Dr Zana Marovic, Phd

Clinical Psychologist, Johannesburg

Health Psychology & Stress

Health Psychology & Stress

Health psychology is a relatively new discipline that applies scientific knowledge of the interrelationships among behavioral, emotional, cognitive, social and biological components in health and disease to promote and maintain health, do prevention, treatment and rehabilitation of illness and disability; as well as improve health care process. The distinct focus of health psychology (also known as medical psychology and psychosomatic medicine) is at the connection between physical and emotional aspects and understanding and treating the overlapping challenges. A vast scientific literature has detailed how negative emotions harm the body.

Stress especially serious, and sustained stress can alter biological systems in a way that, over time, adds up to “wear and tear” and, eventually, illnesses such as heart disease, stroke, and diabetes. Chronic anger and anxiety can disrupt cardiac function by changing the heart’s electrical stability, hastening atherosclerosis, and increasing systemic inflammation as well as causing digestive disorders and infection. Chronic stress and negative attitude can upset the body’s hormone balance and deplete the brain chemicals, as well as have a damaging impact on the immune system.

A research by Harvard University found that early childhood stress and abuse – the sustained activation of the body’s stress response system resulting from early life experiences as chronic neglect, exposure to violence, or living alone with a parent suffering severe mental illness—has harmful effects on the brain and other organ systems.

When we experience emotions of sadness, anger, fear and frustration our body responds to the way we think, feel and act. This is called the “mind/body connection”. Even our everyday language points to the effects emotions have on our body, metaphorically and literary: “that breaks my heart,” “it’s a pain in the neck” or “I just love it to death”. When feelings are kept inside, they operate invisibly and eventually start inflicting damaging changes in the body.

According to research, around 75% of people report experiencing moderate to high levels of stress. The National Institute of Mental Health in USA defines stress the “brain’s response to any demand.” Some stress can be positive and you may have found that stress has forced you to perform better. The “fight-or-flight” response, is when our brain identifies a threat and responds by releasing hormones that encourage us to protect ourselves from perceived harm. But when this fight-or-flight response overreacts or there is a chronic situation causing us to overreact, it can potentially cause significant health impact. Below are some of the health conditions that may be caused or exacerbated by stress:

Heart diseases: Research suggests that type A personality has a higher risk of high blood pressure and heart problems. Stress increases heart rate and blood flow, and causes the release of cholesterol and triglycerides into the blood stream. Emotional stress can be a trigger for serious cardiac problems, including heart attacks.

Headaches: Stress is considered one of the most common triggers for headaches — not just tension headaches, but migraines as well.

Asthma: Many studies have shown that stress can worsen asthma. There is evidence that parental chronic stress may increase the risk of developing asthma in their children.

Obesity. Stress causes higher levels of the hormone cortisol, which increases the amount of fat that’s deposited in the abdomen.

Gastrointestinal and bowel problems: Stress is a commonly associated with many bowel conditions, such as heartburn, reflux, irritable bowel, hemorrhoids, etc.

Diabetes: Stress can worsen diabetes. It may increase the likelihood of damaging behavior, for example unhealthy eating or/and excessive drinking. Further, stress causes a raise of glucose levels in people with type 2 diabetes.

Fertility: Studies show that stress in men can lead to reduced sperm and semen quality, which may negatively affect fertility. Elevated cortisole levels were found to suppress production of female hormones, affecting woman’s fertility.

Depression and anxiety. Recent studies found that people who had stress related to their job, like demanding work had an 80% higher risk of developing depression and anxiety, than people with lower stress.

Alzheimer’s disease. Stress might worsen the disease, causing its brain lesions to form more quickly.
Accelerated aging. Studies show evidence that stress can affect how we age. Research reports that high stress.impacts a particular region of the chromosomes showed the effects of accelerated aging of about 9 to 17 additional years.

Chronic illnesses are often caused or worsen by stress. Today, chronic diseases are among the most prevalent, costly, and preventable of all health problems. Chronic diseases are now the major cause of death and disability worldwide and they account for 59% of the 57 million deaths annually and 46% of the global burden of disease. For example, weight and obesity are affecting more than one billion adults worldwide, with 300 million of them clinically obese. In 2011 366 million people worldwide were diagnosed with diabetes and by 2030 this will rise to 552 million. 10 to 15 % of general population suffer from irritable bowel syndrome worldwide. Pelvic floor disorders (PFD) constitute another global health problem affecting hundreds of millions of women and man throughout the world. The prevalence of at least one form of PFD like pelvic pain, constipation, urinary and fecal incontinence, pelvic organ prolapse, has been reported to be as high as 46%.

Poor compliance with medication and/or treatment plan are very common in chronic illness.  The more complex and painful the treatment – the higher the chance that non-compliance will become an issue. It may therefore not be surprising that compliance rates have been found to be below 50% among chronic illness patients.

When a family has a member with a chronic illness, the family also has a chronic relationship with different medical and health professionals. Noncompliance is often located at the interface between the patient and the health/provider system, for example, effective communication and consistent and caring relationship were found to have major positive effect on patient’s compliance rates. Multi-disciplinary team approach is found to be most effective in chronic conditions.

The somatic and body oriented psychotherapy addresses mind-body connection by focusing on clients’ awareness of their physical body, and its relationship to mental and emotional habits. Somatic psychotherapy also teaches clients how to develop a positive relationship with one’s physical body and how to use body-mind connections to improve overall health.

Pelvic Floor Disorders

Pelvic floor problems include pelvic pain, constipation, pelvic organ prolapse, and incontinence of urine or feces. There are many causes of these problems, and their manifestations affect different people in different ways. Symptoms can range from minor inconveniences to causing major restrictions of lifestyle, ability to work, or sexual function. Feelings of helplessness, anger, and frustration are common. Many patients have visited multiple doctors or tried a number or treatments without relief of their symptoms.

In USA every ninth women will undergo surgery for a pelvic floor disorder in her lifetime, with 30 percent of those women requiring additional surgery for the same condition. There were 28.1 million woman diagnosed with pelvic floor disorder in 2010 and number will rise to 43.8 million in 2050. Twelve percent of people worldwide suffer from constipation while 20 percent of women experience chronic pelvic pain, and about 61 percent of the cases go undiagnosed. Sixty five percent of women and 30 percent of men sitting in a GP waiting room report some type of urinary incontinence, yet only 31 percent of these people report having sought help from a health professional. Women comprise over 70 percent of people affected by incontinence, with problems arising primarily after childbirth and menopause. There are no available statistics specifically for South Africa.

Pelvic Floor Disorder Units in South Africa

Although not a new field of medicine globally, the treatment of PFDs in SA is in its infancy as evinced by the fact that the first national meeting focusing on the field took place just five years ago.

The Pelvic Floor Unit at the Wits Donald  Gordon Medical Centre (WDGMC) is the  only private practice center of its kind in SA, with colorectal surgeon, Dr Brendan Bebington, as the chair of the pelvic floor unit. The multi-disciplinary approach and meetings include several other disciplines: urology, gynecology, radiography, a women’s health physiotherapy team and clinical psychology. Dr Marovic is a member of Donald Gordon multi-disciplinary team.

Psychology of Pelvic Floor

The majority  of people (40-80%) with pelvic floor disorders do not seek help or there is a delay obtaining help. Most common reasons given for not seeking treatment include: embarrassment, shame, fear of surgery, and hope of improvement without treatment. Dealing with constipation, diarhea, bladder or feces incontinence, pelvic pain or other embarrassing issues related to pelvic floor disorders eventually leads to depression, anxiety, social isolation, self-esteem & body-image problems.

There are valid physiological reasons why people have problematic bowel movements such as lack of exercise, poor diets, pregnancy, illness and others. However, root cause of bowel problems may be imbedded in the mind.

If you’ve ever had a headache after a stressful day, a sick feeling in your stomach before an interview, or felt anxiety before an exam, you have first hand experience with the undeniable connection between feelings and their ability to produce physical ailments. Similarly, a long history of suppressed feelings of anger, hatred, grief or anxiety, and the genetic predisposition to bowel disorders, may result in bowel problems. So our thoughts and emotions materialize into physical matter. The body-mind relationship has a direct effect on our state of health as well as our ability to heal. Long periods of unexpressed anger, grief and other stressful emotions directly affect bowel movements and lead to bowel problems.

Psychotherapy may be helpful in addressing some of the following aspects of pelvic floor disorders:

  • Dealing with emotional aspects related to pelvic floor disorders
  • Management of pelvic floor condition.
  • Addressing  traumatic  or other emotional  events related to pelvic floor dysfunction
  • Hypnotherapy  for pelvic floor pain management
  • Expectations in relation to surgery
  • Somatic psychotherapy  to build body-mind  awareness and connection
  • Teaching stress-management techniques
  • Addressing relationship issues
  • Dealing with sexual dysfunctions
  • Improvement of medical compliance.


Diabetes is a chronic illness in which the body is unable to produce or unable to properly use and store glucose (a form of sugar). Glucose backs up in the bloodstream — causing one’s blood glucose or “sugar” to rise too high. In South Africa we currently have approx 6,5 million diabetics, only 8 000 of whom are registered with Diabetes South Africa (DSA) – shocking statistics!

There are two main types of diabetes:

Type I diabetes or insulin-dependent diabetes (formerly called juvenile-onset diabetes, because it tends to affect persons before the age of 20) affects about 10 percent of people with diabetes. With this type of diabetes, the pancreas makes almost no insulin.

Type II diabetes or non-insulin-dependent diabetes. This was previously called “adult-onset diabetes” because in the past it was usually discovered after age 40. However, with increasing levels of obesity and sedentary lifestyle, this disease is now being found more and more in adolescents – and sometimes even in children under 10 – and the term “adult onset” is no longer used. Type II diabetes comprises about 90 percent of all cases of diabetes. With this type of diabetes, either the pancreas produces a reduced amount of insulin, the cells do not respond to the insulin, or both.

Symptoms and Treatment of Diabetes

Diabetes can occur in anyone. However, people who have close relatives with the disease are somewhat more likely to develop it.

Other risk factors include obesity, high cholesterol, high blood pressure, and physical inactivity and stress. The risk of developing diabetes also increases as people grow older.

Risk factors: sedentary life style, obesity, advanced age, unhealthy life style, family history of diabetes, stress,  certain type of medication (cortisone and high blood pressure medication). The warning signs:

Type I: Frequent urination, increased thirst, extreme hunger, unexplained weight loss, extreme fatigue, blurred vision, irritability, nausea and vomiting.

Type II: Any Type I symptom, plus: unexplained weight gain, pain, cramping, tingling or numbness in your feet, unusual drowsiness, frequent vaginal or skin infections, dry, itchy skin and slow healing sores.

Diagnosis of Diabetes. Besides a complete history and physical examination, the doctors will perform a battery of laboratory tests. There are numerous tests available to diagnose diabetes, such as a urine test, blood test, glucose-tolerance test, fasting blood sugar and the glycohemoglobin (HbA1c) test.

Treatment. There are certain things that everyone who has diabetes, whether type 1 or type 2, needs to do to be healthy. They need to have a meal (eating) plan. They need to pay attention to how much physical activity they engage in, because physical activity can help the body use insulin better so it can convert glucose into energy for cells.

Everyone with type 1 diabetes, and some people with type 2 diabetes, also need to take insulin injections. Some people with type 2 diabetes take pills called “oral agents” which help their bodies produce more insulin and/or use the insulin it is producing better. Some people with type 2 diabetes can manage their disease without medication by appropriate meal planning and adequate physical activity.

Everyone who has diabetes should be seen at least once every six months by a diabetes specialist (an endocrinologist) as well as other members of a diabetes treatment team, including a diabetes nurse educator, and a dietitian and, a psychologist for help with the stresses and challenges of living with a chronic disease.

Diabetes complications. Please be aware of the following problems that exist with insulin intake:

  • Hypoglycemia (low blood sugar) is sometimes called an insulin reaction or insulin shock. It can occur suddenly in people using insulin if too little food is eaten, if a meal is delayed or in the case of extreme exercise. Symptoms include feeling cold, clammy, nervous, shaky, weak or hungry, and some people become pale, have headaches or act strangely.
  • Hyperglycemia (high blood sugar) occurs when too much food is eaten or not enough insulin is taken. The warning signs are large amounts of sugar in the urine and blood, frequent urination, great thirst and nausea.

Ketoacidosis (in its most severe form – diabetic coma) develops when insulin and blood sugar are so out of balance that ketones accumulate in the blood. Symptoms include high blood sugar or ketones in the urine, dry mouth, great thirst, loss of appetite, excessive urination, dry and flushed skin, labored breathing, fruity-smelling breath and possible vomiting, abdominal pain and unconsciousness.

Stress in Diabetes & Psychotherapy

In people with diabetes, stress can alter blood glucose levels. It does this in two ways. First, people under stress may not take good care of themselves. They may drink more alcohol or exercise less. They may forget, or not have time, to check their glucose levels or plan good meals. Second, stress hormones may also alter blood glucose levels directly. Physical stress, such as illness or injury, causes higher blood glucose levels in people with either type of diabetes.

Many newly diagnosed diabetics go through the typical stages of mourning. These are denial, anger, depression and acceptance.

  • Denial: This can be one of the more dangerous stages of the grief process. It may not occur only once. Many individuals cycle back to this phase several times. The honeymoon phase, associated with early Type I diabetes, may reinforce denial. Denial is a common stance for adolescent diabetics.
  • Anger: It really does seem unfair. The type II diabetic, trying to lose weight, may envy heavier people who seem to enjoy good health. One might erupt at someone who innocently offers a desert. Unfortunately, anger can drastically affect glucose levels.
  • Depression: Mild depressive feelings are a normal part of grieving and adaptation. Even though depression is not generally listed as a complication of diabetes, studies have shown that the rate of depression in diabetics is much higher than in the general population.
  • Acceptance: Individuals achieve different degrees of acceptance and inner peace. Some will need to experience the denial, anger and depression several times as they move through different phases of life and different stages of diabetes. Some people move through a chronic disease to a state of much greater self-knowledge and deeper understanding of themselves and their relations to others.

However, coping problems are very common among people with diabetes largely because the demands of diabetes management are so substantial. The sense of being overwhelmed is one factor leading to the low levels of diabetes self care. Self care is a critical issue in diabetes and focus of therapeutic intervention is on the development of coping skills and techniques designed to help diabetics establish self care goals, and develop and commit to a plan for achieving that goal.


Receiving a diagnosis of “infertility” can make you feel helpless, frustrated and depressed. The stress of infertility is a two way street. The emotional experience can’t help but create tension in one’s body. And tension in one’s body can’t help but intensify the worry that you are somehow contributing to the problem. You are not responsible for your infertility, but you can choose to be responsible to your infertility in ways that go beyond whatever you are already doing.

Negative feelings and unexpressed emotions such as the anguish, guilt, stress, anxiety and shame can create extreme emotional conflict, which affects every cell of the body and can cause or compound reproductive problems.

Negative self-talk has a direct causative effect on the endocrine (hormonal) system.

Fears that might be block woman’s conception: pregnancy, childbirth, physical changes in body, medical treatments, loss of her independence, is she ready to be a mother, will she be a good mother, will dysfunctional patterns from her childhood be repeated, will the new baby be a threat to the relationship with her spouse, miscarriages, abortions, feelings of inadequacy, and high expectations.

Infertility & Psychotherapy

It is aimed at addressing woman’s underlying fears that might be causing her infertility. Further, providing ways to handle stress by exposing her to coping skills that she really needs and learning how to achieve state of relaxation using breathing techniques will enhance woman’s ability to conceive. A Harvard Medical School Study showed that of 184 women with fertility problems, 55% of those who completed a 10 week course of relaxation training and stress reduction had a viable pregnancy within one year, compared with just 20% of the group who had no stress reduction training. Another study found that women undergoing fertility treatments who remained relaxed and optimistic had better overall outcomes than women who were pessimistic about their ability to conceive.


Hypnotherapy can help women identify and process emotional issues within the subconscious that might be interfering with conception. Hypnotherapy reduces stress and increases confidence, instilling a sense of control, which in turn enables woman to maximize chances of conceiving naturally and/or increase the success of medical assistance. A recent Israeli study on 185 woman showed that the success rate of IVF treatments doubled in his test group from 14% to 28%, when the subjects underwent hypnosis during implantation.

Couple Therapy

Infertility might bring questions about integrity or meaning of couple’s relationship. It might go something like this, “If we can’t have children, maybe we aren’t meant to be married.” Or “If we can’t have children, who are we? Are we a real family?” These thoughts are entirely normal, but they are also not true.

Studies show that when it comes to medical issues, women make the first medical appointments in dealing with infertility, and they make most of the follow-up visits as well.

They ask more questions than their male partners; and female patients spend more time with the doctor than do male patients.

The result: Woman takes over the infertility treatment plan and is the captain of the team.

Even though the diagnosis of infertility factors is evenly split between men and women, women view this issue as more impactful in their lives and self-image than do men. In one study 15% of men and 50% of women said that infertility was “their greatest burden ever.” One reason for this is biological: the female reproductive system has a limited supply of eggs and time is pressing on. Another reason is sociological: most women expect to become mothers from childhood, when they began playing mommy with their dolls. Choosing not to have children is one thing, but being unable to conceive and bear children is quite another.

Sexuality and infertility

People tend to confuse infertility with sexuality. The terms “sterile man” or “barren woman” are unappealing and emotionally hurtful. When we internalize these images, we feel wounded and unattractive as well. Old stereotypes persist that people without children must have sexual issues: he can’t “get it up” or she must be “cold or frigid.” The truth is that these days, sexual issues are rarely a cause of infertility. It’s rather the reverse: dealing with infertility affects people’s sex lives. More than half of the couples dealing with infertility experience a decrease in sexual activity as well as a less satisfying sex life. They also report more sexual problems related to anxiety, depression, and medication side effects, such as less sex drive, erectile dysfunction, premature ejaculation, and lack of orgasm.

Consider couples therapy when:

  • You feel isolated with your problem & need external support.
  • You disagree on a treatment plan or adoption path.
  • Struggle with sexuality.
  • Either you or your partner are clinically depressed and need a safe treatment setting in addition to your individual support.
  • You are handling marital conflict poorly or in destructive ways.
  • The integrity of your relationship feels threatened by the stressors or identity challenges of infertility treatment.

Successful strategies

  • Partnership Mentality: “We’re in this together.” “We’re on the same side.” “Partners share the problem 50:50 but each is 100% responsible for their own part.”
  • Discuss with whom you can share your situation. Respect partner’s need for privacy while meeting your needs for support. Getting outside help puts less pressure on your relationship.
  • Define what you can and cannot control. Don’t expect to control either yours or your partner’s feelings.
  • Limit yourselves to ten minutes each of respectfully listening to the other without interrupting.
  • When you feel overwhelmed, resist letting discussions about infertility consume your time together.
  • Don’t mistake differences in communication styles as differences of intention.
  • Make differences in decision-making and communication an asset rather than a threat.
  • Create a center of your life separate from infertility.
  • Focus on positive life lessons. Through resolving their infertility, many couples report improvements in communication, self-esteem, and maturity. Overall, they feel that their marriage or relationship is stronger.

Acupuncture & infertility

More than 3,000 years old, the theory behind the success of acupuncture is that we are all made up of energy and there are specific points, or meridians of energy, which run through the body. By stimulating these blocked areas of the meridian using thin, solid acupuncture needles, the energy flow is restored. This creates harmony in the body and eventually resolve the illness.

A German study on the influence of acupuncture and pregnancy, in conjunction with Western medical fertility treatment suggested that if a woman with good embryos receives acupuncture twenty-five minutes before and after an embryo transfer, her chances for a positive pregnancy would significantly increase. Recent studies have also found that women, who combine acupuncture with in vitro fertilization, have increased pregnancy rates unlike those who do not.

Acupuncture is a low cost and low risk treatment which will, at the very minimum reduce stress during what can be a very painful, frustrating and emotional time.


Donald Gordon Pelvic Floor Unit

Diabetes West