Psychosocial Influences on Health

Psychological Factors

Numerous psychological factors affect health. We discuss here a common approach to personality, the five-factor model, and an essential psychological resource for healthy behavior, self-control. We also review key findings from the literature on the relationship between emotions and health.

The most prominent approach to personality at present is the five-factor model (Goldberg, 1993). The five broad personality domains of this model, for which OCEAN is an acronym, are openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism (Table 3-2). Research on the relationship of these factors to health variables has generated several findings. Whereas conscientiousness has been associated with longevity among healthy individuals and better functional status in those with physical illnesses or impairments, neuroticism is consistently found to be negatively correlated with health (Bogg and Roberts, 2013; Goodwin and Friedman, 2006; Smith and Mackenzie, 2006). Agreeableness, extraversion, and openness to experience generally tend to have weaker associations with health.

Because personality style tends to be quite stable across the life span, physician focus on changing personality for health reasons is not a sensible pursuit. However, an understanding of a particular patient's personality can help guide the physician toward interventions that are more likely to be effective.

Because health behaviors are a major factor in the development of, management of, and morbidity from chronic illnesses, self-control or willpower is a critical psychological resource. Children with more self-control have been found to have better health as adults. Adults with more self-control have healthier behaviors. Research indicates that willpower operates like a muscle; it is a resource that people have in limited supply, and it can be exhausted (Baumeister and Tierney, 2011). Fortunately, it can also be replenished. Importantly, various demands for willpower draw from the same common resource. Willpower is used to control thoughts, regulate emotions, manage impulses (the task most commonly associated with willpower), and direct performance. Making decisions uses willpower. Numerous studies have demonstrated that tasks requiring willpower deplete the self-control resource, so that performance declines on subsequent tasks requiring willpower. Inter­estingly, when there are competing demands for the self-control resource, managing negative emotions predictably takes precedence over other demands. Given the multiple emotional and behavioral challenges associated with the management of chronic illness, a patient with excessive demands on the limited self-control resource is particu­larly vulnerable to worsening health. See Table 3-3 for a summary of key factors about self-control, including how it can be replenished.

The ongoing experience of chronic negative emotions (depression, anxiety, and anger) tends to be associated with poorer health. There is an extensive research literature linking negative affectivity and pessimism to adverse health outcomes (Peterson et al., 1988; Salovey et al., 2000). Although the experience of negative emotions is a natural part of the human experience, effective management of such emotions through cognitive strategies, active coping, and social support can be learned, and medications can be a helpful adjunct when negative emotional states are prolonged or severe.

Likewise, a large body of research indicates that positive emotional states are associated with better health and longevity. Happiness, optimism, and positive attitudes toward aging have been associated with 7 more years of life (Danner et al., 2001; Levy et al., 2002). Almost three decades of research have shown that an optimistic outlook has a positive effect on coping and on mental and physical health outcomes (Peterson and Steen, 2002). Family physicians have long recognized the importance of mobilizing and maintaining patient hopefulness through encouraging words that foster positive expectations of medical treatment. The demonstrated efficacy of placebos affirms the importance of this approach (Sobel, 1991).

Social Factors

A gradient between socioeconomic status (SES) and health is consistently found in epidemiologic studies (Marmot, 2004). Persons with less education and income tend to have poorer health than their better educated and richer counterparts. A recent analysis indicates that in the year 2000 in the United States, 245,000 deaths could be attributed to low education, 176,000 to racial segregation, 162,000 to low social support, and 133,000 to poverty (Galea et al., 2011). Interestingly, subjective SES (i.e., individuals' perceptions of where they view themselves on the social ladder) has an even stronger relationship to health than objective SES (Singh-Manoux et al., 2005). Negative affect, stress, pessimism, and a decreased sense of control are among the factors thought to contribute to the relationship between lower subjective SES and poorer health (Operario et al., 2004).

In general, social support reduces stress and contributes to more positive health outcomes. Social support refers to the process by which a social network provides psychological and material resources to enhance an individual's ability to cope with stress (Cohen, 2004). Both quantity and quality of support are important, and sources of support include spouses, lovers, friends, family, coworkers, and health care professionals. A person who has many friends but no confidant may have inadequate social support in a time of need. Some people report high levels of satisfaction with just a few close friends, but others require larger social networks.

There are several varieties of social support (Cohen, 2004). Emotional support involves the expression of caring, concern, and empathy toward the person and typically involves opportunities for the recipient to express emotions. Instrumental support involves providing some type of direct assistance, which might include financial resources, transportation, or help with daily tasks. Informational support involves giving advice or information relevant to an individual's situation.

Social support appears to undergird health by buffering the person against negative effects of stress, perhaps by affecting the cognitive appraisal of stress. When people encounter a strong stressor, such as a major financial crisis, individuals with high levels of social support may appraise the situation as less stressful than will those with low levels of support. Social support may further buffer the stress by modifying people's response to a stressor as they turn to friends for advice, reassurance, or material aid. Social integration, or participating in a broad range of social relationships, benefits health and well-being by enhancing self-esteem and fostering positive health behaviors in people who believe that others count on them. Social integration is beneficial, whether or not an individual is experiencing stress (Cohen, 2004).

Relationships also can involve significant negative social exchange and be harmful to health; negative interactions in troubled marriages have adverse effects on cardiovascular, endocrine, and immune system function (Robles and Kiecolt-Glaser, 2003). Recent research has found specific links between negativity in relationships and cellular aging, such as shortening telomere length (Uchino et al., 2012).

Misconceptions

Polan (1993) identified and addressed two common misconceptions about the biopsychosocial model. First, contrary to popular belief, a physician who is “humanistic” is not necessarily practicing biopsychosocial medicine. A physician can be ethical and caring but still neglect scientific knowledge from the social and behavioral sciences and relevant data from the patient's life. For example, compassion by itself is of limited usefulness to a physician who needs an effective treatment plan for a patient with asthma who smokes. Interventions should be informed by knowledge of the social environment and the individual psychology of the patient.

The second misconception is that people can be reduced to distinct biologic, psychological, and social categories or that their problems can then be expressed as a set of scientific principles from which diagnosis and treatment can be neatly derived. In fact, use of the biopsychosocial model increases rather than decreases the level of complexity required to understand patient status, introducing multiple avenues for intervention. Interpreting the biopsychosocial model as a new opportunity for reductionist thinking diminishes its power to inform more holistic treatment. Borrell-Carrio and colleagues (2004) proposed a biopsychosocially oriented clinical practice based on self-awareness, active cultivation of trust, an emotional style characterized by empathic curiosity, self-calibration to reduce bias, cultivation of emotional sensitivity to assist with diagnosis and therapeutic relationships, use of informed intuition, and communication of clinical evidence to foster dialogue.

Another important misconception is that educating patients about important biologic, psychological, social, or environmental factors will necessarily change behavior. Much of human behavior is automatic, cued by environmental or situational factors. Health behaviors are frequently less a product of thoughtful choices than of nonconscious factors (Sheeran et al., 2013). Although intention and motivation affect adherence to treatment regimens and health behavior recommendations, multiple other factors (e.g., depletion of self-control, media and peer influences, physical environment) play important roles.

The Systems Approach

Humans are infinitely complex. Adequately conceptualizing a person in health or illness requires a systems approach that encompasses this complexity. The concept of systems was first developed by von Bertalanffy (1968) to refer to the dynamic interrelationships of various components. A systems approach rejects the notion of linear causality in favor of multidimensional and multidirectional models.

The systems approach has strongly influenced conceptualizations of family functioning. Smilkstein (1978) developed one of the first applications of “family systems” thinking for family medicine. Physician attention is important in the systemic interactions of family members and the impact of crisis, coping styles, and resources on family functioning. He incorporated these components into the “family APGAR” (adaptation, partnership, growth, affection, and resolve), a simple instrument and mnemonic device for assessing the functioning of a family system in health and illness (not to be confused with the newborn Apgar score).

The Stress and Coping Model

General relationships among life stresses, coping resources, and health outcomes are presented schematically in Figure 3-1. This approach represents another example of the application of a systems model. In this model, health outcomes are impacted by how life stresses affect the individual. The effect of stress is moderated by the individual's appraisal and coping responses, personality, and the person's available social resources. Although the complex synergistic interactions that characterize these relationships are beyond the scope of this chapter, the major variables provide a basis for considering physician interventions.

The Life Span Perspective

The life span perspective emphasizes the importance of an individual's place on his or her personal developmental trajectory. Past development, current status, and anticipated developmental changes and challenges are taken into account. On the biologic level, changes in cellular functions occur from infancy through old age; decline in physical stamina is one manifestation of this dynamic change. On the psychological level, personality interacts with ongoing changes that occur across the life span (e.g., becoming a parent), and each developmental stage brings its own psychosocial challenges. Erikson's eight stages of development highlight the importance of trust issues in infancy, autonomy issues in early childhood, and issues of generativity and meaning in old age (Erickson, 1959). On the social level, family and peer relationships change throughout life, with significant implications for health, which may be either positive or negative. For example, the typical adolescent's shift toward greater reliance on peer relationships may lead to behaviors that endanger health, such as smoking or substance abuse. The death of a husband who has been physically abusive may lead to improved well-being for the surviving wife. The primary care physician needs to keep the life span model in mind and assist patients in addressing psychosocial factors that facilitate or block health and development.

The Ethnomedical Cultural Model

Every encounter between a patient and a physician is a cross-cultural transaction. Each person brings to the physician–patient relationship a unique mix of culturally embedded attitudes, knowledge, and beliefs. Ethnicity, gender, religion, language, education, and personal history shape expectations and behavior on both sides of the relationship. A physician's cultural proficiency is instrumental in establishing rapport and gathering information for accurate and comprehensive diagnosis and treatment (Carrillo et al., 1999). The patient's acculturation status and cultural background are important to understand, and physicians should become familiar with the dominant cultural groups they serve.

The ethnomedical cultural model emphasizes cultural concepts relevant to health and illness (Kleinman et al., 1978), including patient beliefs and expectations about the body, illness, and treatment. Berlin and Fowkes (1983) operationalize this model in clinical encounters with their LEARN acronym, exhorting physicians to do the following:

The ethnomedical cultural model highlights cross-cultural elements in all physician–patient interactions.

Collection of Psychosocial Data

In family practice settings, the most common and natural approach to gathering psychosocial data is interviewing the patient over time. Freud suggested that the major achievements of healthy development were the abilities “to work and to love,” and this is often a good place to start. Where does this patient work, and how does he or she feel about the job, school, or household responsibilities? Who is “family” for this patient, and what is the nature of the support system? Detailed inquiries about work and love made in the context of the ongoing physician–patient relationship result in significant accretion of knowledge over time and make it easy to flag stressful changes in these important arenas.

Other important areas of inquiry include the patient's physical and social environment. Factors such as the quality of housing, neighborhood, food, and financial resources all affect patient safety, health care use, family stress, and physical health. Understanding the ethnic, religious, and political culture of a patient and family is important for guiding culturally appropriate care. Personal and family history, usually gathered gradually over time, can alert the physician to important family coping patterns, strengths, and liabilities. Of special importance is information on major personal family “dislocations,” including losses, illness, and trauma. Knowledge of any traumatic encounters with previous health professionals or with previous medical procedures may help the physician anticipate and manage potential crisis situations.

Information from patient dialogue can be supplemented by standard measures such as health questionnaires (e.g., Short Form 36); screening inventories (e.g., Beck Depression Inventory); and stress, coping, and social support tools. Other means of gathering relevant data include informal interviews with family members, structured assessments (e.g., family APGAR), review of existing records (e.g., school records), consultation with nonmedical colleagues (e.g., psychologist, occupational therapist), observation of the patient's environment through home visits, and consultation with cultural informants and translators. Perhaps most important is the ongoing use of open-ended questions, so that important psychosocial data are elicited from the patient in the patient's own words.

Interventions Using Psychosocial Data

A comprehensive review of interventions addressing psychosocial influences in health is beyond the scope of this chapter and would require discussions of clinical psychology, social work, nursing, occupational therapy, and public health. Even in optimal circumstances, competency can be achieved only within a limited range. Realistically, family physicians should pursue basic proficiency in selected interventional strategies and additional training in areas of interest relevant to their specific practice needs and the population they serve. Here we discuss pragmatic interventions for practicing physicians based on the general model of stress, life events, coping, and health discussed earlier.

Because health outcomes are affected by stressful life events, coping (e.g., stress appraisal), and resources (e.g., personality, social support), addressing any of these dimensions can have a positive effect on functioning. As stress increases relative to available support and coping capacities, disequilibrium results. Put simply, interventions that decrease stress or enhance support tend to improve well-being. Physician attention to factors that exacerbate or mitigate is always valuable. For example, because a new medical diagnosis is stressful but a loving partnership is a source of support, assuring the presence of a loving family member when bad news is to be shared with a patient may lessen its negative impact. Some life events, such as the death of a supportive partner, affect several elements in the model, as the bereaved partner confronts a major loss (stress) without the person who had previously offered comfort in such times (decreased support). Not surprisingly, persons who are grieving are at higher risk for experiencing health problems (Rogers and Reich, 1988), and a focus on their support systems and coping strategies is almost always warranted.

Interventions that should be part of the standard repertoire for family physicians are those that do no harm, usually help, and use traditional skills. Specifically, physicians can work with patients directly to reduce stress, to enhance or mobilize social support resources, and to reinforce or model positive stress appraisal and coping. Direct approaches to stress reduction may include intervening in the patient's environment (e.g., arranging respite care for an older patient to relieve stress on his middle-aged daughter) and allaying a patient's unrealistic fears about an illness. Social support can be enhanced directly through the provision of more contact with the physician or indirectly through mobilizing the patient to increase contact with family or friends. Physicians can support positive coping through instilling hope, modeling optimism, and encouraging patients who adapt. Reminding patients of personal strengths previously used to confront crises is also helpful. The physician often can implement these strategies by asking questions that allow the patient to respond in a broader perspective (e.g., “What do you remember doing to help you cope with the death of your good friend several years ago?”). Especially when behavior change is indicated, collaborating in discussing options rather than giving advice is more likely to be effective. One collaborative approach that has demonstrated efficacy is motivational interviewing (Rollnick et al., 2008; Rubac et al., 2005).

In the provision of care within a biopsychosocial model, interdisciplinary teams, rather than solo practitioners, have the advantage, and physicians can have more positive impact on their patients' lives when they harness the wisdom of colleagues from other fields through referral or consultation. Depending on physician training, interest, and time, these basic categories of intervention can be supplemented by a wide range of psychosocial interventions, from family therapy to behavior modification.

Important Times for Psychosocial Interventions

Interventions that attend to psychosocial issues are especially important at specific times in the provision of family medical care. Natural transitions in the family life cycle, such as the birth of a child or the death of a spouse, call on the physician to provide empathic support, assess the patient's support system, normalize emotional reactions, and provide anticipatory guidance as patients confront changing family roles and functioning.

When adherence or lifestyle issues impinge on health, interventions that focus on biologic mechanisms alone are likely to be ineffective. The health effects of substance abuse, domestic violence, poverty, or inactivity are often best addressed through attention to social environment and psychological concerns.

A dramatic change in patient symptoms also indicates consideration of psychosocial factors. A psychosocial crisis can provoke an exacerbation of a chronic condition (e.g., rheumatoid arthritis), a new manifestation of illness (e.g., myocardial infarction), or emotional-psychiatric symptoms (e.g., anxiety, trouble sleeping) best treated through stress reduction and symptomatic care.

A significant medical diagnosis may precipitate emotional distress or psychosocial upheaval and requires physician attention to the context of the patient's life. Effective physician intervention may involve anticipating the nature of the potential family crisis, including family members in discussions with the patient, and addressing family needs for support. Timely provision of accurate information can enhance a patient's sense of control. Direct support by the physician during the initial adjustment phase can minimize more serious emotional disruption.

Patients living with chronic illness require sensitive psychosocial care. Managing a chronic health problem challenges a person's ability to adhere to medical recommendations and to cope with other life stressors. Patients often cope in highly idiosyncratic ways. Pollin (1995) identified eight emotionally charged issues that patients with chronic illnesses inevitably confront: control, self-image, dependency, stigma, abandonment, anger, isolation, and death. These issues can often be effectively addressed within the physician–patient relationship and through judicious referral to support groups for chronically ill patients. As elaborated by Pollin, each issue can be met by an appropriate and helpful professional stance. In response to control issues, for example, professionals should help patients express their feelings of loss of control and identify areas where they may feel powerless. Normalizing the patient's feelings and fears is the first step in helping address control issues. The goal of intervening in regard to the issue of loss of control is to reinforce the patient's confidence in being able to cope with the demands of the medical condition.