1. Characteristics of psychophysiological disorders (p. 204) Anxiety and stress have some role in sudden death syndrome, unexpected death that often seems to have no physical basis. Sudden death, the leading cause of death in industrialized countries, is related to the likelihood of blood clotting, blood pressure rising and tearing off fat deposits, and heart rhythm changes. Sudden death among Hmong immigrants in the United States may be due to severe culture shock.
   In earlier versions of the DSM, certain disorders (psychosomatic disorders) were seen as stemming from psychological problems. Now, psychological problems are believed to be potential factors in almost any physical problem. Disorders that include both psychological and physical problems are called psychophysiological disorders. Unlike in conversion disorders, the tissue damage is real. The DSM-IV-TR diagnosis of psychological factors affecting medical condition requires a medical condition and one of the following: a relationship in time between the psychological factor and the condition; a psychological factor that interferes with treatment; and psychological factors that add to the individuals health risk.
2. Models for understanding stress (p. 206) Stress is an internal response to an external, threatening event, or stressor. Stressors can be biological, psychological, or social. In the general adaptation syndrome, formulated by Selye, the body automatically reacts to prolonged stress in three stages: alarm (the body reacts with rapid heartbeat, loss of muscle tone, decreased temperature and blood pressure), resistance (the body mobilizes to defend against the stressor), and exhaustion (body resources are depleted and illness or even death may occur). Sustained stress may not only reduce resistance to disease, but may also alter its course.
   The life change model emphasizes the frequency and characteristics of the stressors. Cumulative changes, both positive and negative, are measured on the Social Readjustment Rating Scale (Holmes and Rahe) in life change units. The more units, the greater the likelihood and severity of illness, although it is too soon to say if stressors are the cause of illness. Evidence shows that negative life events have greater impact than those that are positive.
   Lazarustransaction model suggests that both the situation and the persons reaction to it explain stress-related illnesses. Perceptions of events are critical; those who adapt cognitively may reduce susceptibility to illness or limit its course by changing health-impairing habits and sticking to treatment guidelines.
3. Stress and the immune system (p. 210) Viral conditions, such as herpes infection, Acquired Immune Deficiency Syndrome (AIDS), and even the common cold may be influenced by cognitive and emotional factors. There are a variety of biological, behavioral, cognitive, and social pathways that affect the immune system. For example, biologically, depression may directly produce deterioration of the immune system. Part of the stress response involves the release of neurohormones, such as corticosteroids and endorphins, which compromise immune functioning. Behavioral characteristics associated with depression, such as poor diet or lack of exercise may also contribute, as may failure to follow treatment guidelines. Psychological factors, too (e.g., negative self-image), have been associated with decreased immune functioning. This relation may be moderated by various psychosocial variable, such as self-efficacy and social support. Stress reactions release chemicals that suppress such immune system components as lymphocytes (B-, T-, and natural killer cells) and phagocytes. Divorce, bereavement, and other stressors can impair immune functioning directly or indirectly through such poor health practices as sleeping less or drinking more, although a happy marriage seems to act as a buffer for men.
4. Mediating the effects of stressors (p. 213) Perception of control over the environment seems to reduce stress effects, as evidenced by rats ability to reject cancer cells and by reduced mortality rates in nursing home patients given additional responsibilities. Hardiness, a personality trait characterized by openness to change, commitment, and a sense of personal control, appears to protect individuals against stress-related illness. However, the reduction in immune functioning caused by psychological factors is often quite small. Two other mediators that affect health are self-efficacy and optimism.
5. Personality, mood states, and cancer (p. 215) Positive emotions and the expression of such negative ones as anger may be involved in the development, course, and recurrence of cancer. However, research and methodological problems make these propositions controversial. Even well-designed studies linking anger expression and breast cancer have alternative explanations. However, in one prospective study, MMPI depression scores predicted cancer even when lifestyle and family history factors were taken into account. Further, research on humor suggests that it may influence the disease process: with a direct impact on physical functioning; it may influence health promoting behaviors; it may buffer stressors and negate stress; and it may make a person more likely to receive social support; also, laughter has been found to increase immune functioning.
6. Psychological involvement in specific physical disorders (p. 218) Coronary heart disease (CHD), a narrowing of arteries in or to the heart, kills nearly 400,000 people in the United States annually. One risk factor for CHD is depression, which is more common in women than in men, although women seem to develop CHD about ten years later than menperhaps due to the effects of estrogen prior to menopause. Stress also plays a role: psychosocial stressors are associated with increases in a blood-clotting compound; a prospective study found that anxiety symptoms predicted death due to cardiac arrest. The Type A personality pattern is also involved in CHD. Type As are time-pressured, competitive, and often hostile and irritable. It is the hostility and irritability (whether expressed or hidden) that seem to be the only significant risk factors for Type As.
   Essential hypertension (high blood pressure) can lead to heart attacks and other fatal disorders. Higher stress levels correlate with higher blood pressure. Anger, expressed and unexpressed, may be related to chronic hypertension, particularly for men. Hypertension is a greater problem for blacks than for whites, perhaps because of differences in psychosocial resources. High-status jobs together with the perception that hard work is needed for success are associated with high blood pressure in women and African American men, but not in white men.
   Stress contributes to all three types of headaches: migraine, tension, and cluster headaches. The classic migraine headache has neurological warning signs, such as distorted vision or numbness in the body, followed by intense, throbbing pain. In the common migraine, there may be no neurological symptoms. Although the name implies it, tension headaches are not necessarily caused by muscular tension; psychological factors are often the precipitants. Cluster headaches are excruciating and center on the area around the eye. Drug therapy, exercise, eliminating certain foods from the diet, relaxation, biofeedback, and cognitive therapy show promise in treating headaches.
   Asthma is a chronic inflammatory disease that makes breathing difficult. There has been a recent and unexplained rise in deaths resulting from asthma. Most sufferers are adolescents or young children who have allergies, although genetics or psychological factors involving family dynamics can also be involved.
7. Perspectives on etiology (p. 227) According to Alexander (1950), a psychoanalyst, each type of psychophysiological disorder is caused by a specific unconscious conflict. Research support for this is not strong.
   There is some evidence that genetics influences the rate of psychophysiological disorder. Somatic weakness theory proposes that certain organs are weakened by earlier experience and are vulnerable to disease under stress. The autonomic response specificity hypothesis argues that each person has a unique way of responding to stressors. The general adaptation syndrome may be combined with the previous two theories to understand illness as a disease of adaptation.
   Classical conditioning may explain how certain stress reactions can generalize to a wide range of stressful stimuli. However, this perspective cannot account for the original reaction. Operant approaches note that internal processes originally thought to be involuntary can be influenced by external reinforcement and biofeedback.
   Sociocultural factors, particularly social support, conflict with cultural expectations, and other cultural factors are implicated in medical conditions. Japanese who retain close social and emotional ties and maintain traditional values seem to have lower coronary heart disease levels than acculturated Japanese Americans.
8. Treatment of psychophysiological disorders (p. 229) Behavioral medicine comprises a range of disciplines that study the social and psychological issues in health and apply that knowledge to stress management approaches. In relaxation training, individuals are taught to alternately tense and relax muscle groups in the body. In biofeedback training, clients are informed about small internal changes (such as in blood pressure and heart rate). They learn to control these internal processes and eventually do not need the monitoring devices. Essentially an operant technique, biofeedback has been used to treat a range of psychophysiological disorders, from headache to asthma. Stress management programs often include such cognitive-behavioral interventions as self-instructional techniques and cognitive restructuring.