6 0 McKendrick, M . W., 3 9 9 McKenzie, M . , 336 M c K e y , B., 2 5 4

M c K i b b o n , Κ. Α., 2 1 4 McKinlay, J . B., 3 6 7 McKinlay, S. M . , 4 7 1 McLellan, A. T., 197 M c L e o d , C. C , 34 M c L e o d , J . , 473 M c M a h o n , J . , 88 McMillan, C , 3 3 0 M c M u r r y , J . F., 3 0 7 , 308, 309 M c N a g n y , S. E . , 2 6 5 M c N a i r , D. M . , 3 4 2 McPhee, S. J . , 4 6 1 M c V a r y , K. T., 368 Meagher, B. R., 2 3 4 M e a n a , M . , 366 Mears, B., 3 3 5 Mediansky, L . , 3 3 5 Meenan, R. F., 156 Meichenbaum, D., 1 8 1 , 2 1 6 , 241 Meilahn, E., 133 Meilan, Ε. N., 2 5 8 Meinders, A. E . , 136 Meisler, A. W., 3 6 9 Meissner, J . S., 4 0 9 Melisaratos, N., 334 Mellinger, B. C , 3 6 7 Mellinger, G. D., 4 2 5 Melton, L . J . , 4 9 0 Meltzer, H. Y., 106 Melzack, R., 2 3 0 , 2 3 8 , 2 4 2 , 3 4 3 , 4 0 4 , 4 1 0 Mencher, P., 2 3 4 Mendall, Μ . Α., 399 Menditto, Α. Α., 528 Mendlowicz, M . V., 34 Menkes, M . S., 253 Mensah, G. Α., 253 M e n z a , Μ . Α., 3 6 8 , 4 8 7 M e r c a d o , A. M . , 172 Mercier, L . , 4 9 1 Merimsky, O., 3 4 1 Merrick, G. S., 3 6 0 Merskey, H . , 2 2 9 , 2 4 1 Mertz, FL, 4 0 2 , 4 0 3 Meshkinpour, FL, 4 0 4 Mesmer, C , 4 1 4 Messerli, F. FL, 2 5 7 Meston, C . M . , 3 6 0 , 3 6 2 Metz, Μ . Ε . , 3 6 0 , 3 6 5 , 369 Metzack, R., 4 0 3 Meulman, J . , 63, 288 Meyer, D., 44 Meyer, R. E . , 79, 80 Meyer, T. J . , 66 Meyers, H . F., 4 6 1 Meyler, W. J . , 2 4 2 Michael, R. T., 3 5 9 , 3 6 2 Michaels, S., 359, 3 6 2 Michal, M . M . , 334 Michie, S., 33 Miles, S., 493

Name Index Milesi, C , 151 Milgrom, J . , 33 Miller, Β. Α., 4 5 7 Miller, C , 331 Miller, D., 3 6 0 Miller, D. S., 3 3 1 Miller, E. R., 2 6 1 Miller, G., 64 Miller, J . P., 4 9 1 Miller, Κ. M . , 147, 148, 149 Miller, L . J . , 4 7 6 Miller, Ν. E . , 56 Miller, Ν. H . , 2 6 5 Miller, N. S., 83, 192 Miller, W. R., 4 2 - 4 5 , 4 7 - 5 2 , 6 2 , 1 1 1 , 197, 199, 2 0 2 , 2 1 2 Milner, P., 104 Milon, H . , 2 5 7 Minor, Μ . Α., 156 Miscovich, S. J . , 2 1 1 Mishra, Α., 368 Misra, D., 2 6 5 Mitchell, E . , 4 7 2 Mitchell, J . E . , 108 Mockett, S., 155 Mockrin, S. C . , 2 5 2 Moffitt, P. F., 4 2 6 Moffitt, T . E . , 4 7 0 M o k d a d , A. H . , 126, 127 Moldofsky, H . , 4 2 6 Molinari, S., 2 1 Molinari, S. P., 193 Montain, S. J . , 2 6 1 Montaner, J . S. G., 389 Monterrosa, Α., 4 5 7 M o n t o y e , H . J . , 148 M o o d y , D. S., 2 4 0 M o o r e , L . , 393 M o o r e , M . S., 154 Morales, Α., 3 7 5 M o r e n o , J . D., 5 1 6 M o r e n o , R., 2 3 9 M o r g a n , D. L . , 32 M o r g a n , K., 4 9 1 M o r g a n , R. K . , 3 2 Morgenstern, H . , 336 Morin, C. M., 429, 430, 432 M o r i s a k i , N., 308 Morisky, D . E . , 2 1 4 , 2 1 7 Morisky, D. M . , 6 1 Morley, J . E . , 4 9 2 Morley, S., 24 Morley, S. M . , 4 1 4 Morokoff, P. J . , 3 6 2 Morrill, R. G., 2 9 4 Morris, J . , 3 5 , 36 Morris, J . Α., 398 Morris, R., 238 Morris, T., 3 3 1 , 3 3 2 Morris-Yates, A. D., 4 0 0

Morrison, Α., 4 9 2 Morrison, J . R., 4 8 8 , 4 8 9 Morrison, R. L . , 4 9 0 M o r r o w , J . R., 162 M o r s e , E . , 103 Morse, J . M., 490 Mortensen, P. B., 333 M o r t o n , N . W., 22 Moses, H., 522 M o s k o , S. S., 428 M o s s , Η. B., 85 M o s s , Ν. E . , 4 7 4 Moulin, D. E . , 241 M o u n t , Κ. Α., 51 M o u r a , N . G. M . , 2 1 4 Mourice, J . , 63 M o y , T. F., 4 6 0 Moye, J . , 494 M o y e r s , T. B., 4 4 M u d d e , A. N., 62 Mueller, J . , 343 M u i r , K . R., 155 Mulhall, J . P., 368 Mullen, P. E . , 4 7 9 Muller, H . F., 4 8 8 Muller, M . J . , 368 Mullooly, J . P., 3 3 5 M u l r o w , P. J . , 2 6 4 Multiple Risk Factor Intervention Trial Research G r o u p , 2 1 6 Munakata, J . , 402 M u n d a l , R., 2 5 2 M u n d y , W. R., 107 M u n o z , F., 103 Murai, M., 367 M u r a m a t s u , T., 85 M u r a y a m a , M . , 85 Murphy, J . G., 504 Murphy, J . K . , 2 8 9 Murphy, S. L . , 325 Murray, M . , 3 3 0 M u r r a y , Μ . Α., 3 0 9 , 4 9 3 Murrell, S. Α., 493 Musselman, D. L . , 3 3 9 M u s t , Α., 1 2 7 M u s t , S., 129 Myer, E . , 2 3 5 Myers, H . F., 4 5 9 Myers, M . G., 105, 2 5 6 Myers, N . F., 2 6 2 Myers, R. E . , 4 6 1 Myers, W. Α., 3 6 4 Nabe, C., 495 Nadeau, L., 24 Nadelson, C. C . , 4 7 4 N a g o s h i , C . T., 84 N a j a r i a n , B., 6 0 Nakashima, J . , 367 N a k a s h i m a , Y., 2 5 8

555

556

T H E HEALTH PSYCHOLOGY HANDBOOK Naliboff, B. D., 3 1 5 , 4 0 2 , 4 0 3 , 4 7 7 N a m i , R., 152 N a r a y a n , Κ. M . V., 3 1 4 N a r b r o , K . , 137 N a t h , S. R., 5 3 1 National Center for Health Statistics, 4 5 6 , 4 5 7 National Heart, Lung, and Blood Institute, 6 5 , 126, 130, 1 3 1 , 132, 133, 134, 136, 137, 138, 2 0 8 , 4 5 7 , 504 National Institute of Diabetes and Digestive and Kidney Diseases ( N I D D K ) , 6 2 , 3 0 4 , 3 0 5 , 3 1 2 National Institute on Alcohol Abuse and Alcoholism, 44 National Institute on Drug Abuse (NIDA), 188, 192 National Institutes of Health (NIH), 6 1 , 6 2 , 126, 130, 1 3 1 , 132, 133, 134, 136, 137, 138, 154, 4 3 4 National Office of Vital Statistics, 56 National Sleep Foundation, 4 3 6 Natural Medicines Comprehensive Database, 434, 435 Naugle, A. E . , 528 Neal, D. L . , 30 Neal, M . J . , 106 Neale, Α. V., 3 0 7 , 335 Nealey, J . R., 5 7 Nease, D. E . , J r . , 64 Neaton, J . D., 2 5 2 Nedeljkovic, S. S., 2 4 1 Neijt, J . P., 343 Neish, N., 2 3 2 Nelson, A. R., 4 5 6 Nelson-Gray, R. O., 514 Nelson, R. O., 4 7 7 , 528 Nemeroff, C. B., 3 3 9 Nesbitt, S., 2 5 5 Nesselroade, J . R., 4 5 9 N e s s m a n , D. G., 2 1 0 Nestler, E. J . , 85 Nesvacil, L . , 369 Nettelbladt, P., 3 6 9 Nettleman, L . , 30 Neundorfer, B., 368 Neutel, J . M . , 2 5 7 Newlin, D. B., 83, 84 N e w m a n , A. B., 4 9 1 N e w m a n , B., 103, 111 N e w m a n , C . F., 90 Newman, E., 479 N e w m a n , J . , 83 N e w m a n n , J . P., 4 9 3 Newton, C. R., 2 3 1 , 2 3 9 , 243 Newton-John, T., 2 4 2 Newton, P., 3 1 0 N i a u r a , R., 6 1 , 6 2 , 106 Niaz, U., 343 Niazi, N., 4 0 2 Nicassio, P. M . , 57, 2 3 9 Nichol, M . B., 191 Nicholas, M . K., 3 0 , 33

Nickens, H . W., 4 5 6 Nieto, F. J . , 2 6 0 Nishimoto, R., 3 3 5 Nishino, K., 2 5 8 Nissenkorn, I., 368 Nitz, A. J . , 183 Nitzan, R., 336 N o a c k , R., 136 Nolen-Hoeksema, S., 473 N o m u r a , Α. M . Y., 3 3 2 N o o n a n , W. C , 44 N o r b i a t o , G., 2 6 2 Norcross, J . C , 4 3 , 92 Norell, S. E . , 2 1 7 N o r m a n , L . , 35 Norris, J . L . , 158 Norris, S. L . , 63, 3 1 4 Northern California Neurobehavioral G r o u p , 2 2 Northrop, L., 494 N o s e d a , G., 136 N o t m a n , M . T., 4 7 4 N o u w e n , Α., 3 0 9 Nowinski, J . , 90 N o y , S., 2 1 Noyes, R., J r . , 3 4 1 Nugent, C. Α., 2 1 0 Nunnally, J . C , 2 1 9 Nurnberg, H . G., 3 6 0 Nurnberger, J . I., 83, 134 N u s s b a u m , P. D . , 2 0 Nygren, M . , 4 9 4 Obarzanek, E . , 4 6 0 O'Brien, B., 505 O'Brien, C. P., 197 Ockene, I. S., 2 6 5 Ockene, J . K., 6 2 , 109, 112, 113, 114, 2 1 5 Ockene, S., 2 1 4 O'Donnell, W. E . , 2 4 O'Donoghue, W. T., 3 6 0 O'Donohue, W., 364 O'Donohue, W. T., 5 0 5 Oexmann, M. J . , 460 O ' G o r m a n , T. W., 84 O ' H a r a , M . W., 67, 4 7 6 Ohayon, M . , 4 9 1 O k a m o t o , K., 2 5 3 O'Keefe, Ε. Α., 3 9 9 Okifuji, Α., 2 4 3 , 2 4 4 Olawuyi, F., 399 Olden, K. W., 4 0 6 Oldridge, Ν. B., 1 5 1 , 2 1 4 Olds, J . , 104 O'Leary, Α., 4 7 2 Oliveria, S. Α., 156, 2 6 5 Ollendick, T. H . , 34 Olubuyide, I. O., 399 O'Malley, J . E . , 3 3 1 O'Malley, S. S., 87 Oparil, S., 2 5 7 , 2 5 9 , 2 6 0

Orleans, C. T., 2 1 5 , 2 1 6 Ornish, D., 64 O r o s a n , P., 137 Orth-Gomér, K., 4 7 2 Osborn, M . , 366 Oslin, D. W., 4 9 0 Ossorio, R. C , 2 1 6 Osterweil, D., 4 9 2 Ostfeld, A. M . , 3 3 3 , 336 Ostroff, J . , 336 Oswald, I., 4 9 1 Otto-Salaj, L. L . , 3 8 9 Overall, S., 2 2 Overholser, J . C , 91 Owen, A. E . , 177 Owen, K., 3 0 5 Owen, N., 162 O x m a n , A. D., 2 1 0 Padgett, D. K., 4 5 8 Paffenbarger, R. S., 2 6 1 Pagani, M . , 2 6 2 Paige, N. M . , 368 Palace, E. M . , 3 6 0 Palmer, B., 4 9 3 Palsson, O., 3 9 9 Pankratz, L . , 188 Paoletta, Α., 2 5 4 Paoletti, N . , 32 Parati, G., 2 5 7 Paris, M . , 30 Park, D., 4 8 6 Park, J . , 152 Park,J. J . , 261 Parker-Dominguez, T., 4 5 9 Parran, T., 189 Parran, T. P., 190, 196, 197 Parrino, L . , 4 9 1 Parrott, A. C . , 106 Parsons, O., 153 Parzer, P., 4 7 9 Pasacreta, J . V., 4 8 9 Pasis, S., 4 9 2 Paskett, E. D., 4 6 1 Pate, R. R., 2 6 0 Patel, C . , 180 Patenaude, A. F., 15 Paterson, D., 389 Patino, P., 105 Patrick, C . , 458 Patrick, D. L . , 4 1 1 Patterson, T., 3 Patterson, T. L . , 2 0 9 Patton, G. K., 32 Paty, J . Α., 103 Paul, G., 5 1 6 Paul, G. L . , 528 Paul, L . C . , 309 Paulauskas, S., 306 Pauporte, J . , 3 6 0

Pavlik, V. N., 2 6 4 Payne, T. J . , 110 Pearcy, J . N., 4 5 6 Pearl, D., 3 3 6 Pearlman, R. Α., 3 2 9 Peck, J . R., 2 3 9 Pederson, H . E . , 4 8 9 Pedula, K. L . , 3 0 5 Pegg, S. H . , 4 7 0 Peirce, N . S., 156, 157 Pelcovitz, D., 4 7 9 Pena, B., 368 Penman, D. T., 3 3 1 Pennebaker, J . W., 5 0 7 Penzien, D. B., 2 4 2 Pepe, M . S., 129 Pereira, M . Α., 156 Perkins, Κ. Α., 1 0 2 , 106 Perkins, R. H . , 2 3 6 Perlis, M . L . , 4 2 6 Perri, M . G., 154, 2 1 4 Perrin, J . M . , 127 Perskey, V. W., 333 Person, E . S., 364 Pert, Α., 104 Pertschuk, M . , 106 Pervin, L. Α., 3 6 7 Pescosolido, Β. Α., 2 1 5 Peternell, Α., 4 7 1 Peters, A. L . , 2 1 6 Peters, J . C . , 128 Petersen, L . , 3 4 1 , 343 Petersen, R. C . , 193 Peterson, E . W., 4 9 1 Peterson, L . , 2 4 1 Peterson, P. L . , 5 0 4 Peterson, T., 3 1 0 Petrella, R. J . , 2 6 1 Pettinati, H . M . , 197 Pettingale, K . W., 3 3 1 , 3 3 2 Pettitt, D . J . , 129 Peyrot, M . , 306 Peyrot, M . F., 3 0 7 , 3 0 8 , 3 0 9 , 3 1 0 , 3 1 3 , 3 1 5 , 316, 318 Pfaus, J . G., 3 6 0 Pfluger, H . , 368 Phelan, S., 138 Philbrick, J . T., 9 Phillips, C. L . , 3 1 0 Phillips, M . M . , 5 0 4 Phillips, R. L . , 3 6 2 Phillips, S. F., 4 0 2 Pi-Sunyer, F. X . , 130, 3 0 5 Piasecki, M . P., 519 Piasecki, T. M . , 106 Pickering, E . , 2 8 9 Pickering, T., 2 6 2 , 2 6 5 Pickering, T. G., 56, 2 5 6 Pierce, A. P., 365 Piesse, C . , 4 0 5

558

T H E HEALTH P S Y C H O L O G Y HANDBOOK Pieterse, M . E . , 62 Pietrobelli, Α., 129 Pihl, R. O., 87 Pilowsky, I., 2 4 , 4 2 6 Pincomb, G., 2 5 4 Pingitore, G., 108, 128 Pinkerton, S. D., 3 8 9 Pinto, Β. M . , 154 Piper, M . E . , 107, 108 Pither, C. E . , 2 3 5 Pivik, J . , 2 3 9 Pivik, R. T., 4 9 1 Pizzi, L. T., 533 Planthara, P., 533 Plas, E . , 368 Plaud, J . J . , 360 Polatin, P. B., 2 4 0 Polednak, A. P., 330 Polen, M . R., 88 Polich, J . , 86 Poling, Α., 189 Polit, D. F., 4 7 1 Polivy, P., 137 Polk, D. E . , 2 8 1 Pollard, T. M . , 172 Pollets, D., 360 Pollock, M . L . , 2 6 1 Pomerleau, C. S., 103, 104, 105 Pomerleau, O., 106 Pomerleau, O. F., 103, 104, 105, 107 Pomidossi, G., 2 5 7 Ponticas, Y., 365 Pool, D., 4 9 4 Pope, C . R., 335 Pope, K. S., 4 4 6 Popkin, M . K., 340, 341 Populla-Vardi, C , 192 Porcellati, C . , 2 5 7 Porcher, H . C . , 102, 103 Pories, W. J . , 137 Porjesz, B., 86 Porst, H . , 368 Portenoy, R. K., 2 4 1 , 343 Porter, M . R., 339 Posavac, E. J . , 5 2 5 Poston, W. S., 136 Poston, W. S. C , 106 Potter, J . F., 2 6 0 Potters, L., 368 Powell, R. D., 3 6 5 Powell, S. H . , 24 Poynard, T., 4 1 2 , 4 9 2 Pratt, L. Α., 2 9 5 Pratt, M . , 155 Price, D. W., 34 Price, R., 393 Price, R. Α., 128, 129 Priestman, S. G., 3 3 2 Priestman, T. J . , 3 3 2 Prigatano, G. P., 153

Prior, Α., 4 1 4 Prior, A. C. S., 403 Pritchard, W. S., 102 Prochaska, J . , 111 Prochaska, J . O., 4 3 , 92, 110, 2 1 1 , 2 1 2 Professional Liaison Committee (Australia) Project T e a m , 28 Project M A T C H Research G r o u p , 89 Promax, H . , 2 5 7 Pronk, N . P., 5 0 2 Prudhomme, D., 136 Pruitt, S. D., 208 Prus-Wisniewski, R., 2 5 8 Pryor, J . L., 3 6 9 Puder, K . L . , 4 1 1 Pugh, J . Α., 4 5 7 Puhl, R., 137 Pukkala, E . , 156 Pulvirenti, L . , 105 Pyczynski, S., 2 1 0 Q u a d a g n o , D., 364 Quesada, J . R., 341 Quick, J . , 5 2 2 Quick, R. E . , 44 Quiles, J . , 2 6 5 Quine, L . , 66 Quinn, E. P., 110 Quinsey, V. L . , 3 6 0 Rabe-Hesketh, S., 2 3 5 Rabkin, J . G., 3 9 0 , 3 9 1 , 3 9 2 R a c i o p p o , M . W., 62 Raczek, A. E . , 3 3 2 Raczynski, J . M . , 2 5 9 , 5 0 4 Radcliffe, Κ. Α., 105 Radley, Α., 32 Radzius, Α., 102 Ragusea, S. Α., 5 0 7 Rahe, R., 173 Raikkonen, K., 2 5 5 Raine, Α., 87 Rajfer, J . , 368 Ramsden, V., 2 6 2 Rand, C , 2 0 8 R a n d , C . S., 208 R a n d , L. I., 306 Randall, R., 32 Rankinen, T., 128 R a o , Κ. N., 86 R a o , S., 24 Rapkin, A. J . , 4 7 7 R a p o p o r t , A. M . , 2 3 6 Rapoport, L., 258 R a p o p o r t , Y., 3 2 7 , 3 3 2 , 3 3 7 R a p p , S., 329 R a p p , S. R., 208 R a p p a p o r t , Ν . B., 150 Rasanen, P., 8 7 Rask, K. J . , 2 6 5

Name Index Ratcliffe, Μ . Α., 334 Rather, B. C , 88 Ravussin, E . , 129, 154 Rawling, P. J . , 315 Ray, N . F., 303 Raybould, Η. E . , 4 1 1 R a y m o n d , S. Α., 2 4 1 Raynor, W. J . , 333 R e a d , N . W., 3 9 9 Redd, W. H . , 3 3 0 Redding, C . Α., 3 3 0 Reed, C. S., 5 2 5 Reed, D . M . , 3 3 2 Reeves, R. Α., 2 5 6 Reeves, S., 3 7 Regan, P. C , 3 6 0 Regimbeau, C , 4 1 2 Reheiser, E. C , 106 Reid, J . , 3 0 6 Reid, J. B., 91 Reinert, D. F., 199 Reisin, E . , 2 5 9 Reiss, D., 3 3 6 Reiter, J . , 137 Reitsma, A. M . , 5 1 6 Rejeski, W. J . , 157, 158, 162 Relman, A. S., 5 2 5 Resch, F., 4 7 9 Resnick, H . , 3 4 1 Resnick, Η . E . , 3 1 0 Resnick, M . , 192 Resnicow, K., 44, 62 Réthelyi, J . M . , 4 7 7 Reus, V. I., 103 Revenson, Τ. Α., 3 3 1 Revenstorf, D., 5 3 2 Reynard, A. M . , 4 9 0 Reynolds, P., 3 3 5 Reynolds, W. M . , 23 Rho, J . P., 4 9 0 Rhoads, K., 290 Rhyne, C , 192 Riba, M . B., 30 Ribisl, P. M . , 2 0 8 Ricciardelli, L . Α., 88 Rich, M . , 4 Rich, Μ . Α., 2 3 0 Rich, M . W., 288 Richards, K. J . , 127 Richardson, H . , 3 3 5 Richmond, M . , 106 Richter-Heinrich, E . , 2 6 2 Richter, J . E . , 2 8 1 Richter, S., 368 Rickels, K . , 4 7 7 , 478 Ridker, P. M . , 2 8 0 Rifai, N., 2 8 0 Rifkin, Α., 4 8 8 Riggs, B. L . , 4 9 0 Riley, J . F., 243

Riley, J . L . , 2 3 1 Rimer, E. T., 3 2 6 R i m m , Α. Α., 151 Rincon, J . , 156 Riner, W., 128 Ringdall, G. I., 3 3 1 Ringel, Α., 368 Rios, Α., 3 4 1 Rischmann, P., 3 6 0 Riskind, J . H . , 2 3 1 Rita, H . , 332 Ritter, S., 104 Ritterband, L. M . , 60, 316 Rivara, F. P., 4 2 , 62 Rivera, M . , 2 6 5 Rivera-Meza, B. L . , 106 Rizvi, K . , 368 Robbins, R. Α., 2 4 0 Robins, L. N . , 3 5 9 Robinson, J. H . , 102, 106 Robinson, M . D., 114 Robinson, M . E . , 2 3 1 , 2 3 2 , 2 4 0 Robinson, T. E . , 8 5 , 103, 104, 1 0 5 , 107 Robison, J . , 23 Robles, T. F., 66 Rochester, C . L . , 153 Rockhold, R. W., 2 5 5 Rodin, G. M . , 309 Rodriguez, B., 4 6 1 Rodriguez, H . S., 86 Rodriguez, L. A. G., 398 Roehling, M . V., 128 Roehrich, L . , 88 Rogentine, G. N . , 3 3 1 Rogers, C . R., 4 8 , 92 Rogers, J . C . , 34, 2 4 4 Rogers, J . L . , 183 Rogers, L. K., 5 3 1 Rogler, L. H., 110 Rohan, K. J . , 4 7 6 Roland, M . , 2 3 8 Rolf, C . A. M . , 2 4 2 Rollnick, S., 4 2 - 5 1 , 62, 1 1 1 , 197, 199, 2 0 2 , 2 1 2 Romano, J . M., 234, 239 R o m a n s - C l a r k s o n , S. E . , 4 7 9 Ronalds, C. M . , 4 7 7 Roose, S., 360 R o o s e , S. P., 368 Root, M . P. P., 4 7 4 R o s a m o n d , W. D., 4 6 0 R o s a s , M . , 106 R o s e , J . E . , 104, 107 Rosen, E. C . , 3 6 2 , 3 6 5 Rosen, J . C . , 137, 138 Rosen, R., 3 6 0 Rosen, R. C , 3 6 7 , 368 Rosenfeld, B., 329 Rosenman, R. H . , 2 7 9 , 2 8 8 Rosenstiel, A. K . , 2 3 9 , 4 1 0 Rosenstock, I. M . , 2 1 1 , 2 1 2

559

560

T H E HEALTH PSYCHOLOGY HANDBOOK Rosenthal, R., 531 Rosenthal, T. L . , 2 8 9 Rosin, R., 3 3 7 Roski, J . , 88 Rosner, B., 2 6 0 Rosomoff, H . , 2 3 4 , 2 4 1 Rosomoff, R. S., 2 4 1 R o s s , S. L . , 315 Rossi, J . S., 3 3 0 Rossi, P. H . , 5 2 5 Rossner, S., 136 Rostaing, L . , 360 Roter, D. L . , 63, 64, 2 1 4 , 2 1 5 , 2 6 5 Roth, S., 5 9 , 4 7 9 Rounsaville, B. J . , 65 Rouse, D., 2 3 2 Rowe, J . W., 4 5 9 , 4 8 5 Rowland, D. L . , 3 6 9 Rowland, J . H . , 331 Rowland, M . , 3 1 0 Rozanski, Α., 2 8 6 Rozensky, R. H . , 6, 10, 11 Rubel, E. C , 51 Rubin, Ε. H . , 308 Rubin, R. R., 306, 3 0 8 , 3 0 9 , 310, 3 1 3 , 3 1 5 , 3 1 6 , 318 Rudy, T. E . , 2 3 1 , 238 Ruff, G. Α., 4 7 9 Ruffin, R. E . , 4 8 8 Ruigozmez, Α., 398 R u m m a n s , Τ. Α., 2 8 2 Ruof, J . , 368 Rush, Α., 4 1 1 Rush, A. J . , 64 Ruskin, J . N., 2 8 2 Rusktailis, M . , 4 7 6 Rutter, D. R., 66 Ryan, J . J , 2 2 Ryden, M . B., 4 9 3 Ryff, C. D., 4 5 9 Ryujin, D . H . , 458 Rzepski, B., 399 Sabourin, S., 4 7 8 Sacks, F. M . , 2 5 9 Sadock, B. J . , 4 7 5 Saelens, Β. E . , 148 Salbe, A. D., 154 Salin-Pascual, R. J . , 106 Salkovskis, P., 4 7 6 Salles, C . , 2 2 Sallis, J . F., 148, 162, 2 0 9 Sallis, J . , J r . , 3 Salmon, D., 2 8 , 36, 37 Salonen, J . T., 2 5 4 Salvadori, C . , 364 Salzman, C . , 192, 4 9 0 Samet, J . M . , 3 3 5 Sammons, M., 507 Samson, J . Α., 310 Samuel-Hodge, C. D., 3 1 0

Sanchez, R. Α., 368 Sanchez-Reyes, L . , 136 Sanderson, R. S., 138 Sandler, R. S., 3 9 9 Sandy, J . M . , 88 Sannibale, C , 80 Santor, D., 2 3 2 Santos, Α., 32 Santos, J . , 4 9 0 Sarason, I. G., 177 Saris, W. Η. M . , 148 Sarramon, J . P., 3 6 0 Sarwer, D. B., 137, 138, 2 5 8 Satariano, W. Α., 3 3 5 Saudek, C . D., 315 Saunders, R., 128 Saunders, R. D., 2 3 4 Savidge, C . J . , 478 Schaefer, C . , 177 Schafer, E . , 59 Schafer, M . , 4 7 9 Schafer, R. B., 59 Schaffner, L . , 331 Scharff, D. E . , 365 Scharff, L . , 4 0 4 , 4 0 5 , 4 1 4 , 5 2 0 Scheidt, S., 2 8 0 Scheier, M . F., 331 Schein, R. L . , 153 Schiavi, R. C . , 3 0 6 , 3 5 9 , 3 6 4 Schillaci, G., 2 5 7 Schipperheijn, J . M . , 4 7 5 Schlecte, J . Α., 4 7 6 Schlesinger, H . J . , 458 Schmaling, Κ. B., 44 Schmid, C . H . , 63 Schmidt, M . , 2 0 Schmidt, P., 334 Schmidt, U., 4 7 7 , 4 7 8 Schmidtke, Α., 4 7 9 Schnack, B., 4 7 9 Schneekloth, T., 14 Schneider, M . , 3 6 9 Schneider, R. H . , 2 6 2 Schnoll, S. H . , 199, 4 7 1 Schoeller, D. Α., 129 Schoenborn, C.A., 147 Schofield, W., 4 Schoicket, S. L . , 4 3 2 Schonfield, J . , 3 3 1 Schover, L. R., 3 6 0 , 369 Schreiner-Engel, P., 3 0 6 , 3 6 4 Schroeder, C , 36, 6 7 , 68 Schuckit, Μ . Α., 83, 88 Schueler, G., 3 3 4 Schulberg, H . , 64 Schulberg, H . C , 64, 6 5 , 66 Schuld, V., 4 7 9 Schulman, Β. Α., 2 1 5 Schultheis, K . , 2 4 1 Schultz, J . H . , 179

Name Index Schulz, R., 59, 3 4 5 , 4 9 2 Schuster, J . M . , 30 Schuster, M . M . , 4 0 1 , 4 0 5 Schwartz, G. E . , 56, 180, 2 1 0 Schwartz, I., 3 3 7 Schwartz, M . F., 3 6 5 Schwartz, S., 33 Schwartz, S. M . , 2 8 1 , 2 8 2 , 2 8 5 Schwarz, S. P., 4 0 5 , 4 0 9 Schwebel, A. I., 2 3 9 Sciolla, Α., 3 9 2 , 393 Scollay, J . , 516 Scott, F. B., 369 Seaberg, E. C . , 4 8 9 , 4 9 0 Sears, S. F., 2 8 2 Seeber, M . , 365 Seeley, J . R., 4 9 3 S e e l y , J . F., 493 Seeman, A. Z . , 87 Seeman, M . , 8 7 Seeman, T., 4 5 9 Seeman, T. E . , 4 5 9 S E E R Program, 3 2 5 Sees, K. L . , 103 Seevers, M . H . , 83 Sega, R., 151 Segraves, R. T., 3 5 9 Seibert, S., 192 Seidel, K. D., 129 Seidman, S. N . , 3 6 0 , 368 Seime, R. J . , 11 Selby, V., 2 4 1 Selenta, C . , 2 5 6 Self, D. W., 85 Sellschopp, Α., 336 Seltzer, M . L . , 24 Semet, C . , 4 7 4 Serdula, M . , 126 Servaes, P., 334 Severson, Η. H . , 102 Severson, K . T., 329 Sevick, Μ . Α., 208 Sewell, M . C . , 3 9 2 Sexton, M . M . , 5 0 4 Seydel, E . R., 62 Shabsigh, R., 368 Shaked, S., 3 3 1 , 3 3 7 Shaked, T., 3 3 1 Shalev, M . , 368 Shaper, A. G., 151 Shapiro, A. P., 2 6 2 Shapiro, D., 56 Shapiro, M . E . , 368 Shapiro, P. Α., 288 Shapiro, R. M . , 2 1 4 Shapiro, Y., 157 Sharkansky, E. J . , 86 Sharpe, L., 2 4 2 Sharpe, P. Α., 3 0 9 Shatford, L. Α., 4 7 8

Shaw, B., 4 1 1 Shaw, B. F., 64 Shea, S., 2 6 5 Shearer, E . C . , 4 7 0 Sheehan, D. V., 2 9 3 Sheftell, F. D., 2 3 6 Sheikh. J . , 4 9 3 Sheiner, L. B., 102 Shekelle, R. B., 333 Sheldrick, R. C . , 5 3 1 Shelton, B. J . , 399 Shelton, D. R., 3 3 5 Shenenberger, D. W., 368 S H E P Cooperative Research G r o u p , 2 1 6 Shepherd, M . D . , 368 Sher, K. J . , 83, 86 Sherbenou, R. J . , 2 2 Sherbourne, C . D., 4 1 1 Sherman, J . E . , 103 Sherman, J . H . , 2 5 4 Sherwood, Α., 6 1 , 152 Shiffman, S., 103, 104, 1 1 1 , 2 8 1 Shifren, J . L . , 3 6 0 Shirai, M . , 368 Shires, Α., 3 6 0 Shnidman, S. R., 56 Shows, W. D., 8 Shuster, E . , 5 1 5 Shutty, M . S., 2 3 8 , 2 3 9 Sidwa, Η. K., 398 Siegal, W. C , 152 Siegel, B. S., 3 3 6 Siegel, J . M . , 88, 177 Siegel, W. C , 2 6 1 Siegelaub, A. B., 2 6 0 Siegrist, B., 336 Sigmon, S., 4 7 7 Sigmon, S. T . , 4 7 6 Sikkema, K. J . , 389 Silberstein, S. D . , 189 Silva, F., 528 Silva, P. Α., 4 7 0 Silverman, D. H . , 4 0 3 Simkin-Silverman, L. R., 133, 2 5 8 Simon, Κ. M . , 2 1 0 , 2 1 1 Simon, R., 4 7 2 Simpson, K., 3 0 7 Singer, B., 4 5 9 Singer, Β. H . , 4 5 9 Singh, B. S., 188 Sinha, R., 87 Sipski, M . , 3 6 0 Sivan, A. B., 2 0 Sjôstrôm, L . , 136, 137 Skillman, T . G., 4 8 9 Skinner, B. F., 2 1 0 Skinner, H . , 2 1 3 Skinner, Η. Α., 199 Skjorshammer, M . , 3 7 Skrabski, Α., 4 7 0 , 4 7 5

561

562

I

T H E HEALTH PSYCHOLOGY HANDBOOK

Skrinar, Α., 2 1 3 Slade, P., 4 7 7 , 4 7 8 Slaughter, J . R., 3 6 2 , 4 8 9 Slaven, L . , 4 7 2 Slavin, L . , 3 3 1 Slawsby, Ε. Α., 2 4 1 Slob, A. K., 368 Small, M . P., 368 Small, S. D., 32 Smedley, B. D., 4 5 6 , 4 5 8 Smerieri, Α., 491 Smets, Ε. Μ . Α., 343 Smit, B. J . , 4 7 1 Smit, E . , 161 Smith, Α., 4 8 5 Smith, A. P., 176 Smith, C . M . , 4 9 0 Smith, D. E . , 4 4 , 83, 89, 197 Smith, D. H . G., 2 5 7 Smith, G. R., 2 3 5 Smith, G. T., 88 Smith, H . , 306 Smith, S. J . , 63, 2 3 2 Smith, S. S., 112 Smith, T. L . , 88 Smith, T. W., 5 5 , 57, 69, 2 3 9 Smolak, L . , 127, 129 Sneeuw, K. C. Α., 3 4 0 Snellgrove, C. Α., 368 Snowden, L. R., 4 5 8 Snyder, P. J . , 2 0 Sobel, H . J . , 3 4 2 Sobell, L. C . , 5 1 , 92, 5 2 1 , 5 2 8 , 533 Sobell, M . B., 92, 5 2 1 , 5 2 8 , 533 Sobol, A. M . , 127 Society for Research on Nicotine and T o b a c c o Subcommittee on Biochemical Verification, 110, 111 Solomon, Α., 493 Sommer, I. E. C . , 4 8 7 Sommerfeld, Β. Κ., 106 Sondheimer, S. J . , 4 7 7 Sonino, N., 2 5 4 Sonksen, J . , 368 Sotile, W., 2 8 2 Sourkes, B. M . , 345 Sovereign, R. G., 4 5 Soyka, M . , 4 7 9 Spangler, J . G., 368 Sparrow, D., 2 8 9 Spector, I. P., 3 5 9 , 3 6 5 Spector, S. L . , 2 1 7 Spector, T. D., 155 Spelsberg, Α., 3 0 5 Spence, J . D., 2 6 2 Spence, S. H . , 2 4 2 Spiegel, D., 5 9 , 6 5 , 67, 3 3 6 , 3 4 5 , 346 Spielberger, C. D., 106, 108, 177, 4 1 1 Spira, J . L . , 5 9 , 3 4 5 Spitzer, R. L . , 110, 4 1 1

Sprafkin, J . N., 2 8 5 Spring, B., 106, 108, 128 St-Pierre, S., 136 Staats, N., 4 9 4 Stacey, B. R., 243 Stafford, M . , 213 Stallings, V. Α., 129 Stamler, J . , 2 5 9 Stamler, R., 2 5 2 , 2 5 8 , 2 5 9 Stampler, F. M . , 4 7 7 Stanish, W., 2 3 2 Starks, H . E . , 329 Starkstein, S. E . , 4 8 7 Stason, W., 5 0 4 Stavraky, K . M . , 3 3 5 Steckel, S. B., 2 1 4 Steed, L . , 23 Steele, C. M . , 83 Steele, R., 2 3 4 Steer, R. Α., 2 3 , 177 Steers, W., 368 Steger, H . G., 2 3 7 , 2 4 0 Stein, L., 104 Stein, M . B., 2 3 , 34 Steinberg, C . , 2 5 8 Steinberg, T. F., 3 0 6 Steinglass, P., 336 Stennie, K., 192 Stern, M . , 393, 504 Sternberg, J . Α., 131 Stetson, Β. Α., 2 9 2 Stevens, C. F., 105 Stevens, J . , 126 Stevens, V. J . , 2 5 8 , 4 6 0 Stewart, A. L . , 4 1 1 Stewart, J . , 87 Stewart, K . J . , 2 6 1 Stewart, Μ . Α., 2 1 5 , 3 3 5 Stewart, P., 478 Stewart, R. C . , 366 Stewart, W., 2 3 5 Stith, A. Y., 4 5 6 Stitzer, M . L . , 114 Stockwell, D. H . , 2 6 5 Stoddart, G. L . , 5 0 5 Stoeckle, J . D., 2 1 3 Stoehr, G. P., 4 9 0 Stoever, W. W., 2 8 9 Stoleru, S., 3 6 0 Stone, G. C . , 2 1 5 , 4 4 4 Stone, N . J . , 2 5 7 , 2 5 8 Story, M . , 128 Stossel, C . , 63 Stott, H . D., 113 Stoyva, J . M . , 179 Straatmeyer, A. J . , 3 1 5 Strain, J . J . , 3 0 Strassberg, D. S., 366 Strassels, S., 398 Strecher, V. J . , 61

Streissguth, A. P., 80 Striepe, M . I., 5, 6 Strohschein, L . , 4 7 4 Strosahl, K., 5 1 7 Stroud, M . W., 2 3 2 , 2 3 9 Strumpf, M . , 2 4 1 Strupp, H . H . , 89 Stuart, R. B., 56, 134 Stuart, S., 6 7 Stulp deGroot, C . , 34 Stunkard, A. J . , 127, 129, 131 Sturgis, E. T., 183 Sue, S., 458 Sullivan, M . , 3 2 9 Sullivan, M . D., 2 3 5 Sullivan, M . E . , 2 3 2 Sullivan, M . J . L . , 2 3 1 , 2 3 2 , 2 3 9 Sullivan, P. F., 127 Suis, J . , 2 4 0 Suis, J . M . , 4 0 5 Sumartojo, E . , 2 1 7 Summerson, J . H . , 368 Sung, Β. H . , 2 5 4 Sung, J . C . , 191 Supnick, J . Α., 110 Surtees, P. G., 3 3 5 Surwit, R. S., 64, 3 0 7 , 3 1 5 Sutherland, G., 113, 114 Sutlief, S., 3 6 0 Sutton, A. J . , 155 Suzuki, Y., 2 5 7 Swain, M . S., 2 1 4 Swan, G. E . , 106, 2 6 2 Swann, C. P., 364 Swanson, G . M . , 3 3 5 Swanson, R., 193, 194, 198 Sweet, J . J , 6, 10 Swencionis, C . , 2 5 9 Swingen, D. N., 3 6 4 Sydeman, S. J . , 177 Szedmâk, S., 4 7 5 Szklo, M . , 332 Tache, Y., 4 0 4 Taenzer, P., 2 6 2 T a k e d a , Κ., 2 5 5 Takeuchi, D. T., 4 5 8 T a k i m o t o , Y., 368 Talajic, M . , 4, 64, 2 8 8 , 5 0 4 Talbot, F., 3 0 9 Talley, N . J . , 3 9 8 , 399, 4 0 0 , 4 0 6 , 4 0 9 , 4 1 4 T a l p a z , M . , 341 Tarn, S. W., 368 T a n , S., 2 6 6 T a n g , T. S., 4 5 7 Tantleff-Dunn, S., 127 Tapert, S. F., 5 0 4 Taplin, S. H., 44 Tarter, R. E . , 86 Tataranni, P. Α., 129

Tataryn, D., 3 2 9 T a t e , R., 4 7 1 T a u b , E . , 398 T a u b , K. J . , 309 Taverner, D., 191 Taylor, C . B., 214, 2 6 2 Taylor, M . , 14 Taylor, R. R., 2 3 6 , 2 3 7 Taylor, S. E . , 2 1 4 Taylor, V. M . , 4 6 1 Teesson, M . , 34 Tekdogan, U. Y., 368 Tellegen, Α., 108 T e m o s h o k , L . , 3 3 1 , 333 Ten Have, T. R., 310 Tennant, C. C . , 4 0 5 Tennen, H . , 2 3 2 Terestman, N., 3 6 4 Teri, L . , 4 9 0 Terzano, M . G., 4 9 1 Thadhani, R., 2 6 0 Thamer, M . , 303 Theorell, T., 3 3 2 , 4 7 3 , 4 7 4 Thevos, A. K., 44 Thoits, P. Α., 4 7 3 T h o m a s , F. B., 4 8 9 T h o m a s , K. C , 4 5 8 Thomas, M. E., 456 T h o m p s o n , J . K., 127, 129, 137 T h o m p s o n , Κ. M . , 88 T h o m p s o n , R., 64 T h o m p s o n , W. G., 4 0 0 , 4 0 9 T h o m s o n , J . B., 8 3 , 84 T h o m s o n , Μ . Α., 2 1 0 Thoresen, C . J . , 32 Thorn, Β. E . , 2 3 0 , 2 3 1 , 2 3 2 , 2 3 9 , 2 4 3 , 2 4 5 Thune, I., 156 Tideiksaar, R., 4 9 0 Tiefer, L . , 3 6 0 Tiffany, S. T., 103, 107 Tiihonen, J . , 8 7 Tilley, B. C . , 3 3 5 Timm, G. W., 3 6 9 Tindale, R. S., 128 Tinetti, M . E . , 4 9 0 Tipp, J . E . , 83 Tissingh, G., 4 8 7 Tobert, Α., 306 Tobin, D. R., 4 9 5 T o d a r o , J . F., 2 8 2 T o d d , T., 31 Tollison, C . D., 3 6 7 Tomkins, S., 108 T o n a , F., 2 5 4 Toobert, D. J . , 3 1 5 , 3 1 6 Toomey, T. C., 477 Topitz, Α., 4 7 1 Torgerson, J . S., 137 T o r g r u d , L . J . , 127 Torre, T., 368

564

T H E HEALTH PSYCHOLOGY HANDBOOK Torrence, G. W., 505 Torres, D., 2 6 5 Toscani, M . R., 533 Toth, S., 188 Tovian, S. M . , 6 Townley, M . , 4 2 6 Tracy, J . I., 103 T r a s k , P. C , 2 8 1 , 298 Trauer, T., 28 Treasure, J . L . , 44 Treiber, F. Α., 253 Tremblay, Α., 136 Trials of Hypertension Prevention Collaborative Research G r o u p , 2 6 2 Triandis, H . C , 2 1 1 , 2 1 2 Trief, P. M . , 307, 310 Trigwell, P., 44 Tripp, D., 2 3 2 Tripp, D. Α., 2 3 2 Trotman, F., 4 9 5 Troughton, E . , 84 T r u a x , P., 5 3 2 Trull, T. J . , 86 Tryba, M . , 2 4 1 Tryon, W. W., 110 Trzepacz, P. T., 343 T s o h , J . Y., 103 Tsuang, J . W., 83 Tsuang, M . T., 80 Tsujimura, Α., 368 Tu, Χ., 426 Tucker, G. J . , 3 4 0 Tucker, J . Α., 105, 5 0 2 , 5 0 3 , 5 0 4 , 5 0 6 , 508 Tulin, M . , 4 0 2 Tuomilehto, J . , 311 Turcotte, Ν., 86 Tureck, R., 4 7 8 Turk, D. C , 2 1 6 , 2 2 9 , 2 3 1 , 2 3 8 , 2 4 0 , 241, 243, 244 Turkinton, R. W., 316 Turnbull, J . E . , 4 7 5 Turner, J . Α., 2 3 4 , 2 3 9 , 2 4 0 Turner, S., 365 Turnock, B. J . , 503 Tursky, B., 56 Tuxen, M . K., 341 Tweedy, D., 6 1 , 152 Twentyman, C. T., 2 1 4 Tylko, S. J . , 4 9 0 Tyrrell, D. A. J . , 176 Uddenberg, N., 369 Uhlenhuth, Ε. H . , 4 2 5 Ujimoto, V. K., 4 5 9 U.K. Trial of Early Detection of Breast Cancer G r o u p , 3 3 0 Ulmer, D., 293 Unterberger, H . , 43 Urban, J . P. G., 155 Urrows, S., 2 3 2

U.S. Department of Agriculture, 101 U.S. Department of Health and H u m a n Services ( D H H S ) , 1 0 1 , 104, 146, 155, 162, 3 1 3 , 4 5 6 , 475, 503, 510 U.S. National Commission for the Protection of H u m a n Subjects of Biomedical and Behavioral Research, 5 1 5 - 5 1 6 Ustiin, B., 82 Vaccarino, A. L . , 4 0 3 V a g g , P. R., 177 Valach, L . , 3 3 1 Valansia, P., 3 1 0 Valdez, Α., 4 6 1 Valdimarsdottir, Η. B., 3 3 9 , 3 4 0 Valenti, S. Α., 2 6 1 Valoski, Α., 59 van Berlo, W., 3 6 0 V a n den Broek, Α., 2 3 2 Van Der Kolk, B., 4 7 9 Van der Ploeg, H - M . , 3 3 4 Van Doudenhove, B., 2 3 2 Van Dyke, C , 343 Van Eeeden, Α., 4 0 2 Van Egeren, L . , 5, 6 van Elderen, T., 63, 288 van G o r p , W., 393 Van Horn, M . , 5 2 5 van Kippenberg, F. C . E . , 343 Vander, A. J . , 2 5 4 VanHoudenhove, B., 177 VanHuis, A. M . , 4 7 1 Vanltallie, T. B., 126, 128, 130, 134 Varady, Α., 103, 111 Vardi, Y., 368 Varner, M . W., 4 7 6 Vasey, M . W., 2 3 1 Vaughan, C , 4 2 5 , 4 3 8 Vellas, B., 4 9 1 Venkataramana, V., 86 Venner, R. M . , 238 Ventralla, Μ . Α., 183 Venturini, F., 191 Verbrugge, L . M . , 4 7 4 Verdecchia, P., 2 5 6 , 2 5 7 Verhulst, J . , 3 6 4 , 3 6 5 Vernon, M . , 4 8 6 Vernon, S. W., 335 Veronen, L. J . , 4 7 9 Vessey, J . T., 5 3 1 Vetter, H . , 3 3 4 Vetter, V. Α., 4 4 6 Vgontzas, A. N . , 172 Viera, A. J . , 368 Vietorisz, D., 306 Vihko, V., 156 Villeponteaux, L . Α., 4 7 9 Vingerhoets, Α., 3 3 4 Vinicor, F., 127 Visser, A. P., 339

Name Index Vitolins, M . Z . , 2 0 8 , 2 1 7 Vlaeyen, J . W . S., 2 3 1 Vogeltanz, N . D., 4 7 7 Vogt, O., 179 Vogt, R. Α., 137, 138 Vogt, T. M . , 3 3 5 Vollmer, W. M . , 2 5 9 Volpicelli, J . R . , 197 Von Bertalanffy, L . , 56 Von Korff, M . , 2 2 9 , 2 4 4 , 3 9 7 Vreugdenhil, G., 3 3 4 Vuchinich, R. E . , 105 Waddell, G., 2 3 8 Wadden, Τ. Α., 6 2 , 127, 130, 1 3 1 , 134, 137, 138, 153, 258 Wade, D . T . , 4 8 9 Wade, T. C , 2 1 4 Wagener, D. K., 4 5 6 Wagner, Ε. H . , 6 1 , 5 0 4 Wahl, P. W., 4 9 1 Waitzkin, H . , 213 Wakefield, P., 5 Wald, T. G., 3 4 1 Waldinger, M . D., 3 6 0 Walker, L . G., 3 3 4 Walker, M . , 151 Wall, P. D., 2 3 0 , 4 0 4 Wallace, J . I., 329 Wallace, M . , 4 9 2 Wallberg-Henriksson, H . , 156, 157 Wallen, K., 3 6 4 Waller, S., 3 1 5 Wanner, K., 3 6 0 Wallston, Κ. Α., 3 3 4 Walschlager, S. Α., 153 Walser, R. D . , 3 6 0 Walsh, M . J . , 85 Walsh, W. P., 3 3 5 Walsleben, J . Α., 4 2 9 Walter, S. D., 3 3 6 Walters, V., 4 7 4 Walton, V. Α., 4 7 9 Waltz, J . , 5 3 0 Wampold, Β. E . , 90 Wan, C. K., 2 4 0 Wang, C . Y., 308 Wang, G., 155, 156 Wang, T., 4 4 Wannamethee, S. G., 151 Wansley, R. Α., 2 8 9 Ward, C. L . , 2 2 Ward, J . R., 2 3 9 Ward, L. C . , 2 3 2 Ward, M . M . , 106, 2 6 2 Wardle, J . , 2 5 8 Ware, J . E . , 3 3 2 , 4 1 1 Warnock, J . , 28 Washburn, R. Α., 148, 149 Watkins, S. S., 104, 105

Watson, M . , 3 3 2 , 3 3 4 , 3 3 7 Watson, V., 4 9 2 Watt, G. C . , 2 5 4 Waxier-Morrison, N . , 3 3 5 Waylonis, G. W., 2 3 6 Weaver, Μ . Α., 2 4 0 Weber, Μ . Α., 2 5 7 Webster, J . , 125 Wedding, D . , 19 Wei, M . , 1 4 7 Weihs, K., 3 3 6 Weinberger, M . H . , 2 5 9 Weiner, D . W., 3 6 1 Weinstein, M . , 5 0 4 Weinstock, A. M . , 3 3 0 Weinstock, R. S., 3 0 7 Weisberg, R. B., 3 6 0 Weisman, A. D., 3 3 1 , 3 3 4 , 3 4 2 Weisman, C . S., 4 6 9 Weiss, J . N . , 3 6 7 Weiss, R. D., 188 Weiss, S. M . , 2 1 0 Weiss, S. T., 2 8 9 Weissler, K . , 327, 3 3 0 Weissman, M . M . , 6 5 Welgan, P., 4 0 4 Wellisch, D . K . , 3 4 0 Welsch, S. K . , 107 Wensloff, N . J . , 3 0 7 Wentworth, D., 2 5 2 Wenzel, Α., 6 7 Werner, P., 4 9 2 Wessells, H., 368 Wessely, S., 2 3 5 Wesson, D. R., 197 West, R . , 103, 106 Wewers, M . E . , 1 0 7 Whelton, P. K . , 2 5 2 , 2 5 9 , 2 6 0 , 4 6 0 Whitaker, R . C . , 129 Whitbourne, S., 4 8 6 Whitcher-Alagna, S., 2 1 5 White, A. W., 35 White, J . Α., 155 White, J . M . , 191 White, L . C . , 3 6 5 White, M . H . , 3 3 9 Whitehead, W. E . , 3 9 8 , 3 9 9 , 4 0 0 , 4 0 1 , 404, 405, 406, 409 Whitmore, B., 2 5 9 Whittle, G. C . , 4 7 7 Whorwell, P. J . , 3 9 8 , 4 0 3 , 4 1 4 Wiebe, D. J . , 3 0 7 Wilkie, Α., 4 7 7 , 4 7 8 Williams, D., 4 5 6 Williams, D. Α., 6 2 , 2 3 8 , 2 3 9 , 2 4 1 Williams, D . E . , 2 8 2 Williams, D. M . , 2 6 2 Williams, D . R., 4 5 6 Williams, J . , 4 1 1 Williams, J . B. W., 110

565

566

T H E HEALTH P S Y C H O L O G Y HANDBOOK Williams, M . H . , 192 Williams, N . L . , 231 Williams, R., 5 Williams, R. J., 88 Williamson, E. C , 107 Wills, Τ. Α., 88, 473 Wilsnack, S. C , 4 7 7 Wilson, G. T . , 134, 136 Wilson, J . D., 2 5 4 Wilson, J. R., 84 Wilson, M . F., 2 5 4 Wilson, P. H . , 3 1 5 Wilund, K. R., 2 6 1 Wincze, J. P., 3 5 9 , 3 6 0 , 3 6 2 Winders, S. E . , 107 Winefield, A. H . , 32 Winefield, H . R., 3 2 , 35 Wing, R. R., 59, 63, 133, 154, 2 5 8 , 3 0 5 , 3 1 9 Winger, C , 4 0 6 Wirth, Α., 136 Wise, C. D., 104 Wise, R. Α., 104 Wittchen, H-U., 22 Witteman, J . C , 2 6 0 Wofford, A. B., 9 Wolf, M . , 5 3 2 Wolf, S., 369 Wolfe, F., 2 3 6 Wolfe, V. Α., 433 Wolinsky, F. D., 4 9 0 Wolpe, J., 179 Wolters, E . C . , 4 8 7 Womble, L. G., 127 Wong, F. S., 4 9 0 Wong, P. T. P., 4 5 9 W o o d , T. M . , 148 Woodall, K. L . , 2 5 3 Woods, N., 472 W o o d s , N . F., 4 7 1 Wooley, S., 4 0 6 Woolfolk, R. L . , 173, 177 Wooten, G. F., 4 8 7 Worcel, M . , 368 Worden, J. W., 3 3 1 , 3 3 4 , 3 4 2 World Bank, 4 7 8 World Health Organization, 128, 154, 2 0 9 , 5 0 6 Worthman, C . W., 4 7 5 Wright, E . , 153 Wright, Ε. M . , 213 Wright, F. D., 90 Wright, J. Α., 129, 478 Wright, M . , 30, 33

Wright, V., 155 Writing G r o u p for the Activity Counseling Trial, 62 Wulsin, L . , 306 Wyllie, M . , 368 Wysocki, T., 304, 313 Xin, X . , 2 6 0 Yaeger, A. M . , 88 Y a l o m , I., 6 7 Y a m a b e , H . , 253 Y a m o r i , Y., 253 Yan, S., 398 Yancey, A. K., 88 Yanduli, V., 44 Yanek, L. R., 4 6 0 Yasco, J., 345 Y a s k o , J . , 59 Yates, B. T., 526 Yehuda, R., 3 4 1 Yelin, E . , 155 Yellowlees, P. M . , 4 8 8 Ying, Y., 4 5 8 Yohannes, A. M . , 4 8 8 Y o k o t a , F., 88 Young, B., 310 Young, D. R., 2 6 1 Young, S. J., 105 Younger, J . , 4 8 9 Yuzpe, Α. Α., 4 7 8 Zanardi, C , 4 6 9 Zanchetti, Α., 151 Zarit, J . M . , 4 8 6 Zarit, S. H . , 4 8 6 Zauber, Α., 3 3 0 Z a u t r a , A. J., 59 Zayfert, C , 2 3 9 Zeiss, Α., 4 9 3 Zenz, M . , 2 4 1 Z h a n g , A. Y., 4 5 8 Z h a n g , P., 155 Zheng, D., 3 0 7 Ziegelstein, R. C , 2 1 5 Ziegler, F. J., 2 3 5 Zierath, J. R., 156 Zinner, S. H . , 3 6 6 Zinsmeister, A. R., 398, 3 9 9 , 4 1 4 Z o l a , 1. K., 2 1 9 Z o n d e r m a n , A. B., 3 3 5 , 4 0 5 Zurawski, R. M . , 2 6 2

Subject

Index

Note: References to tables or figures are indicated by italic type and the addition of "i" or "f," respectively. Abuse alcohol, 2 4 , 8 2 - 8 3 childhood, 4 0 5 - 4 0 6 of women, 4 7 8 - 4 7 9 Accelerometers, 1 4 8 - 1 4 9 A C E inhibitors, 295t Acoma-Canoncito-Laguna Adolescent Health Program, 4 6 0 Acquired Immune Deficiency Syndrome (AIDS). See AIDS Adaptation, to illness, 2 3 - 2 4 Adherence to medical recommendations, 2 0 8 - 2 1 9 behavioral science role in, 2 0 9 - 2 1 1 and cancer, 3 3 0 case study of, 2 1 8 - 2 1 9 definitions and descriptions of, 2 0 8 - 2 0 9 and diabetes, 313 and HIV, 3 8 8 - 3 9 0 and hypertension, 2 6 5 - 2 6 6 , 266t interventions for improving, 2 1 4 - 2 1 6 measurement of, 2 1 6 - 2 1 7 , 2 1 9 models for understanding, 2 1 1 - 2 1 4 in pediatric populations, 6 - 7 Adolescence, in women, 4 6 9 - 4 7 0 Adrenaline, 1 7 2 African Americans. See also Ethnocultural issues and church role in behavior intervention, 4 6 0 and hypertension, 2 5 2 , 2 5 3 , 2 5 9 , 2 6 0 and nicotine dependence, 1 0 7 and physical activity for hypertension, 1 5 2 research exploitation of, 5 1 5 Aged people. See Older adults Aging, 4 8 6 - 4 8 7 AIAI complex, 2 8 8 AIDS, 3 8 7 . See also H u m a n Immunodeficiency Virus cases of, by exposure and year of diagnosis, 385f cases of, by race/ethnicity and year of report, 384f common opportunistic infections of, 3 8 7 , 388t estimated incidence of, by sex and exposure, 386f Albany GI History, 4 0 9 Alcohol abuse, 2 4 , 8 2 - 8 3

Alcohol dependence, 8 0 - 8 2 Alcohol Expectancy Questionnaire, 88 Alcohol problems, 83 Alcohol use and coronary heart disease, 2 8 9 and hypertension, 2 5 9 - 2 6 0 and insomnia, 4 3 1 - 4 3 2 Alcohol Use Disorders Identification Test, 199 Alcoholism, 7 9 - 9 6 . See also Alcohol abuse; Alcohol dependence; Alcohol problems case study of, 9 4 - 9 6 characterologic factors in, 8 6 - 8 7 cognitive factors in, 8 5 - 8 6 definitions and descriptions of, 7 9 - 8 3 exogenous factors in, 8 7 - 8 9 genetic factors in, 8 4 - 8 5 psychological treatments for, 8 9 - 9 2 reinforcement and, 8 3 - 8 4 stages of change model and, 9 2 - 9 3 Alexithymia, 2 8 9 Alzheimer's Dementia Assessment Scale, Cognitive subscale, 2 1 Α Μ Α . See American Medical Association American Academy of Sleep Medicine, 4 3 6 American Board of Professional Psychology, 12 American College of Rheumatology, 2 3 6 American College of Sports Medicine, 1 4 7 , 2 6 0 American Diabetes Association, 3 1 1 American Heart Association, 1 3 1 , 2 5 3 American Lung Association, 2 3 7 American Medical Association (ΑΜΑ), 1 8 8 , 2 0 5 , 215, 237, 425, 430, 446 American Psychiatric Association, 1 9 2 American Psychological Association (ΑΡΑ), 12, 14-15, 446, 447, 454, 505, 507 American Society of Hypertension Ad H o c Panel, 2 6 5 Anger, and coronary heart disease, 2 8 8 Angina, 2 8 1 - 2 8 2

Annals of Behavioral Medicine, 15 Anorexia, and cancer, 3 4 2 Antiarrhythmics, 2 9 5 1 Anticoagulants, 2 9 5 i Antidepressant prescriptions, 17 Antilipidemics, 295t

567

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T H E HEALTH P S Y C H O L O G Y H A N D B O O K Anxiety and arrhythmias, 2 8 2 - 2 8 3 and cancer, 341 and chronic pain, 2 3 5 and coronary heart disease, 2 8 9 costs of untreated, 34 and diabetes, 3 0 8 , 3 1 8 and HIV, 3 9 2 - 3 9 3 stress and, 176 women and, 4 7 6 - 4 7 7 Anxiety Disorders Interview (ADIS-R), 4 1 1 ΑΡΑ. See American Psychological Association Appetite, of older adults, 4 9 1 - 4 9 2 Arrhythmias, 2 8 2 - 2 8 3 Arthritis. See Osteoarthritis Arthritis Foundation, 155 Ask-advise-assist-arrange model, for dependence treatment, 2 1 5 - 2 1 6 Assessment, 5 - 6 of cancer, 3 4 2 - 3 4 3 of chronic pain, 2 3 8 - 2 4 0 of coronary heart disease, 2 8 4 - 2 9 1 of diabetes, 3 1 1 - 3 1 2 ethical issues in, 4 4 5 - 4 4 6 health outcomes, 5 0 4 - 5 0 5 , 5 0 7 - 5 0 8 of hypertension, 2 5 5 - 2 5 7 of IBS, 4 0 7 - 4 1 1 in medical settings, 1 7 - 2 5 of medication-seeking behavior, 1 9 8 - 1 9 9 of nicotine dependence, 1 0 9 - 1 1 1 of obesity, 1 3 0 - 1 3 1 of physical activity, 1 4 7 - 1 5 0 and p r o g r a m evaluation, 5 2 7 - 5 2 8 of psychological disorders in H I V illness, 390-393, 395 of research, 5 2 0 of sexual dysfunctions, 361 of sleep disorders, 4 2 9 of social validity, 5 3 2 - 5 3 3 of stress, 177 Association for the Behavioral Sciences and Medical Education, 14 Atherosclerosis, 2 8 0 - 2 8 1 Australian Psychological Society, 3 1 , 33 Autogenic training, 179 Automated Reports and Consolidated Orders System ( A R C O S ) , 193 Automatic Nervous System, 1 7 1 . See also Central nervous system ( C N S ) Automatic Nervous System Questionnaire, 23 Back BDI. Beck Beck Beck Beck Beck Beck

pain, 2 3 6 - 2 3 7 See Beck Depression Inventory Anxiety Inventory, 23 Depression Inventory, 2 3 , 2 4 0 , 4 0 5 , 4 1 1 Hopelessness Scale, 23 inventories, 177 Scale for Suicide Ideation, 23 scales, 23

Bedford College Interview for Life Events and Difficulties, 177 Behavior change counseling, 4 6 - 4 7 Behavioral science. See also Psychosocial interventions and adherence behavior, 2 0 9 - 2 1 1 and interventions for ethnic disparities, 4 6 0 - 4 6 2 Benton Visual Retention Test, 2 0 Beta blockers, 295t Beta-Ill, 2 2 Better Outcomes for Mental Health (Australia), 31 Billing, for consultations, 11 Biofeedback, 1 7 9 - 1 8 0 Biopsychosocial model of illness, 5 6 - 5 8 and chronic pain, 2 3 0 - 2 3 2 , 2 4 3 - 2 4 4 clinical application of, Sit and ethnic differences, 4 5 9 - 4 6 0 and IBS, 4 0 6 - 4 0 7 and medication-seeking behavior interventions, 1 9 4 - 1 9 8 , 19Sf and nicotine dependence, 1 0 4 - 1 0 7 Blindness. See Visual impairment Blood pressure. See Hypertension BMI. See Body mass index Body, human. See H u m a n body Body image, 127, 1 3 7 - 1 3 8 Body mass index (BMI), 125, 126t, 130, 1 5 3 - 1 5 4 Bowels. See Irritable bowel syndrome B R E N D A approach, 197 Brief advice, 46 Brief Pain Inventory (BPI), 343 Brief psychotherapies. See Psychosocial interventions Brief Symptom Inventory (BSI), 3 4 2 , 4 1 1 Brief Visual Spatial M e m o r y Test, 2 0 Buproprion, 114 Caffeine, 2 5 4 - 2 5 5 , 4 3 1 C A G E (alcohol abuse screening measure), 24, 199 Calcium channel blockers, 295t California Personality Inventory, Socialization scale, 86 Canadian Medical Association, 2 6 1 , 2 6 2 , 4 2 5 , 4 3 0 Cancer, 3 2 5 - 3 4 8 assessment and treatment of, 3 4 2 - 3 4 6 , 348 case study of, 3 4 7 coping with, 3 3 0 - 3 3 2 crises and problems of, 3 2 6 - 3 2 9 , 3 4 3 - 3 4 4 diagnostic and etiological issues of, 3 4 0 - 3 4 2 and information transmission, 3 3 6 - 3 3 7 , 3 4 4 models of, 3 3 8 - 3 4 0 in older adults, 4 8 9 - 4 9 0 and physical activity, 156 prevention and screening of, 3 2 9 - 3 3 0 research in, 3 2 9 - 3 4 0 , 333t screening of ethnic minorities for, 4 6 1 - 4 6 2 treatment of, 3 2 7 - 3 2 8 Cancer Rehabilitation Evaluation System (CARES), 343 Cannon, Walter, 172 Cardiovascular disease and interventions for ethnic disparities, 460—461

Subject Index and physical activity, 1 5 0 - 1 5 1 stress and, 176 Catastrophic thinking, 2 3 1 - 2 3 2 , 4 1 0 C B T . See Cognitive-behavioral therapy C D C . See Centers for Disease Control and Prevention Center for Epidemiological Studies-Depression Scale (CES-D), 23 Center for Outcomes and Effectiveness Research and Education ( C O E R E ) fellowship, 5 0 9 Centers for Disease Control and Prevention ( C D C ) , 155, 260, 383, 387, 388, 506 Central nervous system ( C N S ) . See also Automatic Nervous System alcoholism and, 8 4 - 8 5 , 8 7 stress treatment and, 1 7 8 - 1 8 0 Cerebrovascular accident, 4 8 9 Cesarean section, 4 7 0 C H D . See Coronary heart disease Checkerboard Cardiovascular Curriculum for American Indian and Hispanic American children, 4 6 0 Chemotherapy, 3 2 7 Chest pain. See Angina Childbirth, 4 7 0 - 4 7 1 Childhood abuse, and IBS, 4 0 5 - 4 0 6 Chinese Community Cardiac Council, 4 6 0 Chronic fatigue syndrome, 2 3 7 Chronic obstructive pulmonary disease in older adults, 4 8 8 and physical activity, 1 5 2 - 1 5 3 Chronic pain, 2 2 9 - 2 4 5 assessment and treatment of, 2 3 8 - 2 4 4 biopsychosocial model of, 2 3 0 - 2 3 2 , 2 4 3 - 2 4 4 case study of, 2 4 5 diagnostic and etiological issues of, 2 3 2 - 2 3 4 pelvic pain in women, 4 7 7 - 4 7 8 prevalence of, 2 2 9 and psychological disorders, 2 3 4 - 2 3 8 , 2 4 0 transactional model of adjustment to, 2311 Classical conditioning, and nicotine dependence, 1 0 7 Clinical Competency Test Interview, 4 9 4

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 130 Clinical Neuropsychology: A Pocket Handbook, 2 0 Clock Drawing Test, 2 1 C N S . See Central nervous system Cocaine use, and coronary heart disease, 2 8 9 - 2 9 0 Cocktail therapy. See Highly active antiretroviral treatment Cognitive-behavioral therapy (CBT), 4, 6 0 - 6 7 , 4 1 9 - 4 2 0 . See also Information-motivationbehavioral skills model for alcoholism, 9 0 - 9 1 for chronic pain, 2 3 0 - 2 3 1 , 2 4 2 - 2 4 3 and coronary heart disease, 287t and depression in diabetics, 3 1 6 for insomnia, 4 3 0 - 4 3 4 for stress, 1 8 1 - 1 8 2

Cognitive Capacity Screening Examination (CCSE), 343 Cognitive Coping Strategies Inventory, 2 3 9 Cognitive disorders. See also Cognitive screening; Dementia and HIV, 3 9 3 , 3 9 5 in older adults, 4 8 6 ^ 1 8 7 Cognitive orientation theory, 346f Cognitive screening, 1 9 - 2 2 and cancer, 3 4 3 Clock Drawing Test, 2 1 and coronary heart disease, 2 9 0 for dementia, 2 0 Folstein Mini Mental State E x a m ( M M S E ) , 2 1 Colleague relations, psychologists and, 4 4 7 - 4 4 8 College of Health Psychologists of the Australian Psychological Society, 33 Combination therapy. See Highly active antiretroviral treatment Committee on Accreditation of ΑΡΑ, 12, 5 0 5 Competence, of psychologists, 4 4 3 - 4 4 6 and assessment, 4 4 5 - 4 4 6 boundaries of, 4 4 4 - 4 4 5 C o m p l e x regional pain syndrome, 2 3 7 Composite primary Symptom Reduction (CPSR), 409-410 Confidentiality, 4 4 9 - 4 5 1 Conflicts of interest, 5 2 1 - 5 2 2 Consent, informed, 4 5 3 - 4 5 4 , 5 1 6 Consultation, 1 1 - 1 2 , 3 0 Contemplation Ladder, 110 Continuous positive airway pressure machine (CPAP), 4 3 5 Conversion disorders, and chronic pain, 2 3 5 Coping and alcoholism, 8 7 - 8 8 with cancer, 3 3 0 - 3 3 2 with chronic pain, 2 3 9 - 2 4 0 , 2 4 3 and coronary heart disease, 2 9 1 - 2 9 3 and diabetes, 3 0 9 , 3 1 4 - 3 1 5 with pain, 4 1 0 - 4 1 1 . See also Coping: with chronic pain strategies of, 1 7 4 - 1 7 5 and stress inoculation, 1 8 1 - 1 8 2 women and, 4 7 2 - 4 7 3 Coping Strategies Questionnaire, 2 3 9 Coronary heart disease ( C H D ) , 2 7 9 - 2 9 8 assessment of, 2 8 4 - 2 9 1 biopsychosocial model of, 2 8 3 - 2 8 4 case study of, 2 9 7 and c o m m o n cognitive errors in patients, 287t definitions and descriptions of, 2 8 0 - 2 8 4 diagnostic and treatment procedures common for, 2 S 4 r evaluation checklist for, 286t medications common for, by function, 2951 self-report measures concerning, 2851 treatment of, 2 9 1 - 2 9 6 , 2 9 8 Corticolimbic system, 170 Cortisol, 1 7 1 , 1 7 2 , 2 5 4 - 2 5 5 , 256f

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569

570

T H E HEALTH P S Y C H O L O G Y HANDBOOK Cost-benefit analyses, 5 2 6 , 5 3 2 Cost-effectiveness analyses, 5 2 6 , 5 3 2 Council on Education for Public Health ( C E P H ) , 505-506 Daily Hassles and Uplifts Scale, 1 7 7 Death and dying, 5 6 , 4 9 4 - 4 9 5 Decision-making capacity, of older adults, 4 9 3 - 4 9 4 Defibrillators, 2 8 2 Delirium, 343 Delirium Rating Scale, 3 4 3 Dementia and mental competence, 4 9 4 in older adults, 4 9 2 screening for, 2 0 Dependence. See Alcohol dependence; Nicotine dependence; Substance abuse Depression. See also Antidepressant prescriptions and cancer, 3 3 3 , 3 3 4 , 3 4 0 - 3 4 1 and chronic pain, 2 3 4 - 2 3 5 and coronary heart disease, 2 8 8 and diabetes, 3 0 7 - 3 0 8 , 316 and HIV, 3 9 0 - 3 9 2 Parkinson's disease and, 4 8 7 physical activity and, 158 postpartum, 4 7 6 and sleep disorders, 4 2 6 stress and, 176 women and, 4 7 5 - 4 7 6 Diabetes, 3 0 3 - 3 1 9 assessment and treatment of, 3 1 1 - 3 1 6 , 3 1 8 background and etiology of, 3 0 4 - 3 0 5 case study of, 3 1 7 - 3 1 8 in older adults, 4 8 8 and physical activity, 1 5 6 - 1 5 7 psychological factors and, 3 0 6 - 3 1 1 Diabetes Prevention Program (DPP), 3 1 1 Diagnosis as assessment tool, 5 - 6 by exclusion, 8 - 9 Diagnostic and Statistical Manual of Mental Disorders. See D S M , various editions Diagnostic Interview Schedule, 110 Diet and IBS, 4 0 7 - 4 0 8 low-calorie Step I, 134t and obesity, 1 3 1 , 133 Dietary Approaches to Stop Hypertension (DASH) diet, 2 5 9 Digit Symbol test, 2 0 , 2 2 Digoxin, 295f Disease. See Illness Diuretics, 29St Division 12 (Society of Clinical Psychology) of ΑΡΑ, 1 4 - 1 5 Division 38 (Health Psychology) of ΑΡΑ, 14 Division 4 0 (Clinical Neuropsychology) of ΑΡΑ, 14 Division 54 (Society of Pediatric Psychology) of ΑΡΑ, 14 D M 2 (Type 2 diabetes). See Diabetes

Doctor shopping, 196 Dopamine, 8 4 - 8 5 , 87, 1 0 4 - 1 0 5 Dreams, 4 2 9 Drug Abuse Screening Test, 199 D r u g Enforcement Agency (DEA), 198 Drug Investigational Units (DIU), 193 Drug-seeking behavior. See Medication-seeking behavior DSM-II (Diagnostic and Statistical Manual of Mental Disorders, second edition), chronic pain, 2 3 3 DSM-III (Diagnostic and Statistical Manual of Mental Disorders, third edition) anxiety, 23 chronic pain, 2 3 3 delirium, 3 4 3 DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, third edition, revised) chronic pain, 2 3 3 , 2 3 4 depression, 4 8 7 D S M - I V (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), 5, 6, 11 alcohol abuse, 8 2 - 8 3 alcohol dependence, 8 0 - 8 2 anxiety, 3 9 2 chronic pain, 2 3 4 delirium, 3 4 3 depression, 126 eating disorders, 1 2 7 emotional distress, 2 8 7 nicotine dependence, 102 psychiatric comorbidity, 4 1 1 sexual dysfunctions, 3 5 9 , 360t, 3 6 2 somatization disorder, 2 3 5 stress, 176 Dysmenorrhea, 4 7 7 Dyspareunia, 3 6 6 - 3 6 7 Eastern philosophy, 173, 1 8 0 Eating disorders, 1 2 7 E B M (Evidence-Based Medicine)-Cochrane D a t a b a s e of Systematic Reviews, 15 Education. See Psychoeducation; Training Effect size statistics, 5 3 1 Ejaculation anejaculation, 3 7 0 premature, 3 7 0 , 3 7 4 - 3 7 5 retrograde, 3 6 9 - 3 7 0 Elderly people. See Older adults Electromyographic ( E M G ) feedback, 1 7 9 - 1 8 0 Electronic Point of Sale Systems (EPOS), 193 E M G (electromyographic) feedback, 1 7 9 - 1 8 0 Emotions and angina, 2 8 1 - 2 8 2 and cancer, 3 3 3 - 3 3 4 , 3 3 4 - 3 3 5 and coronary heart disease, 2 8 6 - 2 8 9 physical activity and, 1 5 7 - 1 5 8 Empowerment, and diabetes, 3 1 5 End-of-life issues. See Death and dying E N R I C H D clinical trial, 2 8 8 Epidemiology

Subject Index history and definition of, 5 0 3 - 5 0 4 and medication-seeking behavior research, 191-192 Epinephrine, 1 7 2 Erectile disorder (ED), 3 6 7 - 3 6 9 Ethical issues, 4 4 3 - 4 5 4 competence, 4 4 3 - 4 4 6 concern for welfare, 4 5 2 - 4 5 4 , 5 1 5 - 5 1 6 conflicts of interest, 5 2 1 - 5 2 2 guidelines and standards, 14 integrity, 4 4 6 - 4 4 8 professional conduct, 4 4 8 - 4 4 9 in research, 5 1 5 - 5 1 6 , 5 1 8 respect for rights and dignity, 4 4 9 - 4 5 2 , 5 1 5 - 5 1 6 social responsibility, 4 5 4 , 5 1 5 - 5 1 6 Ethnocultural issues, 4 5 1 - 4 5 2 , 4 5 6 - 4 6 4 behavioral interventions, 4 6 0 - 4 6 2 diabetes, 3 0 5 , 3 1 0 disparities in health and health care, 456^4-60 HIV, 3 8 4 nicotine dependence, 1 0 7 - 1 0 8 pain, 4 5 7 - 4 5 8 physical activity, 161 recommendations for improved care, 4 6 2 - 4 6 3 European Organization for Research and Treatment of Cancer ( E O R T C ) , 3 4 2 Euthanasia. See Physician-assisted suicide Evaluation of programs. See Program evaluation Evidence-based medicine. See E B M (Evidence-Based Medicine)-Cochrane D a t a b a s e of Systematic Reviews Exercise. See Physical activity Fagerstrôm Test of Nicotine Dependence, 110 Faith-based programs, 4 6 0 Falls, of older adults, 4 9 0 - 4 9 1 Family, and cancer patients, 3 3 6 Family practice model, 2 9 4 Fear Avoidance Beliefs Questionnaire, 2 4 Fear of Pain Questionnaire, 2 4 Fees. See Billing Fellowship p r o g r a m s , 5 0 7 , 5 0 9 - 5 1 0 Fibromylagia, 2 3 6 Finnish Diabetes Prevention Study (FDPS), 3 1 1 Florida Medical Association, 198 Folstein Mini Mental State E x a m ( M M S E ) , 2 1 Food and Drug Administration (FDA), 1 1 3 , 1 3 6 , 414, 434 Functional analysis, in psychological assessment, 5, 6 Functional Assessment of Cancer Therapy (FACT), 3 4 2 Gastrointestinal diseases, 3 9 7 . See also Irritable bowel syndrome similarity to IBS of, 4 0 0 stress and, 176 Gender. See also Women's health and nicotine dependence, 1 0 7 - 1 0 8 and physical activity for hypertension, 1 5 2

Genetics and alcoholism, 8 4 - 8 5 and cancer, 338 and nicotine dependence, 107 and obesity, 1 2 8 - 1 2 9 Geriatric populations. See Older adults Glutamate, 1 0 5 G r o u p psychotherapies, 5 9 . See also Social support H A A R T . See Highly active antiretroviral treatment Halstead-Reitan Neuropsychological Battery Category test, 2 0 Trail M a k i n g test, Part B, 2 0 , 2 2 Hamilton Anxiety and Depression scales, 23 Headaches, 2 3 6 Health Anxiety Questionnaire, 2 4 Health belief model, a n d adherence behavior, 2 1 2 Health care systems and adherence interventions, 2 1 6 and safeguards against medication-seeking, 1 9 3 - 1 9 4 , 198 workings of, 5 0 6 - 5 0 7 Health outcomes assessment, 5 0 4 - 5 0 5 , 5 0 7 - 5 0 8 Health promotion, psychologist role in, 33

Health Psychology, 15 Heart disease. See Coronary heart disease Heart Health for Southeast Asians, 4 6 0 Heart rate monitors, 149 Heart Smart Program, 4 6 0 Hemodynamics, 2 8 3 High blood pressure. See Hypertension Highly active antiretroviral treatment ( H A A R T ) , 383, 388-389 Histories, patient, 19 HIV. See H u m a n Immunodeficiency Virus HIV/AIDS Prevention Research Synthesis Project (CDC), 388 Holmes Alcoholism Scale, 86 Holter monitors, 2 8 1 Homeostasis, 1 6 9 - 1 7 0 H o p e m o n t Capacity Assessment Interview, 4 9 4 Hopkins Verbal Learning Test, 2 0 Hospital Anxiety and Depression Scale (HADS), 284, 3 4 2 Hospitals, skills needed for, 33. See also Medical centers H S D D . See Hypoactive sexual desire disorder H u m a n body, organization of, 169 H u m a n Immunodeficiency Virus (HIV), 3 8 3 - 3 9 5 background and epidemiology of, 3 8 3 - 3 8 7 case study of, 3 7 4 non-nucleoside reverse transcriptase inhibitors for, 390t nucleoside analog reverse transcriptase inhibitors

for, 389t prevention and adherence issues with, 3 8 7 - 3 9 0 protease inhibitors for, 390f and psychological disorders, 3 9 0 - 3 9 3 , 3 9 5 Hyperglycemia, 3 0 4 Hypertension, 2 5 2 - 2 6 9

j

571

572

T H E HEALTH P S Y C H O L O G Y HANDBOOK assessment and treatment of, 2 5 5 - 2 6 6 case study of, 2 6 7 - 2 6 8 diagnostic and etiological issues of, 2 5 3 - 2 5 5 health risks of, 2 5 2 and physical activity, 1 5 1 - 1 5 2 stress and Cortisol and, 2S6f white coat, 2 5 6 - 2 5 7 Hypnosis, 179 Hypoactive sexual desire disorder ( H S D D ) , 3 6 2 , 364-365 Hypoglycemia, 304 Hypothalamus, 1 7 0 - 1 7 1 IBS. See Irritable bowel syndrome IBS-Quality of Life Measure (IBS-QOL), 4 1 1 I C D - 1 0 (International Classification of Diseases, 10th edition), 1 2 - 1 4 Illness improving outcomes of, 6 3 - 6 5 physical activity and, 1 5 0 - 1 5 7 psychological adaptation to, 2 3 - 2 4 risk reduction for, 6 1 - 6 3 stimulus-background model of, 338f Illness Behaviour Questionnaire, 24 Immune function, stress and, 176 Impotence, 369 Inactivity. See Physical activity Incidence, of disease, 5 0 4 Indian philosophy, 180 Infections, AIDS and common opportunistic,

387, 388t Infertility, 478 Information-motivation-behavioral skills model, and adherence behavior, 2 1 2 - 2 1 4 . See also Cognitive-behavioral therapy Informed consent, 4 5 3 - 4 5 4 , 5 1 6 Insomnia, 4 2 7 , 4 2 9 - 4 3 5 , 4 3 6 Instrumental Activity of Daily Living Scale, 2 1 Insurance, reimbursements from, 31 Integrity, of psychologists, 4 4 6 - 4 4 8 Interdisciplinary Professional Education Collaborative, 3 5 , 36 International Association for the Study of Pain, 2 3 7 International Headache Society, 2 3 6 Internships, 12 Interpersonal/social support. See Social support Interprofessional settings. See Multidisciplinary settings Interventions. See Motivational enhancement interventions; Psychosocial interventions Interviews, in assessment, 19 Inventory of Current Concerns, 342 Inventory of Negative Thoughts in Response to Pain, 2 3 9 IQ (intelligence quotient), 22 Irritable bowel syndrome (IBS), 397^120 assessment and treatment of, 4 0 7 - 4 1 5 , 4 1 9 - 4 2 0 background and etiology of, 3 9 7 - 4 0 7 biopsychosocial model of, 4 0 6 - 4 0 7 case study of, 4 1 6 - 4 1 8

diseases with symptoms similar to, 4011 psychological factors and, 4 0 4 - 4 0 6 symptom severity development (case study), 419t Jacobson, Edmond, 178-179 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, 2 5 3

Journal of Behavioral Medicine, 15 Journal of Clinical Psychology in Medical Settings, 15 Journals, 15. See also by name Jung, Carl, 4 2 9 K-awards, 5 0 7 Kaiser Permanente, 2 1 8 - 2 1 9 , 4 3 3 Language for Health, 4 6 0 Liaison roles, 1 1 - 1 2 , 3 0 Life Events Survey, 177 Lifestyle behaviors, 3. See also Diet; Physical activity diabetes and, 3 1 0 , 3 1 1 and obesity, 1 3 1 , 1 3 3 - 1 3 4 Light therapy, 4 3 5 - 4 3 6 Lighten Up, 4 6 0 Literature, medical, 5 2 2 Lotronex, 4 1 4 Lupus, 2 3 7 - 2 3 8 M a c A n d r e w Alcoholism Scale, 86 M a n a g e d care, and mental health workers, 3 1 - 3 2 Maryland Addiction Questionnaire, 24 Mattis Dementia Rating Scale, 2 1 McGill Pain Questionnaire ( M P Q ) , 2 3 8 , 3 4 3 , 4 1 0 Measures, selection of, 528 Medicaid Fraud and Abuse System (MFAS), 193 Medical centers. See also Hospitals organizational and political settings of, 10 psychological practices in, 13 Medical literature, 5 2 2 Medical Outcomes Study Short Form Health Survey ( M O S SF-36), 3 4 2 , 4 1 1 Medication Event Monitoring System (MEMS), 217, 219 Medication-seeking behavior, 1 8 7 - 2 0 6 assessment and treatment of, 1 9 8 - 1 9 9 , 2 0 5 biopsychosocial interventions for, 1 9 4 - 1 9 8 , 195f,

203f case study of, 2 0 0 - 2 0 5 definitions and descriptions of, 1 8 7 - 1 9 1 research in, 1 9 1 - 1 9 4 systemic safeguards against, 1 9 3 - 1 9 4 , 198 varieties of, 196 Medications. See also Pharmacology conflicts of interest involving research on, 521-522 problems of older adults with, 4 9 0 Medicine medical model, 7 - 9 medical versus psychological background, 9 - 1 0 organizational and political settings of, 1 0 - 1 1 , 13 profession of, 18

Subject Meditation, and stress management, 180 M E D L I N E , 1 5 , 191 Melatonin, 4 3 4 - 4 3 5 Memorial Delirium Assessment Scale, 343 Memorial Symptom Assessment Scale (MSAS), 3 4 3 Menopause, 4 7 1 - 4 7 2 Mental competence, of older adults, 493-494 Meridia, 136 Mexican Americans, and physical activity, 161 Michigan Alcoholism Screening Test ( M A S T ) , 2 4 Migraine headaches, 2 3 6 Mind-body dichotomy, 6 Mini-Mental State E x a m ( M M S E ) , 3 4 3 Minnesota Multiphasic Personality Inventory (MMPI), 86, 2 4 0 Minnesota Nicotine Withdrawal Scale, 110 Model-fitting analysis of p r o g r a m evaluation, 530-531 M o o d . See Depression; Emotions Motivational enhancement interventions, 4 2 - 5 2 clinical development of, 4 3 - 4 4 empirical research on, 4 4 - 4 5 for medication-seeking behavior, 1 9 9 varieties of, 4 5 - 5 1 Motivational interviewing, 4 7 - 5 1 , 6 2 . See also Motivational enhancement interventions for alcoholism, 9 2 training in, 52t Multicultural issues. See Ethnocultural issues Multidimensional Fatigue Inventory (MFI), 343 Multidisciplinary settings, 2 8 - 3 8 historical issues of, 2 9 - 3 2 specialized skills for, 3 2 - 3 5 training for, 3 5 - 3 8 Multiple chemical sensitivities, 2 3 7 Multiple Copy Prescription Program (MCPP), 193 Multiple roles, of women, 4 7 3 - 4 7 4 Napping, 4 3 6 Narcolepsy, 4 2 8 - 4 2 9

National Arthritis Action Flan: A Public Health Strategy, 1 5 5 - 1 5 6 National Commission on Sleep Disorders Research, 4 2 5 National Health Service (Britain), 3 1 National Household Survey on Drug Abuse, 1 8 9 , 192 National Institute on Drug Abuse (NIDA), 193 National Institute on Mental Health, 5 1 0 National Institutes of Health (NIH), 3 1 1 , 4 3 4 Negative Alcohol Expectancy Questionnaire, 88 Nervous system, and IBS, 4 0 3 , 4 0 4 , 4 0 6 - 4 0 7 . See also Automatic Nervous System; Central nervous system Neurobehavioral Cognitive Status Examination ( N C S E ) , 2 1 , 2 2 , 343 Nicotine dependence, 1 0 1 - 1 1 8 assessment and treatment of, 1 0 9 - 1 1 4 , 2 1 5 - 2 1 6 biopsychosocial learning model of, 1 0 4 - 1 0 7 case study of, 1 1 5 - 1 1 8

Index

comorbid personality a n d psychopathology and, 108-109 definitions and descriptions of, 1 0 2 - 1 0 4 gender and ethnicity and, 1 0 7 - 1 0 8 genetic factors in, 1 0 7 Nicotine replacement therapy ( N R T ) , 113 Night terrors, 4 2 9 , 4 3 7 - 4 3 8 Nightmares, 4 2 9 , 4 3 6 - 4 3 7 Nitrates, 2951 Nonpsychiatric patients, psychological needs of, 6 - 7 Normative comparisons, 5 3 1 - 5 3 2 Obesity, 1 2 5 - 1 4 1 assessment and treatment of, 1 3 0 - 1 3 8 , 140 case study of, 1 3 9 - 1 4 0 definitions and descriptions of, 1 2 5 - 1 2 6 developmental factors in, 1 2 9 and diabetes, 3 0 5 and disease risks, 131t, 132t environmental factors in, 128 evaluation-treatment interface for, 133f genetic factors in, 1 2 8 - 1 2 9 and hypertension, 2 5 2 , 2 5 7 - 2 5 9 incidence of, 1 2 5 , 1 2 6 , 127t and physical activity, 1 3 3 - 1 3 4 , 1 5 3 - 1 5 5 physical problems associated with, 126 psychological and psychosocial problems associated with, 1 2 6 - 1 2 8 psychosocial treatments of, 1 3 4 - 1 3 6 treatment algorithm for, 131 and weight loss expectations, 138t Older adults age-related changes in, 4 8 6 - 4 8 7 and cancer, 4 8 9 - 4 9 0 and cerebrovascular accident, 4 8 9 and chronic obstructive pulmonary disease, 4 8 8 common problems of, 490—493 and death-related issues, 4 9 4 ^ 1 9 5 and diabetes, 3 0 5 , 4 8 8 diagnostic issues with, 4 9 3 health issues of, 4 8 5 - 4 9 6 and hypertension, 2 5 2 , 2 5 9 and medication problems, 4 9 0 mental competence of, 493—494 and Parkinson's disease, 4 8 7 and thyroid disturbances, 4 8 8 - 4 8 9 O m e g a Screening Instruments, 3 4 2 Online resources, 1 5 . See also by name Operant conditioning, and pain management, 242-243 Oregon Board of Medical Examiners, 1 9 2 Orgasm female disorders of, 3 6 5 - 3 6 6 male disorders of, 3 6 9 - 3 7 0 Orlistat (Xenical), 136 Osteoarthritis, and physical activity, 1 5 5 - 1 5 6 Outcomes. See Health outcomes assessment; Program evaluation Overweight, 1 2 5 . See also Obesity

574

T H E HEALTH P S Y C H O L O G Y HANDBOOK Pain. See also Chronic pain ethnic differences concerning, 4 5 7 - 4 5 8 and IBS, 4 1 0 - 4 1 1 in older adults, 4 9 2 - 4 9 3 Pain Anxiety Symptoms Scale, 2 4 , 2 3 9 Pain Beliefs and Perceptions Inventory, 2 3 9 Pain Catastrophizing Scale, 2 3 9 Pain clinics, 2 4 3 Pain Coping Skills Questionnaire (CSQ), 4 1 0 - 4 1 1 Pain management, 2 4 0 - 2 4 4 Panic, and arrhythmias, 2 8 2 - 2 8 3 Parkinson's disease, 4 8 7 Patient histories, 19 Patient relations, psychologists and, 4 4 6 - 4 4 7 Pedometers, 148 Pelvic pain, chronic, 4 7 7 - 4 7 8 Penn State Worry Questionnaire (PSWQ), 4 1 1 Periodic leg movement disorder ( P L M D ) , 4 2 8 , 4 3 5 Personality alcholism and, 8 6 - 8 7 nicotine dependence and, 1 0 8 - 1 0 9 Pharmaceutical industry, 5 2 1 - 5 2 2 Pharmacology and coronary heart disease, 2 9 4 - 2 9 6 , 2 9 8 and hypertension, 2 6 2 - 2 6 4 , 263-264t and IBS, 4 1 1 - 4 1 4 , 413t and insomnia, 4 3 4 - 4 3 5 and nicotine dependence, 113 and obesity, 136 and pain management, 2 4 1 and psychological disorders accompanying HIV, 391-392, 393, 395 Physical activity assessment of, 1 4 7 - 1 5 0 case study of, 1 5 9 - 1 6 1 and chronic disease risk factors, 1 4 6 - 1 6 2 definitions and descriptions of, 1 4 6 - 1 4 7 and hypertension, 2 6 0 - 2 6 1 and illness, 1 5 0 - 1 5 7 and insomnia, 4 3 2 moderate, 135t and obesity, 1 3 3 - 1 3 4 , 1 5 3 - 1 5 5 and psychological functioning, 1 5 7 - 1 5 8 Physical Maintenance Scale, 2 1 Physician-assisted suicide, 3 2 9

Physician Drug and Diagnosis Audit, 3 9 7 Physicians, and medication-seeking patients, 189-190, 197-198, 199, 2 0 5 P M S (premensrrual syndrome), 4 7 5 - 4 7 6 Postdoctoral fellowships, 12 Postpartum depression, 4 7 6 Posttraumatic stress disorder (PTSD), and cancer, 3 4 1 Pregnancy, 4 7 0 - 4 7 1 Premature ejaculation, 3 7 0 , 3 7 4 - 3 7 5 Premenstrual syndrome (PMS), 4 7 5 - 4 7 6 Prescribing, inappropriate, 1 9 2 - 1 9 3 , 1 9 7 - 1 9 8 Prescription drug abuse. See Medication-seeking behavior Prevalence, of disease, 5 0 4

Primary care and detection of psychological difficulties, 34 and pain treatment, 2 4 4 skills needed for, 3 3 - 3 5 Professional conduct, 4 4 8 - 4 4 9 Professional societies, 1 4 - 1 5 . See also individual

organizations Profile of M o o d States ( P O M S ) , 3 4 2 Program evaluation, 5 2 5 - 5 3 4 analysis of, 5 3 0 - 5 3 3 and appropriate measures, 5 2 8 assessment methods for, 5 2 7 - 5 2 8 defining behaviors for, 5 2 7 and individual versus group designs, 5 2 9 - 5 3 0 method of describing change for, 5 3 1 - 5 3 2 and social validity, 5 3 2 - 5 3 3 steps in, 5 2 6 - 5 2 7 Progressive diabetic retinopathy (PDR), 3 0 6

Progressive Relaxation Training, 179 Project J o y , 4 6 0 Project M A T C H , 4 4 Psychiatric comorbidity, 4 Psychiatric Rating Scale, 23 Psychiatrists, and collaboration with psychologists, 3 0 - 3 1 Psychiatry, clinical health psychology versus, 5 PsychLit, 191 Psycho-oncology. See Cancer Psychoeducation, 6 0 - 6 7 Psychological disorders, chronic pain and, 2 3 4 - 2 3 8 , 2 4 0 Psychological factors cancer and, 3 3 2 - 3 3 5 , 333t diabetes and, 3 0 6 - 3 1 1 IBS and, 4 0 4 - 4 0 6 ignoring of, 9 Psychologists assessment by, 5 - 6 . See also Assessment and collaboration with psychiatrists, 3 0 - 3 1 as consultants and liaisons, 1 1 - 1 2 effective, 10, 14 self-assessment concerning medical-surgical problems, 13t treatment approaches of, 6 - 7 unique contributions of, 4 - 7 , 3 2 Psychology, in clinical versus medical settings, 18, 34 Psychometrics, 5, 1 8 - 1 9 Psychoneuroimmunology, 3 3 9 - 3 4 0 Psychopharmacology, 2 9 4 - 2 9 6 , 2 9 8 Psychosocial factors, interaction with medical conditions of, 5 5 , 58 Psychosocial interventions. See also Behavioral science for alcoholism, 8 9 - 9 2 for cancer, 3 4 4 - 3 4 6 , 348 developments in, 5 6 - 6 0 for nicotine dependence, 1 1 1 - 1 1 3 for obesity, 1 3 4 - 1 3 6 options in medical settings, 59f training for, 6 7 - 6 9 and treatment goals, 6 0 - 6 7

Subject Psychotherapies brief, 5 5 - 6 9 group, 59 Psychotropic drugs, 31 PsycINFO, 15 Public health, 5 0 2 - 5 1 1 and clinical care compared, 5 0 2 - 5 0 3 historical issues and key concepts of, 5 0 3 - 5 0 5 interdisciplinary character of, 5 1 0 - 5 1 1 psychologists and, 33, 5 0 3 , 5 0 8 - 5 1 1 training and skills for, 5 0 5 - 5 1 0 Pulmonary disease. See Chronic obstructive pulmonary disease Q R S interval, 2 9 5 Quality-adjusted life year ( Q A L Y ) , 5 0 4 Quality of life cancer and, 3 3 1 , 3 4 2 - 3 4 3 diabetes and, 3 0 9 - 3 1 0 IBS and, 411 improvements for ill patients in, 6 5 - 6 7 Quetelet's index. See Body mass index Race. See Ethnocultural issues Radiation, 3 2 7 Recurrent Coronary Prevention Project, 6 3 - 6 5 Reinforcement alcoholism and, 8 3 - 8 4 nicotine dependence and, 1 0 4 - 1 0 6 Relaxation and insomnia, 4 3 2 and pain management, 2 4 0 - 2 4 1 , 2 4 2 and stress management, 1 7 8 - 1 7 9 Religion and behavioral intervention, 4 6 0 older adults and, 4 9 5 R E M (rapid eye movement) sleep, 4 2 6 - 4 2 7 , 4 2 8 , 4 2 9 Remission, of cancer, 328 Remodeling, of heart, 283 Report writing, 2 4 - 2 5 Research application of, 7 assessment of, 5 2 0 and conflicts of interest, 5 2 1 - 5 2 2 defining questions for, 5 1 6 - 5 1 7 design of, 5 1 8 - 5 2 0 ethical issues in, 5 1 5 - 5 1 6 , 518 institutional considerations for, 518 in medical settings, 5 1 4 - 5 2 2 methodology of, 32 promotion of, 5 1 7 - 5 1 8 recruitment for, 5 2 0 and treatment, 5 2 0 - 5 2 1 Resistance, responses to, 50t Restless leg syndrome (RLS), 4 2 7 - 4 2 8 , 4 3 5 Rey Auditory Verbal Learning Test, 2 0 "Right to die", 329 Risk factors, for disease, 5 0 4 Risk reduction, for disease, 6 1 - 6 3 Robert W o o d J o h n s o n Foundation, 5 0 7

Index

R o m e II criteria, and IBS, 4 0 0 , 4 0 9 R o m e II Integrative Questionnaire, 4 0 9 Rotterdam Symptom Checklist, 343 Royal M a r s d e n studies, 3 3 1 , 3 3 4 S A D H A R T clinical trial, 288 Salt, and hypertension, 2 5 9 Schizophrenia, and cancer, 333 Schultz, Johannes Heinrich, 179 Screening broad-based, 2 0 for cancer, 3 2 9 - 3 3 0 cognitive. See Cognitive screening ethnic participation in, 4 6 1 - 4 6 2 intellectual, 2 2 in medical settings, 18 psychiatric, 2 2 - 2 3 purposes of, 1 7 - 1 8 for substance abuse, 24 training for, 2 0

Screening for Brain Impairment,

20

Self-assessment, concerning medical-surgical problems, 13t Self-destructive behavior, 4 7 0 Self-management, 2 1 0 and coronary heart disease, 2 9 4 and diabetes, 3 1 3 - 3 1 4 Self-medicating behavior, nicotine dependence as, 108-109 Self-Rating Depression Scale, 23 Self-report measures for coronary heart disease, 28St for IBS, 4 0 9 for physical activity, 148 for psychological functioning, 4 1 1 Sensate focus, 3 6 2 , 363-364t Sensitivity, in psychometrics, 19 Serotonin, 2 9 5 - 2 9 6 Sexual aversion disorder (SAD), 3 6 5 Sexual dysfunctions, 3 5 9 - 3 7 5 assessment and treatment of, 3 6 1 - 3 7 0 , 3 7 4 - 3 7 5 case study of, 3 7 1 - 3 7 4 diabetes and, 3 0 6 female, 3 6 2 , 3 6 4 - 3 6 7 male, 3 6 7 - 3 7 0 , 3 7 4 - 3 7 5 Sexual response, 3 5 9 - 3 6 0 , 3 6 2 ί SF-36. See Medical Outcomes Study Short Form Health Survey Sibutramine (Meridia), 136 Sickness Impact Profile, 2 3 8 Sleep apnea, 4 2 8 , 4 3 5 and coronary heart disease, 2 9 0 Sleep cycles, 426—427 Sleep disorders, 4 2 5 - 4 3 8 assessment and treatment of, 4 2 9 - 4 3 8 background and etiology of, 4 2 5 - 4 2 9 case study of, 4 3 7 effects of, 4 2 5 - 4 2 6 in older adults, 4 9 1 stress and, 176

576

T H E HEALTH P S Y C H O L O G Y HANDBOOK Sleepwalking, 4 3 8 Slosson Intelligence Test, 2 2 Smoking. See Nicotine dependence; T o b a c c o use Smoking Consequences Questionnaire, 110 Smoking Self-Efficacy Questionnaire, 110 Snow, John, 5 0 3 Social cognitive theory, and adherence behavior, 2 1 1 Social learning theory, 4 0 6 Social responsibility, 4 5 4 , 5 1 5 - 5 1 6 Social support. See also G r o u p psychotherapies and alcoholism, 8 8 - 8 9 and cancer, 3 3 5 - 3 3 6 and diabetes, 3 0 8 - 3 0 9 and nicotine dependence, 1 1 2 - 1 1 3 and treatment interventions, 6 0 - 6 7 women and, 4 7 3 Society of Behavioral Medicine, 14 Socioeconomic factors, women and, 4 7 4 - 4 7 5 Sodium, and hypertension, 2 5 9 Somatization disorder, 2 3 5 Specificity, in psychometrics, 19 Spielberger anxiety and anger scales, 1 7 7 Spouse/Friend Ketterer Stress Symptom Frequency Checklist (KSSFC), 2 9 0 SSRIs (selective serotonin reuptake inhibitors), 295-296 St. John's wort, 2 9 6 , 2 9 8 Stages of change model and adherence behavior, 2 1 2 and alcoholism, 9 2 - 9 3 Stanford-Binet-IV, 2 2 Stanford University cancer study, 3 3 6 State-Trait Anxiety Inventory, 4 0 5 , 4 1 1 State University of N e w Y o r k - A l b a n y , 4 0 9 9 Stepped care approach, 111 Stimulation therapies, and pain management, 241-242 Stimulus-background models of disease, 338f of recovery, 339f Stimulus-Organismic-Response-Consequence (SORC), 285 Stress, 1 6 9 - 1 8 4 . See also Posttraumatic stress disorder and alcoholism, 8 7 - 8 8 assessment and treatment of, 1 7 6 - 1 8 2 and cancer, 3 3 2 - 3 3 3 , 3 3 4 case study of, 1 8 3 - 1 8 4 chronic, 1 7 2 - 1 7 3 , 1 7 5 - 1 7 6 and chronic pain, 2 3 0 and coronary heart disease, 2 9 1 - 2 9 4 , 292t definitions a n d descriptions of, 1 6 9 - 1 7 3 and diabetes, 3 0 7 and hypertension, 2 5 3 - 2 5 5 , 2S6f models of, 1 7 3 - 1 7 5 and obesity, 135 physiology of response to, 171 f women and, 4 7 2 Stress inoculation, 1 8 1 - 1 8 2 Stress management

and coronary heart disease, 2 9 3 and diabetes, 3 1 5 and hypertension, 2 6 1 - 2 6 2 techniques for, 1 7 7 - 1 8 2 theory of, 1 7 3 - 1 7 4 Stroke, 4 8 9 Structured Clinical Interview for D S M - I V Axis I Disorders (SCID), 110, 4 1 1 Substance abuse. See also Alcohol dependence; Nicotine dependence and medication-seeking behavior, 192 screening for, 2 4 stress and, 176 Suicide, and cancer, 3 4 1 . See also Physician-assisted suicide Surgery and cancer, 3 2 7 and obesity treatment, 1 3 6 - 1 3 7 and pain management, 2 4 1 Swedish Obesity Study, 137 Symptom Checklist-90, 3 3 4 Symptom Checklist-90—Revised, 2 3 , 177, 2 4 0 0 Symptom Reduction Score, 4 0 9 Systems, health care. See Health care systems

Tarasoff v. Board of Regents of the University of California (1976), 4 5 0 Target behaviors, 5 2 7 T a s k Force on Benzodiazepine Dependency of American Psychiatric Association, 192 Technology, and diabetes interventions, 3 1 5 - 3 1 6 Terminal stage, of cancer, 3 2 8 - 3 2 9 Test of Nonverbal Intelligence-2, 2 2 Theory of interpersonal behavior, and adherence behavior, 2 1 2 Theory of reasoned action, and adherence behavior, 211-212 Thyroid disturbances, in older adults, 4 8 8 - 4 8 9 T o b a c c o use. See also Nicotine dependence and coronary heart disease, 2 8 9 detrimental effect of, 101 incidence of, 101 and insomnia, 4 3 1 Tolerance, of nicotine, 102 Trail M a k i n g test. See under Halstead-Reitan Neuropsychological Battery Training, 5 curriculum for public health/medical psychology program, 509f in medical settings, 9 - 1 0 , 2 5 in motivational enhancement interventions, 5 0 - 5 1 in motivational interviewing, 52t for multidisciplinary settings, 2 8 , 3 5 - 3 8 in practical skills, 1 2 - 1 3 preprofessional, 12 in public health, 5 0 5 - 5 1 0 in screening, 2 0 Transtheoretical model, and adherence behavior, 2 1 2 Trials of Hypertension Prevention project, 2 6 2 Tripler Army Medical Center, 194

Subject Index Tuskegee Syphilis Study, 5 1 5 Type 2 diabetes ( D M 2 ) . See Diabetes Type A personality, 2 7 9 , 2 8 8 Type C personality, 3 3 3 - 3 3 4 University of A l a b a m a at Birmingham (UAB), 5 0 5 , 508-510 University of N e v a d a School of Medicine, 5 1 5 University of Washington, 2 4 3 U.S. Consumer Product Safety Commission, 2 3 7 U.S. Department of Health and H u m a n Services, 44 U.S. Environmental Protection Agency, 2 3 7 U.S. F o o d and Drug Administration, 2 9 6 U.S. Public Health Service, 5 0 7 Vaginismus, 3 6 7 Vanderbilt Pain M a n a g e m e n t Inventory, 2 3 9 Vicitimization of women, 4 7 8 - 4 7 9 Vietnamese Community Health Promotion Project, 4 6 0 Visual Analogue Scale (VAS), 343 Visual impairment, diabetes and, 3 0 5 , 3 0 6 Vogt, Oskar, 179 Waist circumference measurements, 130 Walk-in clinics, 188 Wechsler Adult Intelligence Scale-Ill (WAIS-III), 20, 22

Wechsler Adult Intelligence Scale short forms, 22 West Haven-Yale Multidimensional Pain Inventory, 2 3 8 White coat hypertension, 2 5 6 - 2 5 7 Wisewoman, 4 6 0 Withdrawal, nicotine, 1 0 2 - 1 0 3 Women's health, 4 6 9 - 4 7 9 anxiety, 4 7 6 - 4 7 7 chronic pelvic pain, 4 7 7 - 4 7 8 depression, 4 7 5 - 4 7 6 dysmenorrhea, 4 7 7 hypertension, 2 6 0 infertility, 4 7 8 life course perspectives on, 4 6 9 - 4 7 2 psychosocial factors in, 4 7 2 - 4 7 5 sexual dysfunctions, 3 6 2 , 3 6 4 - 3 6 7 vicitimization, 4 7 8 - 4 7 9 Women's Healthy Lifestyle Project Clinical Trial, 133 Workplace issues, 32 Xenical (orlestat), 136 Y o g a , and stress management, 180 Zuckerman's Sensation Seeking Scale, 8 7

\

577

About the Editors

Lee M . C o h e n , P h . D . , is Assistant Professor in the Clinical Division o f the D e p a r t m e n t o f Psychology at T e x a s T e c h University and Assistant Adjunct Professor in the D e p a r t m e n t o f Neuropsychiatry and Behavioral Sciences at the T e x a s T e c h University Health Sciences Center. H e completed his predoctoral clinical internship and a p o s t d o c t o r a l fellowship funded by the N a t i o n a l Institute on D r u g Abuse at the University o f California, San D i e g o , specializing in behavioral medicine. H e completed his graduate training in clinical psychology at O k l a h o m a State University. His research interests involve systematically exploring the behavioral and physiological m e c h a n i s m s that contribute t o nicotine use and dependence. Dennis E . M c C h a r g u e , P h . D . , is R e s e a r c h Assistant Professor in the Clinical Division o f the D e p a r t m e n t o f Psychology at the University o f Illinois at C h i c a g o and H e a l t h R e s e a r c h Scientist in R e s e a r c h Services at E d w a r d H i n e s , J r . , V e t e r a n s Affairs Hospital. H e is currently funded by the N a t i o n a l Institute on D r u g Abuse on a M e n t o r e d Clinical Scientist Development A w a r d . H e completed his predoctoral clinical internship at B o s t o n University/Boston V e t e r a n s Affairs M e d i c a l Center C o n s o r t i u m and completed his p o s t d o c t o r a l training at the University o f Illinois at C h i c a g o . H e completed his graduate training in clinical psychology at O k l a h o m a State University. His research interest revolves a r o u n d testing biobehavioral m e c h a n i s m s that contribute to the development, maintenance, and eventual treatment o f t o b a c c o use disorders, especially a m o n g those individuals vulnerable t o psychopathology. F r a n k L . Collins, J r . , P h . D . , is Professor and D i r e c t o r o f Clinical T r a i n i n g in the D e p a r t m e n t o f Psychology at O k l a h o m a State University and Adjunct Professor in the D e p a r t m e n t o f Psychiatry at the University o f O k l a h o m a H e a l t h Sciences Center, where he serves on the executive c o m m i t t e e for the O k l a h o m a C e n t e r for A l c o h o l and D r u g - R e l a t e d Studies. H e received his d o c t o r a t e from A u b u r n University and completed his clinical psychology internship at the University o f Mississippi M e d i c a l Center. Prior to c o m i n g to O k l a h o m a State University, he was on the faculty at W e s t Virginia University and Rush-Presbyterian-St. L u k e ' s M e d i c a l C e n t e r in C h i c a g o . His research focuses on biobehavioral models o f nicotine dependence.

About the Contributors

Mustafa al'Absi, P h . D . , is Associate Professor o f Behavioral M e d i c i n e at the University o f M i n n e s o t a S c h o o l o f M e d i c i n e . H e directs a research p r o g r a m focusing o n stress, risk for hypertension, a n d t o b a c c o addiction. H i s research has been funded by grants from the N a t i o n a l C a n c e r Institute, N a t i o n a l Institute o n D r u g Abuse, and N a t i o n a l Health, Lung, and B l o o d Institute. H e completed his biological and clinical psychology training at the University o f O k l a h o m a a n d O k l a h o m a State University. H e completed his clinical psychology residency, specializing in behavioral medicine, at the University o f Mississippi M e d i c a l Center. H e has led several collaborative research initiatives focusing o n biobehavioral mechanisms o f hypertension a n d t o b a c c o addictions. David O . Antonuccio, P h . D . , is Professor o f Psychiatry and Behavioral Sciences at the University o f N e v a d a School o f M e d i c i n e and D i r e c t o r o f the Stop S m o k i n g P r o g r a m at the R e n o V e t e r a n s Affairs M e d i c a l Center. H e received his d o c t o r a t e in clinical psychology from the University o f O r e g o n in 1 9 8 0 . H e served o n the N e v a d a State B o a r d o f Psychological E x a m i n e r s from 1 9 9 0 t o 1 9 9 8 . H e holds a diplomate in clinical psychology from the American B o a r d o f Professional Psychology a n d is a fellow o f the A m e r i c a n Psychological Association. H i s clinical and research interests include the behavioral treatment o f depression, anxiety, and smoking. Krista A. Barbour, P h . D . , is a Postdoctoral Fellow in Behavioral M e d i c i n e in the D e p a r t m e n t o f Psychiatry a n d Behavioral Sciences at the D u k e University M e d i c a l Center. She completed her predoctoral clinical internship at the University o f Mississippi M e d i c a l C e n t e r / J a c k s o n Veterans Affairs M e d i c a l C e n t e r C o n s o r t i u m , specializing in health psychology. She received her d o c t o r a t e in clinical psychology at the University o f Southern California. H e r research interests involve e x a m i n a t i o n o f physical activity in the t r e a t m e n t o f depression a n d c h r o n i c disease and the relationship between e m o t i o n a l expression a n d health. Cynthia D. Belar, P h . D . , A.B.P.P., is Executive D i r e c t o r o f the American Psychological Association E d u c a t i o n D i r e c t o r a t e and Professor in the D e p a r t m e n t o f Clinical and H e a l t h Psychology at the University o f Florida Health Science Center. She received her d o c t o r a t e from O h i o University in 1 9 7 4 after completing an internship at the D u k e University M e d i c a l Center. Since then, she has been

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T H E HEALTH PSYCHOLOGY HANDBOOK engaged in education, training, research, practice, and administration in clinical and health psychology. Nicole E. Berlant, P h . D . , is a Behavioral M e d i c i n e C o n s u l t a n t in the Departments o f N e u r o l o g y and Adult M e d i c i n e for the Permanente M e d i c a l G r o u p in S a c r a m e n t o , California. She received her doctorate in clinical health psychology from the University o f Florida in 2 0 0 2 . She received her undergraduate degree from the University o f California, San D i e g o , and completed a clinical internship at the Veterans Affairs M e d i c a l Center in L o n g B e a c h , California. She has authored or coauthored m o r e than 1 0 professional articles, abstracts, and b o o k chapters in the area o f behavioral medicine. Andrew C . Blalock, P h . D . , is a Coordinating Center Liaison for the M e n t a l Health H I V Services C o l l a b o r a t i v e P r o g r a m , a 5-year Substance Abuse and M e n t a l H e a l t h Services Administration-funded service project. H e completed his doctoral training at Georgia State University and completed his predoctoral internship in the D e p a r t m e n t o f Psychiatry at the University o f C h i c a g o . H e was awarded a N a t i o n a l Institute o f M e n t a l H e a l t h H I V / A I D S clinical research postdoctoral fellowship through the D e p a r t m e n t o f Psychiatry and Behavioral Sciences at E m o r y University before joining the D e p a r t m e n t o f Behavioral Sciences and Health Education in the Rollins S c h o o l o f Public Health. His clinical and research interests include employment and return-to-work issues for persons with H I V / A I D S and neuropsychological aspects o f H I V disease progression. Lindsey Bloor, M . S . , is a graduate student in the Clinical H e a l t h Psychology P r o g r a m o f the D e p a r t m e n t o f Psychology at the University o f Utah. H e r research interests involve exploring the influence o f psychosocial factors, particularly social support, on physical and mental health o u t c o m e s . H e r clinical interests include facilitating support groups for people living with c a n c e r . Jennifer L. Boothby, P h . D . , is Assistant Professor in the D e p a r t m e n t o f Psychology at Indiana State University. She completed her graduate training in clinical psychology at the University o f A l a b a m a in T u s c a l o o s a and completed her predoctoral clinical internship at the University o f N o r t h Carolina S c h o o l o f M e d i c i n e . H e r research interests involve the application o f forensic issues t o health psychology and chronic pain such as pain and malingering, personal injury assessment, and health issues affecting prisoners. Joaquin Borrego, Jr., P h . D . , is Assistant Professor in the Clinical Division o f the D e p a r t m e n t o f Psychology at T e x a s T e c h University and Clinical Professor in the C o m m u n i c a t i o n Disorders D e p a r t m e n t in the S c h o o l o f Allied Health at the T e x a s T e c h University H e a l t h Sciences Center. H e received his master's and doctorate in clinical psychology from the University o f N e v a d a , R e n o . H e completed his predoctoral clinical internship at the University o f California, San D i e g o . His research interests include the assessment and treatment o f child physical abuse, behavioral observations o f physically abusive parent-child relationships, assessment o f different cultural parenting and discipline practices in the c o n t e x t o f child maltreatment, c o m m u n i t y interventions with ethnic minority populations, and the

About the

Contributors

development, implementation, and evaluation o f psychosocial treatments with Spanish-speaking populations. Peter E . Campos, P h . D . , is D i r e c t o r o f P R N D a t a , a private health research consulting business. H e currently serves as c o o r d i n a t o r o f the clinical core o f the Substance Abuse and M e n t a l Health Services Administration-funded

Mental

H e a l t h H I V Services Collaborative P r o g r a m through the Rollins School o f Public Health at E m o r y University. H e received his doctorate in clinical/community psychology at the University o f H a w a i i and completed his predoctoral internship at the University o f Mississippi M e d i c a l Center. H e was previously a faculty m e m b e r in psychiatry and behavioral sciences at E m o r y University's School o f M e d i c i n e , where he was clinical director o f mental health services at the Grady Infectious Disease P r o g r a m . His interests in H I V w o r k include culturally competent mental health services, psychosocial and psychiatric sequelae o f living with H I V , and the intersection o f Eastern philosophy and cognitive-behavioral therapy. John M. Chaney, P h . D . , is Professor o f Clinical Psychology at O k l a h o m a State University and Clinical Associate Professor o f Psychiatry at the University o f O k l a h o m a H e a l t h Sciences Center. H e completed his internship in pediatric psychology at the O k l a h o m a University Health Sciences Center and received his doctorate from the University o f M i s s o u r i - C o l u m b i a in 1 9 9 1 . H e is the current president o f the N a t i o n a l Society o f Indian Psychologists and serves on the A m e r i c a n Psychological Association's C o m m i t t e e on Ethnic M i n o r i t y Affairs. His research interests focus on children's adjustment to chronic medical illness and on implicit racism affecting academic achievement a m o n g Native Americans. Anna Chur-Hansen, P h . D . , is Senior Lecturer in the D e p a r t m e n t o f Psychiatry at the University o f Adelaide in South Australia. She is a m e m b e r o f the Australian Psychological Society's College o f H e a l t h Psychologists and was the recipient o f the Australian and N e w Z e a l a n d Association for M e d i c a l Education A w a r d for R e s e a r c h in 2 0 0 0 . She has taught medical undergraduate students in the behavioral sciences since 1 9 8 7 . H e r research focuses on evaluations o f teaching initiatives and their assessment for medical and health sciences students, particularly the disciplines o f psychology, anthropology, and psychiatry. Matthew M. Clark, P h . D . , A.B.P.P., is Associate Professor o f Psychology and C o - S e c t i o n H e a d o f Outpatient M e d i c a l Psychiatry and Psychology, as well as D i r e c t o r o f the M e d i c a l Psychology Fellowship Program, in the D e p a r t m e n t o f Psychiatry and Psychology at the M a y o Clinic in R o c h e s t e r , M i n n e s o t a . H e received his doctorate in clinical psychology from F o r d h a m University, was a predoctoral clinical psychology intern at the Syracuse Veterans Affairs M e d i c a l Center, completed a postdoctoral fellowship in behavioral medicine at the B r o w n University School o f M e d i c i n e , and is a board-certified clinical health psychologist. His research focuses on behavioral interventions for weight m a n a g e m e n t , nicotine dependence, and coping with c a n c e r . Currently, his research is funded by the N a t i o n a l C a n c e r Institute.

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T H E HEALTH PSYCHOLOGY HANDBOOK Monica Cortez-Garland, B . A . , is a doctoral student in the Clinical Division o f the D e p a r t m e n t o f Psychology at T e x a s T e c h University. H e r research interests fall within addictive disorders. H e r current research endeavors include the investigation o f personality characteristics and their relation to smoking behavior. Csilla T . Csoboth, M . D . , is Assistant Professor in the Institute o f Behavioral Sciences at Semmelweis University in Budapest, Hungary. She received her medical diploma at Semmelweis University and specializes in psychiatry. She is currently completing her doctorate on the psychosocial risk factors affecting w o m e n ' s mental health. H e r other research interests include health-damaging behavior (e.g., obesity, nicotine and alcohol abuse), violence against w o m e n , and methods o f prevention a m o n g w o m e n . Patricia M. Dubbert, P h . D . , is Associate Chief o f M e n t a l Health and D i r e c t o r o f Psychology at the G . V . (Sonny) M o n t g o m e r y Veterans Affairs M e d i c a l Center and Professor o f Psychiatry, Preventive M e d i c i n e , and M e d i c i n e at the University o f Mississippi School o f M e d i c i n e . She received her bachelor's degree in nursing in 1 9 6 8 from the University o f M i s s o u r i - C o l u m b i a , her master's in mental health nursing in 1 9 7 2 from N e w Y o r k University, and her doctorate in psychology in 1 9 8 2 from Rutgers University. Mitch Earleywine, P h . D . , is Associate Professor o f Clinical Sciences in the D e p a r t m e n t o f Psychology at the University o f Southern California. H e received his doctorate from Indiana University and completed internship at the University o f Mississippi M e d i c a l School C o n s o r t i u m . H e has m o r e than 4 0 publications in the addictions literature, including the b o o k Understanding

Marijuana.

Barry A . Edelstein, P h . D . , is Professor o f Psychology in the Clinical Psychology Program at W e s t Virginia University. His current research interests include decision-making processes, assessment o f decision-making c o m p e t e n c e , anxiety, and suicidality a m o n g older adults. Sadie Emery, B . S . , is a doctoral student in the Clinical Division o f the Department o f Psychology at T e x a s T e c h University. H e r current research interests include investigating whether Cortisol is a m a r k e r for nicotine withdrawal and investigating the effect o f emotional expressive writing on nicotine withdrawal. Joel Erblich, P h . D . , is Assistant Professor o f Biobehavioral M e d i c i n e in the C a n c e r Prevention and C o n t r o l Program o f the Ruttenberg C a n c e r Center at the M o u n t Sinai School o f M e d i c i n e in N e w Y o r k City. H e completed his predoctoral clinical internship at the University o f California, Los Angeles, and completed a postdoctoral fellowship funded by the N a t i o n a l C a n c e r Institute at the M e m o r i a l Sloan Kettering C a n c e r Center, specializing in behavioral medicine. H e completed his graduate training in clinical psychology at the University o f Southern California. His research interests involve understanding the cognitive, behavioral, and genetic influences on risk for addiction. Myles S. Faith, P h . D . , is Associate R e s e a r c h Scientist at the N e w Y o r k Obesity Research Center ( N Y O R C ) and Assistant Professor o f Psychology in Psychiatry at the C o l u m b i a University College o f Physicians and Surgeons. H e received his

About the

Contributors

doctorate in clinical/school psychology from Hofstra University in 1 9 9 5 , after which he completed a 3-year postdoctoral fellowship at the N Y O R C . During this fellowship, he received training in behavioral-genetic methods for studying h u m a n obesity and focused on determinants o f childhood obesity. H e is funded to study genetic and environmental influences on caloric regulation and body fat in young children and has conducted behavioral interventions for c h i l d h o o d obesity. William C . Follette, P h . D . , is Associate Professor in the Clinical P r o g r a m o f the D e p a r t m e n t o f Psychology, as well as R e s e a r c h Associate Professor in Family and C o m m u n i t y M e d i c i n e , at the University o f N e v a d a , R e n o . H e received his doctorate in clinical psychology from the University o f W a s h i n g t o n . H e has served on a n u m b e r o f review panels for the N a t i o n a l Institutes o f Health and the N a t i o n a l Institute on Drug Abuse. In addition to interests in applied clinical behavior analysis and psychotherapy research design and methodology, he studies psychotherapy treatment development. Michael D . Franzen, P h . D . , is Associate Professor o f Psychiatry in the H a h n e m a n n School o f M e d i c i n e at D r e x e l University and Chief Psychologist at Allegheny General Hospital in Pittsburgh, Pennsylvania. H e completed his doctorate in clinical psychology at Southern Illinois University at C a r b o n d a l e . H e completed an internship and a postdoctoral fellowship in neuropsychology at the University o f N e b r a s k a School o f M e d i c i n e . H e is a fellow o f Division 4 0 o f the A m e r i c a n Psychological Association and a fellow o f the N a t i o n a l A c a d e m y o f Neuropsychology. H e has published extensively in the area o f neuropsychological assessment, test construction, dementia, and head injury. Sheila Garos, P h . D . , is Assistant Professor in the D e p a r t m e n t o f Psychology at T e x a s T e c h University and Assistant Adjunct Professor in Neuropsychiatry in the Division o f Urology at the T e x a s T e c h University Health Sciences Center. She has m o r e than 1 8 years o f experience in mental health. H e r areas o f clinical expertise include the assessment and treatment o f sexual disorders and dysfunctions, marital therapy, addiction, and adult psychopathology. H e r research interests include sexual attraction, compulsive sexual behaviors, w o m e n ' s sexuality, and psychometrics. Elizabeth V . Gifford, B . A . , is a doctoral candidate at the University o f N e v a d a , R e n o , and an intern at the Veterans Affairs (VA) Palo Alto H e a l t h Care System. She is currently working with the Center for Health C a r e Evaluation at Stanford University, the V A Palo Alto Health Care System, and the V A T a s k F o r c e on Violence Prevention. She is the recipient o f a Career D e v e l o p m e n t A w a r d from the N a t i o n a l C a n c e r Institute. H e r interests include addiction treatment, t o b a c c o control, social c o n t e x t and coping, and social and health policy. Suzy Bird Gulliver, P h . D . , is Staff Psychologist and D i r e c t o r o f H e a l t h Psychology at the Veterans Affairs B o s t o n H e a l t h c a r e System Outpatient Clinic as well as Assistant Professor in the B o s t o n University School o f M e d i c i n e ' s D e p a r t m e n t o f Psychiatry and Assistant Clinical Professor in the D e p a r t m e n t o f Psychology at B o s t o n University. She completed her doctoral training in clinical psychology at the University o f V e r m o n t . H e r predoctoral internship was conducted at the W e s t

585

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T H E HEALTH PSYCHOLOGY HANDBOOK H a v e n Veterans Affairs M e d i c a l Center, followed by a N a t i o n a l Institute on Alcohol Abuse and Alcoholism postdoctoral fellowship in a l c o h o l treatment o u t c o m e at B r o w n University. H e r research interests are in cross-addictions, c o m o r b i d psychopathology, and the role o f affect (dys)regulation. Kimberly R. Haala, B . S . , is a graduate student in clinical psychology at O k l a h o m a State University. She received her b a c h e l o r ' s degree at M i n n e s o t a State University, M a n k a t o . H e r research interests include investigating behavioral and physiological correlates o f nicotine use. Ahna L . Hoff, M . S . , is a pediatric psychology intern in the Department o f Psychology at Columbus Children's Hospital in Columbus, O h i o . She completed her graduate training in clinical child psychology at O k l a h o m a State University. H e r research interests include the development o f behavioral and cognitive interventions designed to mitigate psychological distress in the c o n t e x t o f chronic illness. Richard G. Hoffman, P h . D . , is Associate Professor o f Behavioral Sciences and Associate D e a n for M e d i c a l E d u c a t i o n and Curriculum at the University o f M i n n e s o t a School o f M e d i c i n e in Duluth. H e completed his predoctoral clinical internship in clinical and pediatric psychology and his postdoctoral fellowship in clinical neuropsychology at the University o f O k l a h o m a Health Sciences Center. H e completed his graduate training in clinical psychology in the B r o o k l y n Center at L o n g Island University. H i s research interests include brain-behavior relationships in closed head injury and the effects o f stress on neuropsychological functioning. Timothy T. Houle, P h . D . , is a postdoctoral fellow in behavioral medicine in the Center for Pain Studies at the R e h a b i l i t a t i o n Institute o f C h i c a g o / N o r t h w e s t e r n M e d i c a l School. H e completed his predoctoral clinical internship at the University of Mississippi M e d i c a l C e n t e r / J a c k s o n Veterans Affairs M e d i c a l Center C o n s o r t i u m , specializing in health psychology. H e completed his graduate training in clinical psychology at the Illinois Institute o f T e c h n o l o g y . His research interests involve the use o f time-series analysis in the clinical m a n a g e m e n t o f chronic pain. Wei-Chin Hwang, C.Phil., is a graduate student in clinical psychology at the University o f California, L o s Angeles. H e is currently completing his predoctoral clinical internship at the R i c h m o n d Area Multi-Services' N a t i o n a l Asian American Psychology Training Center. H i s research interests include cultural influences on the prevalence, etiology, diagnosis, and expression o f mental illness as well as ethnocultural differences in help seeking and treatment progress. Mark W. Ketterer, P h . D . , is a m e m b e r o f the Senior Bioscientific Staff at H e n r y F o r d Hospital and Adjunct Associate Professor o f Psychology at W a y n e State University. H e received his doctorate from the University o f M a r y l a n d , completed his internship at the J o h n s H o p k i n s University School o f M e d i c i n e , and completed a postdoctoral fellowship at the Uniformed Services University o f the Health Sciences. His research interests include behavioral risk factors in c o r o n a r y heart disease, circumventing denial/minimization o f e m o t i o n a l distress in c o r o n a r y heart disease patients, treatment o f anginal chest pain with cognitive-behavioral therapy and selective serotonin reuptake inhibitors, clinical trials, and health care reform.

About the

Contributors

J o s h u a C . K l a p o w , P h . D . , is Associate Professor in the D e p a r t m e n t s o f Psychology and Health Care O r g a n i z a t i o n and Policy at the University o f A l a b a m a at B i r m i n g h a m . H e received his doctorate in clinical psychology from the University o f California, San D i e g o , where he also completed a postdoctoral fellowship in geriatric health services research. His research focuses on the evaluation o f health status and quality o f life in chronic illness, including the use o f multivariate statistical modeling to evaluate change in health status. Lesley P . K o v e n , Μ . Α., is a doctoral student in the Clinical Psychology P r o g r a m at W e s t Virginia University. She earned her b a c h e l o r ' s degree at the University o f M a n i t o b a and earned her master's in clinical psychology at W e s t Virginia University. H e r research interests include geropsychology and behavioral medicine. H e r m o s t current project involves the e x a m i n a t i o n o f etiological variables related to the " s u n d o w n s y n d r o m e " in nursing h o m e residents with dementia. Shulamith Kreitler, P h . D . , is Professor o f Psychology in the D e p a r t m e n t o f Psychology at Tel-Aviv University and H e a d o f the P s y c h o - O n c o l o g y Unit at Tel-Aviv M e d i c a l Center. She completed her doctorate in psychology and psychopathology at Bern University in Switzerland. She also was a postdoctoral fellow at Y a l e University and a research fellow at the Educational Testing Service in Princeton, N e w Jersey. H e r research interests involve exploring the psychological correlates o f disease occurrence and different kinds o f disease course, especially in c a n c e r . Melissa C . Kuhajda, P h . D . , is Assistant Professor in the Department o f C o m m u n i t y and Rural Medicine and the Department o f Psychiatry and Behavioral Medicine in the College o f C o m m u n i t y Health Sciences at the University o f A l a b a m a in T u s c a l o o s a . She is also Assistant Director for Research in the University o f A l a b a m a Institute for R u r a l Health Research and is Adjunct Assistant Professor in the Department o f Psychology. She completed her doctorate in clinical psychology at the University o f A l a b a m a and completed her predoctoral internship at the M e m p h i s Veterans Affairs Hospital. H e r research interests involve the study o f treatments for chronic pain management and rural health issues. Jeffrey M . L a c k n e r , Psy.D., is Assistant Professor in the D e p a r t m e n t o f M e d i c i n e , as well as R e s e a r c h Assistant Professor in the Departments o f Neurosurgery and Anesthesiology, at the State University o f N e w Y o r k , Buffalo, M e d i c a l S c h o o l . H e completed his predoctoral clinical internship at the University o f T e x a s M e d i c a l School in H o u s t o n before receiving a N a t i o n a l Institutes o f Health-funded postdoctoral fellowship in behavioral medicine/pain at the University o f R o c h e s t e r M e d i c a l School. H e completed his graduate training in social psychology at the L o n d o n School o f E c o n o m i c s , in experimental psychology at the College o f W i l l i a m and M a r y , and in clinical psychology at Rutgers University. His primary research interests include o u t c o m e research and cognitive processes underlying painful medical disorders as well as their relationship to physiological mechanisms o f health and illness. T h a d R . Leffingwell, P h . D . , is Clinical Psychologist and Assistant Professor in the D e p a r t m e n t o f Psychology at O k l a h o m a State University. H e completed his

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T H E HEALTH PSYCHOLOGY HANDBOOK graduate training at the University o f W a s h i n g t o n and his predoctoral internship at the Puget Sound Veterans Affairs Healthcare System-Seattle. His research interests include brief motivational interventions for health behavior change and motivational predictors o f self-directed and assisted behavior change. H e has w o r k e d on five different federal, state, and privately funded intervention projects that investigated adaptations o f motivational interviewing. William R. Lovallo, P h . D . , is Professor o f Psychiatry and Behavioral Sciences at the University o f O k l a h o m a Health Sciences Center and D i r e c t o r o f the Behavioral Sciences Laboratories at the O k l a h o m a City Veterans Affairs M e d i c a l Center. His doctorate in biological psychology is from the University o f O k l a h o m a . H e was associate director o f the M a c A r t h u r Foundation's R e s e a r c h N e t w o r k on M i n d - B o d y Interactions and is the author o f Stress and Health: Psychological

Interactions.

Biological

and

H e has received funding from the Veterans

Administration and the N a t i o n a l Institutes o f Health to study stress mechanisms and risk for disease. Alexander Michas, B . A . , is currently pursuing his graduate education in California. H e completed his undergraduate education in psychology with honors at the University o f California, Santa Cruz. After working as a mentor and counselor in California, he joined the Health Psychology Clinic at the Veterans Affairs Boston Healthcare System Outpatient Clinic as a senior research assistant. Brian I . Miller, B . S . , is a doctoral student in clinical psychology at O k l a h o m a State University. H e completed his bachelor's degree at the State University o f N e w Y o r k at B i n g h a m t o n , majoring in psychobiology. His research interests include exploring the role o f the acoustic startle response and emotion-modulated startle in deprived and nondeprived smokers. Larry L. Mullins, P h . D . , is Professor o f Clinical Psychology and Associate D i r e c t o r o f Clinical Training at O k l a h o m a State University as well as Clinical Professor o f Psychiatry at the University o f O k l a h o m a Health Sciences Center. H e completed his internship in pediatric psychology at the O k l a h o m a University Health Sciences Center and received his doctorate from the University o f M i s s o u r i - C o l u m b i a in 1 9 8 3 . His research interests focus on the relationship o f cognitive appraisal mechanisms and children's adjustment to various chronic illnesses. Jack L.-M. Mutnick, B . S . , is a medical student at the University o f Nevada School o f Medicine and will be completing his M . D . in M a y 2 0 0 4 . H e earned his bachelor's degree in biology at the University o f N e v a d a , R e n o . Hector F . Myers, P h . D . , is Professor o f Psychology at the University o f California, Los Angeles ( U C L A ) , and D i r e c t o r o f the R e s e a r c h Center on Ethnicity, Health, and Behavior at the Charles R . D r e w University o f M e d i c i n e and Science. H e received his doctorate in clinical psychology from U C L A and is actively involved in research on psychosocial stress and behavioral contributors to ethnic health disparities in hypertension and cerebrovascular disease, H I V / A I D S , and m o o d disorders. H e has m o r e t h a n 1 0 0 publications and has received several awards for his research and student mentoring.

About the Contributors Kathleen M. Palm, M . A . , is a graduate student in clinical psychology at the University o f N e v a d a , R e n o . She received her master's in clinical psychology from M i n n e s o t a State University, M a n k a t o , in 1 9 9 8 . H e r research and clinical interests involve issues related to t r a u m a and behavioral medicine. Chebon A . Porter, P h . D . , is Staff Psychologist at the B i r m i n g h a m Veterans Affairs M e d i c a l Center's ( B V A M C ) Southeastern Blind R e h a b i l i t a t i o n Center. H e is also Assistant Professor in the D e p a r t m e n t o f Psychology at the University o f A l a b a m a at B i r m i n g h a m (UAB) S c h o o l o f M e d i c i n e and Assistant Adjunct Professor in the D e p a r t m e n t o f Psychology at Samford University. H e completed his postdoctoral fellowship in the U A B D e p a r t m e n t o f Psychiatry and Behavioral N e u r o b i o l o g y , completed his predoctoral clinical internship at the U A B / B V A M C Clinical Psychology T r a i n i n g C o n s o r t i u m , and completed his graduate training in clinical psychology at O k l a h o m a State University. His research interests include mental health issues in A m e r i c a n Indians and Alaska Natives. Eric H . Prensky, M . A . , is a doctoral student in the American Psychological Association-accredited Clinical Psychology Program at T e x a s T e c h University. His research interests involve smokeless t o b a c c o and personality variables. Sheri D . Pruitt, Ph.D., is Director o f Behavioral Medicine for the Permanente Medical Group in Sacramento, California. She received her doctorate in clinical psychology from the University o f N e w M e x i c o in 1 9 9 0 . She has 2 0 years o f health care experience in both the private and public sectors and has been a faculty member at the University o f California, San Diego, School o f Medicine and in the Department o f Psychology at San Diego State University. She has worked as a scientist for the W o r l d Health Organization ( W H O ) , was the principal writer for the recently published W H O global report on innovative care for chronic conditions, and continues to be an ongoing consultant to the W H O ' s Department of Noncommunicable Diseases. She has authored more than 5 0 professional articles, abstracts, and b o o k chapters in the area o f behavioral medicine. Steven M. Schwartz, P h . D . , is D i r e c t o r o f R e s e a r c h for O a k w o o d H e a l t h c a r e System and Clinical Assistant Professor in the Behavioral M e d i c i n e P r o g r a m o f the Department o f Psychiatry at the University o f M i c h i g a n . H e received his doctorate in clinical psychology from Virginia C o m m o n w e a l t h University with a behavioral medicine specialty and completed his predoctoral internship at H e n r y F o r d Hospital in D e t r o i t , specializing in medical psychology. H e went on to a postdoctoral fellowship in the Behavioral M e d i c i n e P r o g r a m at the University o f M i c h i g a n , where he subsequently served as the faculty c o o r d i n a t o r o f behavioral medicine services for University o f M i c h i g a n Hospital until taking over as director o f research for O a k w o o d . His research interests include behavioral cardiology, self-management o f chronic illness, and effectiveness research. Richard J . Seime, P h . D . , A.B.P.P., is Associate Professor o f Psychology, C o - H e a d o f the Section o f Integrated Evaluation and T r e a t m e n t , and C o o r d i n a t o r o f the Adult Behavioral T h e r a p y - C l i n i c a l H e a l t h Psychology T r a c k in the M e d i c a l Psychology Fellowship P r o g r a m o f the D e p a r t m e n t o f Psychiatry and Psychology

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THE HEALTH PSYCHOLOGY HANDBOOK at the M a y o Clinic in R o c h e s t e r , M i n n e s o t a . H e received his doctorate at the University o f M i n n e s o t a , completed his internship at the M i n n e a p o l i s Veterans Affairs M e d i c a l Center, and is board certified in clinical psychology. H e previously served as professor and chief in the Section o f Psychology o f the Department o f Behavioral M e d i c i n e and Psychiatry at the W e s t Virginia University School o f M e d i c i n e . His current research and clinical focus is the identification and treatment o f depression. Andrea K . Shreve-Neiger, M . A . , is a doctoral student in the Clinical Psychology P r o g r a m at W e s t Virginia University. She earned her bachelor's degree at the College o f W o o s t e r and earned her master's in clinical psychology at W e s t Virginia University. H e r primary research and clinical interests lie in geropsychology, with a special interest in spiritual and religious issues. Nicole J . Siegfried, Ph.D., is Assistant Professor in the Department o f Psychology at Samford University. She is also Project M a n a g e r in the Department o f Medicine o f the Division o f Preventive Medicine at the University o f A l a b a m a at Birmingham (UAB) School o f M e d i c i n e , where she also completed her postdoctoral fellowship. She completed her predoctoral clinical internship at the U A B / B i r m i n g h a m Veterans Affairs M e d i c a l Center Clinical Psychology Training Consortium. H e r graduate training was completed at O k l a h o m a State University. H e r research interests focus on prevention and treatment o f w o m e n ' s health disorders. C a t h y A . Simpson, P h . D . , is Assistant Professor o f Psychology at J a c k s o n v i l l e State University. She completed her predoctoral clinical internship at the University o f Mississippi M e d i c a l C e n t e r / G . V . (Sonny) M o n t g o m e r y Veterans Affairs C o n s o r t i u m and completed postdoctoral fellowships at the University o f Kentucky and the University o f A l a b a m a at B i r m i n g h a m , specializing in addictive behaviors. She completed her graduate training in clinical psychology at Auburn University. H e r research interests involve behavioral e c o n o m i c models and analyses o f substance use and abuse. T i m o t h y W . Smith, P h . D . , is Professor in the D e p a r t m e n t o f Psychology at the University o f U t a h . H e completed his graduate training in clinical psychology at the University o f K a n s a s . H e completed his predoctoral clinical internship and a postdoctoral fellowship at B r o w n University, specializing in behavioral medicine. H e is a past president o f the Division o f Health Psychology o f the American Psychological Association and is a m e m b e r o f the A c a d e m y o f Behavioral M e d i c i n e R e s e a r c h . His research interests focus on personality and social risk factors for cardiovascular disease, particularly in the c o n t e x t o f close personal relationships such as marriage. Kristen H . S o r o c c o , P h . D . , is a N a t i o n a l Institute on A l c o h o l Abuse and Alcoholism postdoctoral fellow in the Behavioral Sciences L a b s o f the D e p a r t m e n t o f Psychiatry and Behavioral Sciences at the University o f O k l a h o m a Health Sciences Center. She completed her graduate training in clinical psychology at O k l a h o m a State University, where she is n o w a visiting assistant professor. She completed her predoctoral clinical internship at the Veterans Affairs Palo Alto Health Care System, specializing in geropsychology. H e r research interests involve

About the

Contributors

examining the relationship between psychological stress and physiological processes a m o n g dementia caregivers. A d a m P. Spira, M . A . , is a doctoral student in the Clinical Psychology P r o g r a m at W e s t Virginia University. H e earned his b a c h e l o r ' s degree at the State University o f N e w Y o r k at Stony B r o o k and earned his master's in clinical psychology at W e s t Virginia University. His research interests include operant conditioning with older adults with dementia and functional neuroimaging. J . Kevin T h o m p s o n , P h . D . , has been affiliated with the D e p a r t m e n t o f Psychology at the University o f South Florida since 1 9 8 5 . H e received his doctoral degree in clinical psychology from the University o f Georgia in 1 9 8 2 . H e has authored, c o a u t h o r e d , edited, or coedited four b o o k s in the area o f eating disorders, body image, and obesity. His current research interests involve the identification o f risk factors for the development o f eating disorders, body image disturbance, and obesity. H e has been on the editorial b o a r d o f the International Disorders

Journal

of

Eating

since 1 9 9 0 and is also on the editorial boards o f four other journals.

Beverly E . T h o r n , P h . D . , is Professor and D i r e c t o r o f Clinical T r a i n i n g in the D e p a r t m e n t o f Psychology at the University o f A l a b a m a . She completed her graduate training in clinical psychology at Southern Illinois University and completed her predoctoral clinical internship at the University o f A l a b a m a at B i r m i n g h a m . H e r research interests involve the assessment and treatment o f c h r o n i c pain and illness. She is particularly interested in c o m p o n e n t analyses o f cognitive-behavioral treatments for c h r o n i c pain. J a l i e A . T u c k e r , P h . D . , M . P . H . , is Professor in the D e p a r t m e n t o f H e a l t h Behavior o f the School o f Public Health at the University o f A l a b a m a at B i r m i n g h a m ( U A B ) . H e r research, funded by the N a t i o n a l Institute on A l c o h o l Abuse and Alcoholism, investigates help seeking for drinking problems and h o w change occurs through different pathways, including natural resolutions. Because o f the relevance o f public health approaches, in 1 9 9 8 she earned a master o f public health degree in health care organization and policy from U A B . J a n e l l e L . W a g n e r , M . S . , is a graduate student in clinical psychology at O k l a h o m a State University. H e r research interests focus on psychosocial adjustment in children with c h r o n i c illnesses, specifically the juvenile rheumatic diseases, and their families. Stephen P. Whiteside, P h . D . , is a postdoctoral fellow in the D e p a r t m e n t o f Psychiatry and Psychology at the M a y o Clinic in R o c h e s t e r , M i n n e s o t a . H e completed his predoctoral clinical internship at Geisinger M e d i c a l Center in Danville, Pennsylvania, specializing in pediatric psychology. H e completed his graduate training in clinical psychology at the University o f K e n t u c k y . His research interests involve investigating the effectiveness o f psychological interventions, including the effects o f cognitive-behavioral therapy on the cognitive misattributions and neural activity in obsessive-compulsive disorder. D e b o r a h J . W i e b e , M . P . H . , P h . D . , is Associate Professor in the D e p a r t m e n t o f Psychology at the University o f U t a h , where she is D i r e c t o r o f Clinical T r a i n i n g .

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T H E HEALTH PSYCHOLOGY H A N D B O O K She also holds an adjunct faculty appointment in the D e p a r t m e n t o f Family and Preventive M e d i c i n e at the University o f U t a h H e a l t h Sciences Center. She completed her graduate training in clinical psychology at the University o f A l a b a m a at B i r m i n g h a m , specializing in medical psychology a n d public health. She completed her predoctoral clinical internship in behavioral medicine at the W e s t Virginia University H e a l t h Sciences Center. H e r research interests involve personality, self-regulation, health, and the interpersonal and developmental aspects o f coping with c h r o n i c illness. Helen R. Winefield, P h . D . , is Associate Professor in the Faculty o f H e a l t h Sciences at the University o f Adelaide in South Australia, where she has j o i n t appointments in the Departments o f Psychology a n d Psychiatry. She is also a fellow o f the Australian Psychological Society; a m e m b e r o f its Colleges o f Clinical, Organizational, a n d H e a l t h Psychologists; a n d a registered psychologist. T h e author o f an early t e x t b o o k in behavioral science for medical students, she currently directs the university o f Adelaide's Clinical Psychology P r o g r a m a n d holds a research grant from the Better O u t c o m e s in M e n t a l Health C a r e initiative in Australia. Valerie A . Wolfe, P h . D . , is Behavioral M e d i c i n e Consultant at Kaiser Permanente in N o r t h e r n California. She received her doctorate in counseling and health psychology from Stanford University. She w a s a teaching fellow at Stanford, an adjunct faculty m e m b e r at Santa C l a r a University, a n d a researcher/clinician at the Palo A l t o , M e n l o P a r k , a n d Albuquerque Veterans Affairs hospitals. Before starting at Kaiser, she w a s the director o f a 3 0 - b e d residential treatment center. She has trained hundreds o f physicians in the use o f cognitive-behavioral strategies to treat insomnia and has presented at national meetings regarding the treatment and evaluation o f insomnia. Barbara A . Wolfsdorf, P h . D . , is Staff Psychologist a n d Associate D i r e c t o r o f Health Psychology at the V e t e r a n s Affairs (VA) B o s t o n H e a l t h c a r e System Outpatient Clinic and Assistant Professor o f Psychiatry at the B o s t o n University School o f M e d i c i n e . She completed her doctoral training in clinical psychology at the University o f M i a m i . She subsequently completed a predoctoral internship at the B o s t o n V A Internship C o n s o r t i u m and a N a t i o n a l Institutes o f H e a l t h postdoctoral fellowship in c o m b i n e d treatment o u t c o m e research at the B r o w n University S c h o o l o f M e d i c i n e . T h e focus o f her research is the process o f e m o t i o n regulation as it applies t o psychopathology (e.g., depression, posttraumatic stress disorder) a n d addictions (e.g., a l c o h o l , nicotine) as well as the treatment o f these difficulties.