Transcript 01 Greenough-Psy 400 INTRO 2006

Behavioral Science
Faculty:
William Greenough: Course Director
Brian Ross, Psychology
Michael Wilson, College of Medicine
Donna Korol, Psychology, Medicine
Karl Rosengren, Psychology, Kinesiology
Robert Rich, College of Law
Aaron Grossman, Teaching Assistant
Bill Greenough, Professor of
Psychology, Psychiatry and Cell
and Structural Biology
[email protected]
Office Hour: 11-12 Tu or by appt.
Phone: 333-4472 (for appts.)
Course Objectives: Bases
•Many of the greatest health risk factors today
are behavioral, the realm of Behavioral Science
•Self-injurious behaviors such as smoking,
alcohol and drug abuse, poor dietary and
exercise habits, now constitute the largest
controllable risk factors for mortality
•Psychiatric disorders: major cause of disability
•Behavior can put others at risk (e.g., ARND)
•Physician’s responsibility to inform and
advise patients at risk or putting others at risk
Course Objectives: Bases
•Other behavioral issues important in Medicine
•Stress is a serious medical issue (CardioVascD)
• Compliance (taking medicine, following
medical advice, regular preventative medicine)
• Sexual function (taking a sexual history)
• Is my child “normal”? Development and Aging
• Stress-related or affected disorders
• Lifestyle (Tobacco, Diet, Exercise, Alcohol,
Sleep)
Dramatic changes have occurred across the past century in causes and ages of death.
Infectious disease has become largely controlled, and hence people are living longer
and dying from different causes
Source: U. S. Senate Sub-Committee on Aging,
OASDI, 2003
*Infectious Disease
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*Lifestyle
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Life Expectancy, 1900 = 54.3; 1996 = 81.5 (Sweden)
Source: S. E. Taylor, Health Psychology (5th Edition), Mc Graw-Hill, 2003
Is Smoking on the Decline? Not over the last decade
(Source CDC, 2003; Behavioral Risk Factor Surveillance System)
Current Smokers*
Nationwide
Year: Median %
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
23.0
23.1
22.2
22.6
22.7
22.4
23.4
23.2
22.9
22.6
23.2
22.8
States include District of Columbia and Puerto Rico in applicable years
*All respondents 18 and older who have ever smoked 100 cigarettes
in their lifetime and reported smoking every day or some days.
Alcohol Use: Chronic Drinking*
Nationwide (CDC, 2003)
Year: Median %
1990
3.2
1991
3.4
1992
3.0
1993
3.0
1994** No Data
1995
2.8
1996** No Data
1997
3.0
1998** No Data
1999
3.6
2000** No Data
2001
5.1
States include District of Columbia and Puerto Rico in applicable years
*All respondents 18 and older who report an average of two
or more drinks per day i.e., 60 or more alcoholic drinks a month.
Denominator includes all survey respondents except those with
missing, don't know, and refused answers.
Obesity: By Body Mass Index* Nationwide
Year: Median %
1990
11.6
1991
12.6
1992
12.6
1993
13.7
1994
14.4
1995
15.8
1996
16.8
1997
16.6
1998
18.3
1999
19.7
2000
20.1
2001
21.0
States includes District of Columbia and Puerto Rico in applicable years
*All respondents 18 and older who report that their Body Mass
Index (BMI) is 30.0 or more. BMI is defined as weight in kilograms
divided by height in meters squared (w/h**2).
Denominator includes all survey respondents except those with
missing, don't know, and refused answers. (Source CDC, 2003)
Look again at the diseases that are increasing:
Source: S. E. Taylor, Health Psychology (5th Edition), Mc Graw-Hill, 2003
Risk Factors for Leading Causes
of Death in US
• Heart Disease: Tobacco, Obesity, Blood
Pressure, Cholesterol (Diet), Exercise
• Cancer: Tobacco, Improper Diet, Alcohol,
Environmental Exposure
• Stroke: Tobacco, Blood Pressure, Cholesterol,
Exercise
• Accidents: Seat Belts, Alcohol, Home Hazards
• Chronic Lung Disease: Tobacco, Environment
Source: M. McGinnis (1994). The role of behavioral research in National Health Policy, in S. Blumenthal et al.
New Frontiers in Behavioral Medicine: Proceedings of the National Conference. NIH Publications.
Cost of Treatment for Selected
Preventable Conditions
• Heart Disease: Coronary Bypass surgery,
$30,000
• Cancer: Lung Cancer Treatment, $29,000
• Injuries: Quadriplegia (lifetime), $600,000
• Total Annual US Cost of Alcohol Abuse:
$148,021,000,000*
Source: M. McGinnis (1994). The role of behavioral research in National Health Policy, in S. Blumenthal et al.
New Frontiers in Behavioral Medicine: Proceedings of the National Conference. NIH Publications.
*Source:THE ECONOMIC COSTS OF ALCOHOL AND DRUG ABUSE IN THE UNITED STATES,
1992. H. Harwood, D. Fountain, and G. Livermore. Analysis by the Lewin Group. Rockville, MD:
DHHS, NIH, NIDA, OSPC, NIAAA, OPA.
Biomedical Model
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Illnesses arise from somatic causes
Biochemical-Physiological bases
Psychiatric: Neurophysiological bases
Psychological and social processes largely
independent of disease processes
Biopsychosocial Model
• Emphasizes health maintenance over
disease
• Biological, Psychological and Social
Factors are all important determinants of
health
• Health maintenance requires addressing
issues at all of these levels
As a Physician, your Job is to
Optimize Health
Go Where the Problems Are
Arguably, if saving (or extending)
lives is your principal goal,
Behavioral Science is the most
important pre-clinical course you
will take
Course Objectives: Basis
• Knowledge of human behavior is a critical
tool of the physician.
• Behavior is a product of the biology of the
individual--physician or patient
• Behavior is not only your primary source of
information about your patients, it is also a
primary tool for restoring or improving their
health
Course Objectives
• To understand behavior and its origins in the brain
• To understand relationships of behavior to health
and disease
• To begin to understand psychiatric disorders and
their treatment
• To understand basic issues of human behavior
• To know about development across the lifespan:
Adulthood and aging are part of the development
process
Course Objectives
• To appreciate the differences between
human and veterinary medicine.
• Mammalian physiology is very similar in
animals and humans (but not the same in all
cases).
• What differs most is the capacity of the
brain, which makes humans human.
Physicians have to recognize this.
• To prepare for the Behavioral Science
component of Step I of the Boards!
Why is there so much to learn in
medical school?
The number of hours in the basic
sciences curriculum has not changed
appreciably since 1953.
The amount of relevant basic science
has changed
Sociobehavioral Aspects of
Cardiovascular Disease (CVD): A
Case Study
• Long history of interest in relationships of
behavior, stress and susceptibility to CVD,
Coronary Heart Disease (CHD)
• CHD: Myocardical Infarction (MI) [heart attack],
pre-clinical signs (arterial plaque, angina [chest
pain])
• “ Type A” coronary prone behavior pattern
(Friedman & Rosenman)
Source: KA Matthews, Psychological perspectives on the development of coronary heart disease, American
Psychologist, 60: 783-796, 2005
Coronary Heart Disease
• Atherosclerosis: Dynamic and progressive
disease
• Arterial endothelial dysfunction and
inflammation
• Initial endothelial damage by oxidized lowdensity lipoprotein cholesterol, smoking,
high blood pressure
• Inflammatory response: Intimal layer
thickening: monocytes => macrophages
• Plaque (lipid and tissue accumulation)
closes off artery; rupture => thrombosis
Atherosclerosis
• Progressive disorder
• Non-invasive assessment: Ultrasound scanning (corotid
artery intima media thickness), electron beam tomography
to assess aortic and coronory calcification
Source: KA Matthews, Psychological
perspectives on the development of
coronary heart disease, American
Psychologist, 60: 783-796, 2005
Risk Factors for CHD: Most
Involve Behavioral Management
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High blood pressure
High cholesterol
Central adiposity (distribution: waist circumference)
Obesity
Smoking
Sedentary
Diabetic
Low Socioeconomic background
Psychosocial Predictors of
Coronary Events
• Stressful Environments
– Jobs
• High effort; low reward
• Low decision-making latitude
– Primary relationships
• Marital distress, dissatisfaction (divorce during
study)
• Poor communication
• Personal Characteristics
Psychosocial Predictors of
Coronary or Atherosclerotic Events
• Stressful Environments
• Personal Characteristics
– Hostility
• Angry affect, mistrustful attitudes towards others,
and antagonistic behavior
– Depression and anxiety
– Major depression and anxiety disorders
Who Gets CHD?
• These are not just idle speculations but collective
findings of many (>20) large scale prospective
studies with data collection “blind” to subject
characteristics during the study
• Criteria included both incidence of CHD and
subclinical atherosclerosis measures
• Direction of associations can be uncertain, e.g.,
does stress lead or contribute to hostility and/or
anxiety and depression?
Speculations on Mechanisms
• Stress-associated hormones (e.g., glucocorticoids)
(McEwen, Sapolsky)
• Cytokines (signaling compounds released by
inflamed or damaged tissue acting via receptors)
• Irritative effects of risk behavior elements (e.g.,
tobacco compounds, excess alcohol)
Take home points
• Behavior and lifestyle characteristics clearly
affect susceptibility to cardiovascular
disease
• There is evidence for mechanisms
mediating these phenomena at system,
cellular and molecular levels
• Psychosocial variables can have critical
physiological and medical consequences
beyond the realm of mental health