Promoting Health Intervention Strategies from Social and Behavioral Research (2000) / Chapter Skim
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Paper Contribution L: Behavioral and Psychosocial Intervention to Modify Pathophysiology and Disease Course
Paper Contribution L: Behavioral and Psychosocial Intervention to Modify Pathophysiology and Disease Course
Pages 450-488
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Other diseases and serious medical conditions are also considered briefly. Stress and Cardiovascular Disease The effects of stress on the pathophysiology of heart disease, hypertension, stroke, and other cardiovascular disorders are broad and increasingly well documented.
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The first describes simple relationships between behavioral variables and cardiovascular disease, the second considers behavioral influence and cancer, and the third depicts simple relationships between behavior and HIV disease.
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, offer some of the best evidence of stress effects on cardiovascular diseases (e.g., Manuck et al., 1983~. Animal studies clearly suggest that stress can accelerate pathogenesis of coronary heart disease and hypertension and can evoke cardiac events (Smith and Gallo, 1994~.
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Periodic reorganization of social groups has been used to generate chronic stress as animals repeatedly experience unstable social conditions, and this manipulation has permitted detailed observation of the impact of social dominance, diet, and stress on the development of cardiovascular disease (Kaplan et al., 1984~. Dominant monkeys in unstable conditions exhibited the most extensive signs of heart disease, but these effects were dramatically increased by high-cholesterol diets (Manuck et al., 1986~.
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Stress and Cancer Like heart disease, cancer is a slowly developing disease that features gradual pathophysiological activity and disease events that may have specific triggers. Also like cardiovascular disease, cancer may be influenced by behavioral factors
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Unfortunately, we cannot detect early development of most cancers and cannot specify the length of the recruitment period. In some cases, a nascent breast cancer, for example, may be detectable after 5 years of development, in other cases, this developing tumor
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A meta-analysis of 46 studies linking mood and anxiety disorders, childhood environment, personality, coping, and stress with the development of breast cancer yielded small but significant effects for denial or repressive coping, separation and loss experiences, and stressful life events (McKenna et al., 1999~. The authors concluded that there was evidence of a moderate association between these psychological variables and breast cancer, but the size of these relationships was interpreted as equivocal support for the notion that stress contributes to development of the disease (McKenna et al., 1999~.
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The extent to which the original diagnosis of cancer was stressful did not predict recurrence of breast cancer in one study but chronic stress assessed before cancer diagnosis was made was a strong predictor of relapse (e.g., De Brabander and Gertis, 1999~. Other studies have also shown associations between stress or other biobehavioral factors and cancer recurrence or progression (e.g., Levy et al., 1985, 1989, 1990, Ramirez et al., 1989~.
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Stress and HIV Disease HIV disease and AIDS are also different from cardiovascular disease in many ways. They refer to the chronic disease established by infection with the human immunodeficiency virus, a relatively new retrovirus that lives in and destroys components of the immune system.
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However, there are now sufficient data to establish a plausible case for such influences. Like cardiovascular disease and cancer, HIV disease has a variable course and progresses through latency or as it overwhelms immune defenses at widely variable rates.
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The results of this clearly indicated that adjustment problems associated with HIV disease were an important source of distress but could not specify whether these adjustment problems were a product of disease progression or fed back to affect disease course. An interesting avenue of investigation has been studies of inhibition and stress as predictors of disease course.
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Because HIV disease and AIDS are diseases that are centrally immunological and involve suppression of immune responses that are also suppressed by stress, it remains likely that behavioral influences on immune status constitute modifiable variance in disease progression. CONCEPTUAL BASES FOR BEHAVIORAL INTERVENTIONS Simply stated, theories underlying behavioral intervention to modify disease course are based on the assumptions that behavioral or psychosocial influences on disease course are modifiable and that reducing negative influences will slow disease progression or minimize recurrence of disease following treatment.
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What has become clear is that modification of these "health-impairing" behaviors and processes is an important goal, that comprehensive programs appear to be well suited for this effort, and that an emphasis on substituting "health-enhancing" behaviors for less healthy activities is important as well. As suggested by this, interventions remain eclectic and loosely centered on one or another basic approach to stress management, psychoeducation, support provision, and/or behavior change.
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Nearly 40% of cancer patients report problems with loss of appetite or inability to eat, and cancer patients or survivors appear more likely than healthy people or people who have never had cancer to report sleep difficulties (e.g., Celia and Tross, 1986, Wellisch et al., 1989~. The detailed analysis of these and other health behaviors as well as direct effects of cancer treatments on these behaviors describes a compelling framework within which to view psychosocial and biobehavioral mediation of disease course.
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Some studies find evidence supporting the notion that behavioral interventions can reduce risk for cardiovascular disease by reducing physiological developments that predispose or trigger these disorders. For example, stress management interventions can reduce the hostility, competitiveness, and time urgency associated with Type A behavior, can lower serum cholesterol, and can reduce blood pressure (Bennett and Carroll, 1990b)
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Biofeedback-assisted stress management can also reduce muscle tension and cortisol responses that contribute to high blood pressure (McGrady et al., 1987~. The most frequent target of interventions to reduce cardiovascular disease have been directed at hypertension.
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The efficacy of relaxation training in reducing blood pressure has been shown as well (e.g., Irvine et al., 1986, Albright et al., 1991, Broota et al., 1995~. A 4-year study of relaxation and behavior change to reduce cardiovascular disease risk found poor long term adherence to the program (only 17% of the intervention group reported that they still engaged in regular relaxation after 4 years)
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Although large-scale prospective evaluations of comprehensive cardiovascular risk reduction interventions using biological markers of disease progression have generally not been reported, several studies using broad interventions to slow disease progress or otherwise reduce the likelihood of disorders or cardiovascular events have been done. For example, cardiovascular risk reduction programs that are aimed at simultaneous alteration of several risk-enhancing behaviors are associated with beneficial changes in several intermediate outcomes linked with coronary heart disease (Lovibond et al., 1986~.
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Many are with breast cancer patients (e.g., Helgeson et al., 1999) , but this approach is being broadened to include other cancers at a variety
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For example, Helgeson and her colleagues have compared a psychoeducational intervention for primary-stage breast cancer patients with an intervention concentrating on social support and one dealing with both approaches simultaneously (Helgeson et al., in press)
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Relaxation training, education, and coping skills training also reduced levels of stress hormones and increased overall numbers of lymphocytes among breast cancer patients (Schedlowski et al., 1984~. Two months of relaxation training for ovarian cancer patients who were receiving chemotherapy were associated with more lymphocytes and higher white blood cell counts (Lekander et al., 1997~.
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There are other behavioral factors that affect immunity in ways that could contribute to HIV disease progression, but evidence is insufficient to draw firm conclusions. Many of these factors are also affected by stress: alcohol use, for instance, is affected by stress (Breslin et al., 1995)
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. These effects appear to be relatively stable over time and provide compelling evidence of the pervasive influences of biobehavioral processes on HIV disease and of the ameliorative impact of intervention in this population.
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It has been assumed, for example, that women respond more positively to group interventions and social support than do men, and a variety of theoretical justifications can support such predictions. Comparisons are sparse, in part because the majority of these studies are for breast cancer, and early results from prostate cancer interventions suggest that men also respond well to these approaches.
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(19954. Hemoconcentration and stress: A review of physiological mechanisms and relevance for cardiovascular disease risk.
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. Stress management approaches to the prevention of coronary heart disease.
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(1995~. Depression as a risk factor for cardiac events in established coronary heart disease: A review of possible mechanisms.
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(1990) Type A behavior and coronary heart disease: The third stage.
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(1993~. Immunological responses of breast cancer patients to behavioral interventions.
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(1992~. Behavioral clusters and coronary heart disease risk.
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(1998~. Social isolation and cardiovascular disease: An atherosclerotic pathway?
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(1988~. Environmental stress and biobehavioral antecedents of coronary heart disease.
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(1986~. Changing coronary heart disease risk-factor status: The effects of three behavioral programs.
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(1987~. Psychologic treatment for the Type A behavior pattern and for coronary heart disease: A meta-analysis of the literature.
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(1991~. Type A behavior pattern and coronary heart disease: The hostilitv factor?
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(1991~. Personality and coronary heart disease.
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(1994~. Psychosocial influences on coronary heart disease.
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Effect of mild acute stress on immune cell distribution and natural killer cell activity in breast cancer patients. Biological Psychology, 48~1)
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