UNIT 3

Coronary Heart Disease (CHD)

[Link] of CHD

●​ CHD refers to heart disease involving coronary arteries that do not function properly.
●​ Major forms of CHD:
○​ Angina – Severe chest pain (can radiate down the left arm) due to restricted blood flow, causing
oxygen deprivation to the heart muscle.
○​ Acute Myocardial Infarction (MI, Heart Attack) – Occurs when blood flow is restricted
below a threshold level, leading to heart tissue damage. It can also be caused by blood clots
restricting blood flow.
○​ Sudden Cardiac Death – More common in patients with prior heart damage from MIs but can
also occur in individuals with previously healthy arteries.
●​ Cause: Atherosclerosis – narrowing of arteries due to fatty deposits, obstructing blood flow.

[Link] of CHD

●​ CHD accounts for- 33% of deaths in men under 65; 28% of all deaths in the UK
●​ CHD was the leading cause of death in the UK.
●​ Mortality rates in 1992: 4300 deaths per million men; 2721 deaths per million women
●​ Economic impact: Estimated cost to the UK NHS in 1985–86 was £390 million
●​ Higher CHD death rates are found in:
○​ Men and women in manual labor classes
○​ Men and women of Asian origin
●​ Gender differences:
○​ Middle-aged men have up to five times higher death rates than women.
○​ In old age, CHD is the leading cause of death for both men and women.
○​ Women experience poorer recovery from MI in terms of mood and activity limitations.

[Link] Factors for CHD

●​ Non-Modifiable Risk Factors: Educational status, Social mobility, Social class, Age, Gender, Stress
reactivity, Family history, Ethnicity
●​ Modifiable Risk Factors: Smoking behavior, Obesity, Sedentary lifestyle, Perceived work stress, and
Personality (though the extent to which it can be changed is debatable).
●​ Risk factors include:
○​ Biological: High cholesterol, high blood pressure, inflammation, diabetes.
○​ Behavioral: Smoking, obesity, physical inactivity.
○​ Metabolic Syndrome: Obesity (especially around the waist), high blood pressure, low HDL
cholesterol, poor blood sugar metabolism, and high triglycerides.
●​ Risk factors begin clustering by age 14, especially among low-SES individuals.
IV. Role of Psychology in Coronary Heart Disease (CHD)

1. Beliefs About CHD

●​ People have various beliefs about CHD, including its causes.

●​ French et al. (2002):
○​ Studied public understanding of MI.
○​ Differentiated between proximal causes (direct) and distal causes (indirect, mediated by other
factors).
○​ Findings:
■​ Type of work → Stress → High blood pressure → MI.
■​ Stress is seen as operating through blood pressure, not behavior.
■​ Genes are believed to affect CHD, not mediated by behavior or physiology directly.
●​ Gudmundsdottir et al. (2001):
○​ Studied MI patients' beliefs over a year.
○​ Methods:
■​ Spontaneous attributions – Open-ended responses about illness.
■​ Elicited attributions – Open-ended responses about MI cause.
■​ Cued attributions – Responses to a given list of causes.
■​ Most important attribution – Selecting the main cause from the list.
○​ Common causes cited:
■​ Smoking, stress, family history, work, eating fatty foods.
○​ Beliefs changed over time – patients became less likely to blame their behavior or personality.

2. Psychological Impact of CHD

●​ CHD is linked to psychological morbidity, including anxiety and depression.

●​ Lane et al. (2002):
○​ Studied depression and anxiety post-MI (longitudinal design).
○​ Findings:
■​ 30.9% reported elevated depression in the hospital.
■​ 26.1% reported elevated anxiety in the hospital.
■​ Psychological distress persisted over a year.
●​ Johnston et al. (1999b):
○​ Examined counseling vs. normal care for post-MI patients (RCT design, 1-year follow-up).
○​ Findings:
■​ Patients without counseling experienced increased anxiety and depression
post-discharge.
■​ Partners of MI patients had high anxiety and depression during hospitalization, which
dropped only if counseling was received.
●​ Bury (1982):
○​ CHD is a "biographical disruption" – forces individuals to question their health and future.
●​ Radley (1984, 1989):
○​ CHD patients try to balance symptoms vs. social expectations.
○​ They develop a new identity of being ill but appearing healthy.
○​ Family and social concerns influence patients’ behavior and coping.
3. Predicting and Changing Behavioral Risk Factors for CHD

●​ CHD is linked to multiple modifiable behavioral risk factors.

●​ Smoking
○​ Responsible for 1 in 4 CHD deaths.
○​ Smoking >20 cigarettes/day increases CHD risk threefold.
○​ Quitting smoking halves the risk of another heart attack.
●​ Diet & Cholesterol
○​ Top 20% cholesterol level group → 3x more likely to die from CHD than the lowest 20%.
○​ Cholesterol reduction strategies:
■​ Reduce total fats and saturated fats (from animal fats).
■​ Increase polyunsaturated fats and dietary fiber.
●​ High Blood Pressure (Hypertension)
○​ Higher blood pressure = Higher CHD risk.
○​ A 10 mmHg reduction in blood pressure could reduce CHD mortality by 30%.
○​ Influenced by genetics, obesity, alcohol, salt intake.
●​ Type A Behavior & Hostility
○​ Type A behavior (competitive, time-urgent, hostile) studied as a CHD risk factor.
○​ Conflicting research:
■​ Support: Rosenman et al. (1975), Jenkins et al. (1979), Haynes et al. (1980).
■​ No relationship found: Johnston et al. (1987).
○​ Hostility (linked to stress reactivity) is now a focus of research: Williams & Barefoot (1988),
Houston (1994), Miller et al. (1996).
●​ Stress
○​ CHD is linked to stress reactivity, life events, and job stress.
○​ Stress management interventions reduce CHD risk.
○​ Jones & Johnston (2000):
■​ Stress management for 79 distressed student nurses (compared to a control group).
■​ Results:
●​ Reduced anxiety, depression, and distress.
●​ Increased direct coping.
○​ Kaluza (2000):
■​ 12-week intervention for 82 workers (assertiveness, cognitive restructuring, time
management, relaxation, exercise).
■​ Results:
●​ Improved emotion-focused & problem-focused coping.
●​ Balanced coping profiles led to higher well-being.

4. Psychology and Rehabilitation of CHD Patients

Role of Psychology in CHD Rehabilitation

●​ Psychological interventions are used in the rehabilitation of CHD patients, including those with angina,
atherosclerosis, or post-heart attack recovery.
●​ Rehabilitation programs involve health education, relaxation training, and counseling to modify risk
factors such as exercise, type A behavior, general lifestyle, and stress.
Modifying Exercise

●​ Exercise-based rehabilitation programs aim to restore physical, psychological, and social functioning.
●​ Meta-analyses (Oldridge et al., 1988) suggest positive effects on cardiovascular mortality.
●​ However, studies may be biased toward publishing positive results.
●​ It remains uncertain whether these programs influence other risk factors (e.g., smoking, diet, type A
behavior).

Modifying Type A Behavior

●​ Friedman et al. (1986) developed the Recurrent Coronary Prevention Project to modify Type A
behavior.
●​ The study involved 1,000 heart attack patients, assigned to:
○​ Cardiology counseling
○​ Type A behavior modification (relaxation, cognitive restructuring, reducing work demands)
○​ No treatment
●​ Findings (5-year follow-up):
○​ Type A behavior modification reduced reinfarction rates.
○​ Suggests that Type A behavior can be modified.
●​ However, recent discussions indicate Type A behavior may sometimes be protective against CHD.

Modifying General Lifestyle Factors

●​ van Elderen et al. (1994) developed a health education and counseling program for CHD patients.
●​ Study Details:
○​ 30 CHD patients + partners received intervention.
○​ 30 CHD control patients received standard care.
○​ Weekly follow-ups via telephone.
●​ Findings (2-month follow-up):
○​ The intervention group showed increased physical activity & improved diet.
○​ Partner involvement enhanced smoking reduction.
●​ Findings (12-month follow-up):
○​ Lifestyle improvements were sustained, particularly in eating habits.
●​ Contradictory Results (van Elderen & Dusseldorp, 2001):
○​ Compared different interventions (health education, psychological input, medical care, and
physical training).
○​ All patients initially improved, but many relapsed into unhealthy habits after 1 year.
○​ Psychological interventions helped diet but hindered smoking cessation and exercise.
○​ Suggests potential limitations of psychological interventions in rehabilitation.

Modifying Stress

●​ Stress management includes:

○​ Self-awareness of stress triggers
○​ Cognitive restructuring ('self-talk')
○​ Relaxation techniques
○​ Time management & problem-solving skills
 ●​ Stress management has been shown to reduce CHD risk factors:
○​ Lower blood pressure (Johnston et al., 1993)
○​ Reduced cholesterol levels (Gill et al., 1985)
○​ Modified Type A behavior (Roskies et al., 1986)
●​ Impact on Angina & Heart Attack Risk:
○​ Gallacher et al. (1997):
■​ 452 angina patients randomized into stress management or no intervention.
■​ Stress management group had reduced chest pain frequency at 6-month follow-up.
○​ Bundy et al. (1998):
■​ Examined combined effects of stress management & exercise on angina.
■​ Stress + exercise group had fewer angina attacks & reduced medication use.
●​ Conclusion: Stress management may help reduce angina, potentially lowering heart attack risk.

V. Role of Stress in CHD Development

●​ Biological Reactivity to Stress:

○​ Stress-related physiological responses damage coronary vessels, promoting plaque buildup.
○​ Delayed recovery from stress increases cardiovascular disease risk.
●​ Chronic and Acute Stress:
○​ Linked to CHD and adverse events like heart attacks and angina.
○​ Stress can lead to plaque rupture and clot formation, triggering acute coronary events.
●​ Socioeconomic Status (SES) and CHD:
○​ Low SES is associated with higher risk due to chronic stress exposure.
○​ Poor social support and harsh childhood environments increase CHD vulnerability.
○​ African Americans face disproportionate CHD risk due to chronic stress.
●​ Workplace and Social Factors
○​ Job-related Risk Factors: High work demands with low control, job strain, job insecurity, and
low workplace support increase CHD risk.
○​ Life Imbalance: High personal and professional demands with little control elevate
atherosclerosis risk.
○​ Social Instability and CHD: Migrants and socially mobile individuals have higher CHD rates.
Industrialized nations report higher CHD prevalence than underdeveloped regions.

VI. Women and Coronary Heart Disease (CHD)

1. Prevalence and Mortality

●​ CHD is the leading cause of death among women in the U.S. and other developed countries.
●​ Women typically develop CHD about 10 years later than men.
●​ Despite the later onset, women are more likely to die from a heart attack than men.
●​ 50% of women die from their first heart attack, compared to 30% of men.

2. Biological Factors and CHD Risk

●​ Estrogen’s Protective Role:

○​ Estrogen helps regulate sympathetic nervous system arousal.
 ○​ Premenopausal women experience lower blood pressure and stress-related responses than men.
○​ Risk of CHD significantly increases after menopause due to weight gain, higher blood pressure,
and increased cholesterol/triglycerides.
●​ Hormone Replacement Therapy (HRT):
○​ Initially thought to reduce CHD risk, but research suggests it may actually increase risk.

3. Gender Disparities in CHD Research and Awareness

●​ Historically, CHD research has focused on men, leaving gaps in knowledge about women’s heart
disease.
●​ Women are less informed about their CHD risk and receive less medical counseling.
●​ Women are more likely to be misdiagnosed or undiagnosed and are less likely to receive life-saving
treatments like aspirin.

4. Risk Factors for CHD in Women

●​ Similar to men: High cholesterol, high blood pressure, obesity, diabetes, physical inactivity.
●​ Psychosocial factors:
○​ Depression, anxiety, hostility, anger suppression, and chronic stress increase CHD risk.
○​ Social support, especially in marriage, is linked to better CHD outcomes.
●​ Socioeconomic factors:
○​ Low SES, including childhood SES, is associated with higher CHD risk.
○​ Clerical workers have higher CHD risk than white-collar workers.
●​ Job-related factors:
○​ Workplace stress, job strain, and job insecurity increase CHD risk, similar to men.

5. Gendered Personality Traits and Health Risks

●​ Agency (self-focus): Associated with better physical and mental health (higher in men).
●​ Communion (relationship focus): No strong impact on health (higher in women).
●​ Unmitigated Communion (self-sacrifice, neglecting self-care): Linked to poor physical and mental
health (higher in some women).

6. Findings from Long-Term Studies (Nurses' Health Study)

●​ CHD incidence was lower than expected due to healthier lifestyle changes (reduced smoking, improved
diet).
●​ Women who follow recommended health guidelines (diet, exercise, no smoking) have very low CHD
risk.
●​ Rising obesity levels may increase future CHD rates among women.

[Link], Cardiovascular Reactivity, and Coronary Heart Disease (CHD)

1. Role of Negative Emotions in CHD Risk

●​ Anger and Hostility:

○​ Anger increases the risk of metabolic syndrome and CHD.
 ○​ Anger predicts poor survival rates after heart attacks and acts as a trigger for heart attacks.
○​ Hostility, particularly cynical hostility, which involves suspicion, resentment, and distrust, is
especially harmful to cardiovascular health.
○​ Hostile individuals are more likely to experience interpersonal conflict, poor social support, and
sleep disturbances, further increasing CHD risk.

2. Hostility and Gender Differences

●​ Development of Hostility:
○​ Hostility can be reliably measured in childhood and shows stability in boys but not girls.
○​ Men generally exhibit higher hostility than women, which may contribute to their greater CHD
risk.
○​ Non-whites and those with lower socioeconomic status (SES) tend to have higher levels of
hostility.
●​ Hostility and Social Relationships:
○​ Hostile individuals tend to have more interpersonal conflicts and receive less social support.
○​ Hostility can increase cardiovascular reactivity during stressful interpersonal interactions,
especially in men.
○​ Hostile individuals may seek out or create more stressful situations, undermining the support
networks they need.

3. Physiological Reactivity and Hostility

●​ Cardiovascular Reactivity:
○​ Hostile individuals exhibit exaggerated cardiovascular responses to stress, such as higher blood
pressure and longer-lasting reactions.
○​ Hostility, when combined with anger and depression, leads to elevated inflammation markers
(e.g., C-reactive protein).
●​ Health Behaviors and Risk Profiles:
○​ Hostile people may engage in behaviors that increase CHD risk, such as higher caffeine
consumption, smoking, alcohol consumption, and poor diet.
○​ These individuals are also more likely to have hypertension and higher lipid levels, which
contribute to their CHD risk.

4. Hostility and Cardiovascular Reactivity as Social Manifestations

●​ Hostility may reflect a social manifestation of heightened cardiovascular reactivity to stress.

●​ Chronic Reactivity: Hostile individuals show greater and longer-lasting cardiovascular responses to
stress.
●​ Health Implications: Over time, heightened cardiovascular reactivity increases the likelihood of
developing CHD and other related complications.

5. Developmental Antecedents of Hostility

●​ Hostility often develops from feelings of insecurity and negative feelings towards others, especially in
childhood.
●​ Parenting styles that involve punitiveness, lack of acceptance, and conflict can foster hostility.
 ●​ Hostility can run in families, suggesting both genetic and environmental influences.

6. Impact on Health Interventions

●​ Hostile individuals tend to have low adherence to cognitive-behavioral interventions designed to reduce
hostility.
●​ Hostility may also be a precursor to depression, further compounding health risks.

[Link] and Coronary Heart Disease (CHD)

1. Depression as an Independent Risk Factor for CHD

●​ Impact on CHD Development and Prognosis:

○​ Depression is strongly linked to the development, progression, and mortality of CHD.
○​ It is considered an independent risk factor for CHD, not merely a by-product of other risk
factors.
○​ Depression's effect on heart disease is greater than that of secondhand smoke, emphasizing its
significance in CHD risk.
○​ Even non-human primates (e.g., depressed monkeys) show elevated risk for CHD.
●​ Assessment and Treatment:
○​ There is a call for assessing and treating depression in all CHD patients to improve outcomes.

2. Depression and Risk Factors for CHD

●​ Connection to CHD Risk Factors:

○​ Depression is associated with several risk factors for CHD, including:
■​ Metabolic Syndrome (linked to depression, especially in women).
■​ Inflammation, indicated by C-reactive protein levels, a marker for plaque buildup in
arteries.
■​ Increased likelihood of heart attacks and poor recovery following events like coronary
artery bypass graft surgery.
○​ Inflammation is particularly important in how depression impacts CHD progression.
○​ The relationship between depression and inflammation is stronger in men and in African
Americans.
○​ Environmental Factors (rather than genetic) seem to drive the depression-CHD relationship.

3. Depression, Inflammation, and CHD

●​ Role of Inflammation:
○​ Depression is strongly associated with inflammation markers such as C-reactive protein, which
reflects artery plaque buildup.
○​ Inflammatory processes linked to depression may contribute to the onset and worsening of CHD.
○​ Stress-induced inflammation, including viral reactivation, may contribute to coronary events
(e.g., heart attacks).
4. Treatment of Depression and CHD Outcomes

●​ Antidepressants and CHD Recovery:

○​ Antidepressant treatments, especially serotonin reuptake inhibitors (e.g., Prozac), may improve
long-term recovery from heart attacks.
○​ These medications block serotonin receptors, potentially preventing blood clot formation and
platelet aggregation in arteries, acting like blood thinners.
○​ Antidepressants have also been shown to reduce inflammation, further benefiting CHD patients.

5. Challenges in Diagnosing and Treating Depression in CHD Patients

●​ Underdiagnosis and Untreatment:

○​ Despite the growing evidence of depression's impact on CHD, it remains underdiagnosed and
undertreated in many CHD patients.
○​ Co-existing psychiatric disorders among CHD patients highlight the need for better recognition
and management.
○​ The importance of further research into the role of psychiatric disorders in CHD is emphasized.

IX. Other Psychosocial Risk Factors and CHD

1. Vigilant Coping and Anxiety

●​ Vigilant Coping: Chronic search for potential threats in the environment (vigilant coping) is linked to
increased risk for heart disease (Gump & Matthews, 1998).
●​ Anxiety and Heart Disease:
○​ Anxiety is associated with a worsened course of illness and sudden cardiac death (Moser et al.,
2011).
○​ Anxiety may reduce vagal control of heart rate, contributing to cardiovascular risk (Phillips et
al., 2009).

2. Negative Affectivity as a General Risk Factor

●​ Composite of Negative Emotions:

○​ A combination of depression, anxiety, hostility, and anger (negative affectivity) may be a better
predictor of CHD than each factor in isolation (Boyle et al., 2006).
○​ Negative affectivity is considered a broad general risk factor for CHD (Suls & Bunde, 2005).

3. Vital Exhaustion and CHD

●​ Vital Exhaustion:
○​ Vital exhaustion, characterized by extreme fatigue, dejection, irritability, and feelings of defeat,
is associated with cardiovascular disease (Cheung et al., 2009).
○​ It may be a bodily expression of depression (Vroege, Zuidersma, & de Jonge, 2012).
●​ Impact on Heart Health:
○​ Vital exhaustion in combination with other risk factors predicts the likelihood of a heart attack
(Bages et al., 1999) and the risk of a second heart attack (Kop et al., 1994).
○​ It also predicts mortality (Ekmann et al., 2012).
4. Hostility, Social Isolation, and Interpersonal Conflict

●​ Hostility and Social Support: Hostility can reduce the ability to seek or receive social support, which
in turn increases CHD risk.
●​ Social Isolation and Chronic Conflict:
○​ Both social isolation and chronic interpersonal conflict independently increase CHD risk (Smith
& Ruiz, 2002).
○​ Inflammatory processes may play a role in these associations (Wirtz et al., 2003).

5. Type D Personality and CHD

●​ Type D (Distressed) Personality:

○​ Type D personality, characterized by negative emotions and inhibition of emotional expression,
may be a risk factor for CHD (Denollet et al., 2006; Pedersen et al., 2010).
○​ However, the evidence is mixed (Coyne et al., 2011; Grande et al., 2011).
●​ Explanatory Factors:
○​ Factors like poor regulation of the HPA axis and unhealthy behaviors may explain the effects of
Type D personality on CHD (Molloy et al., 2008; Williams et al., 2008).

6. Protective Psychosocial Factors

●​ Positive Emotions and Well-Being:

○​ Positive emotions, emotional vitality, mastery, optimism, and general well-being protect against
depressive symptoms in heart disease (Kubzansky et al., 2001).
○​ These positive factors help protect against CHD risk factors (Roepke & Grant, 2011) and
improve recovery following surgery (Tindle et al., 2012).
○​ Positive psychosocial factors also contribute to better CHD outcomes (Boehm & Kubzansky,
2012).

[Link] of Heart Disease

1. Delay in Treatment and Mortality

●​ Delays in Seeking Treatment:

○​ High rates of mortality and disability are linked to patients delaying treatment after a heart
attack. Symptoms are sometimes misinterpreted as less severe, like gastric distress
(Perkins-Porras et al., 2008).
○​ Depression and the belief that symptoms are caused by stress can increase delays in seeking
medical help (Bunde & Martin, 2006).
○​ Older patients and African Americans tend to delay longer. Interestingly, patients with a history
of angina or diabetes also show longer delays (Dracup & Moser, 1991).

2. Initial Treatment and Hospital Care

●​ Acute Treatment:
○​ Upon diagnosis, treatment can vary, including coronary artery bypass graft (CABG) surgery for
major artery blockages.
 ○​ Patients are typically admitted to coronary care units where cardiac functioning is monitored.
○​ Anxiety during the acute phase of myocardial infarction (MI) can predict complications, while
denial may reduce anxiety during this period (Contrada et al., 2008).
○​ Depression, PTSD, anger, and poor social support are linked to longer hospital stays (Oxlad et
al., 2006).

3. Cardiac Rehabilitation

●​ Rehabilitation Program:
○​ Cardiac rehabilitation helps patients improve their physical, medical, psychological, and social
well-being.
○​ It aims to reduce disease severity, prevent further progression, and promote psychological and
social adjustment.
○​ Success relies on the patient’s active participation and commitment (Sarkar et al., 2009).
○​ A key goal is restoring a sense of self-efficacy to improve adherence to rehabilitation (Sarkar et
al., 2009).

4. Medication in Cardiac Treatment

●​ Medications:
○​ Beta-adrenergic blockers are commonly prescribed to reduce sympathetic nervous system
stimulation, though side effects like fatigue and impotence can affect adherence.
○​ Aspirin is prescribed to prevent blood clots, and statins are used for patients with elevated lipids
following acute coronary events (Facts of Life, 2007).

5. Lifestyle Modifications

●​ Diet and Exercise:

○​ Cardiac rehabilitation involves dietary modifications and exercise programs (e.g., walking,
jogging) to improve prognosis.
○​ Regular exercise is especially important for those with low socio-economic status (Puterman et
al., 2012).
○​ Adherence to these changes can be challenging, but reinforcing their significance is crucial for
recovery.

6. Stress Management

●​ Stress and Heart Disease:

○​ Stress can trigger fatal cardiac events, making stress management a vital component of
rehabilitation (Donahue et al., 2010).
○​ Younger patients, women, and individuals with poor social support are particularly vulnerable to
stress (Brummett et al., 2004).
○​ Stress management techniques like relaxation and mindfulness can improve coping (Cole et al.,
1992).
7. Targeting Hostility and Anger

●​ Hostility as a Risk Factor:

○​ Programs designed to reduce anger and hostility have shown some success (Gidron et al., 1999).
○​ However, hostility may reflect cardiovascular reactivity rather than directly causing
cardiovascular risk (Sloan et al., 2010).

8. Depression and Its Impact

●​ Depression in Cardiac Patients:

○​ Depression is prevalent during cardiac rehabilitation and can negatively affect treatment
adherence and outcomes (Casey et al., 2008).
○​ Cognitive-behavioral therapy can have modest benefits, and even brief interventions like
telephone counseling show positive effects (Bambauer et al., 2005).

9. The Role of Social Support

●​ Importance of Social Support:

○​ Social support and marriage are linked to better recovery outcomes, such as lower depression
rates and better adherence to treatment (Molloy et al., 2008).
○​ Social isolation and lack of a spouse or confidant worsen recovery (Shankar et al., 2011).
○​ Supportive relationships can improve exercise tolerance and prognosis during rehabilitation
(Fraser & Rodgers, 2010).
○​ Spousal conflict and caregiving strain can complicate recovery (Itkowitz et al., 2003).

10. Family Education and Follow-Up Care

●​ Family Role in Recovery:

○​ Families should be educated to recognize heart attack symptoms and act promptly. This reduces
delays in treatment and improves outcomes in case of recurrence.

11. Evaluation of Cardiac Rehabilitation

●​ Effectiveness of Rehabilitation:
○​ Numerous studies confirm that targeted interventions addressing weight, blood pressure,
smoking, and quality of life are effective in reducing heart disease risk and even death (Pischke
et al., 2008).
○​ Psychosocial interventions (e.g., depression management, social support) enhance rehabilitation
outcomes by reducing psychological distress and lowering the likelihood of recurrent cardiac
events (Lisspers et al., 2005).
 HYPERTENSION

●​ Hypertension (high blood pressure or cardiovascular disease) occurs when blood flow through vessels is
excessive.
●​ Caused by high cardiac output (pressure on arterial walls) or peripheral resistance (resistance in small
arteries).
●​ Prevalence and Impact:
○​ Nearly 30% of U.S. adults have hypertension, but one-third are unaware due to a lack of
symptoms (Yoon et al., 2012).
○​ 47% of adults at risk for hypertension (Fryar et al., 2012).
○​ Increases the risk for heart disease, kidney failure, and cognitive dysfunction (e.g., learning,
memory, and attention issues), especially in young hypertensives (Waldstein et al., 1996).
●​ Measurement:
○​ Measured by systolic and diastolic blood pressure via sphygmomanometer.
○​ Systolic pressure: pressure during heart contraction.
○​ Diastolic pressure: pressure when the heart is relaxed, related to resistance in blood vessels.
○​ Systolic pressure is more significant in diagnosing hypertension.
○​ The systolic range for mild hypertension: 140-159; moderate: 160-179; severe: 180+.

Causes of Hypertension

●​ 5% due to kidney failure; 90% is essential (unknown origin).

●​ Risk factors include:
○​ Childhood temperament: Emotional excitability linked to future CVD (Pulkki-Råback et al.,
2005).
○​ Blood pressure reactivity: Predicts hypertension later in life (Ingelfinger, 2004).
○​ Gender: Men at higher risk before 45; after 65, women have higher risk.
○​ Genetics: Family history increases likelihood (45% if one parent, 95% if both have
hypertension).
○​ Emotional factors: Depression, hostility, anger, and rumination contribute to higher blood
pressure (Betensky & Contrada, 2010; Harburg et al., 2003).
○​ Social environment: Stress, job strain, low SES, urban living increase hypertension risk.
●​ Stress and Hypertension:
○​ Chronic stress, social conflict, and job strain (high demands, low control) contribute to
hypertension.
○​ Stress has been a suspected cause for many years (Henry & Cassel, 1969).
●​ Hypertension in African Americans:
○​ Hypertension more prevalent in African American communities, linked to stress and low SES
(Hong et al., 2006).
○​ Factors:
■​ Stressful neighborhoods and psychological distress.
■​ Discrimination and racism interfere with normal blood pressure regulation (Salomon &
Jagusztyn, 2008).
■​ Obesity: Common in African Americans and related to hypertension.
 ■​ Diet, smoking, exercise: Diet (e.g., salt intake), lack of exercise, and smoking contribute.
■​ Cardiovascular reactivity: Older African Americans may face clustering of risk factors
(metabolic syndrome) including higher heart rate, obesity, and diabetes risk (Waldstein et
al., 1999).
●​ John Henryism:
○​ A concept coined by S.A. James to describe a personality predisposition in which individuals
cope actively with stressors in an effort to succeed despite insurmountable odds.
○​ Especially lethal for disadvantaged groups, particularly low-income, poorly educated African
Americans (James et al., 1983).
○​ Linked to greater cardiovascular reactivity and slower recovery from stress (Merritt et al., 2004).

Treatment of Hypertension

●​ Common Treatments:
○​ Medications: Most common treatment.
○​ Lifestyle Changes: Low-sodium diet, Reduced alcohol consumption, Weight reduction for
overweight patients, Regular exercise for all hypertensive patients, and Caffeine restriction
(caffeine increases blood pressure in combination with stress) (Lovallo et al., 2000).
●​ Cognitive-Behavioral Treatments:
○​ Methods: Biofeedback, progressive muscle relaxation, hypnosis, meditation, deep breathing, and
imagery.
○​ These methods induce low arousal, helping to lower blood pressure.
○​ Effectiveness: Modestly positive effects, but adherence is modest (Davison et al., 1991;
Hoelscher et al., 1986).
●​ Anger Management:
○​ Anger has been linked to hypertension; teaching anger management skills through role-playing
and behavioral techniques can lower blood pressure reactivity (Davidson et al., 1999; Larkin &
Zayfert, 1996).
●​ Depression: Depression affects both adherence to treatment and overall well-being (Krousel-Wood et
al., 2010).
●​ Evaluation of Cognitive-Behavioral Interventions:
○​ Non-drug treatments like weight reduction, physical exercise, and cognitive-behavioral therapy
(CBT) are successful (Linden & Chambers, 1994).
○​ Advantages: Inexpensive, easy to implement, can be done without supervision, and have no side
effects.
○​ CBT may reduce the need for drugs in hypertension treatment (Shapiro et al., 1997).
○​ Especially effective for mild or borderline hypertensives, and in some cases, CBT may replace
drug treatment.
●​ Adherence Issues:
○​ People’s “commonsense” understanding of hypertension (e.g., thinking stress reduction alone is
enough) can hinder adherence (Hekler et al., 2008).
○​ Because hypertension is symptomless, many people underestimate their risk and avoid necessary
medication (Frosch et al., 2008).
●​ Best Approach:
 ○​ Combination of medication and cognitive-behavioral treatments is currently the most effective
approach for managing hypertension.

The Hidden Disease Notes:

●​ Hypertension is often a "hidden" disease because it is largely symptomless.

●​ Many individuals with hypertension are unaware of their condition, especially if they do not undergo
regular physical exams.
●​ Despite the lack of symptoms, hypertension leads to:
○​ Lower quality of life.
○​ Compromised cognitive functioning.
○​ Reduced social activities (Saxby et al., 2003).
●​ National Campaigns and Public Education:
○​ Public education campaigns have made some progress in helping people get diagnosed (Horan &
Roccella, 1988).
○​ Worksite screening programs have been effective in identifying individuals with hypertension
(Alderman & Lamport, 1988).
●​ Community Interventions:
○​ Community-based screening programs are increasing:
■​ Mobile units.
■​ Blood pressure checks at community centers, churches, or drugstores.
○​ These programs improve early identification of hypertensive individuals, aiding in better
management of the disease.
 DIABETES

Type II Diabetes Notes:

●​ Prevalence and Impact:

○​ Type II diabetes is the third most common chronic illness in the U.S. and a leading cause of
death (Centers for Disease Control and Prevention, 2011).
○​ Over 8% of the U.S. population has diabetes, with 7 million undiagnosed cases (Centers for
Disease Control and Prevention, 2011).
○​ Diabetes costs the U.S. over $174 billion annually in medical expenses.
○​ The global incidence of diabetes is increasing dramatically, and it is considered a pandemic
(Taylor, 2004).
○​ Diabetes contributed to 231,404 deaths in 2007 alone (Centers for Disease Control and
Prevention, 2011).
●​ Demographic Trends:
○​ Type II diabetes, once mostly seen in middle-aged and older adults, is becoming increasingly
prevalent in younger people due to obesity and diet (Malik et al., 2010).
○​ Children and adolescents are now at risk, with the disease progressing faster and being harder to
treat in younger individuals (Grady, 2012).
○​ The disease is most common in individuals over 45, with 90% of sufferers being overweight
(American Diabetes Association, 2012).
○​ It disproportionately affects minority communities, with higher risk in African Americans,
Hispanic Americans, and Native American tribes (American Diabetes Association, 1999).
●​ Mechanisms and Symptoms:
○​ Glucose metabolism involves a balance between insulin production and insulin responsiveness.
In Type II diabetes:
■​ Insulin resistance occurs in muscle, fat, and liver cells.
■​ The pancreas compensates by producing more insulin, but eventually insulin production
declines (Alper, 2000).
○​ Symptoms include frequent urination, fatigue, dry mouth, impotence, and slow healing of cuts.
○​ Early signs of insulin resistance can appear in children as young as 10, particularly in low-SES
and obese children (Goodman et al., 2007).

Health Implications

●​ Diabetes is linked to:

○​ Coronary heart disease, kidney failure, blindness, and amputations.
○​ Nerve damage, including pain and loss of sensation.
○​ Depression, Alzheimer's disease, and vascular dementia (Ryan et al., 2012; Xu et al., 2009).
○​ A shortened life expectancy.
●​ It also contributes to sexual dysfunction, cognitive dysfunction, and psychological distress, which can
further increase mortality risk (Hamer et al., 2010).
●​ Stress and Diabetes:
○​ Stress negatively impacts Type II diabetes:
■​ It alters glycemic responses, potentially triggering the disease (Gonder-Frederick et al.,
1990).
 ■​ Stress exacerbates diabetes progression and management difficulties (Surwit &
Schneider, 1993; Surwit & Williams, 1996).
■​ The sympathetic nervous system is involved in the pathophysiology of both heart disease
and diabetes.

The Management of Type II Diabetes

●​ Self-Management:
○​ Active self-management is key to controlling Type II diabetes (Auerbach et al., 2001).
○​ Type II diabetes can be prevented through lifestyle changes in high-risk individuals (Tuomilehto
et al., 2001), including:
■​ Exercise, weight loss, stress management, and dietary control (Wing et al., 1986;
Wing et al., 1994).
■​ Dietary changes focus on reducing sugar and carbohydrate intake.
■​ Weight loss is particularly important as obesity stresses the insulin system.
●​ Challenges to Adherence:
○​ Many Type II diabetics are unaware of their health risks, such as heart disease (New York Times,
2001).
○​ A lack of understanding about glucose utilization and insulin metabolism can affect adherence
(Mann et al., 2009).
○​ Ensuring patients have correct beliefs about their illness is crucial for long-term commitment to
treatment.
●​ Factors Influencing Adherence:
○​ People with strong self-control skills are better at managing their diabetes (Peyrot et al., 1999).
○​ Social support is generally beneficial, though it may sometimes lead to temptation and poor
eating choices (Littlefield et al., 1990).
○​ Spousal support for exercise, however, improves adherence (Khan et al., 2012).
●​ Cognitive-Behavioral Interventions:
○​ Interventions have targeted nonadherence issues like forgetting medications or running out of
supplies (Hill-Briggs et al., 2005).
○​ Training in blood sugar monitoring and even brief interventions (e.g., via telephone) have proven
beneficial (Wing et al., 1986; Sacco et al., 2009).
○​ Technological aids like personal digital assistants have also been used to prompt patients about
self-care (Sevick et al., 2010).
●​ Psychological Aspects:
○​ Depression complicates management and worsens prognosis (Katon et al., 2009).
○​ Anger may negatively affect glycemic control (Yi et al., 2008).
○​ Interventions focus on improving self-efficacy and addressing emotional issues related to
diabetes (Cherrington et al., 2010).
●​ Stress Management:
○​ Stress has a significant impact on Type II diabetes, both in terms of development and
management (Herschbach et al., 1997).
○​ Stress management programs have been explored to improve diabetes control.
●​ Lifestyle Interventions:
 ○​ Multifactor lifestyle interventions (addressing diet, exercise, etc.) have shown mixed results
(Angermayr et al., 2010).
○​ Self-management and problem-solving training are key components of successful interventions
(Hill-Briggs, 2003).
○​ Building self-efficacy is crucial (Nouwen et al., 2011).
●​ Prevention:
○​ Diabetes Prevention programs focus on high-risk individuals with elevated blood sugar but not
yet diagnosed with diabetes.
○​ One study (Diabetes Prevention Program Research Group, 2002) showed a 58% reduction in
diabetes incidence after 4 years in the intensive lifestyle intervention group (focused on weight
loss, exercise, and diet), and a 31% reduction in the medication group.
○​ Modest weight loss and small increases in physical activity were effective in reducing diabetes
incidence.
●​ Future Directions:
○​ Internet-based diabetes self-management programs and mobile phone apps may be the future
of diabetes care, helping to monitor and support adherence (Glasgow et al., 2010; Mulvaney et
al., 2012).