healthy psychology

what is stress

Definition: When the demands placed upon you exceed your ability to cope
Or "negative emotional experience accompanied by predictable biochemical, physiological, cognitive, and behavioral changes that are directed either toward altering the stressful even

primary appraisal of stress

the person tries to understand the stressful situation and what it means to them:
Harm, threat or challenge

secondary appraisal of stress

the person assesses whether or not their resources are sufficient to meet the demands of the stressful situation: sufficient resources mean the event is more likely to be interpreted as a challenge, insufficient resources may result in experiencing a grea

Walter Cannon (1932)

the "fight-or-flight" response
-The body mobilizes a coordinated physiological response to escape from the threat or to attack the threat

taylor and her colleagues (2000)

suggest "tend and befriend" is a potential response as well
-Affiliative response to stress which involves coming together and helping each other during threatening times
-Found more commonly among females
-The observed sex difference is due to different

The general adaptation syndrome

Hans Selye's (1956, 1976)
-A set of nonspecific reactions with predictable physiological patterns
-Selye exposed rats to various stressors and observed a three part response consisting of:
-Alarm- the organism mobilizes to meet the threat
-Resistance- act

direct physiological pathways of stress

-Stress impacts upon biological functioning
-contribution of stress to illness

indirect effects via behavioral pathways of stress

-Stress is related to various poor health habits
-contribution of stress to illness

indirect effects via psychosocial pathway of stress

-Stress may make people avoid others that could be potential sources of social support
-contribution of stress to illness

indirect effects via health services of stress

-individuals under stress may delay seeking health services
-Adherence to medical recommendations is lower among individuals under stress
-contribution of stress to illness

effects of long-term stress and allostatic load

-Humans are well adapted to short term stressors, but not to the constant barrage of stress modern life exposes us to
-"Allostatic load" refers to the negative physiological changes associated with repeated or chronic stress
-Long term stress is associate

reactivity

-degree of change in your body as a result of stress
-Greater reactivity =greater allostatic load
-Reactivity may be linked to the presence of ACEs, or adverse childhood events, with increased vulnerability to stress resulting from exposure to poverty and

dimensions of stressful events

negative, uncontrollable, ambiguous, overload
-People can adapt to chronic stressors such as noise and crowding (habituation) BUT chronic stress in vulnerable individuals is associated with LACK of habituation and negative outcomes

negative

Positive events (e.g., wedding planning) can also be stressful!

uncontrollable

Predictable events over which you have control are much less stressful

ambiguous

Not knowing what to do or how to do it is stressful

overload

Having too much to do and not enough time can be stressful

PTSD

-Extreme stressors (combat exposure, assault/rape, domestic violence, natural disaster) can lead to symptoms such as:
-Reliving the trauma
-Impaired memory and concentration
-Sleep disturbances, psychic numbing and detachment
-Depression (with a heightene

less severe aftereffects than ptsd

-Shortened attention span
-Cognitive disruptions
-Ongoing distress and physiological arousal

acute stress paradigm

Inducing brief stress in a laboratory setting causes both psychological distress and physiological arousal
-May help identify individuals who are most vulnerable

inducing (mild) illness

Stressed individuals are more likely to get sick in response to exposure to a flu virus

stressful life event inventories

Events that cause greater disruption in various areas of life are at the "top" of the stress scale
-Inventories are no longer frequently used because of vague methodology and lack of emphasis on individual differences

Daily hassles and its effects

-Daily hassles, or "microstressors" can include:
-Parking at Rowan!, chores, traffic, waiting in line...
-The effects of microstressors can be cumulative
-They can wear a person down and cause illness
-They can "synergistically" combine with life events o

sources of chronic stress: adverse childhood events

-ACEs can affect physical and mental health across the lifespan
-ACEs include low SES, abusive or harsh families, exposure to familial mental illness or alcoholism
-Greater # of ACEs = higher risk of stress-related health problems
-Kauai longitudinal stud

chronic stress and ses

-SES is arguably the most critical variable in both physical and mental health
-SES is often tied to racial/ethnic differences
-Lower SES African-Americans are more likely to experience poverty, unemployment, riskier living situations, and lack of access

chronic stress and the workplace

-Occupational stressors include:
--Work overload - too much to do
--Role conflict - conflicting information about priorities and difficulty deciding what tasks to pursue
--Work ambiguity - lack of clarity about tasks
--Lack of control over work tasks
---J

multiple roles and stress

Juggling several life roles, and the potential role conflict this causes, can be a source of stress, particularly for women
-Men are affected too: Men with high levels of work stress are likely to have fewer interactions with their children
-Supportive, h

stress moderators

-Modify how stress is experienced and the effects it exerts
--Stress moderators can:
--Buffer the extent to which a stressor impacts upon a person's life
--Reduce the actual stress experienced
--Attenuate the relationship between stress and illness
--Exam

coping with stress

Coping is defined as the thoughts & behaviors used to manage both the internal and external demands of stressful situations
--Coping is a dynamic, ongoing process - not a one-time action
--Both emotional reactions and voluntary, tangible actions are consi

personality and coping

Overall research suggests that our general levels of negative affectivity and positive affectivity have a fairly strong genetic basis
-Research also suggests that these personality characteristics can be (somewhat) modified

negative affectivity

pervasive tendency to express discomfort and dissatisfaction across many situations; also known as neuroticism
-Marked by anxiety, depression, and hostility
-Related to:
--Poor health
--All-cause mortality
--Higher levels of stress indicators
-Associated

positive affectivity

pervasive tendency to have a positive emotional reaction across many situations; e.g., the "glass is half full"
-Promotes better mental and physical health
-Linked with lower levels of stress indicators
-Triggers better immune responses
-Improves coping

optimism and what it is related to

-a generalized tendency to expect positive events to occur
-Optimism is related to:
-Better physiological stress profiles
-Active and persistent coping efforts when needed
-A sense of personal control
-Better physical health, greater resistance to illness

psychological control

-the belief that you can determine your own behavior, influence your environment, and attain desired outcomes
-Much classic research in psychology viewed an internal locus of control as foundational to healthy functioning and motivation
-secondary control

secondary control

a belief that good outcomes are possible through collaboration/cooperation with others (including medical practitioners)

control-enhancing interventions

such as those utilized in CBT, improve coping and stress management

psychosocial resources

optimism, psychological control, selfesteem (can help moderate stress particularly at lower levels of stress), conscientiousness (is associated with lower stress), self-confidence and emotional stability, intelligence

intelligence

Possibly people with the above characteristics take better care of themselves and have the opportunity to accumulate more resources

resilience

ordinary magic"
-Helps individuals bounce back and adapt flexibly to stressful situations
-Resources that promote resilience:
-Sense of coherence and purpose about life
-Sense of humor and trust in others
-Sense that life is worth living
-Religious belie

coping style

-Propensity to deal with stressful events in a particular way; important individual difference
-avoidant coping style
-approach coping style
-problem-focused coping
-emotion-focused coping
-emotional approach coping
-proactive coping

avoidant coping style

Coping by avoiding or minimizing the stressful situation

approach coping style

-Coping by gathering information or by directly taking action
-Overall, approach coping styles are more successful, although they can exacerbate stress in the short term; avoidance tends to be unsuccessful in cases of chronic stress

problem focused coping

Attempting to do something constructive about the stressful conditions

emotion focused coping

Regulate emotions experienced due to the stressful event
-The nature of the stressful event may determine the success of these different approaches: when you can do something about the stress, problem-focused coping is more successful, when the stressor m

emotional approach coping

(A type of emotion-focused coping):
-Clarifying, focusing on, and working through the emotions in response to a stressor
--Aids in adjusting to chronic life situations and medical conditions
--Helps manage stress better

proactive coping

Anticipating potential stressors and acting in advance
-Great if you can do it!
-Not as much research to date on this type of coping

coping and external resources

-Greater external resources provide individuals with more ways of coping with stress and result in better outcomes
-Some examples of external resources:
--SES - possibly the most potent resource because it is associated with many others
--Friends and fami

how is coping measured?

Successful coping is assessed in many ways, including:
--Resuming daily activities
--Adjusting to/accepting negative realities or events
--Maintaining a positive self-image
--Reducing physiological measures of stress to healthy or healthier levels
--Conti

ways of coping

mindfulness meditation, ACT, expressive writing (journaling), relaxation training

mindfulness meditation

Teaches individuals to:
-Have a heightened awareness of the present
-Focus on the present and accept it

mindfulness-based stress reduction

Helps people to react mindfully to stress rather than automatically reacting to stress
--Studies indicate MBSR enhances cortical activity and lessens activity in brain regions associated with negative emotions/anxiety
--May have beneficial effects on phys

ACT

-Acceptance and commitment therapy (ACT) - Teaches individuals to:
--Accept the problem
--Be aware of its occurrence and the conditions that elicit it
--Change behaviors and work to overcome a stressor while accepting difficult thoughts and feelings
--Hel

expressive writing (journaling)

-Lowers psychological and physiological indicators of stress
--Although it can increase short term distress to write about a traumatic experience
-Aids in effective coping
-Helps organize thoughts and find meaning
-Helps to focus attention on positive asp

relaxation training

Affects the physiological experience of stress by reducing arousal. Can involve multiple methods, such as:
-Deep breathing
-Progressive muscle relaxation training
-Guided imagery
-Transcendental meditation and yoga; which have been found to have significa

coping effectiveness training

Typically draws on CBT techniques to help people:
-Assess stressful events
-Break stressors into specific parts that can then be focused upon and dealt with more effectively
-Learn about what aspects of the stressor can be changed and what aspects cannot

stress management and college students

-80% of college students say they experience stress on a frequent or daily basis
-Stress Management programs are multi-faceted and typically involve:
--Learning what stress is and how to identify personal stressors
--Acquiring and practicing coping skills

elements of stress management for college students

Completing take-home assignments
--"stress diaries" and accompanying thoughts
Setting new goals
--Helps students be specific and concrete about possible actions
-Engaging in positive self-talk and self-instruction: encouraging yourself!
-Time management a

social support

Information/emotions/actions from others that let one know that one is:
--Loved and cared for
--Esteemed and valued
--An important part of a network of communication and mutual obligations
-Helps people reduce stress, cope better, and live more positively

types of social support

tangible assistance, informational support, emotional support, invisible support

tangible assistance

-provision of material support
-services, financial assistance, or goods

informational support

providing support through information

emotional support

reassuring someone that they are important and cared for

invisible support

helping someone without him or her being aware of it

effects of social support on illness

-Lowers the likelihood of illness
--People take better care of themselves when they experience social support
---Although bad health habits are possible as well depending upon the habits of one's peer group
-Speeds up recovery
-Reduces the risk of mortali

biopsychosocial pathways involved in social support

-Social support has positive effects on the cardiovascular, endocrine, and immune systems
--Lowers physiological and neuroendocrine responses to stress
--Decreases cortisol responses to stress
--Better immune functioning
--Modifies brain's responses to st

direct effects hypothesis

Social support is generally beneficial during non-stressful as well as stressful times

buffering hypothesis

-Physical and mental health benefits of social support are chiefly evident during periods of high stress
--The buffering hypothesis maintains that social support blunts the effects of high levels of stress
--Research evidence suggests that both direct eff

effective kinds of support

-A good marriage, support from family/friends
-PETS!
-Support from the community
-Matching support to the stressor

matching hypothesis

-Support that meets the needs of a stressful event is the most effective support
-The "wrong" kind of support can actually increase the stress that is experienced

giving social support

-Has beneficial effects on the mental and physical health of the person giving it
-Enhancing social support is critical; loneliness is a growing problem as people live longer and also report having fewer friends
-Social network and internet-based support

recognizing and interpreting symptoms

-is not a straightforward process
-People's awareness of what is going on in their bodies is somewhat limited, and many factors influence health decisions:
--Individual differences
--Situational factors
--Stress
--Mood/attentional differences

individual differences

hypochondria, neuroticism, age

hypochondria

-Hypochondriacs assume normal body variations are symptoms of illness
--Only 4-5% of the population, but disproportionately represented among those seeking medical services

neuroticism

This pervasively negative view of the world extends to bodily symptoms

age

older people report more symptoms than younger people

attentional differences

-Self-focus increases awareness of and attention to symptoms
--Self focus is associated with boredom, too much time alone, lower levels of activity
-Busy or distracted individuals notice symptoms less
--A more active social life or more satisfying/busy wo

situational factors

-Boring situations increase focus on symptoms
--You'll notice that sore throat when you're alone as opposed to out with friends
--Medical student's disease: you read about it, you have it!
-Stress can either precipitate or exacerbate the experience of sym

interpretation of symptoms

prior experience (common disorders are regarded as less serious than rare disorders), expectations (unexpected symptoms are ignored and expected symptoms are amplified), seriousness of the symptoms (treatment is sought only when the symptom: affects a hig

commonsense beliefs

-Held by people about their symptoms and illnesses
--Result in organized illness representations
-Includes basic information about an illness
--Identity - Name of the illness
--Causes - Factors believed to have led to the illness

commonsense model of illness components

Consequences - Symptoms, treatments, and their implications for quality of life
Time line - Length of time the illness is expected to last
Control/cure - Whether the person believes the illness can be managed or cured
Coherence - How well these beliefs re

acute illness

-believed to be caused by viral or bacterial agents
-short in duration, with no long-term consequences

chronic illness

-believed to be caused by multiple factors
-long in duration, with severe consequences

cyclic illness

alternating periods of either no symptoms or many symptoms

lay referral network

-Family and friends who offer their own interpretations of symptoms way before the treatment is sought
-The Internet can also be seen as a "lay referral network", with two-thirds of users seeking health information via the web
-Advice is offered regarding

who uses health services?

-Age - Infants and the elderly use health services most frequently
-Gender
--Men are expected to be "stoic" and ignore problems
--Women use it more than men
---Pregnancy and childbirth are major factors
---Women have better homeostatic mechanisms; may be

psychological complaints

-Nonmedical complaints that stem from anxiety and depression
--The majority of patients in a family practice are there because of psychological factors, but few ever see a mental health expert
-People use health services for psychological complaints becau

delay behavior

-Delay behaviors occur when an individual should seek health services but does not
-Serious, dramatic symptoms such as severe shortness of breath, seizures and extreme abdominal pain can precipitate the use of services quite rapidly
-However, patients can

appraisal delay

time taken to decide that a symptom is serious

illness delay

time between the recognition that a symptom implies an illness and the decision to seek treatment

behavioral delay

time between deciding to seek treatment and actually doing so

medical delay

time that elapses between the person's calling for an appointment and his or her receiving appropriate medical care

causes of delay

-Common among people:
--With no regular contact with a physician
--Who are phobic about medical services
-Symptoms that are likely to cause delay seeking treatment are:
--Those similar to a previous one that turned out to be minor
--Those that do not hurt

consumerism and the health care delivery system

-As you know, many individuals increasingly value the idea of a "partnership" between themselves and their health care provider(s)
-Patients are "consumers" who want to make informed choices; practitioner authority is more likely to be questioned than in

types of health care providers

nurse practitioners, advanced-practice nurses,
physician's assistants

nurse practitioners

-Affiliated with physicians in private practice
-See their own patients
-Provide routine medical care
-Prescribe treatment
-Monitor progress of chronically ill patients
-Explain disorders and their origins, diagnoses, prognoses, and treatments

advanced practice nurses

-Certified nurse midwives
-Clinical nurse specialists
-Certified nurse anesthetists
-Some obstetrical care and births
-Cardiac or cancer care
-Administering anesthesia

physician's assistants

-Educated in 2-year programs in medical schools and teaching hospitals
-Perform many routine health care tasks

health-care structure

-Private, "fee-for-service" practitioners are increasingly rare
-Most Americans currently receive services through "managed care" organizations, such as HMOs (health maintenance organizations)
--Employers or individuals pay a monthly rate, receive service

types of health care plans

Health maintenance organization (HMO), Preferred-provider organization (PPO), Point-of-service plan (POS), Traditional indemnity plan

HMO

-Managed care: Employer pays an agreed-on monthly rate
--Employee can then use services at no additional cost
-Have their own staff, from which enrollees must seek treatment

PPO

-Network of doctors offer plan members a discounted rate
-Enrollees must choose from these practitioners when seeking treatment

POS

-Administered by insurance companies or HMOs
-Let members go to doctors and hospitals out of the network for a price

Traditional indemnity plan

-Patients select their own doctors and hospitals and pay on a fee-for-service basis
-They do not need a referral to see a specialist

patient dissatisfaction with managed care

-The medical marketplace is becoming increasingly differentiated and confusing
-Patients often express dissatisfaction with:
--The lack of personal choice given when selecting providers
---Accessibility remains an issue
--The quality of care provided
---M

structural issues with health care

-The original intention of HMOs and other managed care organizations was to save consumers money and allow flexibility, but...
--Patient-provider relations are often undermined by the structure of the system
---A colleague orientation may develop
----Prov

nature of patient-provider communication

-Technical quality of care and the manner in which care is delivered are unrelated
-Setting
--Medical office is an unlikely setting for effective communication
---The average office visit is from 12-15 minutes
--Role of provider is tough as well- He or sh

provider behaviors that contribute to faulty communication

inattentiveness, use of jargon, baby talk, depersonalization

inattentiveness

the avg physician interrupts a patient within 23 seconds

use of jargon

assumes an expertise that patients probably don't have

baby talk

On the other hand, oversimplifying and "dumbing down" information is condescending and unnecessary!

depersonalization

-Patients are seen as "non-persons", e.g., "the heart attack in Room 224" instead of as unique individuals
-Can provide emotional protection to practitioners by helping them maintain their equilibrium in distressing situations

stereotypes of patients

Health care providers are not immune to societal stereotypes:
-Less support and information is provided to lower SES patients and sometimes patients of color
-Elderly patients are viewed more negatively
-Sexism abounds
--Women are far more likely to be gi

patients contribution to faulty communication

Patients are not blameless:
-Health illiteracy - the inability to understand their condition or relevant risk factors
-The inability to communicate information about their condition/symptoms effectively
-Neurotic/overly anxious patients may exaggerate sym

patients attitudes toward symptoms

-Misunderstanding the provider's emphasis on factors that they consider to be incidental
--Patients want to be "treated", so a physician's suggestion of dietary or other lifestyle changes can be rejected or ignored
-Paying little attention
-Believing that

interactive aspects of the communication problem

-Lack of opportunity for feedback to the provider
--The short visits necessitated by managed care often leaves patients feeling "shortchanged"
-Difficulty in knowing when a relationship has been established with a patient
-Learning is fostered more by pos

results of poor patient-provider communication

-Dissatisfied patients
-Non adherence is the major issue
--Less likely to comply with treatment recommendations
--More likely to turn to alternative services that satisfy emotional rather than medical needs
--Less likely to obtain medical checkups and fol

nonadherence to treatment regimens

-Patients do not adopt the behaviors and treatments their providers recommend
-Nonadherence rates vary depending on the treatment recommendations
--Research finds a range of 15%-93%
---85% fail to adhere completely to prescribed medications
--Adherence is

measuring adherence

-Asking patients about their adherence yields artificially high estimates
--In other words, patients lie, particularly when it comes to such behaviors as quitting smoking, reducing "bad" foods, and exercising
-Researchers draw on indirect measures of adhe

when is adherence highest in patients?

-Clear, jargon-free explanation is received
-Instructions are repeated if necessary
-Instructions are written down
--It's always good to bring another person with you if difficult or complicated news is possible
-Unclear recommendations are singled out an

treatment regimen

-Qualities of the treatment regimen influence adherence
--Long-term regimens, complicated regimens, and those that interfere with pleasant activities bring about lower adherence
--Supportive family and friends increase adherence

creative nonadherence

Intentionally modifying, supplementing or skipping a prescribed treatment regimen

malpractice and faulty communication

typically patients want to find out what happened, want an apology from the doctor or hospital, want to know that the mistake will not happen again

teaching providers how to communicate

training providers, training patients,
probing for barriers to adherence

training providers

-Simple behaviors that are seen as warm and supportive
-Nonverbal communication

training patients

-Skills to elicit information from physicians
-Thinking of their own questions ahead of time

probing for barriers to adherence

-Barriers can be discovered by talking to the patient
-Breaking advice into manageable subgoals that can be monitored
-Rate of adherence increases if lifestyle changes are prescribed rather than merely suggested

patient in hospital setting

Structure of the hospital
-Depends on the health program under which care is delivered
-Cure - Performing treatment action that has the potential to restore patients to good health
--Largely responsibility of physicians
-Care - Orientation of the nursing

cure, care, core

-The different functions of the hospital aren't always compatible
--Contributes to highly segregated occupational groups in the hospital
--Lack of communication between personnel can contribute to nosocomial infections- hospital acquired infections that a

role of health psychologists

-The role of health psychologists in a hospital setting has more than doubled in the last decade
-Participate in diagnosis and evaluation
-Pre- and postsurgery preparation and pain control
-Interventions to increase medication and treatment compliance
-Te

burnout among providers and what its linked to

Burnout is an occupational risk in any helping profession
-Defined as the presence of emotional exhaustion, cynicism, and low self-efficacy
Burnout is linked to absenteeism, turnover, and poorer functioning outside the professional role
-May be especially

impact of hospitalization on the patient

Patients are required to entrust themselves completely to strangers in an uncertain environment
-May result in problematic psychological symptoms, including depression and anxiety
Patients who have been prepared are:
-Less emotionally distressed
--But "mo

the hospitalized child

-Hospitalization can be hard on children
-Environment can be lonely and isolating
-May become socially withdrawn
-Children benefit from preparation as well
--Child Life specialists are increasingly common in hospitals and are trained to provide needed sup

placebo effect

-Medical procedure that produces an effect in a patient because of its therapeutic intent
-Many people have recovered from various illnesses when given "medicine" or other interventions that were actually completely ineffective
--Medicine is replete with

patient characteristics and placebo effects

-People who show stronger placebo effects are those who:
--Have a high need for approval or are anxious
--Have low self-esteem and are persuadable
-Shape, size, color, taste, and quantity of the placebo also impact upon effects
-Setting that is similar to

social norms and placebo effects

-Placebo effect is facilitated by norms that surround treatment regimens
--Expected way in which treatment will be enacted
-Placebos are effective because people believe that drugs work
-Fundamentally, placebo effects are good examples of the power of the

how common are chronic illnesses

At any given time, half the population has a chronic illness
-One third of adults 18-44 have at least one chronic condition
-Chronic illnesses account for 75% of health care costs
Most of today's leading killers (heart disease, cancer, diabetes, AIDS) can

quality of life

Until fairly recently, QOL was NOT considered medically significant
--Length of survival and symptoms were almost exclusively focused upon
--Research increasingly revealed that physicians and patients often had wide disagreement about QOL
---Physicians wo

defining/measuring QOL

-Assessments measure the extent to which a patient's normal life activities have been compromised by disease and treatment
-Components
--Physical functioning
--Psychological status
--Social functioning
--Disease- or treatment-related symptoms

Why study quality of life?

provides basis for interventions, helps identify the problems likely to emerge for patients, assesses the impact of treatments, used to compare therapies, can inform decision-makers about care

emotional responses to chronic illness

denial, anxiety, depression

denial

Defense mechanism by which people avoid the implications of an illness, often an immediate and natural response to diagnosis
-Can interfere with absorption of treatment information and thus compromise health

anxiety

Patients become overwhelmed by potential changes in their lives and/or the prospect of death/disability
-Interferes with treatment and is also intrinsically distressing; anxious patients can exacerbate their own symptoms

depression

Complicates treatment adherence and medical decision making
-About 1/3 of all inpatients suffer from depression
-Depression's medical significance is increasingly recognized: it clearly exacerbates chronic illnesses
-People who get depressed:
--Experience

personal issues in chronic disease

self-concept, body image, achievement, social functioning, private self

self-concept

Stable set of beliefs about one's personal qualities
-Evaluated by self-esteem
-Chronic illness can produce temporary and sometimes permanent changes in self-esteem

body image

Perception and evaluation of one's physical functioning and appearance
-Poor body image raises the risk of depression and anxiety
-Influences a person's adherence to treatment and willingness to adopt a comanagement role

achievement

-Important to self-esteem and self-concept
--Returning to vocation/hobbies/activities as much as possible is critical for regaining well-being

social functioning

-Provide information, help, and emotional support
--Family participation in illness management is important

private self

-Patient's identity can be affected by chronic illness
--Often future plans must be changed or re-envisioned

coping with chronic illness and strategies that work

Most common strategies:
-Social support/direct problem-solving
-Distancing
-Positive focus
-Cognitive escape/avoidance
-Behavioral escape/avoidance
--Strategies that work - Active coping and coping with positive responses

patients beliefs about nature of the illness for chronic illness

-Patients can adopt an inappropriate model for their disorder
-Most often they see the disease as "acute" rather than chronic, which interferes with management

patients beliefs about their cause of illness for chronic illness

-Patients blame stress, physical injury, disease-causing bacteria, and God's will for their illness
-Self-blame can lead to guilt, self-recrimination, or depression

patients belief about controllability of the illness

-Sometimes, self-blame can be adaptive because it can increase the motivation to change
-Belief in control and a sense of self-efficacy with respect to the disease and its treatment are adaptive
-Experience of control or self-efficacy may prolong life

comanagement of chronic illness

physical rehabilitation, developing a comprehensive rehab program, chronic illness leads to a decrease in sexual activity (which can be psychological in nature), adherence, vocational issues in chronic illness, social interaction problems, gender and the

physical rehab

Learning
-How to use one's body as much as possible
-How to sense environmental changes to make appropriate accommodations
-New physical management skills
-How to control the expenditure of energy

developing a comprehensive rehab program

-Patients may need a pain management program
-There may be a need for assistive technologies
-Factors that contribute to recurrence or that exacerbate the disease should be identified

adherence

-Increased by appropriate education
-Predicted by high expectations for controlling one's health and by self-efficacy and knowledge of the treatment regimen

vocational issues in chronic illness

Discrimination against the chronically ill
-Most are covered by the 1990 Americans with Disabilities Act

social interaction problems

-Negative responses/stereotyping from others
-Impact on family
--Changes in responsibilities and roles
--The caregiving role can be burdensome emotionally, physically, and financially

gender and the impact of chronic illness

-Women have more deficits in social support
-Married women are more likely to be institutionalized than their husbands

positive changes in response to chronic illness are possible

-Experiencing positive reactions and optimism
-Inspiration to act now instead of postponing it
-Acquiring more empathy and compassion
-Feeling stronger and more self-assured
-Positive attitudes predict better adjustment and a lower rate of complications

when the chronically ill patient is a child

-Confused because they do not understand the diagnosis and treatment
-Cannot follow the treatment regimen without help from family
-Exposed to isolating and frightening procedures
-May develop maladaptive coping styles and behavioral problems

improving coping for chronically ill child

-Parents can soothe children emotionally and provide an informed basis for care
-Child Life Specialists can help families navigate the treatment setting
-Children should be encouraged to take care of themselves as much as possible
--Regular school attenda

pharmacological interventions

Prescription of antidepressants is common

individual therapy

-Can be episodic rather than ongoing
-Collaboration with patient's physician and family is critical
-Requires respect for patient's defenses
-Requires comprehensive understanding of the illness and its modes of treatment
-Guided by cognitive behavioral th

coping skills training can improve functioning for chronic diseases

-Increases knowledge about the disease
-Reduces anxiety
-Increases patients' feelings of purpose and meaning in life

psychological interventions for chronic illness

-Telephone and Internet-based interventions represent cost and time effective ways of reaching chronically ill patients
-Mindfulness Based Stress Reduction can improve adjustment and coping
-Acceptance and Commitment Therapy (ACT) helps patients accept th

social support interventions

family support, support groups

family support

-Enhances patient's physical/emotional functioning
-Promotes adherence to treatment
-Improves course of illness

support groups

-Discuss issues of mutual concern that arise as a consequence of illness
-Low-cost, convenient treatment option
--Internet-based support groups are a valuable option that need further study

CHD

is the #1 cause of death worldwide, for both men and women
-CHD kills more people than all forms of cancer combined
-CHD is a disease of modernization (essentially a disease of lifestyle)
-Conditions also related to CHD are stroke and hypertension
-Type I

risk factors for CHD

-Overall, CHD is caused by atherosclerosis, the narrowing of the coronary arteries that supply the heart with blood. Risk factors include:
--High cholesterol, high blood pressure
--Elevated levels of inflammation
--Smoking
--Obesity
--Sedentary lifestyle

metabolic syndrome

is diagnosed with a person has 3 or more of the following:
-Obesity centered around the waist
-High blood pressure
-Low levels of HDL ("good" cholesterol)
-Difficulty metabolizing blood sugar (hyperinsulemia, a risk factor for diabetes)
-High levels of tr

stress and CHD

-Both chronic and acute stress are linked to CHD and adverse clinical events
--Extreme emotions can precipitate a heart attack
-Interacts with genetic factors to increase likelihood of CHD
-Associated with increased inflammatory activity
-Stress poses a s

women and CHD

-Leading cause of death in women in developed nations
-Most research on CHD has historically been done with males, leading to a relative dearth of knowledge regarding women and CHD
--Cardiac symptoms in women are often attributed to psychological factors

personality, carviovascular reactivity and CHD

-Negative emotions, particularly anger and cynical hostility, increase the risk for metabolic syndrome and CHD
-Hostility is a relatively stable trait and can result from:
--Insecure and negative feelings
--Negative child rearing practices (authoritarian

depression and CHD

-Depression affects the development, progression, and mortality from CHD; it may be as dangerous to heart health as smoking
-Linked to risk factors for:
--Coronary heart disease
--Metabolic syndrome
--Inflammation and likelihood of a heart attack
---Treat

psychosocial risk factors

-In addition to hostility and depression, the following have been linked to CHD:
-Vigilant coping (a form of anxiety)
-Vital exhaustion - the somaticizing of depression
-Social isolation and chronic interpersonal conflict
-On the bright side, positive emo

role of delay in the management of heart disease

-One of the reasons for high rates of mortality and disability following heart attacks
-People often wait hours or even days to seek help, because symptoms are vague and often misinterpreted

initial treatment for management of heart disease

-Coronary artery bypass graft (CABG) surgery to treat blockage of major arteries
-Patients are closely monitored following myocardial infarction (MI)

anxiety and depression with managing heart disease

-Anxiety and depression predict complications during the hospitalization phase
--Reinfarction (another heart attack) and recurrent ischemia (blockage in blood flow to the heart)

cardiac rehab

-Helps patients to attain their optimal level of functioning across many dimensions
-Rehabilitation involves symptom relief, reducing the likelihood of another cardiac event, and reducing the risk of death
--Patient involvement is absolutely critical

treatment by medication

-Self-administration of beta-adrenergic blocking agents
-Aspirin - Prescribed for people recovering from or at risk for heart attacks
-Statins - Prescribed for patients following an acute coronary event
--Adherence to medication is potentially complicated

stress management

Patients are taught to recognize stressful situations and avoid or manage stress

targeting depression

Cognitive-behavioral therapy is used

social support for heart disease

Married patients tend to do better
Predicts exercise tolerance and adherence to medication and lifestyle changes

problems of social support

Primary relationships are threatened
--Conflict over changes in lifestyle can increase marital strife

cardiac invalidism

Patients and their spouses see the patient's abilities as lower than they actually are
--In one study, wives who personally experienced the treadmill workout that their husbands were expected to do became more supportive and more likely to see their husba

evaluation of cardiac rehab

-Patients' risks for heart disease can be reduced by interventions that target weight, blood pressure, smoking, and quality of life
-Psychosocial treatments for depression and social support should be added to standard cardiac rehabilitation programs
--Su

hypertension

-Cardiovascular disease (CVD) or high blood pressure is itself a major risk factor for CHD
-About 30% of Americans have hypertension, about 1/3 are unaware because it has no symptoms
-Untreated hypertension is a risk factor not only for CHD but for kidney

causes of hypertension

-90% is of unknown origin (essential hypertension)
-5% caused by failure of the kidneys

hypertension risk factors

-Childhood temperament and blood pressure reactivity
-Gender
-Genetic factors
-Emotional factors
-Family environment that breeds anger and hostility
-Stress, particularly the chronic strain of high demand, low control environments

stress and hypertension among African Americans

-Hypertension very common among African Americas (41% versus 27% among Caucasians)
-Tied to stress of racial discrimination and low SES
-Obesity
--Also more common among lower SES individuals
-John Henryism: Personality predisposition to cope actively wit

treatment of hypertension

-Drug treatments
-Low-sodium diet (DASH diet)
-Reduction of alcohol
-Weight-reduction in overweight patients
-Exercise
-Caffeine restriction
-CBT techniques can be used to moderate the risk factors associated with hypertension
--Adherence is unfortunately

stroke

-Often cited as the third most common cause of death in America
-Results from a disturbance in blood flow to the brain (think of it as a "brain attack")

stroke causes

-Blood flow to localized areas of the brain is interrupted because of plaque blockage or hypertension
-Cerebral hemorrhage- rupture of blood vessel in brain

stroke warning signs

o Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
o Sudden confusion, trouble speaking or understanding
o Sudden trouble seeing in one or both eyes
o Sudden trouble walking, dizziness, loss of balance or coordinati

risk factors for stroke

o High blood pressure
o Heart disease
o Cigarette smoking
o High red blood cell count
o Transient ischemic attacks
o Negative emotions
o Sudden change in posture to a startling event
o Psychological distress

what are some consequences of a stroke?

� Consequences depend upon the location and extent of the brain damage that occurred
o Motor problems
o Cognitive problems
o Emotional problems

rehabilitative interventions

The brain is "plastic" even into old age and can often be retrained so that lost skills can be at least partially recovered
o Movement therapies
o Use of structured, stimulating environments to challenge capabilities
o Neurorehabilitation - Rewiring the b

distinguish between type 1 and 2 diabetes. which is more common and why?

� Type II Diabetes is the third most common illness in America
� Both Type I and Type II diabetes are diseases of glucose metabolism
o Type I, or "juvenile" diabetes is typically diagnosed before age 20 and is unrelated to lifestyle factors
Type I diabete

risk factors for type 2

� You are at risk if:
o You are overweight
o Get little exercise
o High blood pressure
o Sibling or parent with diabetes
o Baby weighing over 9 pounds at birth
o Member of a high-risk ethnic group, which includes AA, Latinos, Native Americans, Asian Ameri

symptoms of type 2

o Frequent urination
o Fatigue and dryness of the mouth
o Impotence
o Irregular menstruation
o Loss of sensation
o Frequent infection of the skin, gums, or urinary system
o Pain or cramps in legs, feet, or fingers
o Slow healing of cuts and bruises
o Inte

potential complications of diabetes

-Diabetes is the leading cause of kidney failure
-Heart disease and stroke are 2-4x more common among diabetics
--Heart attacks are the leading cause of death in diabetics
-Diabetes is a leading cause of blindness
-Diabetes is a leading cause of neuropath

self management of diabetes

� Self-management of diabetes is key, but many diabetics are unaware of their risks
o Dietary intervention - Reduce sugar and carbohydrate intake
o Diabetics are particularly sensitive to stress, and must manage it properly
o Exercise is needed to control

interventions for type 2 diabetes

o Adherence remains problematic, but "well controlled diabetes is the leading cause of nothing"
o Prevention is critical for the millions of people who are prediabetic, as lifestyle modifications can reverse the risk
o Cognitive-behavioral interventions c

Psychoneuroimmunology

-Defined as the Interactions among different processes of adaptation: behavioral, neuroendocrine, and immunological
-The immune system is the body's "surveillance unit"
--Its primary job is to distinguish between what is "self" and what is "other" and to

The Immune System

The immune system has two overall forms of defense:
natural immunity and specific immunity

natural immunity

Generalized defense against pathogens
-Works rapidly
-Present at birth (through mother)

specific immunity

Delayed response to a specific invader
-Acquired through exposure to pathogens or through vaccination

Studying the Immune System

Researchers study immunity in several ways:
-By measuring antibodies the body produces in response to an inactive virus or to a vaccine
-By measuring the presence of immune-related products in the blood
--Cytokines, which are indicators of inflammation, a

Stress and Immunity in Humans

Overall, most stressors affect the immune system
-Different kinds of stressors require different kinds of defenses
--Short term stressors provoke a different response than long term, chronic stress, which downregulates the entire immune system
-The maxima

Stress and Health Risks

-The immune changes that occur in response to stress do result in health changes
-Stress leaves people more vulnerable to infectious diseases
-Stress predicts more severe illness and higher production of cytokines among people who are already sick
-Autoim

Negative Affect and Immune Functioning

-Stress compromises immune functioning partly because it increases negative emotions
-Depression is associated with:
--Decrease in cellular immunity
--Prolonged inflammatory responses
--Delayed wound healing
--Sleep disturbance

Stress, Immune Functioning, and Interpersonal Relationships

-The quality of personal relationships can be a factor in both immunocompetence and immunocompromise
-Lonely people have poorer health and show evidence of immunocompromise
-People with insecure attachments to others show lower levels of natural killer ce

Marital disruption and conflict

-Separated and divorced women show poorer immune functioning
-Partner violence has been tied to adverse changes in immune functioning
-Risks are higher for women than for men

Caregiving

Stressful for people who provide care for a friend or family member with a long-term illness

Coping and Immune Functioning

-Protective effects of psychosocial resources
--Social support can buffer against adverse immune changes in response to stress
--The presence of resources can limit the deterioration in immune functioning
-Optimism
--Important influence on stress-related

AIDS (Acquired Immune Deficiency Syndrome)

is the sixth leading cause of death worldwide
-AIDS is thought to have initially begun in Africa in the early 1970's, and spread due to the high rate of unsafe sexual practices and the re-use of needles in vaccination programs

Human immunodeficiency virus (HIV)

is a "retrovirus" which attacks the helper T cells and macrophages of the immune system

Progression of HIV Infection

-HIV is transmitted through an exchange of infected body fluids, NOT casual contact
-Rapid growth in the first few weeks
--Infection spreads throughout the body
-After 3 to 6 weeks viral growth is gradual
--Compromises the immune system by killing the hel

HIV to AIDS

-Whether the HIV infection develops into full-blown AIDS depends on multiple factors
--Lower SES African-American and Hispanic individuals develop AIDS more rapidly than HIV-infected Caucasians
---Lack of access to appropriate medical treatment is the pri

Highly Active Antiretroviral Therapy (HAART)

-The treatment of choice for an HIV positive person is HAART, which is VERY expensive and requires a rigorous attention to adherence
-Combination of antiretroviral medications
--HAART has transformed HIV into a chronic disease for more fortunate individua

Psychosocial Impact of HIV Infection

-Depression, bereavement, and thoughts of suicide are quite common
-Stigma associated with AIDS
--Negative reaction toward people with AIDS
--Interventions that reduce depression are beneficial to coping
--HIV+ persons and those with AIDS are covered unde

Disclosure

-Nondisclosure is the major barrier to controlling the spread of HIV
-People with strong social support networks are more likely to disclose
-Benefits of disclosure
--Receiving social support
--Positive health consequences
--More CD4 cells and helper cell

Women and HIV

-Minority women constitute the fastest-growing segment of the population to be diagnosed as HIV+
-Majority of women depend on social services and Medicaid to survive; overall many HIV+ women tend to have unstable living situations
--Resulting depression c

Interventions to Reduce the Spread of HIV Infection

Center around:
-Getting tested: an estimated 21% of HIV+ people are unaware of their status
-Refraining from high-risk sex
-Using a condom at every encounter
-Not sharing needles
Role of education
--Educating the target population about risky activity in

Targeting Sexual Activity

Sexual negotiation skills
-Important in interventions with high risk groups, particularly young women who may be more easily coerced into activities
-Focus interventions on building self-efficacy for practicing safe sex
-Increase motivation for at-risk gr

HIV Prevention Programs

-Developed for adolescents and typically delivered in a school setting
--Warn about the risks of unprotected sexual intercourse
--Help instill safe-sex practices
--Often delivered by HIV+ individuals
-Stage model of behavior change --Guides interventions

Targeting IV Drug Use

-Changing sexual activity
-Reducing risky injection practices
--Information about AIDS transmission
--Needle exchange programs
--Instruction on how to sterilize needles
-Methadone maintenance treatments coupled with HIV-related education reduces the sprea

Factors that increase disease progression

-Negative beliefs about the self and the future
-Depression
-Stress
-Trauma
-Psychological inhibition

Factors that decrease disease progression

-Optimism
-Active coping
-Extraversion
-Conscientiousness
-Spirituality

Cancer

-Cancer is a set of over 100 diseases, all resulting from a dysfunction in DNA
--The DNA dysfunction causes cells to grow too rapidly and over-proliferate, sapping the body's resources
-Cancer is the second leading killer in America
--But earlier/better d

Factors Related to Cancer

-Heredity or shared family environment
--Just because a cancer "runs in families" does not necessarily mean it is genetic in origin
-Ethnicity
-Lifestyle factors
--About half of ALL cancers are linked to smoking
--Poor diet
---Particularly high levels of

Stress and Psychosocial Factors

-The lack of social support is implicated in both the onset and course of cancer
-Avoidance has been tied to a more rapid course of the disease
-Depression exacerbates the impact of other risk factors
-Progression may be related to use of denial or repres

Coping with physical limitations

-Stems from the pain and discomfort
-Fatigue and compromised nutrition
--About 1/3 of cancer patients actually die from malnutrition

Treatment-related problems

-"slash, burn, and poison..."
-Removal of organs in surgical treatment
-Side effects of chemotherapy

Interventions involving stress

Stress aggravates all illnesses and cancers

Issues involving social support

-Strong marital/partner relationship is important
--Unfortunately, relationship problems are not uncommon in the wake of cancer
-Support groups for individuals dealing with the same type of cancer are beneficial
--The American Cancer Society is a good sou

Interventions

-Cognitive-behavioral approaches to cancer-related problems are vital
-Mindfulness-based stress reduction interventions help with coping
-Major target is improving health behaviors
-Pain management is also integral to treatment

Autoimmune Disorders

-Autoimmune disorders occur when the immune system goes awry and attacks healthy tissues as if it were an "invader"
-Rheumatoid Arthritis
-The most crippling form of arthritis, affects mostly women
-Affects the small joints of the hands and feet, wrists,

Rheumatoid Arthritis (RA)

Stress plays a role in the development and progression of RA
-Role of the spouse/support person is critical to successful disease management

Rheumatoid Arthritis (RA) treatment

-Anti-inflammatory and immune suppressing medications, rest, and supervised exercise
-Cognitive-behavioral interventions
-Mindfulness interventions

Osteoarthritis

Extremely common in middle age and beyond
-Cartilage at joints begins to crack or wear away because of overuse, injury, or other causes
-Affects the weight-bearing joints
-Causes depression elevating pain and distress

osteoarthritis treatment

-Weight management, anti-inflammatory medication
-Joint replacement therapy is often indicated, and is getting better all the time!

Type I Diabetes

-Autoimmune disorder characterized by the abrupt onset of symptoms, including raging thirst, frequent urination, rapid weight loss and severe fatigue
--Has a genetic component and is typically diagnosed in childhood or adolescence
--The immune system fals

Managing Type I Diabetes

-Type I diabetes is life-threatening, but can be very successfully managed
-Active involvement of the patient to the treatment process is essential to success
--Regular insulin injections
--Dietary control
--Weight control and exercise
--Stress management

Adherence in Type I Diabetes

-Unfortunately, treatment regimens are complex and only about 15% of patients follow strict adherence
--Severe complications are not evident for 15-20 years, so it's easy to "put it off"
-Active coping strategies help in managing the disease
-Adherence im

Special Problems of Adolescent Diabetics

-Restrictions inconsistent with development are imposed
-May be stigmatized from peers
-Parents might:
--Infantilize or "hover over" adolescents
--Convince the child that he or she is typical and thus contribute to poor treatment adherence
-Psychologists

CAM

People tend to group Complementary and Alternative Medicine (CAM) together, but there are actually 3 distinct approaches

alternative

INSTEAD of "regular" approaches

complementary

in ADDITION to "regular" approaches

integrative

COMBINED with "regular" approaches, with solid scientific evidence and support for the combination

CAM Philosophy

All CAM approaches are rooted in holistic medicine
-Holistic approaches seek to treat/heal the whole person
-Holistic medicine is a logical extension of the biopsychosocial model that we've talked about in this class
-CAM approaches/treatments are not cur

NCCAM - National Center for Complementary and Alternative Medicine

-Founded in 1998
-Part of the National Institutes of Health
-Since formation of NCCAM, approx. 90% of medical schools offer classes on CAM
-40% of hospitals offer at least one CAM therapy

Popularity of CAM and why is it increasing?

-Currently, about 2/3's of the population utilizes some CAM method
-Why is the popularity of CAM increasing?
--Consumers want more control over their healthcare
--Many are less trusting of the medical establishment
--Cost savings can be appealing
--Consum

Goals of CAM

-Many believe in the inherent healing powers of the body - provide the right kind of supportive environment and the body can heal itself
-Identify the root cause of the disorder - lifestyle, diet, stress
-The practitioner is a teacher who stresses empower

Problems with CAM

-Very little empirical research as of yet, slowly changing thanks to NCCAM
-Pharmaceutical companies can't profit from CAM (probably why there is little research)
-70% of patients don't tell their regular practitioners about their CAM use
-The aforementio

Specific CAM Methods

-Acupuncture has the highest level of empirical support - osteoarthritis, migraines, some forms of infertility
--Part of TCM - Traditional Chinese Medicine
--The "qi" of the body is blocked, and such energy blockages cause illness
--Herbs and nutritional

Naturopathic Medicine

-Founded in 1896
-Also called "natural medicine"
-Relies on prevention, not cure
-Foundation is the establishment of correct habits - breathing, exercise, food and sleep
-Elimination of "evil" habits - red meat, alcohol, drugs, improper hours
-Follow good

dietary supplements

-The most common CAM therapies involve dietary supplements
--Half of Americans use dietary supplements
--Unfortunately little evidence that supplements "keep people healthy"
---If specific nutritional deficiencies exist, supplementation is obviously benef

Spiritual Approaches to CAM

-Since CAM is a very broad term, many techniques we have already noted can be included under the CAM umbrella:
--Yoga
--Meditation
--Guided imagery
--In general, individuals who utilize these approaches report multiple benefits, including stress reduction

Future Directions in Health Psychology

-Identifying and focusing on individuals at risk for specific chronic disorders
-Those at risk should learn to:
--Cope with their risk status
--Change their modifiable risk-relevant behaviors
-Studies on people at risk helps identify the promoting factors

Behavioral immunization

Programs focused on smoking, drug abuse, diet and eating disorders

Prevention of Poor Health Habits

-behavioral immunization
-Remember that good health habits can and should be established early!
-Parents should be taught to:
--Reduce the risks of accidents at home
--Practice good safety habits in automobiles
--Instill good dietary and exercise habits i

Reasons for refocusing toward morbidity

-Cost - Chronic diseases are expensive to treat
-To produce a higher quality of life

Priorities for the future - To address:

-More than one behavioral risk factor at a time
-Maintenance of behavior change
-Broader environmental and health policies that support and sustain individual efforts

A Focus on Older Adults

-Older adults are the fastest growing population in America and many other countries
-an emphasis on "successful" and healthy aging is needed to maintain optimal functioning
--Health habits are the primary focus
--An emphasis on healthy aging will benefit

Promoting Resilience/Positive Psychology

-Focusing on the positive factors that reduce morbidity or delay mortality
-Enhancing people's abilities to attract and maintain social support
-Studying how people:
--Spontaneously reduce stress
--Seek out opportunities for rest, renewal, and relaxation

Risk factors tied to low SES

-Alcohol consumption and tobacco use
-High levels of lipids and obesity
-Fewer psychosocial resources
-Higher rates of chronic illness
-Low-birth-weight babies
-Infant mortality
-Higher risk of accidents

Health Disparities

-Racial and ethnic differences
-SES and ethnic differences - Have an impact in the delivery of medical treatment
-Gender - Women are not included as research subjects in studies of many major diseases
--Much progress has been made since the early 1990's,

Stress Research

-Research on the neurophysiology of stress will help understand how stress exerts adverse effects on health
-Social support can buffer stress
--Reduces social isolation
--Promotes the benefits of social ties
--Alleviates factors that promote toxic social

Problems in the health care system

-Very expensive
-Inequitable system
-Inappropriate use of services

Building better consumers

-Health psychologists should help create responsible and informed consumers
-Patients should partner with health care practitioners and deal with their disorders
-Health services accommodating the poor should be developed

Role of health psychologists

-cost-effective interventions
-Being aware of complementary and alternative medicine
--Developing interventions that address the possible psychological needs met by such treatments
-Addressing the ethical issues surrounding death and dying

The Impact of Technology

-An increase and perhaps overreliance on technology has contributed to the exorbitant cost of health care
-To reduce patients' fear:
--Explain the purpose of a technology
--Use control-enhancing interventions
-Advances in the decision sciences help improv

Comprehensive Intervention Models

-Currently geared to specific disorders or issues (such as pain management); will likely expand to address risk factors as well
-Minimal, moderate, and intensive interventions ranging from self-care to long term inpatient or outpatient care are part of th

Cost containment:

Push health psychology in the direction of research designed to keep people out of the health care system

Health psychology interventions

-Documenting effectiveness
-Presenting the data to the general public
-Identifying the most critical components of behavioral interventions
-Health psychology interventions can be very cost-effective

International Health

-Life expectancy and disease risk varies widely across nations
-Factors contributing to a high incidence of acute infectious disease
--Poverty and lack of education
--Lack of health care resources
-Trends in the developing countries
--Increase in smoking