Social influences on health

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Social networks are very important in dealing with the type of stressful circumstances that might eventually have an impact on health or in dealing directly with ill-health and disease. There are a number of aspects to this, the first and most obvious of which is how many people that you might have in your network of social support. To some extent, the more the better. However, sheer numbers would not make up for a lack of any practical support from among them. In other words, the nature of the support is also important, as, also, is the individual's perception of that support. For example, if, from an individual's perspective, his or her family and friends only paid lip service to providing support, the lack of quality involved would be likely to have its impact.

The obvious way in which social support might have an influence on health is by helping the individual deal with stressful situations. This could be through both problem- and emotion-focused coping strategies. Straightforward practical problem-solving coping advice could come from family and friends as also could a friendly ear in which to speak and a friendly shoulder on which to lean - both providing emotion-focused coping.

However, it is also possible to imagine circumstances in which social support, depending on the kind of social support, might not be positive. If a family member contracts an illness and the family gather round and tell stories that they know of others who have had to put up with such an illness, then this might be less than helpful. In such circumstances, people are sometimes prone to catastrophise, to spread rumours as though telling true stories, and so on. In other words, the apparent social support might be more about the person who is offering the 'support' than it is about the person apparently being supported.

For most people at many stages in their lives, their social group is a strong source of influence and such influence might well impact on health. The most obvious time of life in which this happens is adolescence. At this stage, influences might be powerful to smoke, drink, take drugs, eschew exercise, and so on. However, such peer pressure or influence continues later in life. Think of the pressure of executive lunches or the idea that the only proper way to take a break from a manual job is to have a smoke.

In general, broad cultural factors also have a strong influence on health. An obvious example in Western society comes from the huge emphasis on slimness equating with beauty and fashionability throughout the previous two or three decades. No doubt this has not been the only influence on the development of eating disorders in women, with all the attendant health risks, but it has surely been an important factor. Similarly, although, in another sense, by contrast, the large-scale advertising of fast foods has surely added to the potential to be overweight and thus at a greater health risk. There are numerous examples of such influences, such as the influence on tooth decay in children or the advertising of sugar-based products.

All but a very few people experience pain at many times in their lives. And pain has a very obvious adaptive value - it is a clear warning that actual or potential damage is occurring to basic bodily tissues. Again, though, as most people have experienced, pain is not as straightforward as this description makes it seem. Have you ever injured yourself playing sport and not noticed until later? Have you ever been in some extreme situation in which you have had to do something that would normally cause you great pain, but which, again, you have not noticed until later? Have you ever had a chronic pain, such as a toothache or broken bone or extreme indigestion, which seems to have disappeared from your aware ness for a few minutes? It has not 'really' disappeared, but simply seems to have gone from your attention.

There are (at least) two parts to pain. There is a sensory side - a bee-sting hurts at the point of the sting, a tooth aches in and around the tooth. But there is also an emotional side to pain. Pain is always accompanied by an emotional reaction (anger, fear, unhappiness, and so on) and this reaction somehow interacts with the sensory side of pain. For example, if we feel a sudden pain in the chest and start to be afraid that we are having a heart attack, then the chances are that the pain will worsen.

Cognitions are almost always involved in emotions and each individual, depending on personal experience, develops thoughts, beliefs and opinions about pain. These, in turn, might well influence the pain. For example, if I am typically afraid of pain and what it might mean, then the experience of the pain is likely to be more intense than if I believe that I am the sort of person who can easily cope with pain.

This combination of sensation-based and emotion/cognition-based factors have been put together in the well-accepted gate-control theory of pain, suggested in 1965 by Melzack and Wall (1983). A potentially painful stimulus occurs (the bee stings, the shin cracks on the edge of the bath, the toe catches on the leg of the bed) but there is a sort of gate in the central nervous system that, by its degree of opening, determines the extent to which the pain is perceived. In other words, the mixture of emotions and cognitions going on in the brain sends messages to the spinal cord that makes the experience of the pain either more or less intense.

If the gate opens a little, then the threshold for pain is lowered, that is, less of a stimulus leads to a perception of pain. Other reactions might close the gate, raising the pain threshold and thus making it necessary for much more of a stimulus to occur before pain is experienced. To take an obvious example, if I am afraid of painful stimuli and catastrophise them, then the gate opens and I am more likely to experience pain quickly and readily. If, on the other hand, when I notice a potentially painful stimulus, I am able to relax and concentrate on other sensations, then I am less likely to experience intense pain - the gate has been closed somewhat.

The interaction between sensation and emotion/cognition in pain means that two very broad types of pain can be distinguished, even though both factors might be present in both types. Organic pain can be extreme and is what occurs when there is obvious damage to bodily tissue. Psychogenic pain is the type of pain (that can also be intense, severe and long-lasting) that occurs without any obvious physical basis. Of course, this might mean that, as yet, a physical cause for the pain has not been found. There are three major types of such pain. Neuralgia is an intense, shooting pain along a nerve, often in the face, for which no physical cause has been discovered. Causalgia is similar to neuralgia but consists of a severe burning pain in some part of the body. And phantom-limb pain is a pain that is sometimes experienced in a limb that no longer exists (through amputation) or for which there no longer exist any nerves.

As with most aspects of health or disease, there are possible links between pain and personality and various attempts have been made to establish such links. The problem, however, is the usual one of correlations saying little about causes. If, for example, a link is found between anxiety and proneness to experience pain, does this mean that the anxiety causes the intensification of the pain experience, or that the pain leads to increased anxiety, or both, or even that there is some underlying factor that is causing both?

Perhaps the most important aspect of pain to consider is how it can be controlled. This is particularly so where chronic pain is involved, that is, pain that goes on for months or years. The major methods are through: drugs, surgery, acupuncture, biofeedback, hypnosis, relaxation and guided imagery, counter-irritation (of another part of the body) and distraction. As should be clear, some of these techniques work on the sensory side of pain and others on the cognitive/emotional. Most of the techniques are to some extent effective, but each of them, with the exception of relaxation and guided imagery, has its drawbacks.

Teaching relaxation enables the person to lower their state of arousal and relax the muscles. This is usefully induced through meditation techniques. It can be used in conjunction with guided imagery in which people are trained to imagine scenes that help to deal with the pain. For example, one type of guided imagery involves the person being encouraged to imagine fighting the pain, wrestling it into submission, or another might be to imagine taking the pain and wrapping it up so that it becomes smaller and smaller and then disposing of it. Although the relaxation and meditation techniques work well in many cases of pain, the guided imagery tends to work less well where the pain is especially severe.

In the end, a person has to adapt to chronic pain and how well this adaptation occurs will determine how well the person copes with the pain. Such adaptation will depend on the type of factor or sources of influence discussed so far in this chapter. For example, there are background factors such as personality, personal beliefs and culture. There are also aspects of the pain itself, particularly its severity, and finally there are factors such as the nature and kind of social supports available to the person and even the degree of financial support that there might be.

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